The case of the elderly acrobat
An 84 year old man presented with the diagnosis of ‘sciatica’ following a fall, two weeks before Christmas. He was visiting family in Oklahoma when he hit a patch of black ice. His legs went up in the air as he bell backwards landing flat on his back, ankles over ears. This man, a tradesman before retirement, was not muscular, but was more flexible than most. He brushed himself off and thought nothing of it until the next morning when the pain in his back awakened him.
His visit to the local ER resulted in radiological evaluation which demonstrated the anticipated arthritis, desiccated disc and mild osteopenia. No surprises there. Other than thyroid replacement and medications for blood pressure and angina, he was quite healthy.
The pain in his back, radiating to the lateral thigh and down to the calf suggested something a bit more sinister. Being a typical man, and consummate weekend warrior, he chose to wait a while before seeking additional medical attention. He traveled to and from Oklahoma again, and the pain worsened to the point where he found himself using a fitted cane. Now that he was having difficulty sleeping, he was time referred for evaluation and treatment of spinal trauma.
Physical examination was entirely unremarkable except for an area of exquisite tenderness in the inferior-lateral border of the Posterior Superior Iliac Spine. It was only tender if the patient was in the standing position, leaning forward. Pressure there not only caused him to shout, but it reproduced the ‘leg giving away,’ and initiated pain in the lateral calf.
Superior Gluteal Neuralgia
The diagnosis of Neuralgia of the Superior Gluteal Nerve (SGN) was entertained and treatment was initiated. A simple peripheral nerve block of the SGN was performed. Moments later, the patient was able to stand, walk and move about without pain at all. The cane was no longer necessary, at least for 6-8 hours, anyway. Treatment with oral NSAID’s was initiated (meloxicam 7.5 mg) , and high-concentration 40% transdermal MSM (Kinkease® Stages of Life, Inc. was prescribed. The patient was scheduled for follow-up in 2 weeks.
Return visit revealed a patient able to sit without pain and ambulate without a cane. The ‘sciatica’ which was not sciatic at all, has all but abated. Still a bit tender, a second nerve block was performed to ‘seal the deal,’ clinically. Superior Gluteal Neuralgia is quite common in clinical practice. Pain with sitting, leaning forward and driving is typical. Referred pain to the groin, flank and calf can be expected. Physical examination is the essential tool in diagnosis, and diagnostic-therapeutic nerve block will be a life-changing intervention for these patients.