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pseudosciatica-the diagnostic dilema.ppt

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pseudosciatica-the diagnostic dilema.ppt

  1. 1. PseudosciaticaPseudosciatica The diagnostic dilemmaThe diagnostic dilemma Andrea Trescot, MD
  2. 2. MRI StudyMRI Study • 98 asymptomatic patients98 asymptomatic patients • 52% had disc bulges52% had disc bulges • 27% had disc protrusions27% had disc protrusions • 1% had disc extrusions (outside the1% had disc extrusions (outside the annulus)annulus) • 14% had annular defects14% had annular defects • 8% had facet pathology8% had facet pathology • 7% had spondylolithesis7% had spondylolithesis • 7% had stenosis (central or foraminal)7% had stenosis (central or foraminal) Jensen NEJM July 1994
  3. 3. A treatment method can onlyA treatment method can only be as specific as thebe as specific as the diagnosis that accompanies itdiagnosis that accompanies it
  4. 4. DiagnosisDiagnosis
  5. 5. ““The cause of a disorder isThe cause of a disorder is hidden in the patient’s historyhidden in the patient’s history and the site of the lesion isand the site of the lesion is detected by examination.”detected by examination.” A. Staal
  6. 6. ““Disorders unknown to theDisorders unknown to the physician are notphysician are not unearthed.”unearthed.”
  7. 7. Interventional Pain Medicine
  8. 8. Diagnostic Injections • Based on history and physical exam • Small volumes • Precision is key for diagnosis – Landmarks – Nerve stimulator – Fluoroscopy
  9. 9. Facet PathologyFacet Pathology
  10. 10. Lumbar FacetLumbar Facet • Classically taught that pain radiates only to knee but may radiate to foot • Twisting injury or flexion/extension • “pop and lock” • Increased pain with extension
  11. 11. Facet Extension
  12. 12. RF FacetRF Facet
  13. 13. Superior Gluteal NeuralgiaSuperior Gluteal Neuralgia
  14. 14. Superior Gluteal Neuralgia
  15. 15. • Twisting/bending injury or fall on buttocks • Pain from buttocks to foot • Increased with standing and walking, better with sitting • Difficulty getting out of a chair or climbing stairs Superior Gluteal NerveSuperior Gluteal Nerve
  16. 16. Superior Gluteal Nerve
  17. 17. Superior Gluteal Nerve
  18. 18. Superior Gluteal Nerve
  19. 19. Superior Gluteal Nerve
  20. 20. Superior Gluteal NerveSuperior Gluteal Nerve
  21. 21. Cluneal NeuralgiaCluneal Neuralgia
  22. 22. Cluneal NeuralgiaCluneal Neuralgia
  23. 23. Cluneal NeuralgiaCluneal Neuralgia • Usually starts as a “pulled muscle” sensation • Common after iliac graft • Sometimes associated with Maigne’s syndrome • Can refer to the foot
  24. 24. Cluneal Nerve
  25. 25. Cluneal Nerve
  26. 26. Cluneal NerveCluneal Nerve
  27. 27. Cluneal InjectionCluneal Injection
  28. 28. Sacroiliac Joint PathologySacroiliac Joint Pathology
  29. 29. Sacroiliac PathologySacroiliac Pathology • By some estimates accounts for 90% of LBP • Twisting, slip and fall injuries • May switch sides • “Slipped clutch” syndrome
  30. 30. PSIS
  31. 31. SI joint
  32. 32. SI Joint InjectionsSI Joint Injections
  33. 33. SI Nerves
  34. 34. Piriformis SyndromePiriformis Syndrome
  35. 35. • Twisting while lifting, or carrying a load in an awkward position • Pain with hip internal rotation (so foot is inverted) • “entire foot and leg” Piriformis SyndromePiriformis Syndrome
  36. 36. Distal piriformis
  37. 37. Sciatic EntrapmentSciatic Entrapment
  38. 38. Sciatic/Piriformis Complex
  39. 39. Ischial DisordersIschial Disorders
  40. 40. Ischial Bursa • Direct trauma or overuse (bicycle or horseback) • Referred to hamstrings • Pain on extending and flexing hip • + SLR
  41. 41. Greater Trochanteric Bursitis
  42. 42. GT Bursitis
  43. 43. GT Pain Pattern
  44. 44. GT Calcification
  45. 45. Blind Injections Miss the Bursa
  46. 46. Ligament PathologyLigament Pathology
  47. 47. Enthesopathy • A disease pathology at the 'entheses', i.e. attachment sites of muscles, tendons, joint capsules, ligaments and fascia to the bone.
  48. 48. Enthesopathy
  49. 49. Interspinous LigamentInterspinous Ligament • Sudden midline pain with bending or lifting • Often associated with “pop”or “tear” • Pain down one or both legs • Loss of lumbar lordosis
  50. 50. Interspinous LigamentInterspinous Ligament DiagnosisDiagnosis • Tenderness to palpation over the ligament • Edema or palpable defect • MRI may show ligament defect • Central disc bulge • Resolution of back and leg pain with small dose of local anesthetic
  51. 51. Rotated Vertebra
  52. 52. RF ISL
  53. 53. Iliolumbar LigamentIliolumbar Ligament
  54. 54. Iliolumbar Ligament • Mimics L2 or L3 radiculitis • “Someone is squeezing my testicles” • Pseudotrochanteric bursitis • Common after fusion
  55. 55. ILL Exam
  56. 56. Sacrotuberous andSacrotuberous and Sacrospinatus LigamentsSacrospinatus Ligaments
  57. 57. SacrotuberousSacrotuberous SacrospinatusSacrospinatus
  58. 58. Myofascial SyndromesMyofascial Syndromes
  59. 59. Gluteus MinimusGluteus Minimus
  60. 60. Quadratus LumborumQuadratus Lumborum
  61. 61. Quadratus LumborumQuadratus Lumborum
  62. 62. Quadratus LumborumQuadratus Lumborum
  63. 63. Tensor Fascia LataTensor Fascia Lata
  64. 64. Discogenic PainDiscogenic Pain
  65. 65. Discography
  66. 66. Who Will Stop The Pain?

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