Chronic sciatica /buttock pain – I recently received a request for help…
I had a unexpected fall and started having extreme pain in my low back region with radicular pain down the right leg to my foot, I tried steroid shots no help, had an MRI in which they found a Lesion 1.0×3.3cm in my right ilium crest with a fluid level, also a slight bulging at the L5 level, I had a bone scan done and there was no uptake into the lesion, I had a second opinion done and they told me it was an aneurismal bone cyst and nothing to worry about, I went through physical therapy for 2 months, had facet injections and trigger point injections, nothing has helped, the buttock region is very tight and the muscles ache with low back pain and radicular pain down the right leg, I also have a instability while walking on the right side leg wants to buckle at the hip area. 9 months has passed and I am starting to get left side stiffness and light pain down the left leg, I really don’t know if there is something they missed on the mri, there was also a ct scan done to verify no fracture, nothing present, I am curious if anything can be done and if the lesion may be the cause of pain, What to do next, life is on hold for me????
I find it is almost impossible to give advice to people I have not examined and there are many facts I do not have:
- Is patient Diabetic? – neuropathy would be possible as well as tarsal tunnel syndrome which now appears common in this disorder. Is there significant paresthesias/numbnesss in legs – this might suggest a peripheral neuropathy issue like Chronic Inflammatory Demyelinating Polyneuroapthy (CIDP) which is treatable.
- Is subject healthy? – One patient I saw lately had symptoms like this be a PSA of 12.5 suggesting prostate cancer (waiting for biopsy and bone scan at time of writing)
- Are B12 levels normal – low levels mean B12 neuropathy. Are male hormone levels normal? – Low levels here augment pain and suggest sleep apnea.
- Does Patient have Ankylosing spondylitis? – hip and buttock pains could presernt with this – IBD bowel trouble and psoriasis could highly suggest it as well
- Is there true back sciatica? –there could be reduced straight leg raising as a result; with muscle weakness, skin and sensory loss. I feel sorry for someone with so much faith in MRI’s where there can be little to be found and still significant problems. Steroid blocks and if that fails, adding enbrel shots might be helpful. Intra thecal midazolam has been found recently helpful. Remember, steroid shots may not work if they end up on the wrong side of the dural septum, and patient is not asked to lie with bad side down for 20-30 min after the steroid injection.
- How bad is the back ?– poor flexion might point to it. Suggestions of disc disease may respond to MacKenzie extension techniques. Certain back issues involve facets and instability and may respond to injections or prolotherapy.
- Is there a hip issue? – hip buckling suggests something wrong there – If hip xrays show little, then Femoroacetabular hip syndrome might be an issue . Pain on turning hip in passively (leg turns out at same time) suggests it. Does the right hip crest sag and is this associated with pain when subject raises his good left leg (trendelenberg)? – This might suggest among other things, that there may be a gluteus medius muscle tear (rotator cuff of hip).
- How bad is the piriformis? (I think it is a given with that much gluteal tightness it is going to be there). With Gluteal muscles tight, the best way to examine this is with a rectal exam, looking for tenderness in the sciatic notch. There are people who have the sciatic nerve go right through the piriformis and end up with significant sciatica. When my piriformis bothered me, it would radiate down to my lateral calf – but not into feet.
- Does the bone cyst hurt? – cluneal vertebral dorsal nerve roots cross the iliac crest and any pressure on them can cause significant pain. Gluteal nerves in the buttock can also cause problems. Does anti-inflammatory meds help? – suggesting a cyst called osteoid osteoma.
- How back is the Thoracolumbar area of the spine? – this is the level where the lower ribs are. If this area is tender, I will manipulate the joints at the sore level using a device called an activator; and the massage the thoracolumbar rotatories until it is non-tender. Then I will see how easy it is to massage out the gluteal tightness. Many people are very surprised to find the gluteal muscles are no where near as tender and massageable.
- How bad is the Quadratus lumborum, how many fingers distance is there between iliac crest and lateral ribs, and how sore is the QL and iliac crest laterally? With gluteal muscle issues, I usually find a Quadratus lumborum and psoas muscle spasm issue as well. If there is tightness enough, the ribs will rub on the iliac crest with sitting on low chair and sleeping curled up. I will have the patient sit down facing away from me; then I will grab the soft tissues of the flank and feel the QL. I will also feel the iliac crests laterally for tenderness.
- Just how bad are the gluteal muscles? – Injecting gluteal or piriformis triggers can be worthless is not accompanied by brutal stretch massage techniques – for a gluteus medius or piriformis I will engage from above it and push down to feet for 10 minutes. Then I will engage from below and push up for 5 minutes. Then I will knuckle out for count of up to 200.
- Is it coming from the sacroiliac? – Tests of them are poor but a combination of results is suggestive – I usually find that there is a SI problem with a piriformis issue. This and ligaments need mobilization, injection, compressive belt , and perhaps prolotherapy or platelet rich plasma.
- What about the legs? – even a series of a simple peroneal nerve block can give relief of sciatica. I usually find there is some posterior shin splints in the leg (tibialis posterior) and needling that can give some leg relief. Is there frank posterior tibilais tendonitis as well? Treating that could help.
- Is there tenderness on pinching the skin in areas in the legs – if so, it has been recently found that just injecting these spots with 5% dextrose in water (D5W) can significantly reduce pain in legs – having some good luck trying it in a few cases of diabetic neuropathy – will write about it when I have more experience…
- How depressed are you? How much burning, shooting or otherwise neuropathic pain have you? Daily B12 shots could be helpful as recently written and 2-3 times a week ketamine shots augment antidepressant and gabapentin treatments.
- Sorry, this is a discussion in progress as I am sure I have left out many possibilities – maybe others can help fill in what I missed.