Case: 53-year-old Man with Intense Hip Pain

00:01 Now, let's talk about step three.

00:02 What are some of the common cases to remember when it comes to neuropathic pain? So let's start with a case. This is a 53-year-old man with intense leg pain.

00:12 A 53-year old man was playing soccer when he directly fell on his hip.

00:17 He had sudden, intense pain and was unable to move his leg.

00:21 He was immediately taken to the emergency room by his teammates.

00:25 He has no prior history of trauma or any chronic medical conditions.

00:29 His blood press is 128/84, heart rate, 92, respiratory rate, 14.

00:34 He is in no significant distress but is holding his left leg in pain.

00:39 On physical examination, there's sensory loss in the tibial and sural territories of the left leg.

00:45 The medial calf and foot arch are spared.

00:48 Sensation is normal throughout the right leg.

00:50 On the left leg, there is normal knee-jerk and absent ankle-jerk deep tendon reflexes, and deep tendon reflexes are normal throughout the right leg.

01:00 So this is a pretty common case of a patient presenting with neuropathic pain.

01:05 And there are a few things I want you to focus on here.

01:08 First is the localization. This patient presents with findings that are consistent with a peripheral nervous system localization for his problem.

01:16 There are not increased reflexes or spasticity or other signs and symptoms that would point to a central nervous system problem.

01:24 When we think about a peripheral nervous system cause of neuropathic pain, we wanna localize to the root plexus or terminal nerve branches.

01:31 This patient has left leg symptoms that appear to be arising from the nerve root.

01:38 There's both motor and sensory involvement, and this occurred after a trauma.

01:42 This raises strong suspicion for a problem affecting the nerve roots of the left leg.

01:49 So which of the following is the most likely etiology of this patient's condition? Is this cauda equine syndrome, sciatic neuropathy, diabetic polyneuropathy, or a spinal cord tumor? Well, this doesn't sound like a spinal cord tumor.

02:03 Again, the localization for this problem is the peripheral nervous system, not a central nervous system problem like a spinal cord tumor.

02:12 Cauda equina is important cause of peripheral, sensory, and motor dysfunction that can be acute in onset, but here, we see no severe radicular pain.

02:22 We don't hear bowel/bladder dysfunction that is common in cauda equina syndrome.

02:26 And the traumatic event raises stronger suspicion for a nerve root problem than a diffuse cauda equina syndrome. This doesn't sound like diabetic polyneuropathy.

02:37 The symptoms did not start in both legs and slowly, ascend.

02:41 There was no sensory loss observed, and we don't hear other past medical history conditions that raise suspicion for diabetes in this patient.

02:51 And this is a pretty typical description of a sciatic neuropathy, likely, from a herniated disk exacerbated by that acute trauma.

02:59 The patient has focal leg weakness, normal knee-jerk, and absent ankle-jerk as a result of compression of the sciatic nerve.

03:08 So what is a radiculopathy? Well, let's start with a definition.

03:12 Radiculopathy may include a variety of symptoms produced by pinching or compression of the nerve root in the spinal column.

03:20 Sensory complaints are common. Numbness is not uncommon.

03:24 Pain may be observed and weakness may occur in the myotome that is innervated by the nerve root.

03:31 When we think about sciatic neuropathy or a sciatic radiculopathy specifically, there are many common etiologies and trauma is one of those as in our patient and may result from hip dislocation fracture or just a blunt trauma.

03:47 Compression may be an etiology for sciatic radiculopathy from prolonged bedrest or degenerative disease in the back.

03:55 And then occasionally, iatrogenic causes can be seen from injections into that area to manage patients with other pain syndromes.

04:04 Importantly, the sciatic nerve is one of the longest nerves in the lumbosacral plexus, and so you can see the course here.

04:11 It is susceptible to compression on the ischium of the bones of the buttocks and this can result in presentation with sciatic neuropathy or radiculopathy.

04:24 Patients typically present with leg pain, often with associated leg weakness, sensory loss in the peroneal, tibial, and sural territories can be seen and should be evaluated.

04:35 Knee-jerk is typically normal but ankle-jerks are often absent as was seen in our patient.

04:43 How do we manage sciatic radiculopathy or sciatic neuropathies? There are a few principles to think about when managing any compressive mononeuropathy.

04:53 First, in terms of general management, we want to modify lifestyle or ensure adequate control of underlying illnesses or activities that could contribute to the compression of that nerve.

05:05 While there are many different modalities of treatments and they vary for the nerve that's involved, in general, reducing the mechanism of injury is important.

05:15 For the sciatic radiculopathy, preventing compression of the sciatic nerve is important.

05:19 For a carpal tunnel or a median mononeuropathy, avoiding activities that would exacerbate the swelling and pressure of the media nerve are also important.

05:29 Splinting can be used in a variety of other procedures to minimize compression or trauma to a nerve.

05:37 And more severe conditions may require surgical intervention.

05:41 We may need to release the media nerve or reduce compression to a sciatic nerve root as a result of a herniated disk.

05:49 Other treatment options include splinting and immobilization, physical therapy is one of the most important interventions for these patients, and pain control may be needed with non-steroidal agents, or occasionally, corticosteroid injection for local delivery of treatment.

06:07 Other treatment options include surgery if conservative management fails.

06:11 And we typically pursue aggressive conservative management initially.

06:15 Surgical release can be considered for various focal mononeuropathies.

06:21 For example, carpal tunnel syndrome where the media nerve is compressed.

06:25 A focal release of the media nerve at that area could be quite helpful for patients with significant symptoms.

06:32 Nerve grafting may be needed in rare cases and other treatments.