A 30-Year History of Left-Sided ‘Chronic Sciatica’


A 30-Year History of Left-Sided ‘Chronic Sciatica’

Alan J. Taylor, Roger Kerry, Darren A. Rivett

Geoff, a 53-year-old male, presented for assessment of chronic left-leg discomfort and numbness, which he had suffered since his mid-20s. He had been referred by a physiotherapy colleague, who confessed to being bemused by the patient’s presentation. Geoff worked as a self-employed builder and enjoyed cycling in his spare time, as well as competing in triathlons.

Subjective Examination

On examination, Geoff was very lean and fit (he still rode a bicycle daily between 15 and 80 km) and reported no comorbidities, although he had suffered occasional intermittent low back pain over the last 10–15 years associated with work tasks involving bending, lifting or carrying. He was not taking any medications and had no significant past medical or family history, although he reported a recent ‘cardiac ablation for a heart arrhythmia’ performed 18 months previously.

History of Present Complaint

Geoff recounted that the onset of his left-leg symptoms was over 30 years ago, and he recalled feelings of left-leg discomfort, weakness and numbness which were manifest when he was cycling (he was a competitive cyclist at the time). He had no low back pain associated with the symptoms at the time of onset. Geoff recalled his back symptoms later developed in his 30s–40s which he related to the manual nature of his job. Cycling presently still provoked his left-leg symptoms. The pain, weakness and numbness were now reported as being non-specific in terms of distribution (see Fig. 30.1), along with a general feeling of fatigue in the limb. He described that the symptoms would begin in the buttock and hindquarter, then ‘creep’ into the thigh, eventually affecting the whole leg and foot. The numbness was most noticeable in the foot.


Fig. 30.1 Geoff’s body chart.

On consulting his general practitioner, Geoff was given a diagnosis of ‘sciatica’. He was then referred to a physiotherapist, who agreed with this diagnosis, and early management was implemented involving a wide variety of mechanical and manual techniques. These ranged from spinal thrust manipulation to various prescribed exercises. His failure to respond to these physiotherapy treatments led Geoff to visit other manual therapists, including osteopaths and chiropractors. Nonetheless, his condition remained completely unchanged.

Twenty years following the onset of his symptoms, Geoff was categorized under the ‘chronic pain’ label. He went through a process of pain management, counselling, cognitive-behavioural therapy and various combinations of other pain therapies. None of the described interventions or management strategies proved to be successful.

A recent magnetic resonance imaging (MRI) scan confirmed disc protrusions at L4/L5/S1, with mild impingement on the neural tissue at these same levels. Geoff subsequently underwent spinal injections over the last 12 months, which again had made little or no difference in his condition.

All in all, he considered that his overall condition was unimproved, if not worsening, noting, ‘I’ve tried it all, nothing works … and I reckon it’s getting steadily worse’.

From a psychosocial perspective, Geoff reported that he was in a stable relationship, had no underlying psychological issues, engaged in regular exercise and had learnt to ‘cope’, adopting a stoical attitude to his condition. However, he reported remaining frustrated by his condition and his inability to cycle at the same level as his ‘mates of the same age’, and he described being ‘left behind in the hills’ as particularly frustrating. He displayed an element of dismissal for some of the explanations he had received of why he was still in pain, and he retained the opinion that ‘something was wrong’. He indicated that this was why he continued to search for an answer and pay privately for ongoing consultations.

Reasoning Questions:

  1. 1. Can you please provide your initial impressions of Geoff’s presentation at this stage of the consultation? In particular, what were your thoughts on his lack of responsiveness to all previous interventions?

Answer to Reasoning Question:

The key elements of Geoff’s presentation at this time were the long and protracted history, the description of the symptoms (e.g. fatigue, weakness), the exercise-induced nature of the early and current presenting symptoms (induced by cycling) and the failure to respond to any type of intervention. Pattern recognition at this stage, based on previous work in this field, was suggestive of a possible vascular origin of the pain and other leg symptoms (Taylor and George, 2001; Peach et al., 2012). The failure to respond to previous treatments/interventions is a common feature of such cases and is in fact a reason to consider a vascular assessment, particularly when an exercise-induced element is a feature of the presentation. Geoff’s cardiac comorbidity was also potentially a related risk factor, but this seemed unlikely.

From a broader perspective, there was the possibility of a concomitant chronic non-specific low back pain disorder with distal referral, either from somatic or nerve root structures. However this hypothesis was not supported by the examinations of the previous clinicians.

Clinical Reasoning Commentary:

Practitioners generate hypotheses early in the patient encounter, and it is clearly evident in this answer that pattern recognition, that is, a type of fast or inductive thinking (system 1; see Chapter 1), has been automatically employed. As further exemplified in this response, pattern recognition is highly dependent on prior clinical experiences (both direct, personal experiences and those gleaned from other practitioners) with similar presentations and on the recognition of limited but key clinical cues. In this instance, the protracted history, the type of symptoms described, the lack of responsiveness to numerous prior neuromusculoskeletal interventions and, most importantly, the persistent exercise–symptom relationship are all examples of such critical clinical features that form a pattern.

Symptom Pattern

Geoff explained that he used a pulse monitor for cycling and could predict more or less the exact onset of the symptoms related to his heart rate. His symptoms would initially develop in his left buttock at or around 135 beats per minute (bpm); if he continued to elevate his heart rate via increased effort, such as by climbing a hill or cycling harder on the flat terrain, then the symptoms would develop further into the leg, which would concomitantly feel weak or fatigued. He described it as though he was ‘cycling with one leg’ and that his ‘leg goes dead’. There was no reported relationship between his back pain and his leg symptoms experienced during exercise.

On a visual analogue score (VAS), Geoff indicated his discomfort varied between 0 and 8 out of 10 but that he could control it via the modification of effort linked to his heart rate. As Geoff explained, he only needed to ‘ease off’ to just below 135 bpm, and all of the symptoms would disappear. In fact, he was able to ride below the threshold of 135 bpm for hours without the onset of any noticeable symptoms. He denied any residual post-ride/effort symptoms.

Symptoms were now also being experienced in ‘normal or everyday’ effort-related activities, such as pushing a wheelbarrow or climbing stairs. This had only been noticed by Geoff over the last year.

When asked what he expected of his visit to our clinic, Geoff indicated he was seeking a second opinion. In his view, the pain was clearly exercise induced (in the patient’s own words: ‘from day one, I explained that the pain only came on when I exercised’). The overall impression at this stage was that Geoff was a very stoical ‘coper’ who, rather than suffering stress or fear and demonstrating avoidance behaviour, was quite simply frustrated with his condition and had a genuine desire to be more active.

Reasoning Questions:

  1. 2. Did this further information about the exercise-related onset of Geoff’s symptoms cause you to modify any of the hypotheses you may have previously been entertaining, such as the ‘pain type’, the ‘sources of nociception and associated pathology’, or ‘contributing factors to the development and maintenance of the problem’?

Answer to Reasoning Question:

After 30 years of symptoms, it was clear that Geoff fell into the ‘chronic pain’ category, and there was a very real possibility that his symptoms might have had an element of maladaptive central sensitization (Nijs et al., 2015) or nociplastic pain, which would fit with contemporary thinking with regard to pain science. However, a key factor supporting an ischaemic-induced nociception presentation was the very clear pattern of reproducibility of his symptoms during exercise, which began at age 18 years and remained to the present day. The young age of onset also suggested that a differential diagnosis of spinal stenosis would have been unlikely.

Furthermore, it is well known that some sports participants, most commonly cyclists, may suffer unilateral or bilateral arterial flow limitations, postulated to be linked to ‘kinking’ of the arteries and a condition called endofibrosis (Peach et al., 2012). Previous clinical experience with similar patients who had suffered 5- and 15-year delays to diagnosis led to prudence being exercised with regard to accepting the central sensitivity hypothesis. It is well recognized that vascular tissue may be a source of pain either from local nociception/pathology or via the mechanism of ischaemia. The pattern of symptoms in this case suggested the latter and indicated the need for further investigation. In addition, Geoff had been non-responsive to a multitude of pain management interventions for neuromusculoskeletal disorders, which further supported the need to investigate the vascular ischaemic hypothesis.

Clinical Reasoning Commentary:

In this answer, diagnostic reasoning with the simultaneous consideration of hypotheses in two categories is evident (nociplastic – ‘pain type’; vascular ischaemia or local pathology – ‘source of nociception and associated pathology’). Hypotheses regarding pathology are particularly critical for identifying possible sinister and non-musculoskeletal conditions. Notably, red flags, that is, signs and symptoms that may indicate the presence of more serious pathology and systemic or viscerogenic pathology/disease, should elicit consideration of referral for further consultation/investigation, as has been suggested here for Geoff.

Physical Examination

On inspection, Geoff had no apparent deformities or leg-length discrepancies, and a cursory musculoskeletal examination demonstrated full spinal range of motion without any symptom provocation and an entirely normal neurological examination. These tests were performed because it was considered important to scan or check the spinal somatic and neuropathic tissues before moving on to examine other systems. No further musculoskeletal examination was carried out at this point. Instead, it was decided that the session time would be allocated to examining the vascular system.

Vascular Examination

Observation, Palpation and Resting Blood Pressure

Temperature was normal, capillary refill was normal and there were no signs of ischaemia in the lower limbs (e.g. colour or skin changes). Pulses (femoral, popliteal, dorsalis pedis and posterior tibial) were all present and normal for both limbs at rest.

The ankle-brachial pressure index (ABPI) was next tested. ABPI is a non-invasive vascular screening test to identify large-vessel peripheral arterial disease by comparing systolic blood pressure in the ankle to the highest of the brachial systolic blood pressures, which is the best estimate of central systolic blood pressure. This test was indicated both as a baseline measure of resting vascular health and because of the presenting symptoms (Kim et al., 2012).

Repeated and average resting systolic blood pressure values after 15 minutes of resting in supine lying are shown in Tables 30.1 and 30.2. The left resting ABPI was 1.05 (normal), and the right resting ABPI was 1.09 (normal). Values > 1.2 or < 1.0 are considered abnormal, and the lower the value, the greater the magnitude of arterial disease.

Apr 2, 2020 | Posted by in SPORT MEDICINE | Comments Off on A 30-Year History of Left-Sided ‘Chronic Sciatica’

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