Case Study: 60-Year-Old Female with Lower Left Extremity Problems

In this example, we look at the case of a 60-year-old woman suffering from left lower extremity neurologic symptoms. Previously she had experienced some longstanding problems with back pain and ultimately had a lumbar fusion surgery carried out during 2008 and she did obtain good relief of her back pain from that surgery. However the patient continued to experience pain in her buttock and lower leg area.

Through online research she began to consider that she might have Piriformis Syndrome and sought consultation with a local orthopedic doctor. She has had an epidural injection with no effect at all. She has had physical therapy which gives her some very short-term relief over a period of an hour or so with immediate recurrence. The pain has required high doses of narcotic medications. At this point she has come to seek treatment with Dr. Filler at the Institute for Nerve Medicine.

Based on her history, exam, data and findings, there is certainly a strong possibility that this is a piriformis muscle-related problem. She did not respond to epidural injections and the post spine fusion surgery site shows foramina clear and open. She has positive physical exam findings for a piriformis syndrome including reproduction of symptoms with resisted abduction and adduction of flexed, internally rotated thigh and relief with cross-legged traction.

Based on this, an MR neurography study is recommended to evaluate the sciatic nerve at the level of the piriformis muscle. This allows us to view the lumbar spinal nerves and nerve roots as they exit the spinal foramina and traverse the area of the lateral marginal osteophytes to look for other possible source of irritative change. If the imaging is most consistent with piriformis and therefore consistent with the physical examination, the patient would next proceed with the MRI-guided injection of the piriformis muscle for further diagnostic confirmation.

The MR neurography imaging suggests that this is indeed a piriformis syndrome rather than distal root irritation related to a previous spinal disease surgery. Because the patient chose to have the MRI guided injection we can fairly confidently rule out any additional spinal pathology. Even though she did not respond to the epidural, she has excellent relief from the soft tissue imaging injection conducted under MRI. Based on the results of these two diagnostic tests, a minimal access piriformis surgery is planned.

The patient who is now about three weeks out from her piriformis surgery is happy to report she has had a really excellent response and had complete relief of all of her preoperative buttock and leg pain.

As Piriformis Syndrome becomes more readily diagnosed it is often difficult to know if your plan of care is the right one. Many patients do not realize that treating Piriformis Syndrome may often result in both spine and peripheral nerve surgical treatments. As in the case of this patient study her back pain was first treated by an orthopedic doctor through traditional spine surgery and then she sought continued treatment for the soft tissue and muscle related conditions.

Because patients are seeking treatment from multiple resources and providers, it is important that communication is open between providers so that the patient’s overall care is maintained.

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