| Multi-Specialty
Case Reviews: Sciatica |
Sciatica: physiatrist viewpoint
This is a 64-year-old with a three-year history of right leg pain from sciatica. The sciatic pain has been increasing in intensity over the past three years. Initially, the pain was worse with standing and walking, but now he is experiencing pain with sitting as well. The pain from sciatica seems to vary in location as he has discomfort in the right hip immediately above the right buttock, as well as pain in below the right knee and ankle. At times the pain is in the right upper thigh. He did experience benefit with epidural injections, but the pain again returned soon after the third LESI.
The MRI showed L4-L5 hypertrophic facet disease, a
left herniated nucleus pulposus at L4-L5, and a right
paracentral L5-S1 disc herniation.
His physical examination is not consistent with a disc
herniation with compression of an S1 nerve root, and
his description of pain is not consistent with a radiculopathy
involving a disc herniation. No mention of neuroforaminal
narrowing is noted on the MRI, which certainly could
be a contributing factor in his pain syndrome. Again,
his sciatic pain is not consistent with a single nerve root
impingement.
On physical examination, there is mention of tenderness
over the right SI joint and left sacral torsion. His
syndrome is consistent with SI joint dysfunction, and
physical therapy directed at the SI joints consisting
of muscle energy techniques, manipulative therapy, ice,
heat, pelvic and lower extremity range of motion exercises,
and stabilization exercise program may be beneficial.
He also has hypertrophic facet disease, which certainly
can cause pain syndrome similar to patients with pain
varying in intensity, worse with standing and walking,
and occurring in a distribution that is not typical
for a single nerve root impingement. A lumbar stabilization
exercise program with a flexion bias would be beneficial
for this patient.
I do not believe the epidural steroid injections offered
the patient significant relief. Prior to proceeding
with a surgical intervention, I would like to rule out
SI joint involvement, as a fusion surgery will only
worsen the dysfunction about the sacroiliac joints.
A diagnostic and therapeutic right L4-L5 facet injection
may also be performed prior to proceeding with surgical
intervention if treatment for the SI joint is not helpful.
If a multimodality approach with injection therapy,
anti-inflammatory medications, physical therapy and
possibly chiropractic manipulation are not effective
in improving the patient’s discomfort, I would
then proceed with a surgical evaluation. An EMG may
be helpful in finding significant nerve root impingement
of the L5 or S1 roots. A plain x-ray would be helpful
to look at disc space collapse. The multimodality approach
could be accomplished in 4-6 weeks. While I realize
the patient has been in significant discomfort for the
past several months, I believe the conservative approach
is warranted as there does not appear to be one clear-cut
lesion that is causing his pain syndrome at the present
time.
By:
Richard Staehler, MD
May 1, 2001
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