Middle cluneal nerve entrapment mimics sacroiliac joint pain

Sacroiliac joint (SIJ)-related pain is associated with low back- and buttock pain and the SIJ score is diagnostically useful because it helps to differentiate between SIJ-related pain and pain due to other factors such as lumbar disc herniation and lumbar spinal canal stenosis. Middle cluneal nerve (MCN) entrapment (MCN-E) can produce pain involving the lower back and buttocks. Therefore, the origin of the pain must be identified. We successfully treated patients with a high SIJ score whose pain was attributable to MCN-E.

Between August 2016 and June 2017, we treated 40 patients with non-specific low back pain. Among them, 18 (45%) presented with a positive SIJ score. Although SIJ treatment was unsuccessful in 4 of these patients, they responded to MCN-E treatment.

All 4 patients reported tenderness at the site of the sacrotuberous ligament (STL); 3 were positive for the one-finger test and experienced pain while sitting in a chair. The effect of SIJ block was inadequate in the 4 patients. As they reported severe pain at the trigger point in the area of the MCN, we performed MCN blockage. It resulted in pain control. However, in 1 patient, the effect of MCN block was transient and required MCN neurolysis. At the last visit, our patients' symptoms were significantly improved; their average numerical rating scale score fell from 8.3 to 1.0, their Roland-Morris Disability Questionnaire score fell from 12.8 to 0.3, and their average Japanese Orthopaedic Association score rose from 12.5 to 19.5.

In patients with suspected SIJ-related pain, the presence of MCN-E must be considered when the effect of SIJ block is unsatisfactory.