Sciatica caused by spinal epidural abscess as the initial clinical presentation of colon cancer: a rare case report and review of literature.

BACKGROUND: Colorectal cancer is one of the most frequently diagnosed forms of cancer, and it is associated with several common symptoms and signs such as rectal bleeding, altered bowel habits, abdominal pain, anemia, and unintentional weight loss. Sciatica, a debilitating condition in which the patient experiences paresthesia and pain in the dermatome of associated lumbosacral nerve roots or sciatic nerve distribution, is not considered one of these. Here we present a case of colorectal cancer manifesting symptoms of sciatica alone. CASE PRESENTATION: A 68-year-old male presented with progressive lower back pain radiating to his left thigh and calf over L5/S1 dermatome. Sciatica was suspected and initially underwent conservative treatment with analgesics. However, the symptoms progressed and MRI revealed an epidural abscess surprisingly. Surgical debridement was performed and pus culture isolated Streptococcus gallolyticus. Based on the strong association of S. gallolyticus with colorectal cancer, the presence of this pathogen prompted further tumor evaluation, even in the absence of the typical symptoms and signs. This investigation ultimately leads to the diagnosis of sigmoid adenocarcinoma. CONCLUSIONS: Although rare, sciatica caused by S. gallolyticus infection of the spinal epidural space may serve as the initial presentation of colorectal cancer. Physicians should be aware of the strong association between S. gallolyticus and colorectal cancer. Based on what we currently know about the condition; a thorough systematic assessment of occult neoplasia for patients with S. gallolyticus infection is recommended.

[Foot drop and cyclic sensory disturbance of the right lower limb due to endometriosis].

We report the case of a 40-year-old woman, with endometriosis, who presented with a history of foot drop and cyclic sensory disturbance of the right lower limb. She was initially diagnosed with lumbar disc herniation. Neurological examination revealed muscle weakness and sensory disturbance associated with the right sciatic nerve. Nerve conduction studies revealed a low amplitude sensory nerve action potential in the right superficial fibular and sural nerves. Pelvic magnetic resonance imaging revealed an endometriotic cyst in the right ovary, and an endometriotic lesion extending from the right ovary, pelvis, and the right sciatic nerve. Though her symptoms moderately improved with hormonal therapy, the foot drop remained. Our case and previous reports suggest that endometriosis with sciatic neuropathy shows cyclic neurological symptoms during menstruation, with a higher incidence on the right extremity. This case highlights that endometriosis should be considered as a potential differential diagnosis in women of reproductive age with sciatic nerve dysfunction. Its cyclic neurological manifestations should be investigated.

Occult proximal femoral fracture with radiating leg pain masquerading as sciatica: a case report.

BACKGROUND: Occult proximal femoral fractures do not appear as fracture lines in radiographs, causing misdiagnosis and delayed diagnosis unless additional imaging studies, such as computed tomography or magnetic resonance imaging, are performed. Here, we present a 51-year-old male with an occult proximal femoral fracture who experienced radiating unilateral leg pain that took 3 months to be diagnosed because his symptoms mimicked lumbar spine disease. CASE PRESENTATION: A 51-year-old Japanese male experienced persistent lower back and left thigh pain after falling off a bicycle, and was referred to our hospital 3 months thereafter. Whole-spine computed tomography and magnetic resonance imaging revealed minute ossification of the ligamentum flavum at T5/6 without spinal nerve compression, but this did not explain his leg pain. Additional magnetic resonance imaging of the hip joint revealed a fresh left proximal femoral fracture without displacement. He underwent surgery for in situ fixation using a compression hip screw. Post-surgical pain relief was immediate. CONCLUSIONS: Misdiagnosis of occult femoral fractures as lumbar spinal disease may occur if distally radiating referred pain is present. Hip joint disease should be considered as a differential diagnosis in cases of sciatica-like pain with an unknown spinal origin and no specific findings on spinal computed tomography or magnetic resonance imaging accounting for the leg pain, especially following trauma.

Atypical Cause for Back Pain and Sciatica in a 35-Yr-Old Woman With Fibromyalgia.

ABSTRACT: Spinal and extrapelvic lesions causing sciatic symptoms are well recognized in clinical research and practice. 1-5 We present a 35-yr-old woman with a history of axial back pain and fibromyalgia who presented with episodes of radicular type pain down her legs and associated bilateral tingling in her feet. Medicinal and therapeutic interventions for traditional sciatica etiologies failed to provide relief. Lumbar magnetic resonance imaging showed mild multilevel degenerative changes and partially visualized fibroids, but no other significant spinal pathology was appreciated. Subsequent pelvic magnetic resonance imaging revealed an enlarged retroverted uterus with multiple fibroid lesions. The patient elected for laparoscopic myomectomy, which improved her likelihood of fertility while drastically alleviating her axial spine and lower extremity symptomology. This case reinforces the importance of keeping a broad differential that includes intrapelvic etiologies when traditional workup and treatment for sciatic neuropathy fails. To our knowledge, this is the first reported case of sciatic neuropathy secondary to uterine fibroids treated with the intent of both fertility improvement and pain relief.

Ischial osteochondroma as an unusual source of pregnancy-related sciatic pain: a case report.

BACKGROUND: While most cases of sciatica result from degenerative conditions of the low back, some cases result from conditions of the hip and pelvic region. Sciatica developing in relation to pregnancy or labor also presents unique considerations. CASE PRESENTATION: A 37-year-old African American woman with a history of hypertension and polycystic ovary syndrome presented to a chiropractor at a hospital-based outpatient clinic with a seven-week history of low back pain with radiation into the right lower extremity which began during labor. The chiropractor performed a brief trial of care, yet when the patient's symptoms worsened, ordered lumbar spine radiographs, followed by lumbar magnetic resonance imaging (MRI), which were both normal. The chiropractor then ordered hip radiographs, which were suggestive of ischial osteochondroma, and referred the patient to an orthopedic oncologist. MRI findings were compatible with an osteochondroma with associated adventitial bursitis and mass effect on the sciatic nerve. The patient initially chose conservative management with bursa aspiration and therapeutic injection. Despite initial relief, there was eventual return of symptoms. The patient elected to undergo surgical removal, with a positive outcome. CONCLUSION: The key distinguishing features that led to a diagnosis of osteochondroma in this case included attention to the patient-reported symptoms and history, worsening of symptoms despite conservative care, and lack of explanatory findings on lumbar imaging. This case highlights the benefit of evaluating the hip and pelvis when the clinical features of sciatica cannot be ascribed to a lumbar etiology. This case also illustrates the role of a chiropractor working in an integrative health system to facilitate timely imaging and referrals to resolve a challenging diagnosis.

Bilateral ganglion cysts at L4/5 causing central canal stenosis and producing sciatica and neurogenic claudication: a case report.

Symptomatic bilateral juxtafacet ganglion cysts are relatively uncommon in the degenerated spine. The literature describes 16 cases of bilateral ganglion or synovial cysts, none reported sciatica and neurogenic claudication simultaneously. We present a case of a 60-year-old woman who presented with symptoms of bilateral sciatica and neurogenic claudication. Magnetic resonance imaging of the lumbar spine revealed bilateral lesions related to the facet joints at the L4/5 level, causing bilateral lateral recess stenosis and narrowing of the central canal due to encroachment of these bilateral lesions at the same level. She underwent an elective central canal decompression of the L4/5 level and excision of the facet cysts bilaterally with lateral recess decompression, which resulted in good relief of both the radicular and claudication symptoms.

The diagnostic pitfalls of lumbar disc herniation---- malignant sciatic nerve tumour: two case reports and literature review.

BACKGROUND: Sciatica pain is a typical symptom of lumbar disc herniation (LDH), but some neurogenic and malignant tumours surrounding the sciatic nerve can also cause similar symptoms. These tumours are often misdiagnosed or even mistreated as LDH in clinical practice. CASE PRESENTATION: In our clinical practice, we found two patients with malignant tumours who were misdiagnosed with LDH. One patient complained of pain and numbness in the right lower limb. The primary diagnosis was LDH, and the patient underwent posterior lumbar interbody fusion surgery. After the operation, the symptoms were not alleviated. Then, diffuse large B-cell lymphoma involving the soft tissue and the sciatic nerve was identified. Another patient who manifested with radiating pain in the right lower limb was diagnosed with LDH at Chengde Central Hospital. He received regular conservative treatment for approximately 6 months, but his symptoms were not relieved, and then he was referred to our hospital. A malignant peripheral nerve sheath tumour (MPNST) of the sciatic nerve was diagnosed, and he received cisplatin (DDP) chemohyperthermia. CONCLUSIONS: Descriptions of tumour lesions involving the sciatic nerve and misdiagnosed as LDH in the literature are rare. In the reported literature, 7 patients were misdiagnosed with LDH, and all patients presented with sciatica. Among them, 4 patients only received surgical treatment, 1 patient only underwent neurolysis, and 2 patients received both surgical and chemotherapy treatment. Their low incidence and similar clinical manifestations to LDH make malignant tumours involving the sciatic nerve easy to misdiagnose. When the clinical symptoms and signs are inconsistent with the imaging findings, we need to be aware of non-discogenic sciatica, including tumours involving the sciatic nerve. Furthermore, tumours that grow near the exit of the sciatic notch may be misdiagnosed because of their deeper location and because they are covered with gluteal muscles. Sometimes sciatica caused by sciatic nerve tumours is only distal, without any radicular distribution. This pain is more severe than that caused by LDH, and this pain is not related to the position of the lumbar spine. Thus, it is beneficial to perform a detailed physical examination of the sciatic nerve to avoid this kind of misdiagnosis.

Endometriosis of the sciatic nerve masquerading as lumbar spondylosis in a 40-year-old Chinese woman.

A 40-year-old Chinese woman presented with a 4-year history of lower back pain and left lower leg sciatica. The patient had previously tried different modalities of treatments, including massage, acupuncture, ultrasound, alternative Bowen therapy and nonsteroidal anti-inflammatory drugs (NSAIDs), all of which only provided temporary relief. On presentation to a tertiary hospital, careful and comprehensive history taking found that the sciatica pattern of pain always coincided with menstruation. An MRI identified a thickened left sciatic nerve, with surgery confirming sciatic nerve endometriosis. The case highlights the importance of comprehensive history taking in accurately diagnosing a rare aetiology of sciatica with subsequent prompt surgical intervention to avoid severe disability as well as follow-up treatment to prevent recurrence.

Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: a systematic review.

PURPOSE: Clinicians are not confident in diagnosing deep gluteal syndrome (DGS) because of the ambiguity of the DGS disease definition and DGS diagnostic pathway. The purpose of this systematic review was to identify the DGS disease definition, and also to define a general DGS diagnostic pathway. METHODS: A systematic search was performed using four electronic databases: PubMed, MEDLINE, EMBASE, and Google Scholar. In eligibility criteria, studies in which cases were explicitly diagnosed with DGS were included, whereas review articles and commentary papers were excluded. Data are presented descriptively. RESULTS: The initial literature search yielded 359 articles, of which 14 studies met the eligibility criteria, pooling 853 patients with clinically diagnosed with DGS. In this review, it was discovered that the DGS disease definition was composed of three parts: (1) non-discogenic, (2) sciatic nerve disorder, and (3) nerve entrapment in the deep gluteal space. In the diagnosis of DGS, we found five diagnostic procedures: (1) history taking, (2) physical examination, (3) imaging tests, (4) response-to-injection, and (5) nerve-specific tests (electromyography). History taking (e.g. posterior hip pain, radicular pain, and difficulty sitting for 30 min), physical examination (e.g. tenderness in deep gluteal space, pertinent positive results with seated piriformis test, and positive Pace sign), and imaging tests (e.g. pelvic radiographs, spine and pelvic magnetic resonance imaging (MRI)) were generally performed in cases clinically diagnosed with DGS. CONCLUSION: Existing literature suggests the DGS disease definition as being a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space. Also, the general diagnostic pathway for DGS was composed of history taking (posterior hip pain, radicular pain, and difficulty sitting for 30 min), physical examination (tenderness in deep gluteal space, positive seated piriformis test, and positive Pace sign), and imaging tests (pelvic radiographs, pelvic MRI, and spine MRI). This review helps clinicians diagnose DGS with more confidence. LEVEL OF EVIDENCE: IV.

[Tumor involving the sciatic nerve: neurinoma or neurofibroma? Can MRI make the difference?] / Tumeur du nerf sciatique: neurinome ou neurofibrome? L'IRM peut-elle faire la différence?

The sciatic nerve is the terminal branch of the sacral plexus. Sciatalgia is a nerve root pain. In most cases, sciatica originates from degenerative disc disease. Tumor involving the sciatic nerve is extremely rare. We here report the case of a 33-year old patient with nerve tumor detected on MRI performed for drug-resistant sciatica. Tumor involving the sciatic nerve is rare and diagnosis is difficult. MRI data are crucial for establishing an effective surgical approach.

Effects of inhibiting the PI3K/Akt/mTOR signaling pathway on the pain of sciatic endometriosis in a rat model.

This study investigated the relationship between the pain of sciatic endometriosis and the phosphatidylinositol 3-kinase/protein kinase B/mammalian target of rapamycin (PI3K/Akt/mTOR) signaling pathway. Adult female Sprague-Dawley rats successfully received sciatic endometriosis induction. Mechanical paw withdrawal threshold and paw withdrawal latency were recorded to assess the mechanical hypersensitivity and thermal hyperalgesia. Quantitative real-time PCR, Western blotting, and enzyme-linked immunosorbent assays were used to detect PI3K, Akt, and mTOR expressions and their phosphorylation as well as the expressions of substance P, calcitonin gene-related peptide (CGRP), and nerve growth factor (NGF). Mechanical paw withdrawal threshold and paw withdrawal latency significantly decreased after sciatic endometriosis induction in rats; this decrease was ameliorated by inhibiting the PI3K/Akt/mTOR signaling pathway using LY294002. Compared with controls, rats with sciatic endometriosis showed increased PI3K, Akt, and mTOR expressions and elevated p-PI3K, p-Akt, and p-mTOR protein expressions. Higher NGF, substance P, and CGRP expressions were also found in the superficial dorsal horn of the spinal cord in rats with sciatic endometriosis than in control rats 21 days after surgery. Following the injection of LY294002 into rats with sciatic endometriosis, there was a significant decrease in the expressions of NGF, substance P, and CGRP. In conclusion, the inhibition of the PI3K/Akt/mTOR signaling pathway may alleviate endometriosis-associated sciatic nerve pain in a rat model of sciatic endometriosis.

Inflammatory biomarkers in patients with sciatica: a systematic review.

BACKGROUND: This systematic review focusses on inflammation as an underlying pathogenic mechanism in sciatica. We addressed two questions in particular: (1) what inflammatory biomarkers have been identified in patients with sciatica in the literature so far? 2) is there an association between the level of inflammatory activity and clinical symptoms? METHODS: The search was conducted up to December 19th 2018 in MEDLINE, EMBASE, CENTRAL and Web of Science. The study selection criteria: (1) observational cohort studies, cross-sectional studies and randomized clinical trials (RCT), (2) adult population (≥ 18 years) population with sciatica, (3) concentrations of inflammatory biomarkers measured in serum, cerebrospinal fluid (CSF) or biopsies, and (4) evaluation of clinically relevant outcome measures (pain or functional status). Three reviewers independently selected studies and extracted data regarding the study characteristics and the outcomes. Risk of Bias was evaluated using an adjusted version of the Quality in Prognosis Studies (QUIPS) tool. RESULTS: In total 16 articles fulfilled the criteria for inclusion: 7 cross sectional observational studies and 9 prospective cohort studies that included a total of 1212 patients. With regard to question 1) the following markers were identified: interleukin (IL)-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-17, IL-21, tumor necrosis factor-α (TNF-α), phospholipase A2, high sensitivity C-reactive protein (hsCRP), C-X-C motif chemokine 5 (CXCM5), CX3CL1, CCL2, epidermal growth factor (EGF), and monocyte chemotactic protein 4 (MCP-4). With regard to question 2) several positive correlations were found in longitudinal studies: a strong positive correlation between inflammatory mediators or byproducts and pain (measured by visual analogue scale, VAS) was found for IL-21 in two studies (r > 0,8), and moderate positive correlations for TNF-a in both serum (r = 0,629) and biopsy (r = 0.65); severe pain (VAS > 4) is associated with increased hsCRP levels among patients with sciatica (adjusted OR = 3.4 (95% CI, 1.1 to 10). CONCLUSION: In this systematic review there was considerable heterogeneity in the type of biomarkers and in the clinical measurements in the included studies. Taking into account the overall risk of bias of the included studies there is insufficient evidence to draw firm conclusions regarding the relationship between inflammation and clinical symptoms in patients with sciatica.

Comparative responsiveness of four visual analogue scales in microdiscectomy for lumbar disc herniation.

INTRODUCTION: There is a paucity of studies reporting responsiveness of visual analogue scale (VAS) measures in patients treated by discectomy for symptomatic lumbar disc herniation. The aim of this study was to evaluate the responsiveness of different types of VAS. METHODS: VAS score was measured separately for constant leg pain (VAS-LP-constant), severe episode of leg pain (VAS-LP-severe), constant backache (VAS-BP-constant) and severe episode of backache (VAS-BP-severe) in a cohort of patients undergoing discectomy surgery for sciatica. VAS was evaluated preoperatively and postoperatively at final follow-up. Responsiveness was determined using standardised response mean (SRM), effect size (ES) and the area under the curve (AUC) analysis using receiver operating characteristic curves. For AUC analysis, the success of discectomy from the patient's perspective was chosen as the external anchor. RESULTS: Ninety-eight patients were included in this prospective study. Outcome was assessed at a mean follow-up of 12 weeks postoperatively. The SRM of VAS-LP-severe, VAS-LP-constant, VAS-BP-severe and VAS-BP-constant was 2.16, 2.16, 0.87 and 0.53, respectively. The ES of VAS-LP-severe, VAS-LP-constant, VAS-BP-severe and VAS-BP-constant was 3.53, 2.70, 0.89 and 0.53, respectively. The AUC of VAS-LP-severe, VAS-LP-constant, VAS-BP-severe and VAS-BP-constant was 0.88, 0.75, 0.74 and 0.59, respectively. CONCLUSION: We recommend the use of VAS-LP-Severe as the most responsive VAS measure when evaluating the results of discectomy surgery for sciatica.

The utility of diagnostic selective nerve root blocks in the management of patients with lumbar radiculopathy: a systematic review.

OBJECTIVE: Lumbar radiculopathy (LR) often manifests as pain in the lower back radiating into one leg (sciatica). Unsuccessful back surgery is associated with significant healthcare costs and risks to patients. This review aims to examine the diagnostic accuracy of selective nerve root blocks (SNRBs) to identify patients most likely to benefit from lumbar decompression surgery. DESIGN: Systematic review of diagnostic test accuracy studies. ELIGIBILITY CRITERIA: Primary research articles using a patient population with low back pain and symptoms in the leg, SNRB administered under radiological guidance as index test, and any reported reference standard for the diagnosis of LR. INFORMATION SOURCES: MEDLINE (Ovid), MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Science Citation Index, Biosis, LILACS, Dissertation abstracts and National Technical Information Service from inception to 2018. METHODS: Risk of bias and applicability was assessed using the QUADAS-2 tool. We performed random-effects logistic regression to meta-analyse studies grouped by reference standard. RESULTS: 6 studies (341 patients) were included in this review. All studies were judged at high risk of bias. There was substantial heterogeneity across studies in sensitivity (range 57%-100%) and specificity (10%-86%) estimates. Four studies were diagnostic cohort studies that used either intraoperative findings during surgery (pooled sensitivity: 93.5% [95% CI 84.0 to 97.6]; specificity: 50.0% [16.8 to 83.2]) or 'outcome following surgery' as the reference standard (pooled sensitivity: 90.9% [83.1 to 95.3]; specificity 22.0% [7.4 to 49.9]). Two studies had a within-patient case-control study design, but results were not pooled because different types of control injections were used. CONCLUSIONS: We found limited evidence which was of low methodological quality indicating that the diagnostic accuracy of SNRB is uncertain and that specificity in particular may be low. SNRB is a safe test with a low risk of clinically significant complications, but it remains unclear whether the additional diagnostic information it provides justifies the cost of the test.

A rare cause of sciatica discovered during digital rectal examination: case report of an intrapelvic sciatic notch schwannoma.

Intrapelvic sciatic nerve schwannomas are rare causes for non-discogenic sciatica. We describe a 44-year-old female who had a palpable mass on digital rectal examination that exhibited a positive Tinel's sign. The schwannoma was excised by a posterior transgluteal approach. Patients with negative spinal imaging should undergo pelvic scanning to rule out these tumors.

Risk Factors for Low Back Pain: A Population-Based Longitudinal Study.

OBJECTIVE: To identify risk factors for low back pain (LBP) and lumbar radicular pain and to assess whether obesity and exposure to workload factors modify the effect of leisure-time physical activity on LBP and lumbar radicular pain. METHODS: The population of this 11-year longitudinal study consists of a nationally representative sample of Finns ages ≥30 years (n = 3,505). The outcomes of the study were LBP and lumbar radicular pain for >7 days or for >30 days in the past 12 months at follow-up. RESULTS: LBP and lumbar radicular pain were more common in women than in men. LBP slightly declined with increasing age, while lumbar radicular pain increased with age. Abdominal obesity (defined by waist circumference) increased the risk of LBP (adjusted odds ratio [OR] 1.40 [95% confidence interval (95% CI) 1.16-1.68] for LBP >7 days and adjusted OR 1.41 [95% CI 1.13-1.76] for LBP >30 days) and general obesity (defined by body mass index) increased the risk of lumbar radicular pain (adjusted OR 1.44 [95% CI 1.12-1.85] for pain >7 days and adjusted OR 1.62 [95% CI 1.16-2.26] for pain >30 days). Smoking and strenuous physical work increased the risk of both LBP and lumbar radicular pain. Walking or cycling to work reduced the risk of LBP, particularly LBP for >30 days (adjusted OR 0.75 [95% CI 0.59-0.95]), with the largest reductions among nonabdominally obese individuals and among those not exposed to physical workload factors. Using vibrating tools increased the risk of lumbar radicular pain. CONCLUSION: Lifestyle and physical workload factors increase the risk of LBP and lumbar radicular pain. Walking and cycling may have preventive potential for LBP.

Radicular Pain Syndromes: Cervical, Lumbar, and Spinal Stenosis.

Back pain is a top primary and urgent care complaint; radicular pain can be caused by herniation of the nucleus pulposus (intervertebral disc), spinal stenosis, or degenerative changes to the vertebrae. The focus of this clinical review will be the clinical approach and treatment of lumbar radicular pain, cervical radicular pain, and spinal stenosis. Usually localized through neurological history, exam, and imaging, specific signs and symptoms for lumbar radicular, spinal stenosis, and cervical radicular pain can help determine etiology. Once radicular back pain has been diagnosed, a multitude of treatment options are available from rest and physical therapy to medications, epidurals, and surgery. The most common and accepted are reviewed. With accurate diagnosis, safe and effective pain management can be employed to shorten radicular episodes and manage recurrent or chronic radicular syndromes. Using a step-wise approach from diagnosis to conservative therapy to potential surgery, radicular pain syndromes can improve or resolve, and patients may achieve a better functional status and quality of life.