Sacroiliitis presenting as sciatica

The ambiguity of sciatica as a clinical diagnosis: A case series

Sciatica as a clinical diagnosis is nonspecific. A diagnosis of sciatica is typically used as a synonym for lumbosacral radiculopathy. However, the differential for combined low back and leg pain is broad, and the etiology can be one several different conditions. The lifetime prevalence of sciatica ranges from 12.2% to 43%, and nonsuccessful outcomes of treatment are prevalent. Nurse practitioners and other primary care clinicians often have minimal training in differential diagnosis of the complex causes of lower back and leg pain, and many lack adequate time per patient encounter to work up these conditions. Differentiating causes of low back and leg pain proves challenging, and inadequate or incomplete diagnoses result in suboptimal outcomes. Chiropractic care availability may lessen demands of primary care with respect to spinal complaints, while simultaneously improving patient outcomes. The authors describe three patients referred from primary care with a clinical diagnosis of sciatica despite differing underlying pathologies. More precise clinical terminology should be used when diagnosing patients with combined low back and leg pain. Nurse practitioners and other clinicians' triage, treat, and determine appropriate referrals for low back and leg pain. Multidisciplinary care including chiropractic may add value in settings where patients with lower back and leg pain are treated.

Current Concepts Review: Evaluation and Management of Posterior Hip Pain

Understanding the etiology of and evolving research on intra- and extra-articular hip complaints requires comprehensive diagnosis and management of the spectrum of posterior hip diseases. Interest in posterior hip disorders has increased in recent years as new studies and theories have emerged regarding the disease process. Although most of the differential diagnoses around the posterior hip have traditionally been considered uncommon, recent reports suggest that these complaints have instead been commonly overlooked. Failure to identify the cause of posterior hip pain in a timely manner can increase pain perception, deteriorate the patient's hope, and consequently affect quality of life. Posterior hip pain could be differentiated as intrapelvic and extrapelvic, and differential diagnosis is made based on a comprehensive history, physical examination, and imaging studies. Plain radiography, CT, MRI, 3T MRI, and imaging-guided injection tests are usually necessary for accurate diagnosis. Surgical intervention, whether endoscopic or open, is required for patients with long-standing symptoms for whom nonsurgical treatment has been unsuccessful and who have experienced temporary relief of their symptoms after injection. Orthopedic surgeons are uniquely trained in understanding the anatomy, biomechanics, clinical evaluation and treatment of all five layers of the hip.

Sciatica: An Extremely Rare Complication of the Perianal Abscess

Background

Sciatica has been classically described as pain in the back and hip with radiation in the leg along the distribution of the sciatic nerve, secondary to compression or irritation of the sciatic nerve. Spinal abnormality being the most common etiology, is one of the most common indications for MRI of the lumbosacral spine. Here we describe imaging findings secondary to a supralevator perianal abscess causing irritation of the sciatic nerve, which was diagnosed on MRI of the lumbosacral spine.

Case Report

A 47-year-old male patient presented to the emergency department with severe acute pain in the right hip and right leg which was aggravated by limb movement. Clinically, a possibility of sciatica was suggested and MRI of the lumbosacral spine was ordered. The MRI did not reveal any abnormality in the lumbosacral spine; however, on STIR coronal images, a right perianal abscess with air pockets was seen. The perianal abscess was extending above the levator ani muscle with and was seen tracking along the sciatic nerve, explaining pain along the distribution of the sciatic nerve. The abscess was surgically drained, followed by an antibiotic course. The patient was symptomatically better post-surgery. Post-operative scan done 3 days later revealed significant resolution of the infra- and supralevator perianal abscess. The patient was discharged from hospital on post-operative day 3 on oral antibiotics for 7 days. On 15^th post-operative day, the patient was clinically completely asymptomatic with good healing of the perianal surgical wound.

Conclusions

Extra-spinal causes are rare and most often overlooked in patients with sciatica. While assessing patients with sciatica, extra-spinal causes for the radiation of pain along the distribution of the sciatic nerve should always be looked for if abnormalities in the MRI of the lumbar spine are not found. Inclusion of STIR sequences in the imaging of the lumbosacral spine, more often than not, helps to identify the extra-spinal cause of sciatica when MRI of the lumbosacral spine does not reveal any abnormality.

Clinical and electrodiagnostic features of sciatic neuropathies

Sciatic neuropathy is the second most common neuropathy of the lower extremity and a common cause of foot drop. This article reviews the anatomy, clinical features, pathophysiology, and electrodiagnostic assessment of sciatic neuropathies. There are multiple potential sites of pathology, determined in part by the mechanism of insult, including trauma, compression, masses, inflammation, and vascular lesions. Diagnosis is augmented by careful electrodiagnostic studies and imaging to help distinguish sciatic neuropathy from other sources of pathology. Electrodiagnostic studies may also help in assessing for early recovery and in determining prognosis.

CT and MRI in the evaluation of extraspinal sciatica

Sciatica is the most frequently encountered symptom in neurosurgical practice and is observed in 40% of adults at some point in their lives. It is described as pain of the hip and the lower extremity secondary to pathologies affecting the sciatic nerve within its intraspinal or extraspinal course. The most frequent cause is a herniating lumbar disc pressing on the neural roots. Extraspinal causes of sciatic pain are usually overlooked because they are extremely rare and due to intraspinal causes (lumbar spinal stenosis, facet joint osteoarthritis, fracture, and tumors of the spinal cord and spinal column) being the main consideration. Early diagnosis of sciatica significantly improves the likelihood of relieving symptoms, as well as avoiding any additional neurologic injury and unnecessary surgery. We evaluate histolopathologically confirmed extraspinal causes of sciatica cases, accompanied by their presented computed tomography and/or magnetic resonance imaging findings.