Radiofrequency ablation of the superior cluneal nerves to treat chronic low back pain: a description of a novel technique

Introduction

Chronic low back pain is one of the most prevalent and debilitating conditions internationally, with low back pain affecting 619 million people globally in 2020 and a projection of 843 million people by 2050 (1). The severity of low back pain can vary significantly from patient to patient because of the wide range of etiologies, including the entrapment of the superior cluneal nerves (SCNs) (2). This source of pain is currently being recognized as a factor in axial low back pain, and effective therapies are currently being investigated for those who fail to respond to conventional treatments such as physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and transcutaneous electrical nerve stimulation (3,4).

The SCNs originate from spinal nerves and cross over the iliac crest, making them susceptible to entrapment, which manifests as localized lower back pain that radiates into the gluteal region (5,6). This increasingly identified entrapment is an underdiagnosed contributor to axial low back pain, particularly in patients who are refractory to conventional therapies (7,8). As such, patients can be diagnosed with superior cluneal neuralgia, which is defined as irritation or compression of the SCNs leading to referred pain in the lower back, upper buttock, and posterior iliac crest region (9). A diagnostic anesthetic nerve block can confirm the diagnosis if it reproduces the patient’s lower back or gluteal pain. If a patient experiences significant but temporary relief from the nerve block, then radiofrequency ablation (RFA) of the SCN may be performed to offer longer-lasting pain management (10).

RFA is a minimally invasive technique that utilizes selective thermal lesioning of nociceptive sensory nerve fibers responsible for pain transmission to decrease pain sensation (11,12). This technique has been used to treat a variety of other chronic pain disorders involving peripheral sensory nerves, including intercostal, lateral femoral cutaneous, ilioinguinal, iliohypogastric, pudendal, and sural nerves (13-19). Additionally, a previous study has demonstrated the effectiveness of treating SCN-related lower back pain, with preliminary data supporting its efficacy in reducing pain intensity and improving functionality (20). However, all previously published literature has described and recommended the use of pulsed RFA for peripheral nerves. Our study is novel in that we describe lesion mode by both conventional and cooled methods and have explored how larger lesions created by cooled techniques are both safe and effective for treating peripheral neuralgias, including SCN entrapment.

While traditional RFA was initially developed for the treatment of chronic back pain, utilizing RFA to ablate the SCNs was first described and published by Visnjevac et al. in 2022 (20). This novel procedure involves the percutaneous insertion of a radiofrequency (RF) cannula under fluoroscopic guidance, targeting the medial branch of the SCN (20,21). Thermal energy is applied to ablate the nerve, typically at 80 ℃ for 60–90 seconds, following identifying the anatomical landmark and using local anesthesia (22). Accurate probe positioning and lesion size selection are essential to ensure reproducibility and minimize the risk of adverse effects. While evidence suggests that thermal and pulsed RFA have the potential to provide pain relief in peripheral neuropathies, cooled techniques are currently being explored to achieve larger lesions, thereby increasing pain relief and enhancing precision when targeting a specific nerve (15,16).

Despite the effectiveness of RFA in treating pain associated with SCNs, these nerves can be small and difficult to target. Due to anatomical variations, large lesions, and needle placement, fluoroscopy, guided by the patient’s localization of pain, is a pivotal aspect of the procedure’s success. Hence, a proper technique and imaging guidance are crucial to ensure reproducible and successful outcomes. To aid in precisely targeting interventional procedures such as RFA, this report thoroughly outlines an approach to imaging the SCN under fluoroscopic guidance, providing detailed anatomical landmarks, needle positioning, and lesion parameters for reproducible clinical implementation.

Anatomy

The SCNs are terminal sensory branches of the dorsal rami of the lower thoracic and upper lumbar spinal nerves that traverse the thoracolumbar fascia to innervate the skin overlying the posterior iliac crest and upper gluteal region (5,23). While SCNs typically arise from L1, L2, and L3 spinal nerves, Iwanaga et al. demonstrated that these nerves can variably arise anywhere from T11 to L5, with 45% of the dorsal rami of L4 and 10% of the dorsal rami of L5 also giving rise to the SCN in their cadavers (24). The SCN is traditionally thought to have three branches (medial, intermediate, and lateral SCN). Still, Konno et al. found that 35% of cadavers had more than 3 branches running over the iliac crest (25). They further concluded that the proximal part of the SCN can anastomose with regional nerves deep to the thoracolumbar fascia before piercing through it to provide sensory innervation (25).

The distance between the SCNs and the posterior superior iliac spine (PSIS) also demonstrates variability. Wu et al. provided a more detailed analysis, reporting an average distance between the SCN and PSIS on the horizontal axis of 43.10–45.70 mm for the medial branch, 49.20–51.60 mm for the intermediate branch, and 54.20–56.10 mm for the lateral branch (3). The mean distance on the vertical axis was 63.40–63.70 mm for the medial branch, 69.60–71.10 mm for the intermediate branch, and 73.80–76.20 mm for the lateral branch (3). These findings are consistent with those of Loubser et al., who investigated 27 cadavers and reported an average distance of 69.6 mm between the SCN piercing the thoracolumbar fascia and the PSIS (26).

Using detailed cadaveric dissection of 93 cadavers from 53 males and 40 females, Kagaya and colleagues demonstrated that the SCNs course through or are closely related to the thoracolumbar fascia near the iliac crest (23). As seen in Figure 1, the SCNs pierce the thoracolumbar fascia approximately 6–8 cm lateral from the midline, traveling superficially across the iliac crest before distributing cutaneous branches to the gluteal region (27). However, they identified a previously undescribed muscular anomaly along the posterior iliac crest between the erector spinae and gluteal muscles. This muscle was present in six cadaveric specimens from three patients and extended longitudinally from the posterior surface of the sacrum to the iliac crest (23). Due to its anatomical position and multi-layered structure, the authors suggested that this aberrant muscle is most likely a muscularized bundle of the thoracolumbar fascia, with similar innervation and fusion points to the iliocostalis muscle (23). Notably, the SCNs were observed to course either through or in close relation to this aberrant muscle before piercing the thoracolumbar fascia, and histological analysis confirmed innervation of this aberrant muscle by the SCNs themselves.

Figure 1 Cadaveric dissection of the lumbar and gluteal region demonstrating the course of the superior and middle cluneal nerves. The SCNs, derived from the dorsal rami of T11–L5, are seen crossing the iliac crest after piercing the thoracolumbar fascia, with their medial branches traversing a fibro-osseous tunnel that predisposes them to entrapment. Neighboring landmarks include the quadratus lumborum, gluteus medius, piriformis, sacrotuberous ligament, superior gluteal nerve, and sciatic nerve [Reproduced from Karl et al. published by Pain Physician Journal under a Creative Commons Attribution-NonCommercial (CC BY-NC) license, which permits reuse for non-commercial purposes with proper attribution.] (27). PSIS, posterior superior iliac spine; SCN, superior cluneal nerve.

Histological findings confirm that the SCNs are sensory, consisting primarily of small myelinated and unmyelinated fibers, which is consistent with their role in nociception (4,28). While previous anatomic studies emphasized their contribution solely to cutaneous innervation, Kagaya et al. provided novel evidence that the SCNs may also innervate fascia and muscle fibers adjacent to the iliac crest, providing motor or proprioceptive input and expanding their functional relevance beyond previously recognized sensory roles (23). Given their consistent anatomical course and involvement in iliac crest-related pain syndromes, the SCNs have emerged as clinically significant targets for diagnostic nerve blocks and RFA in the treatment of chronic low back and gluteal pain. However, further anatomic and clinical investigations are warranted to clarify the extent of their sensory distribution and potential contribution to thoracolumbar pain. We present this article in accordance with the SUPER reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-25-111/rc).

Preoperative preparations and requirements

All patients eligible for RFA of the SCNs must experience low back or buttock pain that is refractory to conservative management for at least three months and subsequently be diagnosed with superior cluneal neuralgia. Superior cluneal neuralgia is a clinical diagnosis made by reproducing the patient’s chief complaint with a positive iliac crest sign, which is defined as a reproducible trigger point pain upon palpation approximately 7 cm from the midline over the posterior iliac crest (20). To confirm the diagnosis, patients must undergo two diagnostic blocks of the SCN based on the location of the patient’s pain before they are eligible for RFA. For this procedure, palpation techniques and anatomical landmarks are used to insert a 25-gauge, 1.5-inch needle into the SCN to administer 8 mL of 0.25% bupivacaine and anesthetize the nerve. Pain relief from the diagnostic nerve block itself is temporary, lasting only for a few hours to a couple of days. However, the diagnostic nerve block is considered clinically significant, and patients can proceed with RFA if they experience a 50% or greater improvement in pain. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patients for publication of this article and accompany images. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

After patient identification, informed consent, and standard cardiopulmonary monitoring, the patient is positioned prone on the fluoroscopy table with a pillow under the lower abdomen to reduce lumbar lordosis and enhance patient comfort. The gluteal area is prepared with three rounds of a 2% chlorhexidine solution in 70% isopropyl alcohol and sterile draping (20). The skin and subcutaneous tissues are anesthetized with 1–2 mL of 2% lidocaine to numb the skin before needle insertion (20). Using anteroposterior fluoroscopic views, a disposable RF cannula, 18–22-gauge, 100–150 mm in length, with a 5 or 10 mm active tip, is then advanced to the superior border of the iliac crest, targeting the osseoaponeurotic orifice, which can be visualized on fluoroscopy as a small ossified cephalad protrusion at the posterior iliac crest (Figure 2A,2B). After contact with the bone, the cannula is rotated 3–5 mm off the superior border of the iliac crest and often superomedially to the osseoaponeurotic orifice in attempts to avoid deeper and unwanted penetration of non-target tissues, such as viscera or other muscular structures (Figure 2C). The physician is expected to maintain a slight medial angle to follow the expected nerve path, only advancing to the periosteal constant is reached to avoid excessive depth penetration. This positioning allows for targeting the SCN proximal to the portion that traverses the canal, which is approximately 7–8 cm from the midline and often the most significant point of tenderness (20).

Figure 2 Fluoroscopic image of the posterior right superior iliac crest with a radiofrequency cannula targeting the superior cluneal nerve. (A) Initial RF cannula placement near the superior border of the iliac crest, targeting the osseoaponeurotic orifice. (B) Same image as (A), zoomed in with a red circle highlighting the location of the osseoapnoeurotic orifice. (C) Rotation of the RF cannula to target the osseoaponeurotic orifice. (D) RF cannula placement medial to the osseoaponeurotic orifice, repositioned after failure to capture concordant paresthesia with sensory stimulation. RF, radiofrequency.

The correct needle placement is confirmed through sensory stimulation at 50Hz, reproducing the sensation corresponding to the patient’s primary pain complaint. If the sensory testing is negative for reproduction of paresthesia, the cannula tip is repositioned, and sensory testing is repeated. After positive sensory testing, motor testing is performed at 2 Hz up to 2 V and is considered appropriate if there is no motor response distal to the needle insertion site. A diagnostic nerve block with 1% lidocaine or 0.25% bupivacaine with or without a steroid is typically administered before RF lesioning to ensure short-term pain relief (22,29).

Monopolar RFA is then carried out using continuous RF (lesions) mode. This technique delivers sustained energy at 80 ℃ for 90 seconds to create a thermal lesion (21). If the patient received complete pain relief, the needle is removed, and a sterile dressing is applied to the insertion site. However, if pain persists, the needle is repositioned a few millimeters medially or superolaterally along the iliac crest to identify adjacent SCN branches contributing to pain sensation (Figure 2D). After another sensory and motor testing round, RFA lesioning is performed again. Needles are removed after the procedure, and the skin is cleaned and prepared with a sterile dressing.

Alternatively, Dr. A.A.E. has continued to explore the efficacy of RFA by performing this procedure with cooled RFA. While the majority of the technicalities of the procedure are similar to those of thermal RFA, cooled RFA utilizes 17-gauge, 100-mm, cooled RF probes with 4-mm active tips to perform RF lesioning at 80 ℃ for 2 minutes and 30 seconds, thereby reproducing consistent results (30). Given the anatomical variability in the location of the SCN branches, placing the needles based on the site of pain as described by the patient is recommended. Testing before ablation will then confirm needle proximity to the nerves. Use of multiple needles with the ability to produce a large lesion size is recommended. Furthermore, other providers have adapted this procedure using ultrasound guidance instead of fluoroscopy for proper needle placement (31). A growing body of literature supports the use of ultrasound guidance to localize branches of the SCN, which enables visualization of fascial layers, soft tissue variants, and nerve piercing points. Ultrasound may be used in conjunction with fluoroscopy in cases involving complex bony landmarks, obesity, or anatomical deviation; however, it is essential to note that limited depth penetration poses a potential constraint. Other alternative and emerging techniques include bipolar RFA, cryoablation, and peripheral nerve simulation. However, there is currently a lack of comparative data to determine the efficacy of these techniques.

These recommendations, consisting of a standardized sequence of sterile preparation, fluoroscopy-guided needle placement, sensory and motor testing, diagnostic block, and continuous RFA, consistently yield significant and sustained pain relief in patients with low back pain (20,32).

Postoperative considerations and tasks

Patients remain in the recovery room for 15 minutes after the procedure, during which a nurse monitors their vitals and checks for any adverse events, including temporary pain, swelling, numbness, bleeding, or neuritis at the needle insertion site, as well as signs of possible infection and fever. Patients are educated on returning if symptoms worsen or if signs of infection evolve and are scheduled for a follow-up appointment approximately 6–8 weeks after the procedure.

Tips and pearls

Anatomical variability and procedural optimization

While it is essential to have a standardized protocol for RFA of the SCNs, it is also crucial to consider how anatomical variability in fascial thickness, branching patterns, or aberrant muscle slips can redirect cannula placement and impact the clinical outcome of this procedure. Procedural planning must integrate feedback and stimulation responses. Furthermore, instead of solely relying on anatomical landmarks, preprocedural planning is patient-specific. It utilizes image-guided techniques, such as ultrasound, to determine the exact location of the nerve to be targeted for RFA. Additionally, effective patient selection relies heavily on a positive response to the diagnostic nerve block. If the nerve cannot be visualized on ultrasound or the diagnostic block is not sufficiently compelling, other etiologies for the patient’s pain should be explored, potentially excluding the patient from RFA. If the patient is still eligible for the procedure, anatomic variability of the SCNs makes accurate needle placement challenging, potentially causing the intended nerve branches to be missed. The use of landmark-based techniques may contribute to a lower success rate in these patients; however, advancements in image-guided techniques have improved the outcomes of RFA, even for patients with atypical anatomy.

Discussion

Axial low back pain is a highly prevalent and debilitating cause of pain. While some patients obtain relief from traditional therapies such as analgesics and physical therapy, many patients have sustained and/or worsening symptoms, emphasizing the need for interventional approaches. Thus, RFA is a promising alternative with emerging but limited clinical evidence to support the benefit for patients suffering from low back pain related to SCN entrapment (8,21). As such, SCN-related pain pathophysiology has been recently discovered and described through fascial tunneling, nerve irritation at muscular insertion, and a variable piercing site, further reinforcing a multifactorial pathogenesis in which mechanical compression and neural traction inflammation coexist to produce SCN-mediated pain (3,23,25).

Cadaveric studies demonstrate that the distances from the PSIS vary among the medial, intermediate, and lateral branches of the SCNs, and muscular anomalies along the iliac crest may create additional entrapment sites (3,28,32). These anatomical variations underscore the importance of an individualized approach, guided by imaging, when performing RFA (3). As such, our technique targets the osseoaponeurotic orifice at the posterior iliac crest with fluoroscopic guidance, while real-time ultrasound imaging is utilized to confirm landmarks and nerve location when needed (3). After sterile preparation, an 18–22-gauge cannula is advanced to the crest, and sensory stimulation at 50 Hz is used to reproduce the patient’s typical pain. At the same time, motor testing confirms the absence of distal activation (25,33). RFA performed at 80 ℃ for 90 seconds produces a focused thermal lesion, and the cannula can be repositioned to address additional branches if needed (3,28). As such, some patients may require multiple procedures before noticing any improvement in pain symptoms. This conservative approach accounts for the SCN’s anatomic variability and minimizes the risk to adjacent structures (27,34). Our approach differs from previously described RFA techniques of the SNC in that it emphasizes targeted cannula angulation toward the osseoaponeurotic orifice, lesion repositioning guided by concordant stimulation mapping, and the incorporation of procedural optimization principles derived from recent anatomical insights.

Published studies suggest that RFA of the SCN may provide clinically significant pain relief and functional improvement in patients with chronic axial low back pain refractory to conventional treatments (25,34). The SCN has a low risk of motor deficit because of its sensory nature, and reports have shown minimal complications. These findings support the use of RFA of the SCN as a potentially useful and minimally invasive treatment option between conventional treatments and surgical options. However, peer-reviewed comparative trials are still needed (25,34).

Additionally, clinical evidence highlights the effectiveness of the SCN RFA. The clinical outcome of RFA is typically measured by changes in Visual Analog Scale (VAS) pain scores and a calculated percent improvement. Traditionally, RFA is considered successful if there is a 50% or more improvement in pain status based on VAS scoring (35). For RFA of the SCNs in particular, a small case series reports an average of 50% reduction in pain lasting 6–12 months (20,36). Even without complete remission of pain, many patients experience a decrease in long-term morbidity and disability through improvements in the intensity or frequency of the pain, or through functional improvement metrics, such as enhanced daily activities, increased range of motion, and reduced medication usage. The SCN RFA has also been shown to maintain benefit during required repeated procedures without an increase in adverse events (21). Furthermore, these outcomes are similar or better than those reported for other peripheral nerve ablation targets, underscoring the efficacy of this procedure (37).

Although RFA is considered a safe procedure, there is a non-negligible risk of adverse events and complications that are essential to consider to ensure patient health and safety. Before the procedure, patients are counseled on minor expected post-procedural effects, including localized bruising, short-term pain and soreness at the procedural site, and transient quadratus lumborum muscle spasm (20). These side effects are typically temporary and resolve on their own without the need for additional interventions. It is also important to note that no serious complications have been documented in published SCN RFA studies. However, theoretical risks are associated with the heat generated during the procedure and potential for inaccurate needle placement, which could manifest as thermal injury to adjacent structures, bleeding from damage to vasculature, nerve damage, visceral penetration, and infection (21). While these risks are essential to consider for various interventional pain procedures, they can be mitigated through careful needle angulation, fluoroscopic depth control, stimulation testing, and adherence to sterile techniques.

Conclusions

Furthermore, RFA for the SCNs should be considered as a modality for treating chronic low back pain related to the SCNs. Performing diagnostic nerve blocks can aid in confirming the diagnosis to proceed with RFA. While the cost of the procedure can vary depending on the provider, insurance coverage, and the number of sessions, its potential for long-term pain relief and reduced dependency on conventional therapies makes it a cost-effective alternative for managing chronic low back pain.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine for the series “Advances in Radiofrequency Ablation”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-25-111/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-111/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-111/coif). The series “Advances in Radiofrequency Ablation” was commissioned by the editorial office without any funding or sponsorship. A.A.E. serves as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Annals of Palliative Medicine from June 2024 to June 2026. Additionally, A.A.E. is a consultant for Medtronic, Avanos, and Curonix. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patients for publication of this article and accompany images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol 2023;5:e316-29. [Crossref] [PubMed]
2. Iwanaga J, Simonds E, Patel M, Oskouian RJ, Tubbs RS. Anatomic Study of Superior Cluneal Nerves: Application to Low Back Pain and Surgical Approaches to Lumbar Vertebrae. World Neurosurg 2018;116:e766-e768. [Crossref] [PubMed]
3. Wu WT, Mezian K, Naňka O, et al. Enhancing diagnosis and treatment of superior cluneal nerve entrapment: cadaveric, clinical, and ultrasonographic insights. Insights Imaging 2023;14:116. [Crossref] [PubMed]
4. Paracha U, Hendrix JM. Cluneal Neuralgia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.
5. Maigne JY, Doursounian L. Entrapment neuropathy of the medial superior cluneal nerve. Nineteen cases surgically treated, with a minimum of 2 years' follow-up. Spine (Phila Pa 1976) 1997;22:1156-9. [Crossref] [PubMed]
6. Karri J, Singh M, Orhurhu V, et al. Pain Syndromes Secondary to Cluneal Nerve Entrapment. Curr Pain Headache Rep 2020;24:61. [Crossref] [PubMed]
7. Isu T, Kim K, Morimoto D, et al. Superior and Middle Cluneal Nerve Entrapment as a Cause of Low Back Pain. Neurospine 2018;15:25-32. [Crossref] [PubMed]
8. Hostetter JL, Patel K. Superior Cluneal Nerve Entrapment as a Cause of Low Back Pain Refractory to Sacroiliac Joint Fusion: A Case Report. Cureus 2023;15:e44271. [Crossref] [PubMed]
9. Abd-Elsayed A, Gyorfi MJ. Peripheral Nerve Stimulation for the Treatment of Superior Cluneal Neuralgia: A Cadaver Demonstration of a Novel Technique for Lead Placement. J Pain Res 2024;17:1235-41. [Crossref] [PubMed]
10. Lu J, Ebraheim NA, Huntoon M, et al. Anatomic considerations of superior cluneal nerve at posterior iliac crest region. Clin Orthop Relat Res 1998;224-8. [Crossref] [PubMed]
11. Wray JK, Dixon B, Przkora R. Radiofrequency Ablation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.
12. Abd-Elsayed A, Kennedy K. The art of radiofrequency ablation. Ann Palliat Med 2024;13:471-6. [Crossref] [PubMed]
13. Michaud K, Cooper P, Abd-Elsayed A, et al. Review of Radiofrequency Ablation for Peripheral Nerves. Curr Pain Headache Rep 2021;25:63. [Crossref] [PubMed]
14. Abd-Elsayed A, Robinson CL, Peters T. Narrative review of radiofrequency ablation applications in peripheral nerves. Ann Palliat Med 2024;13:893-900. [Crossref] [PubMed]
15. Abd-Elsayed A, Cui C, Eckmann MS. Cooled Radiofrequency Ablation of the Trochanteric Branch of the Nervus Femoralis to Treat Greater Trochanteric Pain Syndrome. Pain Med 2022;23:1375-8. [Crossref] [PubMed]
16. Abd-Elsayed A, Preda A, Shiferaw BT, et al. Cooled Radiofrequency Ablation of Thoracic Medial Branches for the Treatment of Chronic Thoracic Pain. Healthcare (Basel) 2025;13:1468. [Crossref] [PubMed]
17. Abd-Elsayed A, Gyorfi MJ, Ha SP. Lateral Femoral Cutaneous Nerve Radiofrequency Ablation for Long-term Control of Refractory Meralgia Paresthetica. Pain Med 2020;21:1433-6. [Crossref] [PubMed]
18. Patil AS, Gupta M, Knezevic NN, et al. A Comprehensive Review of Treatment Approaches to Ilioinguinal Neuralgia. Pain Physician 2025;28:197-205. [PubMed]
19. Petrov-Kondratov V, Chhabra A, Jones S. Pulsed Radiofrequency Ablation of Pudendal Nerve for Treatment of a Case of Refractory Pelvic Pain. Pain Physician 2017;20:E451-4. [PubMed]
20. Visnjevac O, Pastrak M, Ma F, et al. Radiofrequency Ablation of the Superior Cluneal Nerve: A Novel Minimally Invasive Approach Adopting Recent Anatomic and Neurosurgical Data. Pain Ther 2022;11:655-65. [Crossref] [PubMed]
21. Cohen T. Sustained pain relief from radiofrequency ablation of the superior cluneal nerves using a bipolar palisade technique: A case report. Interv Pain Med 2024;3:100425. [Crossref] [PubMed]
22. Abd-Elsayed A, Anis A, Kaye AD. Radio Frequency Ablation and Pulsed Radiofrequency for Treating Peripheral Neuralgias. Curr Pain Headache Rep 2018;22:5. [Crossref] [PubMed]
23. Kagaya M, Kawai K, Honma S. Novel muscular anomaly along the iliac crest: Innervation from the superior cluneal nerves and topographical relationship to the thoracolumbar fascia. Anat Sci Int 2025;100:228-42. [Crossref] [PubMed]
24. Iwanaga J, Simonds E, Schumacher M, et al. Anatomic Study of Superior Cluneal Nerves: Revisiting the Contribution of Lumbar Spinal Nerves. World Neurosurg 2019;128:e12-5. [Crossref] [PubMed]
25. Konno T, Aota Y, Kuniya H, et al. Anatomical etiology of "pseudo-sciatica" from superior cluneal nerve entrapment: a laboratory investigation. J Pain Res 2017;10:2539-45. [Crossref] [PubMed]
26. Loubser L, Raath RP, Van Schoor AN. Clinical anatomy of the superior cluneal nerve in relation to easily identifiable bony landmarks. Southern African Journal of Anaesthesia and Analgesia 2015;21:77-80. [Crossref]
27. Karl HW, Helm S, Trescot AM. Superior and Middle Cluneal Nerve Entrapment: A Cause of Low Back and Radicular Pain. Pain Physician 2022;25:E503-21. [PubMed]
28. Anderson D, Szarvas D, Koontz C, et al. A Comprehensive Review of Cluneal Neuralgia as a Cause of Lower Back Pain. Orthop Rev (Pavia) 2022;14:35505. [Crossref] [PubMed]
29. Lee JJ, Sohn JH, Choi HJ, et al. Clinical Efficacy of Pulsed Radiofrequency Neuromodulation for Intractable Meralgia Paresthetica. Pain Physician 2016;19:173-9. [PubMed]
30. Abd-Elsayed A, Johnson TN, Ruprecht KK, et al. Outcomes of Cooled Radiofrequency Ablation of Lumbar Nerves as Treatment for Chronic Low Back Pain. Pain Ther 2025;14:949-56. [Crossref] [PubMed]
31. Moritz T, Prosch H, Berzaczy D, et al. Common anatomical variation in patients with idiopathic meralgia paresthetica: a high resolution ultrasound case-control study. Pain Physician 2013;16:E287-93. [Crossref] [PubMed]
32. Arce Gálvez L, Daes Mora J, Valencia Gómez RE, et al. Superior cluneal nerves radiofrequency in the management of chronic low back pain. Interv Pain Med 2024;3:100428. [Crossref] [PubMed]
33. Kuniya H, Aota Y, Kawai T, et al. Prospective study of superior cluneal nerve disorder as a potential cause of low back pain and leg symptoms. J Orthop Surg Res 2014;9:139. [Crossref] [PubMed]
34. Iwanaga J, Simonds E, Schumacher M, et al. Anatomic Study of the Superior Cluneal Nerve and Its Related Groove on the Iliac Crest. World Neurosurg 2019;125:e925-e928. [Crossref] [PubMed]
35. Provenzano DA, Holt B, Danko M, et al. Assessment of real-world, prospective outcomes in patients treated with lumbar radiofrequency ablation for chronic pain (RAPID). Interv Pain Med 2025;4:100576. [Crossref] [PubMed]
36. Iwamoto N, Isu T, Kim K, et al. Treatment of low back pain elicited by superior cluneal nerve entrapment neuropathy after lumbar fusion surgery. Spine Surg Relat Res 2017;1:152-7. [Crossref] [PubMed]
37. Kapural L, Mekhail N. Radiofrequency ablation for chronic pain control. Curr Pain Headache Rep 2001;5:517-25. [Crossref] [PubMed]