PseudosciaticaPseudosciaticaPseudosciaticaPseudosciatica

The diagnostic dilemmaThe diagnostic dilemmaAndrea Trescot, MD

MRI StudyMRI StudyMRI StudyMRI Study

• 98 asymptomatic patients98 asymptomatic patients

• 52% had disc bulges52% had disc bulges

• 27% had disc protrusions27% had disc protrusions

• 1% had disc extrusions (outside the annulus)1% had disc extrusions (outside the annulus)

• 14% had annular defects14% had annular defects

• 8% had facet pathology8% had facet pathology

• 7% had spondylolithesis7% had spondylolithesis

• 7% had stenosis (central or foraminal)7% had stenosis (central or foraminal)

JensenNEJM July 1994

A treatment method can only A treatment method can only be as specific as the be as specific as the

diagnosis that accompanies itdiagnosis that accompanies it

A treatment method can only A treatment method can only be as specific as the be as specific as the

diagnosis that accompanies itdiagnosis that accompanies it

DiagnosisDiagnosisDiagnosisDiagnosis

““The cause of a disorder is The cause of a disorder is hidden in the patient’s history hidden in the patient’s history

and the site of the lesion is and the site of the lesion is detected by examination.”detected by examination.”

““The cause of a disorder is The cause of a disorder is hidden in the patient’s history hidden in the patient’s history

and the site of the lesion is and the site of the lesion is detected by examination.”detected by examination.”

A. Staal

““Disorders unknown to the Disorders unknown to the physician are not physician are not

unearthed.”unearthed.”

““Disorders unknown to the Disorders unknown to the physician are not physician are not

unearthed.”unearthed.”

Interventional Pain Medicine

Interventional Pain Medicine

Diagnostic InjectionsDiagnostic Injections

• Based on history and physical exam

• Small volumes

• Precision is key for diagnosis– Landmarks– Nerve stimulator– Fluoroscopy

Facet PathologyFacet PathologyFacet PathologyFacet Pathology

Lumbar FacetLumbar FacetLumbar FacetLumbar Facet• Classically taught

that pain radiates only to knee but may radiate to foot

• Twisting injury or flexion/extension

• “pop and lock”• Increased pain

with extension

Facet ExtensionFacet Extension

RF FacetRF FacetRF FacetRF Facet

Superior Gluteal NeuralgiaSuperior Gluteal NeuralgiaSuperior Gluteal NeuralgiaSuperior Gluteal Neuralgia

Superior Gluteal NeuralgiaSuperior Gluteal Neuralgia

• Twisting/bending injury or fall on buttocks

• Pain from buttocks to foot

• Increased with standing and walking, better with sitting

• Difficulty getting out of a chair or climbing stairs

Superior Gluteal NerveSuperior Gluteal NerveSuperior Gluteal NerveSuperior Gluteal Nerve

Superior Gluteal NerveSuperior Gluteal Nerve

Superior Gluteal NerveSuperior Gluteal Nerve

Superior Gluteal NerveSuperior Gluteal Nerve

Superior Gluteal NerveSuperior Gluteal Nerve

Superior Gluteal NerveSuperior Gluteal NerveSuperior Gluteal NerveSuperior Gluteal Nerve

Cluneal NeuralgiaCluneal NeuralgiaCluneal NeuralgiaCluneal Neuralgia

Cluneal NeuralgiaCluneal NeuralgiaCluneal NeuralgiaCluneal Neuralgia

Cluneal NeuralgiaCluneal NeuralgiaCluneal NeuralgiaCluneal Neuralgia• Usually starts as a

“pulled muscle” sensation

• Common after iliac graft

• Sometimes associated with Maigne’s syndrome

• Can refer to the foot

Cluneal NerveCluneal Nerve

Cluneal NerveCluneal Nerve

Cluneal NerveCluneal NerveCluneal NerveCluneal Nerve

Cluneal InjectionCluneal InjectionCluneal InjectionCluneal Injection

Sacroiliac Joint PathologySacroiliac Joint PathologySacroiliac Joint PathologySacroiliac Joint Pathology

Sacroiliac PathologySacroiliac PathologySacroiliac PathologySacroiliac Pathology• By some estimates

accounts for 90% of LBP

• Twisting, slip and fall injuries

• May switch sides

• “Slipped clutch” syndrome

PSISPSIS

SI joint

SI Joint InjectionsSI Joint InjectionsSI Joint InjectionsSI Joint Injections

SI Nerves SI Nerves

Piriformis SyndromePiriformis SyndromePiriformis SyndromePiriformis Syndrome

• Twisting while lifting, or carrying a load in an awkward position

• Pain with hip internal rotation (so foot is inverted)

• “entire foot and leg”

Piriformis SyndromePiriformis SyndromePiriformis SyndromePiriformis Syndrome

Distal piriformis

Sciatic EntrapmentSciatic EntrapmentSciatic EntrapmentSciatic Entrapment

Sciatic/Piriformis ComplexSciatic/Piriformis Complex

Ischial DisordersIschial DisordersIschial DisordersIschial Disorders

Ischial BursaIschial Bursa

• Direct trauma or overuse (bicycle or horseback)

• Referred to hamstrings

• Pain on extending and flexing hip

• + SLR

Greater Trochanteric Bursitis

Greater Trochanteric Bursitis

GT BursitisGT Bursitis

GT Pain PatternGT Pain Pattern

GT CalcificationGT Calcification

Blind Injections Miss the Bursa

Blind Injections Miss the Bursa

Ligament PathologyLigament PathologyLigament PathologyLigament Pathology

EnthesopathyEnthesopathy• A disease pathology at the 'entheses',

i.e. attachment sites of muscles, tendons, joint capsules, ligaments and fascia to the bone.

EnthesopathyEnthesopathy

Interspinous LigamentInterspinous LigamentInterspinous LigamentInterspinous Ligament

• Sudden midline pain with bending or lifting

• Often associated with “pop”or “tear”

• Pain down one or both legs

• Loss of lumbar lordosis

Interspinous Ligament Interspinous Ligament DiagnosisDiagnosis

Interspinous Ligament Interspinous Ligament DiagnosisDiagnosis

• Tenderness to palpation over the ligament

• Edema or palpable defect

• MRI may show ligament defect

• Central disc bulge

• Resolution of back and leg pain with small dose of local anesthetic

Rotated VertebraRotated Vertebra

RF ISL

Iliolumbar LigamentIliolumbar LigamentIliolumbar LigamentIliolumbar Ligament

Iliolumbar LigamentIliolumbar Ligament

• Mimics L2 or L3 radiculitis

• “Someone is squeezing my testicles”

• Pseudotrochanteric bursitis

• Common after fusion

ILL ExamILL Exam

Sacrotuberous and Sacrotuberous and Sacrospinatus LigamentsSacrospinatus Ligaments

Sacrotuberous and Sacrotuberous and Sacrospinatus LigamentsSacrospinatus Ligaments

SacrotuberousSacrotuberousSacrotuberousSacrotuberous SacrospinatusSacrospinatusSacrospinatusSacrospinatus

Myofascial SyndromesMyofascial SyndromesMyofascial SyndromesMyofascial Syndromes

Gluteus MinimusGluteus MinimusGluteus MinimusGluteus Minimus

Quadratus LumborumQuadratus LumborumQuadratus LumborumQuadratus Lumborum

Quadratus LumborumQuadratus LumborumQuadratus LumborumQuadratus Lumborum

Quadratus LumborumQuadratus LumborumQuadratus LumborumQuadratus Lumborum

Tensor Fascia LataTensor Fascia LataTensor Fascia LataTensor Fascia Lata

Discogenic PainDiscogenic PainDiscogenic PainDiscogenic Pain

DiscographyDiscography

Who WillStopThePain?

Who WillStopThePain?