Cluneal Nerve Stimulation

What are Cluneal Nerves?

The cluneal nerves are cutaneous nerves that provide touch sensation of the lower back and buttocks. They are often classified according to where they innervate. Specifically, the nerves are as follows:

• Superior cluneal nerves
• Medial cluneal nerves
• Inferior cluneal nerves

What is Cluneal Nerve Stimulation?

This procedure works by targeting one or more nerves with an electrical field, which are transmitting most of the pain. We introduce a small electrical current to these nerves, which helps to mask the pain that you are feeling. This procedure is ordinarily non-destructive and completely reversible.

A number of painful conditions can be treated using cluneal nerve stimulation. Patients with the following conditions who have failed all standard medical therapies may benefit:

• Complex regional pain syndromes ('neuropathic pain')
• Nerve injuries (from trauma or previous surgery)
• Long-standing low back pain

What are the reasons for the procedure?

When medications and other treatments are no longer working well or their side effects are to severe, this minimally invasive procedure may be of value. The goals and potential benefits of the procedure include:

• Pain reduction
• Reduced medication requirements

The chance of obtaining a significant benefit depends upon a wide variety of factors. Dr Warren will give you an indication of the likelihood of success in your specific case.

How successful is cluneal nerve stimulation for pain?

Cluneal nerve stimulation helps to improve pain in more than 80% of the patients selected for treatment. The rate of reduction in pain varies from patient to patient. On average, pain scores are reduced by more than 50%. For example if a patient had a pain score of 10/10 we would be able to reduce it to 5/10.

What are the possible outcomes if treatment is not undertaken?

Potential outcomes of not treating your condition include:

• Ongoing pain
• Reduced quality of life

What do you need to tell the doctor before the procedure?

It is important that you tell your doctor if you:

• Have blood clotting or bleeding problems
• Have ever had blood clots in your legs (DVT or deep venous thrombosis) or lungs (pulmonary emboli)
• Are taking aspirin, warfarin, or anything else (even some herbal supplements) that might thin your blood
• Have high blood pressure
• Have any allergies
• Have any other health problems

What happens before the procedure?

We will ask you to keep a pain diary. This is important for planning your procedure and monitoring your response. Fill this in over a period of a week or so. If your pain varies over the day, do a few scores per day, but if your pain tends to stay the same over the day a daily score will be enough.

You will also be asked to undergo a psychological evaluation. This is a routine test required by insurance to ensure the patient has the capacity to undergo the procedure.

Who will perform your procedure? Who else will be involved?

This procedure is performed by Dr Warren. A surgical assistant will be present and an experienced anesthetist will be responsible for your anesthetic or sedation.

How is cluneal nerve stimulation performed?

This is done in 2 stages.

Stage 1 (Trial)
 You will be taken to the operating room and your skin cleaned with antiseptic. Local anesthetic will be injected and you will be lightly sedated so that you can communicate with Dr Warren and the operating room staff. A small incision will be made and one or two electrodes (wires) will be placed alongside the relevant nerve or nerves. These will be brought out through the skin, and secured in place. You will then be transferred back to recovery room where the stimulator representative will perform programming to ensure the electrodes cover the area of your pain.

The effects of stimulation on your pain will be tested for the next five to seven days. During this period, you will be contacted and asked to score and describe your pain. This will allow us to know if the treatment is working or not. It also gives time for you to decide whether or not you are happy with the amount of pain relief you are getting.

Stage 2 (Electrode Implantation) If you are happy with the amount of pain relief that you obtained from the trial, we will carry out the full implantation several weeks later to allow for you to heal from the Trial. This procedure is also performed under light sedation.

The electrodes (wires) are placed similar to the previous procedure, only this time the other end of the wire is implanted beneath the skin. You will be given an external battery pack with a transmitter which is worn on your belt or under your clothes. Your battery will be programmed over the following days and weeks so that the stimulation you receive will be best for you.

What happens next (after implantation of the permanent system)?

You will follow up with Dr Warren about a week after the implantation to evaluate your initial response to the procedure and to check your wounds.

You will need to take it easy for about 6 weeks after your surgery, during which time your activities will be restricted - no bending, twisting, or stretching in an effort to prevent the electrodes from becoming dislodged. You should do an hour of gentle exercise, such as walking, every day.  

What happens down the track?

We will keep in close contact with you after placement of your stimulator. You may require repeated programming adjustments over the first few months to optimize your pain relief. Your pain medications will be reduced as tolerated. As your pain improves, we may recommend physical therapy in an effort to further improve pain relief. 

How long will the benefits last?

This will vary from patient to patient. Typically, patients obtain a benefit for several years or longer. With time your pain may change, and the benefit may change with it, and so the stimulator settings may be adjusted to compensate for this. A small proportion of patients may benefit from repeat surgery if pain relief drop off.