This case study highlights a patient from the southeastern United States who was referred to The Neurography Institute with a history of low back pain.
This is a 52-year-old woman suffering from right lower extremity neurologic symptoms; she has had several epidural blocks for pain relief. The patient’s condition initially began six years ago when she suffered from a herniated disc while helping her son move into his college dorm room. Orthopedic treatment has helped the initial pain condition.
However, the patient’s symptoms radiated from a focal low back pain to pain in her right hip and thigh area. She has undergone standard testing including 3T imaging followed by epidural block injections, with only pain mild to moderate relief to the low back area.
Presently, she is still experiencing pain in her thigh and hip and her treating doctor has referred her to the Neurography Institute to confirm a diagnosis of Sciatica of non disc origin.
Two-Dimensional MR Neurography Findings
The lumbar and sacral spinal nerves are generally normal in course. There is some loss of disc space height at L5-S1 without any associated nerve root impingement. The sacroiliac joints are normal in appearance without significant inflammatory or degenerative change. The hip joints do not demonstrate any significant inflammatory or degenerative change. The psoas muscles are symmetric in size and shape. The piriformis muscles are symmetric in size and shape and the obturator internus muscles are symmetric in size and shape. At the level of the sciatic notch no anatomical variants are appreciated.
The sciatic nerve itself is generally normal in appearance on the medial aspect of the piriformis and as it exits the sciatic notch; however, commencing just at the level of the ischial spine, there is a significant thickening of the nerve. There is irritative change seen within the peroneal and tibial components as they exit the area of enlargement. This appearance is consistent with a mass, such as a neurofibroma or Schwannoma. The abnormality can be due to focal nerve swelling; however, the degree of size change is more suggestive of mass than neural edema. The 3D reading and possible (with and without) contrast scan of this area should clarify the finding.
Three-Dimensional Reconstruction and Analysis
3D Multiplanar Reformations, image overlay assembly and optional maximum intensity projections were performed on an Advanced 3D Workstation. These images demonstrate the course and caliber of the lumbosacral plexus and proximal sciatic nerve using multiplanar reformat techniques to provide an overview. The general course of the sciatic nerve is generally normal as it traverses the sciatic notch and there is an area of increased caliber just distal to the sciatic notch; although, the fascicular pattern is well seen through this area.
These images suggest focal swelling of the sciatic nerve above the obturator internus tendon rather than a distorting mass. While the 2D images suggested a possible mass, the 3D image overview shows that it this is less likely to be the case. The multiplanar reformats are more consistent with nerve swelling.
Additional MR Neurography imaging utilizing with and without contrast will be helpful to rule out the possibility of the mass.
Confirmation of Diagnosis
After completing an additional contrast MR Neurography, impressions of a possible mass were ruled out and the patient was diagnosed with Piriformis Syndrome. Her referring doctors are hopeful that targeted imaging provided by both series of MR Neurography will help treatment planning for a minimally invasive surgery that will ultimately resolve the pain condition.
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