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Sciatic Pain and Endometriosis

While endometriosis may not necessarily have to be on the sciatic nerve to cause similar symptoms, there have been some cases documented of that happening. Some symptoms could be: cyclical pain along the sciatic nerve (sciatica), back pain, gluteal pain radiating to the front of the thigh and outside the lower leg, positive straight leg raise test (seen in low back disc injuries as well), sensory loss, changes in reflexes, and muscle weakness (Foti et al., 2018). There are multiple case studies demonstrating endometriosis affecting the sciatic nerve region. However, symptoms can occur from lesions near those areas (like the side posterior pelvic region) (Vilos, Vilos, & Haebe, 2002). Pelvic floor dysfunction and other myofascial disorders (such as piriformis syndrome) can also cause similar symptoms (Cass, 2015; Weiss, Rich, & Swisher, 2012). As is often seen with endometriosis, there may be more than one pain/symptom generator present. This might mean utilizing different providers, such as a pelvic physical therapist as well as a surgeon, in order to address all the underlying issues. (See Pelvic Floor Dysfunction and Physical Therapy Resources )

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Studies:

“Cyclic leg signs and symptoms were associated with pelvic peritoneal pockets, endometriosis nodules, or surface endometriosis of the posterolateral pelvic peritoneum. We hypothesize that the pain associated with these lesions is more likely referred pain originating from pelvic peritoneum than direct irritation of the lumbosacral plexus of the sciatic nerve.”

“Endometriosis is a common gynecological disorder that can cause musculoskeletal symptoms and manifest as nonspecific low back pain. The patient was a 25-year-old woman who reported the sudden onset of severe left-sided lumbosacral, lower quadrant, buttock, and thigh pain. The physical therapist examination revealed findings suggestive of a pelvic visceral disorder during the diagnostic process. The physical therapist referred the patient for medical consultation, and she was later diagnosed by a gynecologist with endometriosis and a left ovarian cyst.”

“Radiating leg pain related to the menstrual cycle has been reported as a complication of endometriosis in a number of case studies (Baker et al., 1966; Bjornsson, 1976; Denton & Sherrill, 1955; Floyd et al., 2011; Forrest & Brooks, 1972; Head et al., 1962; Motamedi et al., 2015; Pacchiarotti et al., 2013), and in two surveys (Missmer & Bove, 2011; Walch et al., 2014). A consistent and thus perhaps key diagnostic feature seems to be the cyclical or catamenial nature of the symptom, especially earlier in the progression of the endometriosis (Capek et al., 2016; Dhote et al., 1996; Moeser et al., 1990; Takata & Takahashi, 1994; Zager et al., 1998). However, the symptom duration usually expands with endometriosis progression, developing into constant pain if left untreated.

“Examination findings in women with leg pain due to endometriosis are typical of sciatica due to other causes (Torkelson et al., 1988), including painful straight leg raising testing, and may also include a diminished Achilles tendon reflex, mild muscular atrophy, and tenderness of the sciatic nerve at the sciatic notch. Lumbar spinal investigations (myelogram, CSF analysis) are usually unremarkable, but magnetic resonance imaging can demonstrate larger lesions (Binkovitz et al., 1991; Cottier et al., 1995; Yekeler et al., 2004).

“Surgical descriptions of sciatic endometriosis describe inflammatory lesions that involve surrounding structures that are not necessarily otherwise diseased (Descamps et al., 1995; Yekeler et al., 2004). In an animal model, it has been shown that a focal inflammation of the sciatic nerve (called sciatic neuritis) evokes mechanical sensitivity in the axons of a subset of nociceptive (potentially pain-evoking) neurons without causing overt nerve damage (Bove et al., 2003; Dilley & Bove, 2008; Dilley et al., 2005). Furthermore, the sheaths of nerve trunks are innervated by mechanically and chemically-sensitive nociceptors (Bove & Light, 1995a, b, 1997), which also participate in maintaining the local environment of the nerve (Sauer et al., 1999). These findings suggest that inflamed nerves are a source of pain perceived as coming from the nerve and as coming from the structure(s) that the nerve innervates.”

“Endometriosis (EN) is a common gynecological condition characterized by the presence of functional endometrium located outside the uterine cavity. Sciatic nerve (SN) is rarely affected by EN. Magnetic resonance imaging allows a direct visualization of the spinal and SN, and it is the modality of choice for the study of SN involvement in extrapelvic EN. We report a case of an endometrioma located in the right SN with a systematic review of the literature.”

“The patient is a 49-year-old perimenopausal woman with dysmenorrhea and a left ovarian cyst who presented for evaluation of new onset left hip and leg pain. The left ovarian cyst was first noted 4 years ago and the patient declined surgery at that time, instead opting for surveillance with repeat imaging which now demonstrated an interval increase in the cyst size. The patient had an extensive evaluation for her leg pain including MRI and nerve conduction studies which were all unremarkable. The patient declined medical management or definitive surgical treatment of the suspected endometriosis. She opted for a diagnostic laparoscopy and left ovarian cystectomy.”

  • Roca, M. U., Bandeo, L., Saucedo, M. A., Bala, M., Binaghi, D., Chertcoff, A., … & Pardal, M. F. (2019). Cyclic Sciatica: Presentation of a Case With Intra and Extrapelvic Endometriosis Affecting the Sciatic Nerve and Utility of MR Neurography (P3. 4-026). Retrieved from https://n.neurology.org/content/92/15_Supplement/P3.4-026.abstract  

“A 35-year-old female patient consulted for right low back pain extending along her posterior thigh, calf and foot since 2 years. The pain was recurrent, acute in onset, lasted several days and gradually diminished until disappearing. It was refractory to common analgesics and during the crisis she had difficulties to walk. Neurologist requested a calendar of pain in which the relationship between the menstrual cycle and the pain became evidenced. We performed MRN of the lumbo sacral plexus that showed multiple endometriotic implants in ovaries, L5-S1 roots and a huge one on the sciatic nerve (intra and extrapelvic segment). The patient started oral contraceptives but presented progressive worsening of pain until it became constant and developed step page. Electromyogram showed acute and chronic axonal damage in the sciatic nerve distribution. Medical treatment was changed to leuprolide acetate. The patient evolved with improvement of ovarian endometriosis but persistence of sciatic nerve lesions, leg pain and weakness up to now. Surgical option was considered.”

“A 25-year-old woman presented to her general practitioner with a two-month history of constant pain in her thigh. There was no history of trauma and the onset was insidious. A diagnosis of a soft-tissue injury was made. However, despite anti-inflammatory medication and physiotherapy she developed increasing pain, typically sciatic in nature, from the left buttock, radiating down the posterolateral aspect of the leg and heel. This would escalate to a severe left-sided sciatic pain during menstruation. Two years later she had developed a limp and was referred to an orthopaedic surgeon. At the time of clinical assessment she had marked pain (Visual Analogue Scale (VAS)2 7 and Peripheral Nerve Injury (PNI) scale3 2) and required either two crutches or a wheelchair. On examination, she had an antalgic gait and was unable to bear weight fully on her left leg because of the pain in her buttock and leg. The pain was exacerbated by hip flexion and knee extension. There was no apparent muscle wasting or sympathetic changes in the leg and foot. Palpation of the left gluteal region, especially over the sciatic notch, was painful. Motor power was preserved throughout the leg, except for some weakness in the biceps femoris. Straight-leg raising was to 30° only. Reflexes were present, but the ankle jerk only with reinforcement. Sensation to pin-prick, temperature and light touch was reduced in the heel and sole of the foot.

“The diagnosis of sciatic endometriosis was considered…Histopathological examination confirmed endometriosis of the sciatic nerve with no evidence of malignancy (Figs 4 and 5). Post-operatively and at 12 months follow-up her pain was considerably relieved (VAS2 2, PNI3 1). She was able to walk without crutches and could straighten the leg. There was an improvement in sensation over the heel and sole of the foot to pin-prick, temperature and light touch. She was referred to a gynaecologist, who performed a laparoscopy which now showed no evidence of intra-pelvic endometriosis.”

  • Yanchun, L., Yunhe, Z., Meng, X., Shuqin, C., Qingtang, Z., & Shuzhong, Y. (2019). Removal of an endometrioma passing through the left greater sciatic foramen using a concomitant laparoscopic and transgluteal approach: case report. BMC women’s health, 19(1), 95. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6624926/

“A 20-year-old woman presented with complaints of severe dysmenorrhea lasting for more than 6 years and dysfunction of her left lower limb lasting for approximately 4 months. Both CT and MRI demonstrated a suspected intrapelvic and extrapelvic endometriotic cyst (7.3 cm × 8.1 cm × 6.5 cm) passing through the left greater sciatic foramen. Laparoscopic exploration showed a cyst full of dark fluid occupying the left obturator fossa and extending outside the pelvis. A novel combination of transgluteal laparoscopy was performed for complete resection of the cyst and decompression of the sciatic nerve. Postoperative pathology confirmed the diagnosis of endometriosis. Long-term follow-up observation showed persistent pain relief and lower limb function recovery in the patient.”

“We report a case of a 32-year-old patient who presented with cyclic leg pain in the inner right thigh radiating to the knee caused by a cystic endometriotic mass in the obturator internus muscle with nerve retraction…. Surgical removal of the mass was performed using the laparoscopic approach… A mass located within the right obturator internus muscle, below the right iliac external vein, behind the corona mortis vein, and lateral to the right obturator nerve was identified. The whole region was inflamed, and the nerve was partially involved. Dissection was performed carefully with rupture of the tumor, releasing a chocolate like fluid (Fig. 2), and the cyst was removed. Pathology examination was consistent with endometriosis. Patient improvement was observed, with pain relief and improved ability for right limb mobilization.”

“The signs suggestive of intrapelvic nerve involvement include perineal pain or pain irradiating to the lower limbs, lower urinary tract symptoms, tenesmus or dyschezia associated with gluteal pain. Whenever deeply infiltrating lesions are present, the patient must be asked about those symptoms and specific MRI sequences for the sacral plexus must be taken, so that the equipment and team can be arranged and proper treatment performed.”

  • Walch, K., Kernstock, T., Poschalko-Hammerle, G., Gleiß, A., Staudigl, C., & Wenzl, R. (2014). Prevalence and severity of cyclic leg pain in women with endometriosis and in controls–effect of laparoscopic surgery. European Journal of Obstetrics & Gynecology and Reproductive Biology, 179, 51-57. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0301211514003029

“Before surgery, more women were affected by leg pain in the endometriosis group, compared to the control group (45.5% and 25.9%, respectively). Preoperative VAS scores for leg pain, however, were not significantly different between the two groups. A moderate correlation in the preoperative VAS scores between leg pain and dysmenorrhea was observed. After laparoscopy, we found a significant improvement in leg pain intensity in both groups. Conclusions: The prevalence of leg pain is increased in endometriosis, while leg pain intensity is not, compared to women without endometriosis. Laparoscopic surgery—even without preparation and decompression of nerve tissue—is associated with an improvement in pain intensity in women with endometriosis, as well as in the group without endometriosis.”

“Pelvic floor dysfunction can also arise in response to other common chronic pain syndromes, such as endometriosis, irritable bowel disease, vulvodynia, and interstitial cystitis. A prospective evaluation of patients with chronic pelvic pain of various etiologies found abnormal musculoskeletal findings in 37%, versus 5% of controls.7 For this reason, the pelvic floor should be included in any evaluation regardless of the suspected source of pelvic pain.”

References

Foti, P. V., Farina, R., Palmucci, S., Vizzini, I. A. A., Libertini, N., Coronella, M., … & Milone, P. (2018). Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights into imaging, 9(2), 149-172. Retrieved from https://link.springer.com/article/10.1007/s13244-017-0591-0

Vilos, G. A., Vilos, A. W., & Haebe, J. J. (2002). Laparoscopic findings, management, histopathology, and outcomes in 25 women with cyclic leg pain. The Journal of the American Association of Gynecologic Laparoscopists, 9(2), 145-151. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S1074380405601223

Saeid Gholami

Dr. Saeid Gholami is a medical doctor and the founder of iCareBetter. As a physician, he saw many patients with endometriosis who were suffering. And his patients had to deal with many unanswered questions, misleading information, and the lack of access to qualified experts. For that reason and to combat this issue, he built iCareBetter to optimize how patients and doctors connect.

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