Multi-Specialty Case Reviews: Sciatica

Sciatica

History of present illness
Patient is 64 years old, 6 feet tall and 200 pounds and has enjoyed very good health throughout most of his life with a mildly active lifestyle and a high stress job. A previous MRI of the cervical spine showed left C5-6 disc herniation from 1995 that was treated conservatively and is no longer symptomatic.

While experiencing no back pain, the patient has experienced right leg pain of varying degrees for over two years with no specific history of injury:

• August 1998: mild, occasional pain in the right leg below the knee midway between the knee and ankle and on the outside of the leg. Conservative treatment included osteopathic manipulative therapy, low back exercises and Tylenol.

• October 1998: more frequent and intense lower leg pain with very minor pain in the upper portion of the right hip, immediately above the right buttock. The pain occurs in varying degrees every two or three days only when walking or standing for significant periods of time.

• February 1999: the source of the leg pain is diagnosed as pressure on the nerve sleeve in the L5 area. Recommended stretching exercises were done for several months were not effective in reducing the pain.

• August 1999: the leg pain is more frequent and intense, in the same location, and occurred when walking or standing but not when sitting or lying down. Conservative therapy continued and cortisone injections were recommended if the condition persists.

In June 2000, the patient experienced a mild heart attack resulting in open-heart surgery (quadruple by-pass). The surgery was complicated by post-op paroxysmal atrial fibrillation-flutter which has been recurrent and difficult to manage with antiarrhythimics. For the few weeks following the surgery, his activity was limited to walking a few minutes each day. At this point, his leg pain was very frequent and intense. He walked in the early morning hours for about 45 minutes before having to sit down due to the pain.

Steroid injections
The patient entered a cardiac rehabilitation program in August 2000, and his physician recommended epidural injections for the leg pain in order to get through the 12 weeks (36 sessions) of cardiac rehabilitation exercises.

• September 7, 2000: the first injection of methylprednisone had no effect on the leg pain.

• September 21, 2000: the second injection showed little improvement after two weeks, standing an hour or so before the pain would start.

• October 19, 2000: the third (and last) injection on October 19 produced more improvement (less incidents of painful occurrences).

Currently, the beneficial effects of the injections have disappeared and the right leg pain (to the top of the ankle) has returned, even while sitting, with occasional right leg pain in the upper thigh. The patient has discussed and is considering surgery in the form of either microdiscectomy or discectomy with fusion.

Physical exam
Examination showed no foot drop, no bladder or bowel dysfunction, no straight let raising, no gait abnormality, good range of motion of the hips, no motor or sensory deficit, no pain with palpation or percussion of lumbar spine. Right SI joint was tender and left sacral torsion existed.

Imaging studies
An MRI was performed in August 2000 and shows a right paracentral herniated disc at L5-S1 and left herniated disc at L4-L5 and hypertrophic facet disease.