This case study features a patient who underwent traditional spine surgery upon recommendation of his orthopedic specialist. The patient continued to experience pain symptoms post-surgery.
The patient is a 48-year-old, right-handed male with left foot pain and left buttock tightness since his surgery one year prior. Initially he had left foot numbness and tingling that improved postoperatively with an L5-S1 micro-discectomy; however, within one month from the surgery he had a recurrence with numbness to the left foot and the symptoms continued to progressively worsen. He was unable to tiptoe with the left foot and has been experiencing atrophy to the left calf.
He had completed courses of physical therapy as well as anti- inflammatory drug therapy such as Lyrica with no improvement. The patient then had numerous nerve root blocks, caudal injection and sympathetic blocks with no improvement. He noted that his pain had increased with sitting and improved with lying down. He reported his pain level as 4/10 and continuous and positional. He had contacted The Neurography Institute with interest in obtaining a detailed nerve scan before undergoing further treatment planning.
MR Neurography Findings
The lumbar and sacral spinal nerves demonstrate some abnormalities as they traverse the proximal and distal foramina. On the left side there is significant contact impingement between the descending left L5 spinal nerve and a lateral marginal osteophyte at L5-S1. There is loss of disc space height at L5-S1 and changes on the inferior end plate towards the left side L5 and on the superior end plate of S1. Note is made of a prior history of L5-S1 discectomy surgery, which is consistent with the image findings of the end plate changes.
There is moderate broadening, flattening and hyperintensity affecting the left sciatic nerve more than the right sciatic nerve at the level of the sciatic notch. The patient has a lumbar disorder and a sciatic nerve disorder at the piriformis level contributing to his pain symptoms, or one could be more dominant. This is a complex diagnostic problem and pinpointing the correlation between these conditions and the patient’s pain requires additional testing before additional treatment can be recommended.
Conclusion
This patient does not have a single disorder for treatment consideration; rather, there appears to be a combination of factors that are contributing to the pain symptoms.
Many patients are surprised to learn that a single pain location can actually be the result of a variety of conditions. Treating just the spine or treating just the nerve roots will not provide a comprehensive resolution to the pain problem and this underscores the benefit of MR Neurography, which provided detailed images offering new information of the presence of this patient’s spine and soft tissue conditions.
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