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Kim et al. Common diseases mimicking lumbar disc herniation

Figure 5: The course and entrapment point
(arrowhead) of the lateral femoral cutaneous
nerve (arrow). This sensory nerve branches
off the L2 and L3 nerve roots, merges,
passes through the inguinal ligament inside
the superior iliac spine, and then distributes
subcutaneously through the femoral fascia
(*). From Clinical diagnosis for low back
pain by palpation (2015), Isu T & Kim K,
CHUGAIIGAKU. CO., LTD

Figure 4: Piriformis muscle stretching
pain relief than intra-articular SIJ injection. [24,27,28,34]
SIJ-related structures such as the joint capsule and the Injecting a local anesthetic into the posterior ligament
posterior ligament. can also relieve SIJ pain. While intra-articular SIJ
injection is not recommended as a definitive diagnostic
SIJ pain is commonly perceived in the gluteal region; it tool for pelvic girdle pain, it can be combined with the
can be referred to the lower limbs and groin region, and injection of a local anesthetic into the extra-articular
is similar to symptoms due to lumbar diseases. [24-26] The SIJ ligaments to alleviate pain. [34,35] SIJ denervation or
pain area tends to be located around or within 2 cm fixation is a treatment option in non-responders.
of the posterosuperior iliac spine (PSIS). SIJ pain
should be considered in patients reporting lowerback PERIPHERAL NERVE DISEASES
and buttock pain. [24,27] Approximately 50% of patients
with SIJ pain experience groin pain, [24,28,29] which is Lateral femoral cutaneous nerve EN
exacerbated by sitting on a backless chair. [24] Definition and symptoms
The lateral femoral cutaneous nerve (LFCN) is a
While SIJ pain may occur alone, 39% of patients also sensory nerve that branches off the L2 and L3 nerve
manifested LDH and LSS. [30] It has been reported after roots, merges, passes through the inguinal ligament
lumbar fusion and lumbar decompression surgery. [31-33] inside the superior iliac spine, and is then distributed
In patients with lumbogluteal and/or lower extremity subcutaneously through the femoral fascia [Figure 5].
pain and a high SIJ-related score, [24] SIJ pain should The incidence of LFCN-EN is 33-43 individuals per
be considered even in the absence of lumbar disease 100,000; the site where the nerve penetrates the
or prior lumbar surgery. inguinal ligament is often involved. [36,37]

Diagnosis and treatment Obesity, pregnancy, compression by tight
As it is difficult to identify SIJ pain radiologically, its undergarments and corsets, lower abdominal surgery,
diagnosis is based on clinical symptoms and the effect autogenous iliac bone, and nerve compression due
of SIJ block. Kurosawa et al. [24] proposed a score for to posterior spinal surgery in the prone position have
diagnosing SIJ pain to distinguish it from pain elicited by been reported to be implicated; 77% of LFCN-EN is
other lumbar diseases [Table 1]. Their scoring system idiopathic. [36-38] Diabetes and alcoholism are metabolic
includes six items and is useful for both diagnosing and risk factors for LFCN-EN, which can be unilateral
understanding SIJ pain. Patients often point to an area or bilateral. [38-40] The symptoms are pain, abnormal
within 2 cm around the PSIS as the most painful area perception, numbness, and a burning sensation in the
when instructed to identify the affected area with one [24]
finger (one-finger test). The SIJ shear test is the most Table 1: Sacroiliac joint pain scoring
useful provocation test. With the patient in the prone Item Score Odds ratio
position, the examiner places a palm over the patient’s 1. One-finger test 3 25.9
posterior iliac wing and thrusts the palm inferiorly to 2. Groin pain 2 14.5
produce a shearing force across the SIJ. 3. Pain while sitting on achair 1 1.4
4. Sacroiliac joint shear test 1 1.8
Besides medication and rehabilitation, conservative 5. PSIS tenderness 1 2.2
2.2
6. STL tenderness
1
approaches include a pelvic belt and SIJ block. Blocking Total score 9
the posterior ligament and periarticular region of the PSIS: posterosuperior iliac spine; STL: sacrotuberous ligament.
SIJ under fluoroscopic guidance yielded more effective Scores above 4 are considered high SIJ pain scores
46 Mini-invasive Surgery ¦ Volume 1 ¦ June 30, 2017