Cluneal RFA

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I do this. I do it when two blocks have both given great relief but don't last long. Billed as a single peripheral nerve RFA, but you'll do a bunch of burns. Not really a money maker, but it does help people.
 
Do you do this using US or fluoro landmarks?
 
Flouro. Along the iliac crest. Start at the PSIS and move superior-lateral. I use contrast to confirm location during blocks.
 
I've probably run into one instance of a true Cluneal neuralgia. 99% of the time that pain is referred IMO. But if people see it, diagnose it, and get great results, more power to you. Just haven't seen enough to remain convinced an issue is legitimately arising from the cluneal nerve itself - many times associated with Lumbar Radic, SI, or Piriformis.
 
DrSpine said:
I've probably run into one instance of a true Cluneal neuralgia. 99% of the time that pain is referred IMO. But if people see it, diagnose it, and get great results, more power to you. Just haven't seen enough to remain convinced an issue is legitimately arising from the cluneal nerve itself - many times associated with Lumbar Radic, SI, or Piriformis.
Click to expand...

I’ve diagnosed it twice, yet for some reason it’s always in the back of my mind. Agree with you that it’s usually referred pain. To me, it’s a diagnosis of exclusion and the two patients I diagnosed had such classic symptoms and no other potential sources that made much sense.
 
My most recent patient is a thin lady with severe scoliosis. No facet pain, no SI pain. Pain was iliac creast, QL area with radiating to buttocks. Tinels positive (remember, she's thin). Cluneal NB worked great x2, so RFA.

Agree, most buttock pain is referred SI, piriformis, or radic.
 
I heard lots say it isn't a "real thing" or is is incredibly rare so I didn't really do much with it. However, the I have a few patients over a year or two that I felt were sane, non-whiners that had pain. SIJ didn't help, in one I thought maybe it was piriformis- no help. MBB in another did nothing. So I injected in a band along the crest and they improved. I would imagine as much as peripheral stim leads migrate that this would be an area at high risk for migration, but RF seems reasonable if it can get covered. I have never tried.

For those that have, how many burns to you do? do you insert medial to lateral and then burn, withdraw, burn again, and so on. Where do you like to go from like 4cm lateral to PSIS to about 8cm from PSIS?
 
i have a few patients with this dx, not many. Typically seen w pelvic bone graft site for spine fusion surgery. Sometimes neruoma is palpable at this location, which as noted above is different than SIJ and facet locations (more lateral across the iliac crest) I block it and then do phenol X 2 1 week apart for the ablation. In those patients, approx 9mo 1.5 yr relief.
 
Do you insert the needle to the bone of the illiac crest? Again, how many cites/locations along the crest do you do the ablation at? Are there standardized locations where to perform the burns at?
 
I am just starting to do this procedure and am curious too. I have seen alot of variability in the technique for cluneal nerve block. I have been doing 1 needle entry point then going laterally and medially from this to essentially cover the superior surface of the iliac crest. I put my needle entry at the apex of the illiac crest as best I can tell by palpation and then confirming with ultrasound. I have used a mix of 10mg dexamethasone, 4cc 2% lido and 4cc 0.25% bupiv. My results have been all over the place. anyone else want to share their technique?
 
Multimodal said:
I am just starting to do this procedure and am curious too. I have seen alot of variability in the technique for cluneal nerve block. I have been doing 1 needle entry point then going laterally and medially from this to essentially cover the superior surface of the iliac crest. I put my needle entry at the apex of the illiac crest as best I can tell by palpation and then confirming with ultrasound. I have used a mix of 10mg dexamethasone, 4cc 2% lido and 4cc 0.25% bupiv. My results have been all over the place. anyone else want to share their technique?
Click to expand...


Using fluoro, use traditional RF 80 degrees for 90 seconds. Usually place 2 RF needles unilaterally, burn, then move needles lateral. About 4-5 burns each side along the iliac crest then move to other side, repeat.
 
TheLoneWolf said:
Using fluoro, use traditional RF 80 degrees for 90 seconds. Usually place 2 RF needles unilaterally, burn, then move needles lateral. About 4-5 burns each side along the iliac crest then move to other side, repeat.
Click to expand...
Burning anything in particular or just carpet bombing some muscle?

rhetorical question.
 
TheLoneWolf said:
Using fluoro, use traditional RF 80 degrees for 90 seconds. Usually place 2 RF needles unilaterally, burn, then move needles lateral. About 4-5 burns each side along the iliac crest then move to other side, repeat.
Click to expand...
What do you bill? Also, how do you determine between this and SI joint issues?
 
painfree23 said:
What do you bill? Also, how do you determine between this and SI joint issues?
Click to expand...

unfortunately 64640. imho not worth the effort but it pays some.
SI joint - of course when maneuvers positive.. usually try SIJ first before considering cluneal. cluneal more like diagnosis of exclusion for me.
 
TIVAndy said:
unfortunately 64640. imho not worth the effort but it pays some.
SI joint - of course when maneuvers positive.. usually try SIJ first before considering cluneal. cluneal more like diagnosis of exclusion for me.
Click to expand...

I usually do SI joint —> lateral branch blocks —>> lateral branch RFA.

If none of this works , I guess I’d do cluneal but at that point I’d really have a hard time convincing the patient, 4th times a charm. Just wondering where it falls in ur algorithms
 
painfree23 said:
I usually do SI joint —> lateral branch blocks —>> lateral branch RFA.

If none of this works , I guess I’d do cluneal but at that point I’d really have a hard time convincing the patient, 4th times a charm. Just wondering where it falls in ur algorithms
Click to expand...

if u are doing lateral branch block are you convinced that it's SIJ? if so cluneal shouldn't be entertained..
i rarely do lateral branch/RFA. most pts stick with few months improvement of SIJI.
 
I do SIJ RFA all the time. Good relief from SIJ injection, but short lived. Cluneal nerve block/RFA is not in my algorithm for SI joint pain.

Only have done one cluneal RFA, and that was iliac crest pain with some QL and Buttock pain in a patient with severe scoliosis and osteoporosis. Worked great.
 
Ferrismonk said:
Flouro. Along the iliac crest. Start at the PSIS and move superior-lateral. I use contrast to confirm location during blocks.
Click to expand...

Doing a superior cluneal RF next week, have you every used the bipolar for that or just single lesion multiple times along the iliac crest?
 
Crybaby said:
Doing a superior cluneal RF next week, have you every used the bipolar for that or just single lesion multiple times along the iliac crest?
Click to expand...
I did monopolar multiple burns, but that was more of a function of my RFA generator. Bipolar is just fine.
 
SommeRiver said:
How exactly does one diagnose cluneal pain?
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There should be a list of accounts that are on hold, or revoked - and a reason WHY that happened.

When you see someone's account on hold, aren't you all super curious what they did?

I am...

Anyway SommeRiver, if you ever come back to this bastien of free speech place we call SDN, I would answer your question with this.

Physical exam. They are tender and reproduce their pain with palp over the cluneal nerve as it comes over the iliac crest. Its extremely specific (hardy har har).
 
epidural man said:
There should be a list of accounts that are on hold, or revoked - and a reason WHY that happened.

When you see someone's account on hold, aren't you all super curious what they did?

I am...

Anyway SommeRiver, if you ever come back to this bastien of free speech place we call SDN, I would answer your question with this.

Physical exam. They are tender and reproduce their pain with palp over the cluneal nerve as it comes over the iliac crest. Its extremely specific (hardy har har).
Click to expand...
He’s back. He couldn’t quit us 😉

There are some pain diagrams that show the referral pattern that I think are useful, but for me it’s a last resort when everything else has been ruled out.
 
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