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Home > February Newsletter > Case Series
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| Case History Series: #3: |
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Back & Leg Pain - Radicular Pain
Patient C:
64 year old man with a three year history of gradually increasing left leg pain. The pain used to come and go prior to that time over a ten year period. Treatment had included general advice, physical therapy, stretching exercises, medication and a caudal epidural which had provided one week of substantial relief. |
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The pain was a shooting pain that spread down the leg from the outer buttock to the postero-lateral leg as far as the calf. It was about 50 mm wide. The pain did not having a burning quality. It was more severe above the knee. This pain was variable through any one day. However, the left calf pain was present all the time.
Walking was restricted when the pain was worse. This severe pain had been bad for 4 months. It was still getting worse. The pain in the calf was 9/10, and it would reach that level of intensity by 2 pm each day.
His bowels and bladder were functional. He had tried many pills without help. He was still working as a plumber: he said that some of his work involved heavier bending and lifting but he had recently cut back substantially on the heavy work. He had resorted to lying down during the day and stretching his legs to get some relief.
He had minimal back ache only: it was aggravated more by his work tasks.
EXAMINATION:
There was a full range of painless back mobility. Single leg raise (SLR) on the left was mildly limited compared to the right. Peripheral nervous system examination was intact. The hips moved normally.
INVESTIGATIONS:
MRI taken two months previous showed L4-5 internal disc disruption, with disc space narrowing, some generalised disc bulge towards the left contacting the left L5 nerve root, and this (combined with the reduction in height in association with the disc narrowing) was producing some relative but mild compression of the L5 nerve root.
DIAGNOSIS:
The pain was radicular. It was consistent with left L5 nerve root entrapment due to a combination of disc prolapse and local canal stenosis.
MANAGEMENT:
- Drugs: The one group of drugs that might make a difference is the anti - epileptic or anticonvulsant group. Thus, Tegretol (carbamazepine), Neurontin (gabapentin), Epilim (sodium valproate) etc could be tried.
- Injection: Caudal epidural did not help. A left L5 transforaminal injection is worth trying. If it makes a permanent degree of difference it could be repeated if the improvement was not sufficient. If it made a difference for some months it could be repeated. If it makes no difference, then the next step is operation. He had this procedure on the day. It was with 2ml Xylocaine 2% and one ampoule Celestone.
- Operation: He should be referred to a spinal surgeon for consideration of a left L5 nerve root decompression at the L4-5 level.
- Prognosis: There is no necessity for him to rush off and have treatment. Sciatica such as this can recover, but now that he has a three year history of it, worse over the past four months, it might not recover left untreated.
COMMENTS/OUTCOME:
- The anti-epileptic dose of gabapentin was taken to 1800 mg per day. At that level he achieved a 30% reduction in pain, but some persistent drowsiness. He did not want to try pregabalin, and felt that the improvement was not enough to forego other therapy.
- He underwent a transforaminal injection of local anaesthetic and steroid. After two weeks there was a steady state improvement of 40%. He is currently able to walk better than before, and is waiting to see what might happen in the future. Options for further management include repeat transforaminal and surgical nerve root decompresion.
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| Related Video Episodes: |
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 TFESI -L5 (Use Discount Coupon 'legpain')
A 47 year old man with disc bulging adjacent to the L5 nerve root causing significant right leg ‘sciatica’ referred pain is treated with an L5 transforaminal epidural steroid injection, under live x-ray imaging. |
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TFESI - L4
A young male with right L4 sciatica is presented and treated with a targeted ‘nerve sheath’ transforaminal epidural injection.
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Caudal Epidural
A middle aged man with complex right leg ‘sciatica’ is presented. A caudal epidural is given under fluoroscopic control.
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