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3/10/2014
Uncommon Causes of Leg Pain
Benjamin A Meeks, FNP Disclosures
• Promotional speaker for Pfizer. No promotional consideration or honoraria provided from Pfizer for this presentation.
Agenda
• Common Causes Leg Pain
• Uncommon Causes of Leg Pain: Case Studies • Suggestions for practice
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Common Causes of Leg Pain
• Lumbar Radiculopathy
• Vascular Disease
• Peripheral Neuropathy
Uncommon Musculoskeletal Causes of Leg Pain
• Lumbar Facet Syndrome: Little discussion in medical literature for facets and leg pain
• Sacroilliac Dysfunction: Case report of leg pain with sacroiliac joint malignancy; 77/186 patients in one study leg pain was SIJ related • Degenerative Disease of the Hip: Frequent reports of lateral and anterior thigh pain with hip disease
• Visser et al (2013)
• Wilson (2014)
Case Study #1
• 63 year old female
• CC: Low back and bilateral thigh pain
• PSH: No prior spinal surgeries
• PMH: Hypercholesterolemia, compression fracture at T12
• SOCIAL: Non‐smoker, no alcohol use. Married. Retired.
• VAS: 7
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Case Study #1
• Radiology: L‐Spine MRI reveals disc bulges at L1/2, L2/3, L3/4 and L5/S1. Moderate foraminal stenosis at L1/2. Complete loss of disc height at L2/3 with mild central canal stenosis, moderate lateral recess and foraminal. Mild central stenosis and foraminal stenosis at L3/4. Mild to moderate foraminal and recess stenosis at L4/5.Facet artropathy at L2/3,L3/4, L4/5 andL5/S1. Case Study #1
• Pertinent Physical Exam: Well nourished elderly female, lordotic curve flattened, loss of lumbar range of motion, sensation intact across lumbar dermatomes, no tenderness over the sacroiliac joints, increased pain with extension lumbar spine
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Case Study #1
• Intervention: LESI
• No change in pain.
Case Study #1
• Intervention: Lumbar facet block at bilateral L3, L4 and L5
• Reduction in pain from VAS of 7 to a VAS of 2
• Lasting reduction in pain 6 to 12 months duration
• Patient has received periodic facet injections with consistant
reduction in pain since her initial evaluation in 2007.
Case Study #2
• 81 year old female
• CC: Right hip and thigh pain
• PSH: Cardiac bypass, cholecystectomy
• PMH: Hypertension, Reflux and Hypothyroidism
• SOCIAL: Nonsmoker, no alcohol, no illicit drugs. Retired.
• FAMILY: Hypertension, Fibromyalgia
• MEDS: Tramadol, ASA,Metoprolol,Amalodapine, Gabapentin, Nexium,Synthroid, Hyzaar, Magnesium, Vit B and Vit D
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Case Study #2
• Radiology: L‐Spine MRI: Normal L1/2 and L2/3.Minimal DDD and osteophyte formation at L3/4 without stenosis.L4/5 normal. L5/S1 facet arthropathy to the left with minimal lateral recess stenosis.
• Referred to pain management for sciatic pain.
Case Study #2
• Physical Exam: Normal lordotic curve intact, lower extremity pulses intact, sensation across lower extremity dermatomes intact, no pain with extension lumbar spine, decreased range of motion with pain and stiffness in the right hip
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Case Study #2
• Physical Exam: Increased pain with passive rotation of the right hip
• X‐Ray right hip: Advanced degenerative joint disease.
• Intra‐articular hip injection under fluoroscopic guidance reduced pain by 75%
• Patient wishes to delay hip replacement and is maintaining with periodic intra‐articular steroid injections
Case Study #3
• 38 year old female with nine year history of low back and bilateral leg pain right worse than left following lifting work injury
• PMH: Reflux, Hypothyroidism
• PSH: C‐Sections x 2, Hysterectomy
• SOCIAL: ½ ppd smoker. College educated. Married.
• FAMILY: Osteoarthritis, CAD, hypertension
• MEDICATIONS: Tramadol, Neurontin, Flexeril, Levothroid, Nexium, Singulair, Hydrocodone
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Case #3
• Physical Exam: Well nourished young female, lower extremity pulses intact, flattened lordosis, no pain with extension lumbar spine, tenderness over bilateral sacroiliac joints
• Radiology: L‐Spine MRI: L1/2, L2/3, L3/4 normal. Facet arthropathy and mild disc bulges at L4/5 and L5/S1 without stenosis. Pelvic x‐ray is normal.
• Intervention: Fluoroscopic guided bilateral sacroiliac joint injection provided complete resolution of symptoms for the duration of the local anesetic
Case #3
• Patient was entered into physical therapy and underwent radiofrequency lesioning of her bilateral sacroiliac joints
• Following physical therapy and radiofrequency she was able to discontinue hydrocodone and return to gainful employment
• Visser et al (2013)
Suggestions for Practice
• Include mechanical evaluation of hips, lumbar facet joints and sacroiliac joints for any patient with thigh or lower leg pain.
• Hips: Passive and active range of motion, assessing for stiffness or pain
• Lumbar Facet Joints: Visually inspecting for flattening of the normal lordosis, loss of range of motion and increase pain with extension
• Sacroilliac Joints: Tenderness over the affected joint, Patrick’s sign (place ankle of affected side on opposite knee and exert rapid downward pressure)
• Radiology: Not all radiographic changes cause pain.
Borenstein, et al (2004)
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References
• Borenstein et al. Low Back and Neck Pain. 3rd Ed. (2004) Saunders.
• Visser LH, Nijssen PG,Tijssen CC, vanMiddendrop JJ, Schieving J. Sciatica‐like symptoms and the sacroiliac joint: clinical features and differential diagnosis. Eur Spine J. 2013 Jul;22(7)
• Visser et al. Treatment of the sacroiliac joint in patients with leg pain: a randomized controlled trial. Eur Spine J. Oct 22(10).
• Wilson JJ, FurukawaM. Evaluation of the patient with hip pain. AmFam Physician, 2014 Jan 1;89(1): 27‐34.
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