Right buttock pain down the leg, need management advice

[CarabinerSD]

Sorry for the long write up, but this case has been bothering me. I have a 40 something healthy woman complaining of right lower buttock pain since September 2022 (no trauma, sudden onset). The pain is 4/10 at baseline but worsens to 8/10 with driving (burning sensation). There is also numbness and tingling radiating from the buttock down the lateral hip, calf, and outer sole of her right foot.

Imaging:

• MRI Lumbar: L4-5 with 3mm disc bulge & central annular fissure, mild to moderate right & mild left sided neural foramina narrowing ; L5-S1 with 4mm disc bulge & mild to moderate left and mild right sided foraminal narrowing, no spinal canal stenosis.
• MRI Right hip: no muscle strain or tear (including the gluteal muscles, no evidence of greater trochanteric or iliopsoas bursitis, normal piriformis & sciatic nerve appearances), no significant pathology of right hip, right adnexal cyst 3.4 x 3 x 2.4 cm  Edit: OBGYN said this wouldn’t contribute to the patient’s radiating pain down the right buttock & leg

Medications tried (not helpful):

• NSAIDs (Mobic, Diclofenac, Celebrex)
• Medrol dose pack (ortho)
• Muscle relaxants (Baclofen, Flexeril)

Interventions (not helpful):

• Right PSIS / SI ligament TPI
• Right piriformis TPI (fluoro)
• Right SIJ injection (fluoro)
• Right L4-L5, L5-S1 TFESI

Summary:
Interesting case of right buttock pain in my years of practice without a straight forward pathology or treatment plan thus far. Initially I thought she had SIJ dysfunction or piriformis syndrome but this didn't pan out with the injections. MRI Lumbar not impressive for potential radiculopathy (in fact was seen by spine surgery who didn't recommend surgery) but I gave it a try with a lumbar ESI, no improvements. Did an MRI of the right hip just in case...not much going on there, just an adnexal cyst that OBGYN wasn't too concerned about.

Now I'm stuck trying to figure out what to do next since she appears to have legitimate pain and discomfort, impacting her ability to work as a healthcare professional (pain flares up when driving).

Sending her for an EMG/NCS of the RLE.
Trialing Lyrica & Tramadol
Interventions: ?sacral lateral branch blocks? ?ischiofemoral / quadratus injection..however MRI did not show ischiofemoral impingement?

Appreciate any advice on further workup or treatment.

Edit:
MRI L-spine images are posted here (expires by 4/28/23):

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[MitchLevi]

LOL.

Can't make everyone better.

Get comfortable telling ppl you've done what you can. Offer Lyrica.

Could be the annular fissure.

You tried.

Sacral BB aren't going to help, and ischiofemoral shots are BS.

 

[oneforfighting]

You’re describing an S1 radic but have not done an epidural at that level. Consider S1 TFESI vs right paramedian ILESI. Worse with driving sounds like dural tension and increased intradiscal pressure which could be dynamically abutting nerve root. MRI is static after all. Hopefully you looked at your images too to assess disc encroachment upon nerve roots as well as look for cysts. Radiologists miss things.

What’s the axial to extremity distribution? If primarily axial (what it sounds like) then maybe MBB if there is FJA. I’ve had buttock and radicular pain end up due to spondylosis. If more extremity then consider glute med bursa/GTB injection. Maybe ischial bursa injection.

 

[MitchLevi]

You’re describing an S1 radic but have not done an epidural at that level. Consider S1 TFESI vs right paramedian ILESI. Worse with driving sounds like dural tension and increased intradiscal pressure which could be dynamically abutting nerve root. MRI is static after all. Hopefully you looked at your images too to assess disc encroachment upon nerve roots as well as look for cysts. Radiologists miss things.

What’s the axial to extremity distribution? If primarily axial (what it sounds like) then maybe MBB if there is FJA. I’ve had buttock and radicular pain end up due to spondylosis. If more extremity then consider glute med bursa/GTB injection. Maybe ischial bursa injection.

He injected L4-S1 TF. He certainly covered S1. Facets don't refer to the foot.

 

[Agast]

Ischial bursitis will also give you pain at that butt cheek sit bone and sciatica sensation

If you mash on it is it tender?

 

[Asclepius186]

Had a few of these random middle age woman with intractable buttock pain.

They’re a pain in the ass.

 

[oneforfighting]

He injected L4-S1 TF. He certainly covered S1. Facets don't refer to the foot.

The L4 and L5 nerve roots yes. It’s likely that it would cover S1 but how can you be certain? What did the contrast spread look like?

 

[bedrock]

The L4 and L5 nerve roots yes. It’s likely that it would cover S1 but how can you be certain? What did the contrast spread look like?

Agree with this. I’ve seen plenty of L5-S1 TFESI that cover less than 25% of the L5-S1 disc.

This patient needs an S1 TFESI before you start chasing zebras.

 

[Taus]

L5-s1 right interlam esi w depo.

 

[MitchLevi]

What are yall talking about?

Bedrock. You've seen L5-S1 cover 25% of the disk? No you haven't. You've seen the contrast pattern at the time of the injxn, that's what you've seen.

Injecting S1 when you just did a consecutive level TFESI (I don't do those) makes zero clinical sense in this case.

What exactly are you treating?

What S1 radic?

That pt isn't tight. I would TF L4-5 or L5-S1 (not both) with 4cc of injectate and if it fails there's no follow up ESI.

The more I converse with other pain doctors the more I believe in counter transference. Our pts are making us crazy and we're all making s**t up.

 

[SSdoc33]

It is chemical radiculitis from the L45 or 5-1 disc.

ESI is reasonable. Doesnt matter which one. Lets not circumsize the mosquito. Its hard to treat. Core stabilization, HEP and then buh bye

 

[oneforfighting]

What are yall talking about?

Bedrock. You've seen L5-S1 cover 25% of the disk? No you haven't. You've seen the contrast pattern at the time of the injxn, that's what you've seen.

Injecting S1 when you just did a consecutive level TFESI (I don't do those) makes zero clinical sense in this case.

What exactly are you treating?

What S1 radic?

That pt isn't tight. I would TF L4-5 or L5-S1 (not both) with 4cc of injectate and if it fails there's no follow up ESI.

The more I converse with other pain doctors the more I believe in counter transference. Our pts are making us crazy and we're all making s**t up.

This person has n/t in the buttock, lateral calf and lateral sole of the right foot. Seems pretty specific, no? We can argue the merits of whether an epidural would help with extremity numbness in the absence of pain but this is an dermatomal distribution that fits.
And you would do a single level TFESI at L4-5 to treat the L4 nerve (?) for this patient?

 

[clubdeac]

Agree with oneforfighting and bedrock. Would try an S1 TFESI or ischial bursa injection. Not sure what Mitch is talking about. If someone has S1 pathology you inject at S1, not L5 and proclaim it covers both nerves

 

[RoloTomassi]

Does it look like the L5-S1 disc contacts S1 in the lateral recess? I would do paramedian L5-S1 IL and if that fails, S1 TF. Then you can pretty conclusively rule out S1.

Try MBB for the buttock pain. If it helps the leg that's a bonus. Have had the rare patient where RFA helps leg pain.

Probably wouldn't do QF if no IFI on MRI.

Lastly maybe consider cluneal for the buttock. Or intradiscal PRP if suspecting a chemical radiculitis from annular tears. These are hail Marys.

This is all assuming you had textbook spread on prior procedures.

 

[Snowmen96]

The ovaries are relatively close to the distal segment of the L5 root (far out of the foramen) and less so the lumbo-sacral trunk so perhaps the cyst isn't the cause but it might be compressing a neural structure, especially if it's quite posterior. I had a patient with L5 and S1 "radiculopathy" where it ended up being an ovarian cyst compressing the lumbo-sacral trunk, but the cyst was larger than your patient's.

Another hypothesis is proximal hamstrings tendinopathy since pain with sitting is pretty typical and it can often radiate quite far down the leg, although it wouldn't really cause numbness, but the sensory examination is usually quite unreliable. It would be reproducible with palpation of the ischiatic tuberosity, Puranen-Orava test, resisted knee flexion with the hip in maximal flexion, bent-knee stretch test, modified bent-knee stretch test, etc. If the clinic fits, a pelvis MRI is better than a hip MRI at imaging the proximal tendon and seeing the contralateral side is useful since it's often a case of comparing with the healthy side. You're mostly looking for bone edema at the ischial tuberosity ± heterogenous tendon. UItrasound isn't that good unless the patient is slim and has good echogenicity.

 

[MitchLevi]

Agree with oneforfighting and bedrock. Would try an S1 TFESI or ischial bursa injection. Not sure what Mitch is talking about. If someone has S1 pathology you inject at S1, not L5 and proclaim it covers both nerves

Okay so if someone comes in with S1 symptoms and has zero evidence of S1 compression, but instead has an HNP at L2-3 what do you do?

The patient has an annular fissure at L4-5. You inject at L4-5 on the side of the symptoms directly at the fissure.

Injecting at L5-S1 is fine too (not both). Putting an ESI at S1 makes no sense when the only legitimate sounding pathology is two entire levels higher at L4-5.

 

[clubdeac]

Okay so if someone comes in with S1 symptoms and has zero evidence of S1 compression, but instead has an HNP at L2-3 what do you do?

The patient has an annular fissure at L4-5. You inject at L4-5 on the side of the symptoms directly at the fissure.

Injecting at L5-S1 is fine too (not both). Putting an ESI at S1 makes no sense when the only legitimate sounding pathology is two entire levels higher at L4-5.

Ok I see what you’re saying. That’s the age old question. I will admit I’ve gone back and forth in these situations. Sometimes follow the anatomy and sometimes the patient presentation. In this scenario the patient appears to have a classic S1 radic so I’d try that. Chemical radiculitis is real

 

[deleted875186]

Hard to tell, I tend to agree that you covered the S1 root with your injection, could try a L5-S1 ILESI but I don’t think it will help. If main complaint is burning buttock pain, I would focus on that rather than the leg, because the degree of stenosis is does not explain the symptoms. Try lower facets.

 

[DODOCSS]

Hard to tell, I tend to agree that you covered the S1 root with your injection, could try a L5-S1 ILESI but I don’t think it will help. If main complaint is burning buttock pain, I would focus on that rather than the leg, because the degree of stenosis is does not explain the symptoms. Try lower facets.

agree. L3,4,5 MBB

 

[Taus]

agree. L3,4,5 MBB

Thats a setup for false + and failed rf

 

[MitchLevi]

< 50 with a fissure and LE pain.

 

[Taus]

Sorry for the long write up, but this case has been bothering me. I have a 40 something healthy woman complaining of right lower buttock pain since September 2022 (no trauma, sudden onset). The pain is 4/10 at baseline but worsens to 8/10 with driving (burning sensation). There is also numbness and tingling radiating from the buttock down the lateral hip, calf, and outer sole of her right foot.

Imaging:

• MRI Lumbar: L4-5 with 3mm disc bulge & central annular fissure, mild to moderate right & mild left sided neural foramina narrowing ; L5-S1 with 4mm disc bulge & mild to moderate left and mild right sided foraminal narrowing, no spinal canal stenosis.
• MRI Right hip: no muscle strain or tear (including the gluteal muscles, no evidence of greater trochanteric or iliopsoas bursitis, normal piriformis & sciatic nerve appearances), no significant pathology of right hip, right adnexal cyst 3.4 x 3 x 2.4 cm  Edit: OBGYN said this wouldn’t contribute to the patient’s radiating pain down the right buttock & leg

Medications tried (not helpful):

• NSAIDs (Mobic, Diclofenac, Celebrex)
• Medrol dose pack (ortho)
• Muscle relaxants (Baclofen, Flexeril)

Interventions (not helpful):

• Right PSIS / SI ligament TPI
• Right piriformis TPI (fluoro)
• Right SIJ injection (fluoro)
• Right L4-L5, L5-S1 TFESI

Summary:
Interesting case of right buttock pain in my years of practice without a straight forward pathology or treatment plan thus far. Initially I thought she had SIJ dysfunction or piriformis syndrome but this didn't pan out with the injections. MRI Lumbar not impressive for potential radiculopathy (in fact was seen by spine surgery who didn't recommend surgery) but I gave it a try with a lumbar ESI, no improvements. Did an MRI of the right hip just in case...not much going on there, just an adnexal cyst that OBGYN wasn't too concerned about.

Now I'm stuck trying to figure out what to do next since she appears to have legitimate pain and discomfort, impacting her ability to work as a healthcare professional (pain flares up when driving).

Sending her for an EMG/NCS of the RLE.
Trialing Lyrica & Tramadol
Interventions: ?sacral lateral branch blocks? ?ischiofemoral / quadratus injection..however MRI did not show ischiofemoral impingement?

Appreciate any advice on further workup or treatment.

Post mri images. Mid-sagittal, sagittal w foramen in view and axial t2 in plane of both discs

 

[deleted875186]

At least this person didn’t get fused, or get an ALIF or some other ridiculous thing by the surgeon.

 

[interjectionreflection]

Does it look like the L5-S1 disc contacts S1 in the lateral recess? I would do paramedian L5-S1 IL and if that fails, S1 TF. Then you can pretty conclusively rule out S1.

Try MBB for the buttock pain. If it helps the leg that's a bonus. Have had the rare patient where RFA helps leg pain.

Probably wouldn't do QF if no IFI on MRI.

Lastly maybe consider cluneal for the buttock. Or intradiscal PRP if suspecting a chemical radiculitis from annular tears. These are hail Marys.

This is all assuming you had textbook spread on prior procedures.

Would you still be able to rule out S1 if there was lateral recess narrowing at L5-1 with no response to TFESI? I've had a few patients like this with mild (sometimes moderate) stenosis with radicular-ish but still vague sounding pain and no response to meds, or interventions and get seen by surgeon and have surgery and their symptoms resolve.

 

[RoloTomassi]

Would you still be able to rule out S1 if there was lateral recess narrowing at L5-1 with no response to TFESI? I've had a few patients like this with mild (sometimes moderate) stenosis with radicular-ish but still vague sounding pain and no response to meds, or interventions and get seen by surgeon and have surgery and their symptoms resolve.

Depends on the the degree of lateral recess stenosis and response.

In this case I was assuming mild lateral recess stenosis, if any, given small 4 mm bulge that sounds eccentric to the left. If I did both L5-S1 IL and S1 TF and there no improvement, not even temporary, it would be hard to rationalize a surgery. But these cases are tough and they will present from time to time.

If say, severe lateral stenosis, the diagnosis would be more clear, and good but only temporary response to ESI would likely be treatment failure, and surgical referral more appropriate.

 

[SSdoc33]

Mbb is nonsense.

 

[Orin]

Wait, you aren't all doing LSBs and then moving onto SCS?

I agree though an S1 or L5-S1 ILESI is where I'd start. TFESIs are often too targeted in my opinion, so an ILESI with 7 - 10 mL is a simpler way to flood the zone.

I use patient complaints more than imaging when things are discordant, but I explain I could try either one and then I do if I have to.

Med-wise, with a neuropathic pain state, I agree with the AEDs but why not add in a TCA/SNRI?

I was hoping this would be a more interesting case of a posterior femoral cutaneous neuralgia or something, but this sounds more like a S1 radic.

 

[deleted875186]

Mild disc bulge at L5-S1 without significant stenosis , where is the S1 radic coming from? S1 TFESI will fail, as will ILESI.

 

[interjectionreflection]

Depends on the the degree of lateral recess stenosis and response.

In this case I was assuming mild lateral recess stenosis, if any, given small 4 mm bulge that sounds eccentric to the left. If I did both L5-S1 IL and S1 TF and there no improvement, not even temporary, it would be hard to rationalize a surgery. But these cases are tough and they will present from time to time.

If say, severe lateral stenosis, the diagnosis would be more clear, and good but only temporary response to ESI would likely be treatment failure, and surgical referral more appropriate.

That's been my approach to it as well. It's always hard when they have vague symptoms that could loosely fit with imaging and not even a transient response to injection and insist on seeing a surgeon.

Wait, you aren't all doing LSBs and then moving onto SCS?

I agree though an S1 or L5-S1 ILESI is where I'd start. TFESIs are often too targeted in my opinion, so an ILESI with 7 - 10 mL is a simpler way to flood the zone.

I use patient complaints more than imaging when things are discordant, but I explain I could try either one and then I do if I have to.

Med-wise, with a neuropathic pain state, I agree with the AEDs but why not add in a TCA/SNRI?

I was hoping this would be a more interesting case of a posterior femoral cutaneous neuralgia or something, but this sounds more like a S1 radic.

I think it's reasonable to try if it's a clinical S1 pattern. I wonder what would be the long term plan if they didn't respond to meds but you tried S1 TFESI or ILESI based on clinical picture but in absence of any clear imaging correlates. If the intervention works but temporarily and the patient keeps coming back for repeat what would be their long term treatment plan? They wouldn't be a surgical candidate so only other thing could be SCS possibly? Conversely what if the intervention looses efficacy on repeats? In my limited experience when these Injections loose efficacy over time and repeat imaging shows no interval change I feel like I've exhausted everything I can and often times these patients feel anxious because they don't have a clear cut answer as to a solution and doubt the diagnosis.

 

[bedrock]

Mild disc bulge at L5-S1 without significant stenosis , where is the S1 radic coming from? S1 TFESI will fail, as will ILESI.

You can’t be certain of that. The L5-S1 disc isn’t Terrible but it isn’t normal either.

An when one disc has an annular tear, the adjacent disc has a higher chance to have an annular tear missed on a given MRI cut.

A right S1 TFESI with depo is the best next step.

 

[powermd]

Has this patient done PT for piriformis syndrome?

Piriformis can be tricky to treat. Simply injecting the muscle may not do the job. Stretching can be a miracle, but in some cases will flare it up. Same with piriformis exercise.

One of the first things I do with these people is a good, deep 45 second assisted stretch of the piriformis on the exam table. Then I have the patient get up and walk around. If the leg feels looser and "unburdened" from the pain, that's a clue you may be dealing with sciatic nerve impingement in the buttock.

I've had piriformis cases clear up with injections both superficial and deep to the muscle/tendon (performed laterally where you can see it better). I haven't found a reason yet to put a donut of anesthetic around the sciatic nerve at this level, but that's been on my mind for these.

 

[TweeterB]

unrelated to this patient, if your patient has back pain radiating to the hip, do you guys suspect L4 or L5 impingement? I’ve seen both implicated

 

[Hoya11]

Wait, you aren't all doing LSBs and then moving onto SCS?

I agree though an S1 or L5-S1 ILESI is where I'd start. TFESIs are often too targeted in my opinion, so an ILESI with 7 - 10 mL is a simpler way to flood the zone.

I use patient complaints more than imaging when things are discordant, but I explain I could try either one and then I do if I have to.

Med-wise, with a neuropathic pain state, I agree with the AEDs but why not add in a TCA/SNRI?

I was hoping this would be a more interesting case of a posterior femoral cutaneous neuralgia or something, but this sounds more like a S1 radic.

yes i have seen ILESI provide relief when TFESI has not (and vice versa)

 

[SC Tian]

I have seen several cases like this, i will try us guided piriformis injection one more time instead fluro, should have 2% lido in the injectate.

 

[Laryngospasm]

S1 tfesi with depo, then right sided mbb

 

[Ducttape]

I would not try another TFESI. You did an L5, unless you messed up on the injection you will get S1 coverage, and it will be hard convincing the patient to do essentially the same injection again.

It is not unreasonable to try a L5S1 parasagittal injection.

Agree with EMG more to reassure patient that there is no obvious nerve injury.

Ditch tramadol, meh but okay on gaba or lyrica, try TCA and or duloxetine.

 

[Greenbayslacker]

Interventions (not helpful):

• Right PSIS / SI ligament TPI

What is a PSIS injection? Have many patients reporting pain here, I thought this was Fortin's point and indicated SIJ pathology?

 

[CarabinerSD]

You’re describing an S1 radic but have not done an epidural at that level. Consider S1 TFESI vs right paramedian ILESI. Worse with driving sounds like dural tension and increased intradiscal pressure which could be dynamically abutting nerve root. MRI is static after all. Hopefully you looked at your images too to assess disc encroachment upon nerve roots as well as look for cysts. Radiologists miss things.

What’s the axial to extremity distribution? If primarily axial (what it sounds like) then maybe MBB if there is FJA. I’ve had buttock and radicular pain end up due to spondylosis. If more extremity then consider glute med bursa/GTB injection. Maybe ischial bursa injection.

Definitely more extremity than axial. She basically has no low back pain. Valid suggestions with ischial bursa vs GTB

 

[CarabinerSD]

Ischial bursitis will also give you pain at that butt cheek sit bone and sciatica sensation

If you mash on it is it tender?

No it's not really tender on palpation, only reproduces upon assuming the driving position with foot on gas pedal...

 

[CarabinerSD]

Has this patient done PT for piriformis syndrome?

Piriformis can be tricky to treat. Simply injecting the muscle may not do the job. Stretching can be a miracle, but in some cases will flare it up. Same with piriformis exercise.

One of the first things I do with these people is a good, deep 45 second assisted stretch of the piriformis on the exam table. Then I have the patient get up and walk around. If the leg feels looser and "unburdened" from the pain, that's a clue you may be dealing with sciatic nerve impingement in the buttock.

I've had piriformis cases clear up with injections both superficial and deep to the muscle/tendon (performed laterally where you can see it better). I haven't found a reason yet to put a donut of anesthetic around the sciatic nerve at this level, but that's been on my mind for these.

Did PT for piriformis already, one of the first thing I thought about. It's something about the driving position that provokes it.

 

[CarabinerSD]

What is a PSIS injection? Have many patients reporting pain here, I thought this was Fortin's point and indicated SIJ pathology?

Essentially Fortin's sign yes. Did a trigger point here around the PSIS where she pointed as possible origin of the pain.

 

[Taus]

No it's not really tender on palpation, only reproduces upon assuming the driving position with foot on gas pedal...

Bc its still disc

 

[Taus]

Essentially Fortin's sign yes. Did a trigger point here around the PSIS where she pointed as possible origin of the pain.

Sensitive, albeit non-specific sign, indicating potential sij, not myofascial butt pain

 

[Agast]

Bc its still disc

I thought pain with dorsiflexion of the foot implies L5 or S1

Since he already did L5/S1 tfesi the next would be S1

 

[oneforfighting]

Bc its still disc

Not likely discogenic since “she basically has no low back pain”. Unless you mean the disc is impinging upon the nerve with driving which is much more likely.

 

[oneforfighting]

No it's not really tender on palpation, only reproduces upon assuming the driving position with foot on gas pedal...

Could be ischial bursa or upper hamstring tendinosis/itis. Although the latter appears to be less likely given no mention MRI hip.
Still sounds like a radic.

 

[melancholy]

Sorry for the long write up, but this case has been bothering me. I have a 40 something healthy woman complaining of right lower buttock pain since September 2022 (no trauma, sudden onset). The pain is 4/10 at baseline but worsens to 8/10 with driving (burning sensation). There is also numbness and tingling radiating from the buttock down the lateral hip, calf, and outer sole of her right foot.

Imaging:

• MRI Lumbar: L4-5 with 3mm disc bulge & central annular fissure, mild to moderate right & mild left sided neural foramina narrowing ; L5-S1 with 4mm disc bulge & mild to moderate left and mild right sided foraminal narrowing, no spinal canal stenosis.
• MRI Right hip: no muscle strain or tear (including the gluteal muscles, no evidence of greater trochanteric or iliopsoas bursitis, normal piriformis & sciatic nerve appearances), no significant pathology of right hip, right adnexal cyst 3.4 x 3 x 2.4 cm  Edit: OBGYN said this wouldn’t contribute to the patient’s radiating pain down the right buttock & leg

Medications tried (not helpful):

• NSAIDs (Mobic, Diclofenac, Celebrex)
• Medrol dose pack (ortho)
• Muscle relaxants (Baclofen, Flexeril)

Interventions (not helpful):

• Right PSIS / SI ligament TPI
• Right piriformis TPI (fluoro)
• Right SIJ injection (fluoro)
• Right L4-L5, L5-S1 TFESI

Summary:
Interesting case of right buttock pain in my years of practice without a straight forward pathology or treatment plan thus far. Initially I thought she had SIJ dysfunction or piriformis syndrome but this didn't pan out with the injections. MRI Lumbar not impressive for potential radiculopathy (in fact was seen by spine surgery who didn't recommend surgery) but I gave it a try with a lumbar ESI, no improvements. Did an MRI of the right hip just in case...not much going on there, just an adnexal cyst that OBGYN wasn't too concerned about.

Now I'm stuck trying to figure out what to do next since she appears to have legitimate pain and discomfort, impacting her ability to work as a healthcare professional (pain flares up when driving).

Sending her for an EMG/NCS of the RLE.
Trialing Lyrica & Tramadol
Interventions: ?sacral lateral branch blocks? ?ischiofemoral / quadratus injection..however MRI did not show ischiofemoral impingement?

Appreciate any advice on further workup or treatment.

I might have missed it, but you list symptoms, imaging, meds and other treatments. What's the physical exam like? Are you able to reproduce the symptoms?
With any of the interventions, if you use local anesthetic, did she feel local anesthetic appropriately based on where you did the injection and if so, did any of the impacted areas feel in proximity of where she gets her pain symptoms? Steroids are not 100% reliable, but if patient has a normal response to local anesthetics in injections, you can sometimes use that (or their feedback during the procedure) to get a little better understanding about the pain esp with multiple visits. Do you have access to a stimulator for future injection that might help localize pain generator? (esp as some have suggested S1 TFESI)

EMG prob low yield unless you had some indications on physical exam where you need more physiological data with suspicion of neurological weakness from nerve compression.

 

[melancholy]

unrelated to this patient, if your patient has back pain radiating to the hip, do you guys suspect L4 or L5 impingement? I’ve seen both implicated

be specific about what part of the "hip" - anterior, lateral, posterior/buttock?

 

[melancholy]

I would not try another TFESI. You did an L5, unless you messed up on the injection you will get S1 coverage, and it will be hard convincing the patient to do essentially the same injection again.

It is not unreasonable to try a L5S1 parasagittal injection.

Agree with EMG more to reassure patient that there is no obvious nerve injury.

Ditch tramadol, meh but okay on gaba or lyrica, try TCA and or duloxetine.

Did PT for piriformis already, one of the first thing I thought about. It's something about the driving position that provokes it.

Not sure if fleshing out details might be helpful like how soon after the drive starts do the symptoms start, whether patient gets similar symptoms sitting in other situations like hard chairs, soft chairs. Any difference between commuting days where she spends more time in the car driving vs a short weekend drive to the grocery store.

 

[MitchLevi]

Stop this