Medical mystery: Man’s lower back pain resulted from unusual underlying cause
The man did not reveal muscular weakening nor neurological abnormalities during his exam. He also did not recall an injury that precipitated the pain.
Bill, 58, came to see me complaining of lower back pain, which radiated through his left buttock and down the length of his left leg.
On his initial examination, he did not reveal muscular weakening nor neurological abnormalities. He also did not recall an injury that precipitated the pain. His primary care physician prescribed an MRI.
While waiting for the results, he began physical therapy, and was treated with Tylenol and muscle relaxants, but he did not experience any pain relief.
The MRI revealed degenerative disease of the spinal joints and disc protrusion in the lower back. This is a common finding in aging spines.
Based on the MRI findings, he was then referred to a pain specialist who performed an epidural injection of steroids into the area of the spine that had the disc protrusion.
At his one and two-week follow up visits, there was minimal relief of the pain down his leg.
He came to me for a second opinion.
The first question I asked him was if he sat for extended periods of time. He explained that he worked at the New Jersey Department of Transportation, where he drove a truck and sat most of the day. He further shared how his pain was worse after a long day at work.
I suspected he had another underlying problem causing his pain. I recommended he see a chiropractor who I often referred patients to in these situations.
Solution
The chiropractor first pressed on the muscles along the spine, where the MRI found disc issues, and did not elicit any pain from Bill. But when he pressed on the piriformis muscle, Billy said it was quite painful.
In Bill’s case, the spinal abnormalities noted on the MRI, while abnormal, were not the cause of his pain. Based on the chiropractor’s physical examination findings and other noted history, the chiropractor diagnosed Bill with piriformis syndrome.
The piriformis muscle is a narrow muscle that stretches from the pelvis to the upper part of the thigh bone. Normally, it functions to allow the leg to move outward and inward, and is engaged while walking. If pulled or strained or swollen, it can compress and irritate the sciatic nerve, which comes out of the hip and travels down the leg, often causing leg pain in patients. Some patients also complain of tingling or numbness of the buttocks.
The slight relief Bill had of the pain traveling down his leg, after the steroid injection also helped the chiropractor uncover the root of the problem. The sciatic nerve is compressed with piriformis syndrome, but one of its branches travels under the piriformis muscle, and that branch can have some pain relief when a steroid is injected into the spine where the sciatic nerve comes out. Piriformis syndrome can be worsened with trauma, running, or sitting for extended periods of time, all of which may compress the muscle. Also, as was the case with Bill, if the spine is misaligned, it can put extra pressure on the muscle, resulting in the symptoms. The chiropractor was confident that when he realigned Bill’s spine, it would relieve the extra strain on the muscle.
Chiropractic manipulation can help to stretch and relax the muscle, and correct misalignments of vertebral discs. When combined with ice, massage, and low impact physical exercise programs that include stretching, the condition can be resolved.
Within three weeks of completing a stretching regimen, Bill had made a full recovery.
Bill’s job, which requires him to sit for extended periods of time, was the underlying cause of his problem. To prevent it from recurring, he was advised to avoid sitting for long periods without stretching during shifts.
Alfred Mauro is director emeritus of Jersey City Medical Center Anesthesia and Pain Management. He can be reached at almauro@optonline.net.