Intractable hip and leg pain
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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The following is a discussion of the many conditions that may cause intractable pain in the hip and leg.
Sciatica is inflammation of the sciatic nerve, which passes from its origin in the low back down between layers of the muscles in the buttocks, then into the back of the thigh. Sciatic pain usually starts in the buttocks and radiates down the rear of the thigh and lower leg to the foot. While pain may be present in the lower back, it isn't always.
A primary cause of sciatica is a herniated or bulging lower lumbar (low back) intervertebral disc that compresses one of the nerve roots before it joins the sciatic nerve.
Another cause of sciatica is piriformis syndrome. The piriformis muscle extends from the sacrum to the top of the femur at the greater trochanter, passing over the sciatic nerve. A tight piriformis can compress and irritate the sciatic nerve.
The primary treatment of sciatica is rest. Rest should extend for about three days. Various medications such as non-steroidal anti-inflammatory drugs, analgesics, and muscle relaxants may be prescribed. Also, anesthetic agents may be injected into the area around the spinal cord (epidural injections).
Recently, new surgical techniques, such as microsurgery, have been used. So far, success at relieving pain and neurologic symptoms has been good. Not all individuals with disc problems, however, are suitable for this surgery.
Physical therapy under a doctor's supervision or prescription is often used to relieve the pain of sciatica. Patients are taught to strengthen core muscles, the four muscle groups that support the low back.
Spinal stenosis occurs when the spinal canal is narrowed.
A few diseases can cause spinal stenosis. Among them are osteoarthritis, scarring and overgrowth from previous spinal fusion, can lead to stenosis.
Spinal stenosis usually affects the elderly. Symptoms include back pain with variable leg pain and weakness associated with walking. The pain is severe with standing and walking, and can usually be relieved by a short period of rest.
Spinal stenosis generally becomes progressively more painful over time. After a medical history and physical examination, an MRI should be ordered to confirm the diagnosis..
Treatment of stenosis consists of rest, anti-inflammatory medications, support from a corset or brace, epidural injections, and gradual exercise. The majority of patients with spinal stenosis can be successfully managed without surgery. If these treatments fail, surgery may be the answer. Using a procedure called decompression, a spine surgeon “decompresses” the nerve roots as they exit from the spinal canal into the legs. In some cases, spinal fusion is necessary.
Osteoarthritis of the hip can produce discomfort in the buttock, groin and anterior thigh. When severe, it causes pain not only with weight-bearing but also with rest.
Cancers affecting bone can also cause intractable hip and leg pain. In this situation, a patient will have great difficulty finding a comfortable position to sleep in. Weight loss, night sweats, and a previous history of malignancy are all clues. The diagnosis is further confirmed if a patient develops a pathologic fracture.
Chronic neurogenic pain is a common intractable pain syndrome in MS. This pain is described as constant, boring, burning or tingling intensely. It usually occurs in the legs.
Osteomalacia is a form of metabolic bone disease that can present as chronic pain including intractable bilateral leg and back pain, and leg weakness. The diagnosis is suspected by x-ray findings and confirmed with laboratory testing that shows low levels of vitamin D. Treatment with high dose calcium, phosphate, and vitamin D will cure the condition.
Failed back surgery syndrome
This describes persistent, disabling pain in the leg and/or lower back that follows one or more corrective back surgeries. Treatment is difficult with physical therapy, epidural injections, facet blocks, transcutaneous nerve stimulation, intervertebral disc decompression (IDD), acupuncture, biofeedback, hypnosis, and narcotics all employed with varying degrees of success (or failure).
Complex regional pain syndrome and reflex sympathetic dystrophy
A term used to describe persistent, disabling pain in the leg that follows an injury to the legs. This can also occur after low back surgery. Patients present with severe pain accompanied by color and temperature changes of the skin, abnormal sweating and skin changes involving the affected limb. Treatment consists of physical therapy, sympathetic ganglionic blockade, and narcotic analgesics.
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