Abstract
Introduction
Although back pain / sciatica are common conditions in the general population and their etiology is very well understood, there is a strong interest in non-musculoskeletal origins of pelvic pain masked by symptoms resembling radicular pain such as in the case of circulatory disorders in anatomic sites beyond the spine. This study presents a particular case of low back pain & sciatica as the main symptoms of pelvic venous congestion syndrome.
Material and Methods
A 25 year old female presented to the Spine Institute of New England complaining of 90% low back pain and 10% right lower extremity constant pain affecting the lateral aspect of her thigh and averaging around 6/10 with reported flare-ups up to 10/10 especially at the end of a long day full of activities and with prolonged standing. She has also been complaining of sleep disturbances over the last 6–9 months. She has tried land physiotherapies in the past unsuccessfully. She complained of mild dyspareunia as well. Clinical assessment suggested pain of discogenic and/or facetogenic nature, questionable meralgia paresthetica, and sciatica; however, plain radiographs were equivocal. One month prior to the patient's visit to our clinic, Gynecological laboratories ordered by primary care physician were unremarkable. The patient followed a conservative treatment plan consisted of simple analgesics, non-steroidal (Meloxicam), and steroidal (Methylprednisolone) anti-inflammatory medication, antidepressant (Fluoxetine) and antiepileptic drugs for neuropathic pain (Gabapentin). One month later, she reported no significant improvement especially on her right thigh stating that cortisone has helped initially; NSAID's were somehow helpful unlike Gabapentin, which did not help at all. The patient was followed up with MRI, which demonstrated a tubular fluid-filled structure in the region of the right adnexa in addition to mild effacement of the thecal sac at the L3-L4 level, not a strong evidence of discogenic/radicular pain. Subsequently, a transabdominal US revealed prominent pelvic veins bilaterally – more pronounced on the right side – reflecting the likelihood of pelvic venous congestion syndrome. EMG excluded nerve root compression at the spinal level, while a thorough gynecological clinical examination confirmed the aforementioned diagnosis at initial stage due to hormonal dysfunction.
Results
The patient has been placed on cortisone treatment for ovarian function suppression showing encouraging early outcomes.
Conclusion
Even though pelvic venous congestion syndrome is diagnosed via exclusion of other pathological conditions that most likely cause symptoms of low back pain and/or sciatica, this case report comes to highlight the importance of integrated initial systemic clinical assessment, particularly when more than one medical specialties are involved in the region of interest.