Superior cluneal nerves

Superior cluneal nerves are little known outside of the anatomical and surgical fraternity, yet they have a very important place in clinical chiropractic practice. They supply the skin of the greater part of the buttock, overlying large structures such as the gluteal muscles, the piriformis and the sciatic notch creating complex and oft confusing pain patterns.

Some anatomists believe they supply the groin too.

Orthopaedic surgeons have to be particularly careful because the nerves course over the iliac crests just where they like to harvest bone chips for a fusion.

It is easy to assume that pain in the buttock is from the gluteus maximus, or a piriformis syndrome, or a sacroiliac joint condition.

Likewise, overlying the sciatic notch, it's easy to assume this is a lower lumbar condition causing radiating pain to the buttock. And, because it often occurs simultaneously with a L5 or S1 lesion that is causing posterior thigh pain, it is missed.

As has been well said, remember the patient can have two diseases; he can also have 2 different pinched nerves causing buttock pain, one sciatic which is motor to the gluteals and the other superior cluneal supplying the overlying skin.

In its pure form, unadulterated by lower lumbar complications, the Slump test for sciatica and the straight leg raise of Lasegue will be negative.

Superior cluneal nerves

Buttock pain

Right buttock showing referral pattern. Above the more traditional diagram, and below Dr Maigne's pattern.

They supply a large area of the skin of the buttock reaching from the iliac crest, down towards the posterior hip. Testing the skin for numbness, as compared to the contralateral side, using a Wartenberg pinwheel, is a key part of the examination.

The superior cluneal nerves emerge from the mid to upper lumbar spine.

Unlike the much thicker and better known femoral nerve, however, which comes from the anterior rami of the nerve roots in the same general area, the superior cluneals find their origin in the posterior ramus of L1, L2 and L3, arrowed in red.

This posterior ramus splits into two branches, arrowed above in green. The medial may become involved in a so called double crush syndrome as it passes through a fibrous tunnel as it crosses the iliac crest; this may be a site of entrapment, in addition to that in the spine itself.

In short, these nerves emerge just below the thoraco lumbar junction, in itself a transitional and less stable area of the spine.

It is at this point that a lumbar scoliosis often has an apex, changing direction and providing fruitful ground for subluxations of the spine.

The area may be further complicated by small rudimentary ribs if there is an anomaly occurring at the lumbo sacral junction.

French orthopaedic surgeon Dr Robert Maigne described a syndrome, named after him, in which a facet joint subluxation in the upper lumbar spine can irritate the superior cluneal nerves with referred buttock pain. Interestingly he also claimed that irritable bowel syndrome may be similarly caused.

Chiropractors are faced on a daily basis with patients complaining of buttock pain. It takes a careful and thorough examination to determine whether the source is the sacroiliac joint, a bulging disc or a Maigne's syndrome irritating these nerves.

One can adjust the SIJ or lower back until the cows come home, but they will get minimal relief if the source of the irritation is in the upper lumbar spine.

They are purely sensory nerves with the exception of the multifidi muscles, lying between segments in the spine; they have no motor function in the buttock or leg and so will not cause distal weakness as a sciatica or femoral lesion can do.

If there is wasting of the gluteus maximus, known as the seagull sign, then one should look elsewhere for the origin of the pain and weakness.

Chiropractic adjustment of this part of the spine is particularly difficult, being a transitional area. One may use a P to A thrust with the patient lying prone, or a hyperextension technique with the fists in the small of the back.

A chiropractic lumbar roll may be more successful though L1 is often stubborn, and brute force and ignorance merely causes pain. A prone drop using the Thompson table may be more successful, or the Gonstead knee chest.

Maignes syndrome exercises

Using your hands under your back to you can do specific exercises for the T12-L1-L2-L3 area. These Maignes syndrome exercises are simple to do; every morning BEFORE getting out of bed.

Useful links

» Superior cluneal nerves

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

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