Right buttock pain down the leg, need management advice

[TweeterB]

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

Lateral hip. L4?

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[TweeterB]

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

I’m assuming you’re gonna say: posterior L5 or S1, lateral L4, and anterior L3? TIA!

 

[melancholy]

I’m assuming you’re gonna say: posterior L5 or S1, lateral L4, and anterior L3? TIA!

I guess you could say that certain lumbar dermatomes cross the region of the lateral hip.....

 

[Taus]

I guess you could say that certain lumbar dermatomes cross the region of the lateral hip.....

Still nonspecific unless it is the occasional classic full spectrum of the dermatome/myotome. Any level can go to the buttock or lateral hip. L2, 3, 4 could be anywhere in the anterior or lateral thigh…. Or just glute.

 

[CarabinerSD]

Still nonspecific unless it is the occasional classic full spectrum of the dermatome/myotome. Any level can go to the buttock or lateral hip. L2, 3, 4 could be anywhere in the anterior or lateral thigh…. Or just glute.

Appreciate all the input so far.

I've performed an L5-S1 right ILESI today (good contrast pattern), if not helpful will repeat piriformis injection but with ultrasound instead since she keeps pointing to lower buttock for area of pain and under fluoro it's below SI joint...

So here's the MRI L-spine for further analysis. I can only attach 10 images at a time.

 

[CarabinerSD]

Sagital

 

[CarabinerSD]

Axials

 

[CarabinerSD]

Axial

 

[CarabinerSD]

Axial

 

[CarabinerSD]

Axial

 

[CarabinerSD]

Axial

 

[MitchLevi]

You injected nothing.

You cannot help this person with a needle.

Do NOT inject her again.

 

[RoloTomassi]

Even less impressive than the report

 

[deleted875186]

Agreed, lumbar spine is mild, doesn’t explain the pain.

 

[oneforfighting]

Sacral tarlov cysts? Could explain pain.

 

[lobelsteve]

Sacral tarlov cysts? Could explain pain.

NO it can’t

 

[deleted875186]

I stand by what I said earlier. Try lumbar facets. Would also reconsider the hip joint.

 

[oneforfighting]

NO it can’t

lol not falling for this

 

[MitchLevi]

lol not falling for this

Tarlov cysts do not hurt.

OP - Become okay telling ppl you can't fix them or take away all of their problems.

This pt isn't going to get better with your injxns and she'll prob look back in 24 months and be pissed you kept sticking her.

 

[BobBarker]

Normal mri

 

[Orin]

I do think it's the cyst. If all of it doesn't help, ask an IR to do a cyst aspiration and injection of fibrin. That's a right S2 cyst correct?

Treatment of 213 Patients with Symptomatic Tarlov Cysts by CT-Guided Percutaneous Injection of Fibrin Sealant

This cohort study assesses outcomes in patients who underwent CT-guided aspiration and injection of sacral Tarlov cysts at Johns Hopkins Hospital from 2003–2013. A total of 289 cysts were treated in 213 consecutive patients, with 83% followed ...

www.ncbi.nlm.nih.gov

 

[oneforfighting]

Tarlov cysts do not hurt.

Prove it

 

[MitchLevi]

Prove it

How?

I've never heard of Tarlov cysts causing pain.

 

[oneforfighting]

How?

Thank you

 

[lobelsteve]

I do think it's the cyst. If all of it doesn't help, ask an IR to do a cyst aspiration and injection of fibrin. That's a right S2 cyst correct?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752851/[/

How do you account for the 174 who declined treatments from a statistical standpoint? BOCF.

 

[clubdeac]

How do you account for the 174 who declined treatments from a statistical standpoint? BOCF.


View attachment 369855

but a perineural cyst is different than a tarlov cyst right?

 

[lobelsteve]

but a perineural cyst is different than a tarlov cyst right?

I don't think so for this study. Will have to relook.

 

[oneforfighting]

How?

I've never heard of Tarlov cysts causing pain.

I’ve had at least one patient in last year that I’ve narrowed down to this. Buttock pain only.

 

[MitchLevi]

I’ve had at least one patient in last year that I’ve narrowed down to this. Buttock pain only.

How exactly did you do that?

This discussion has come up repeatedly. I was always taught they don't hurt. Truthfully, I don't know why they would hurt either.

It's pain, not diabetes.

 

[clubdeac]

How exactly did you do that?

This discussion has come up repeatedly. I was always taught they don't hurt. Truthfully, I don't know why they would hurt either.

It's pain, not diabetes.

Honestly I think they’re like anything else in the spine, annular tears, disc protrusions, spondylosis. In the right setting and with enough inflammation they can be painful but typically are asymptomatic

 

[Tboned]

Honestly I think they’re like anything else in the spine, annular tears, disc protrusions, spondylosis. In the right setting and with enough inflammation they can be painful but typically are asymptomatic

In the right setting and with enough inflammation? What are you even talking about? The right setting is never.

 

[clubdeac]

In the right setting and with enough inflammation? What are you even talking about? The right setting is never.

Tbone you’ve established your ignorance before. No need to explain buddy

 

[deleted875186]

In the right setting and with enough inflammation? What are you even talking about? The right setting is never.

I could be convinced cysts cause symptoms of IR drains a cyst and it relieves their symptoms. But excluding other causes doesn’t convince me the cysts are symptomatic, plenty of people have pain symptoms without a clear cause.

 

[Tboned]

Tbone you’ve established your ignorance before. No need to explain buddy

Cmon @clubdeac relax a little bit. If you want to start a new thread called “ the ignorance of Tboned” go ahead. But re: this thread, I’m always willing to learn. Explain what you’re talking about, I’m interested to hear your thoughts on the inflammatory component or a Tarlov cyst. How are you determining that? It’s not an apples to apples comparison with annular tears and other pathology you hinted at.

 

[Orin]

I don't think of Tarlov cysts as necessarily inflammatory. There was some early postulations about inflammation playing a role in their creation, but I don't know if they really cause inflammation. I do see that they are capable of generating a great deal of pressure. As you look for them more, you'll see cysts that cause remodeling of the bone around them from outward pressure. It's not unreasonable to me then that the pressure causes a neuropraxia of a nerve root inside or outside the cyst. Drainage by IR or an aggressive pain doc allows one to verify that this is the generator. That fibrin injection thing may work sometimes, but I've seen mixed results. I haven't seen a surgeon willing to work on them.

How do you account for the 174 who declined treatments from a statistical standpoint? BOCF.

I think of that as "Patient Selection"

I'm not sure I get the BOCF? Google says baseline-observation-carried-forward which might make sense if you're looking at this like a RCT for ITT, but this is a retrospective case series.

I interpret this as a subgroup they selected for have good results with drainage/fibrin patching, but they may have weeded out a lot of cases that they didn't think would have good results. I would love to hear more about that population too and understand the selection criteria.

 

[lobelsteve]

I don't think of Tarlov cysts as necessarily inflammatory. There was some early postulations about inflammation playing a role in their creation, but I don't know if they really cause inflammation. I do see that they are capable of generating a great deal of pressure. As you look for them more, you'll see cysts that cause remodeling of the bone around them from outward pressure. It's not unreasonable to me then that the pressure causes a neuropraxia of a nerve root inside or outside the cyst. Drainage by IR or an aggressive pain doc allows one to verify that this is the generator. That fibrin injection thing may work sometimes, but I've seen mixed results. I haven't seen a surgeon willing to work on them.


I think of that as "Patient Selection"

I'm not sure I get the BOCF? Google says baseline-observation-carried-forward which might make sense if you're looking at this like a RCT for ITT, but this is a retrospective case series.

I interpret this as a subgroup they selected for have good results with drainage/fibrin patching, but they may have weeded out a lot of cases that they didn't think would have good results. I would love to hear more about that population too and understand the selection criteria.

208 had cysts and were the selected patients. 34 had direct surgery referral and 174 said no thanks. Lets say every one of those 208 was treated and had excellent results. Now lets say all 208 had terrible results. It would completely change the outcomes. They only treated 213.

 

[clubdeac]

Cmon @clubdeac relax a little bit. If you want to start a new thread called “ the ignorance of Tboned” go ahead. But re: this thread, I’m always willing to learn. Explain what you’re talking about, I’m interested to hear your thoughts on the inflammatory component or a Tarlov cyst. How are you determining that? It’s not an apples to apples comparison with annular tears and other pathology you hinted at.

So we know inflammation is a necessary component to experience pain in spinal stenosis, facet arthritis, discogenic lbp and particularly radicular pain. You need two things to experience pain in these scenarios, some structural or anatomical pathology AND inflammation. If you take one of these away, the patient typically won’t experience pain regardless of the MRI findings. There are studies showing this.

I’ve seen multiple patients with asymptomatic tarlov cysts as well those where nothing else explains their pain other than the tarlov cyst. In those cases I presume the cyst is pressing on pain generating structures. However based on what we know about spinal pathology, there is likely an inflammatory component. I don’t know that but am rather extrapolating from what we know about other spinal pathologies

 

[MitchLevi]

Pain does not require an anatomical basis.

 

[clubdeac]

Pain does not require an anatomical basis.

I’m talking about typical spinal pain, not CRPS, central pain syndrome, fibromyalgia, phantom limb pain, chronic pelvic pain etc.

 

[MitchLevi]

I’m talking about typical spinal pain, not CRPS, central pain syndrome, fibromyalgia, phantom limb pain, chronic pelvic pain etc.

Me too

 

[Ducttape]

So we know inflammation is a necessary component to experience pain in spinal stenosis, facet arthritis, discogenic lbp and particularly radicular pain. You need two things to experience pain, some structural or anatomical pathology AND inflammation. If you take one off these away, the patient typically won’t experience pain regardless of the MRI findings. There are studies showing this.

I’ve seen multiple patients with asymptomatic tarlov cysts as well those where nothing else explains their pain other than the tarlov cyst. In those cases I presume the cyst is pressing on pain generating structures. However based on what we know about spinal pathology, there is likely an inflammatory component. I don’t know that but am rather extrapolating from what we know about other spinal pathologies

technically, you do not require anything anatomic to experience pain. see fibromyalgia (at least based on what we know about it now)

pain is a subjective experience.

and when i look at MRI scans for failed back syndrome, im not seeing a lot of inflammation. even facet arthropathy - is that were purely inflammation, then steroidal therapy would be the mainstay and only treatment, right?

 

[SSdoc33]

tarlov cysts can cause pain, but it not the cyst itself. it is when a huge cyst scallops out the sacrum or compresses S1 or S2. this is exceptionally rare. maybe 2 cases in 15 years. ive diagnosed them on EMG. surgery is +/-. they shouldt be dismissed outright, but id say 99% of the time they mean nothing

 

[clubdeac]

technically, you do not require anything anatomic to experience pain. see fibromyalgia (at least based on what we know about it now)

pain is a subjective experience.

and when i look at MRI scans for failed back syndrome, im not seeing a lot of inflammation. even facet arthropathy - is that were purely inflammation, then steroidal therapy would be the mainstay and only treatment, right?

I guess no one read what I wrote. Oh well

“So we know inflammation is a necessary component to experience pain in spinal stenosis, facet arthritis, discogenic lbp and particularly radicular pain.”

 

[Ducttape]

yes we did.

so why do you feel that inflammation is a necessary component to experience pain from the 4 conditions you state?

you state there are studies. can you post them?

 

[clubdeac]

yes we did.

so why do you feel that inflammation is a necessary component to experience pain from the 4 conditions you state?

you state there are studies. can you post them?

Studies are from fellowship as are the text book references. I could try and find them but this is like finding the study that shows seat belts save lives, not really necessary. Again I’m talking about the 95% of scenarios with lumbar radic, spinal stenosis, facet arthritis etc

 

[Ducttape]

how often do we see edema or elevated ESR in these patients with arthritic spines?



then again, maybe you are conflating the presence of inflammatory cytokines - substance P, histamines - in the chemical milieu contributing to neuropathic pain in your definition of inflammation....

 

[clubdeac]

how often do we see edema or elevated ESR in these patients with arthritic spines?



then again, maybe you are conflating the presence of inflammatory cytokines - substance P, histamines - in the chemical milieu contributing to neuropathic pain in your definition of inflammation....

I’m not conflating anything. But yes that’s exactly what I’m talking about. Those are inflammatory mediators and although they may not directly raise ESR or CRP, that doesn’t mean there isn’t inflammation present. I mean cmon, we all prescribe NSAIDs for inflammation everyday. Most all of these patients have normal ESRs. Does that mean we’re not treating inflammation or we’re conflating something? This really shouldn’t be difficult or controversial

 

[Ducttape]

inflammatory mediators =/= inflammation.
huge difference.


which is why steroid injections dont work for facet arthritis or degenerative spinal stenosis with neurogenic claudication.



and ive stopped prescribing NSAID for the types of conditions you describe.

why?

they dont work.

because it is not inflammation that is driving their pain.

 

[clubdeac]

inflammatory mediators =/= inflammation.
huge difference.


which is why steroid injections dont work for facet arthritis or degenerative spinal stenosis with neurogenic claudication.



and ive stopped prescribing NSAID for the types of conditions you describe.

why?

they dont work.

because it is not inflammation that is driving their pain.

I give up with you. Steroid injections work remarkably well in the short term (~3 months) for spinal stenosis and facet arthritis. You must be doing them wrong.

I'd be interested in hearing your theory regarding the pathophysiology of facet mediated pain, spinal stenosis, discogenic lbp, painful radiculopathy etc. What is your understanding of nociception?

And when I refer to inflammation I do mean substance P, IL-6, cytokines, TNF-alpha, PLA2 and on and on...

 

[lobelsteve]

I give up with you. Steroid injections work remarkably well in the short term (~3 months) for spinal stenosis and facet arthritis. You must be doing them wrong.

I'd be interested in hearing your theory regarding the pathophysiology of facet mediated pain, spinal stenosis, discogenic lbp, painful radiculopathy etc. What is your understanding of nociception?

And when I refer to inflammation I do mean substance P, IL-6, cytokines, TNF-alpha, PLA2 and on and on...

Steroid injections do not work for facet arthritis.