Diagnostic Conundrum: Nerve Root Pain or Piriformis Syndrome
Patient Background
A female patient in her early 50s was reviewed at Pain Spa for chronic left-sided buttock and lower limb pain of more than two years’ duration. The symptoms had become progressively worse over the past few months, significantly affecting her sleep, mobility, and quality of life.
The onset of pain followed a fall onto her buttocks after slipping on ice. Since then, she reported persistent gluteal pain radiating to the lateral hip and thigh, occasionally extending below the knee. Although the pain did not typically reach the foot, she had previously experienced transient tingling in the left foot. She also noted occasional, milder symptoms on the right side.
She described the pain as a combination of a dull, nagging toothache-like sensation and intermittent sharp, stabbing pain, accompanied by occasional numbness and tingling. The pain was constant but varied in intensity, exacerbated by static standing, gardening, and prolonged sitting. Daytime distraction offered some relief, but her sleep remained significantly disturbed.
Past Treatments
The patient had trialled various conservative treatments, including acupuncture, physiotherapy, chiropractic, osteopathy, and a short course of amitriptyline, all with minimal benefit. She had previously been seen by a pain specialist and was advised to attend a Pain Management Programme, but could not proceed due to work constraints. Furthermore, she was seeking definitive treatment rather than long-term symptom management.
Investigations & Diagnosis
An MRI scan of the lumbosacral spine revealed multi-level degenerative disc changes, including disc bulges and protrusions at L4/5 and L5/S1, resulting in contact with the traversing L5 and S1 nerve roots bilaterally. There was no evidence of significant central canal or foraminal stenosis.
Based on the clinical history and imaging findings, Dr. Krishna concluded that the likely cause of the patient’s symptoms was lumbar nerve root irritation, predominantly involving the L5 and S1 dermatomes. A recent suggestion of piriformis syndrome by a physiotherapist was discussed during the consultation; however, Dr. Krishna felt the clinical features and imaging did not support this diagnosis, noting that piriformis syndrome is frequently misattributed in cases of deep gluteal pain.
Management Plan
A comprehensive management discussion was undertaken, and the following plan was agreed:
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The patient would undergo a fluoroscopically guided left S1 nerve root block, serving both a diagnostic and therapeutic purpose. The potential risks, benefits, and the possibility of only temporary relief were discussed in detail.
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The importance of a post-procedure review at four weeks was emphasised to assess the response and determine next steps.
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Regardless of the injection outcome, the patient was advised to adopt a structured rehabilitation programme, as physical conditioning and activity pacing remain central to long-term management.
Treatment at Pain Spa and Outcome
The patient subsequently underwent a left S1 nerve root block under fluoroscopic guidance as a day case procedure. Following the injection, she experienced excellent pain relief, with near-complete resolution of her buttock and leg symptoms. Her functional ability improved significantly, enabling her to return to many of her usual activities without discomfort. She discontinued all analgesic medications, including Co-Codamol and Ibuprofen. In addition, her sleep quality improved markedly, which had a positive impact on her mood and overall wellbeing. She expressed high satisfaction with the outcome.
Expertise and Technique
Dr. Krishna is a highly experienced pain specialist, recognised for his thorough and methodical clinical assessments, which include detailed history-taking, appropriate physical examinations, and review of imaging. His ability to accurately identify the primary pain generator allows him to perform precise, image-guided diagnostic injections, leading to consistently high patient satisfaction rates.
Technical skill plays a crucial role in the success of interventional procedures. Fluoroscopic or ultrasound-guided injections, when performed with accuracy, can offer both diagnostic clarity and significant therapeutic benefit. This case underscores the importance of clinician expertise and guided precision in achieving optimal outcomes in pain management.
Conclusion
This case highlights the importance of a detailed clinical assessment in patients with chronic gluteal and radicular pain. Although piriformis syndrome is commonly considered, it is often overdiagnosed in the absence of clear supporting evidence. In this instance, the patient’s symptoms were more consistent with lumbar disc-mediated nerve root irritation, and a targeted nerve root injection was appropriately selected as the initial interventional approach. The excellent outcome following the procedure further confirms the diagnosis and demonstrates the potential for significant improvement with accurately guided treatment.
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