Sciatica: Case Study from a Physiatrist's Viewpoint

The patient is a 64-year-old with a three-year history of right leg pain from sciatica.

The sciatic pain has been increasing in intensity over the past three years. Initially, the pain was worse with standing and walking, but now he is experiencing pain with sitting as well. The pain from sciatica seems to vary in location as he has discomfort in the right hip immediately above the right buttock, as well as pain in below the right knee and ankle. At times the pain is in the right upper thigh. He did experience benefit with epidural injections, but the pain again returned soon after the third LESI.

The MRI showed L4-L5 hypertrophic facet disease, a left herniated nucleus pulposus at L4-L5, and a right paracentral L5-S1 disc herniation.

His physical examination is not consistent with a disc herniation with compression of an S1 nerve root, and his description of pain is not consistent with a radiculopathy involving a herniated disc. No mention of neuroforaminal narrowing is noted on the MRI, which certainly could be a contributing factor in his pain syndrome. Again, his sciatic pain is not consistent with a single nerve root impingement.

On physical examination, there is mention of tenderness over the right SI joint and left sacral torsion. His syndrome is consistent with SI joint dysfunction, and physical therapy directed at the SI joints consisting of muscle energy techniques, manipulative therapy, ice, heat, pelvic and lower extremity range of motion exercises, and stabilization exercise program may be beneficial. He also has hypertrophic facet disease, which certainly can cause pain syndrome similar to patients with pain varying in intensity, worse with standing and walking, and occurring in a distribution that is not typical for a single nerve root impingement. A lumbar stabilization exercise program with a flexion bias would be beneficial for this patient.

I do not believe the epidural steroid injections offered the patient significant relief. Prior to proceeding with a surgical intervention, I would like to rule out SI joint involvement, as a fusion surgery will only worsen the dysfunction about the sacroiliac joints. A diagnostic and therapeutic right L4-L5 facet injection may also be performed prior to proceeding with surgical intervention if treatment for the SI joint is not helpful.

If a multimodality approach with injection therapy, anti-inflammatory medications, physical therapy and possibly chiropractic manipulation are not effective in improving the patient’s discomfort, I would then proceed with a surgical evaluation. An EMG may be helpful in finding significant nerve root impingement of the L5 or S1 roots. A plain x-ray would be helpful to look at disc space collapse. The multimodality approach could be accomplished in 4-6 weeks. While I realize the patient has been in significant discomfort for the past several months, I believe the conservative approach is warranted as there does not appear to be one clear-cut lesion that is causing his pain syndrome at the present time.

• Article written By:
• Richard Staehler, MD

May 1, 2001

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