Case Study: 50-Year-Old Male with Sciatic and Pudendal Issues

Case study: a 50 year old right-handed male who is also a physician.

The patient comes to the Institute for Nerve Medicine concerned about ongoing pain symptoms post-surgery and wonders if there is any way to intervene and find relief. He reports right sciatica and pudendal symptoms for the past seven years. Following a nine- to ten-hour car trip, he developed pain and aching to his right buttock and some sciatica. Since that time, his symptoms have been continuous and somewhat varying in intensity. He says his pain is increased with sitting, especially on a hard chair, and gets progressively worse throughout the day. He states that on a pain scale of 1 to 10 that he is consistently between 3 and 4 which may increase depending upon activity and amount of sitting.

Previous medical history shows that the patient underwent a right hip arthroplasty and following the surgery he had some improvement; however, with increased walking he had exacerbation of his symptoms. At that time he felt that he had a throbbing, palpable right sciatic nerve in the area between the greater trochanter and ischial tuberosity. Following the advice of his local physician, the patient underwent surgery of the right sciatic nerve with the right Piriformis release. Immediately postoperatively, he developed right dorsal penile, scrotal and perineum numbness. Following the surgery he underwent physical therapy for three months and has since continued with his own physical therapy and massage therapy for the past six weeks with minimal relief.

After meeting in consultation with INM’s Dr. Aaron G. Filler, MD PhD, the patient underwent an MR Neurography of the pelvis. The findings are consistent with the presence of a distal pelvic sciatic entrapment, as well as de-nervation of the obteruator internus and Piriformis muscles and also partial disruption of the Piriformis muscle.

After Interventional MR-guided injection procedures to confirm the diagnosis of the MR Neurography findings, the patient experiences one full week of pain relief. However, the pain symptoms gradually return and the patient feels that these are now somewhat more intensified. Because the IMR was done using real-time optical guidance under magnetic resonance, the results support surgical planning and accurately define the surgical approach for a minimally invasive procedure. After INM surgery the patient experiences a significant improvement in overall symptoms. Moreover, he is happy to report that all former pain symptoms are alleviated, and he is gradually increasing activity levels so that he may return to his medical practice.