A 37 Year Old Female Dance Instructor with Leg and Buttock Pain

Abstract

HISTORY: A 37 year old female dance instructor with a history of stable multiple sclerosis presented with a 5 year history of left buttock and posterolateral thigh pain with radiation to the plantar surface of her foot that began during pregnancy. Pain was minimal at rest and aggravated by prolonged sitting and activities such as dancing, bicycling, and hiking. Pain progressed and now markedly limited activity. She reported tingling of the posterolateral calf and plantar surface of the foot. She denied weakness. Chiropractic care provided no relief. Previously obtained lumbar spine MRI was unremarkable and the patient completed 6 months of physical therapy without improvement. PHYSICAL EXAMINATION: There was no appreciable deformity, malalignment, or rotation of the lumbar spine, hips, or knees. She walked with a non-antalgic gait, including normal heel and toe walking. Palpation of deep left gluteal muscles reproduced pain with radiation down the left lower limb. Range of motion of the lumbar spine and hips was grossly normal. Manual muscle testing of the lower limbs was normal. Passive hip flexion, abduction, and external rotation, as well as flexion, adduction, and internal rotation of the left hip reproduced pain. Remainder of provocative lumbar spine and hip maneuvers, including straight leg raise, were normal. She was neurovascularly intact. DIFFERENTIAL DIAGNOSIS: Chronic Piriformis Strain Lumbosacral Radiculopathy Hip Osteoarthritis Multiple Sclerosis Flare Sciatic, Tibial, or Peroneal Neuropathy TEST AND RESULTS:FigureMRI Lumbosacral Plexus: 2.8 X 2.5 X 3.0 cm mass along the left sciatic nerve between the gluteus maximus and quadratus femoris with extension into the ischiofemoral space, consistent with cystic schwannoma FINAL WORKING DIAGNOSIS: Left sciatic nerve tumor, concern for cystic schwannoma TREATMENT AND OUTCOMES: Neurosurgery evaluation Underwent surgical resection of mass 16 weeks after surgery, reported 100% resolution of her symptoms