The fourteen year old boy, we will call “Timmy”, was hit by a car while he was out riding his bicycle. He was dragged 150 feet before the car stopped. When medics found him he was conscious but beaten up pretty badly. He was taken to the hospital where he was diagnosed with a fracture on the left side of his pelvis and where a large wound at the bottom of his right buttock was cleaned out under anesthesia. It was two days later, however, that he started having strange new symptoms in the toes of his right foot.  Dr. Christopher J. Winfree, from the The Pain Center, with several colleagues presented this interesting case of theirs in the American Journal of Physical Medicine & Rehabilitation.

Timmy reported to his doctor that he felt, “pins and needles” and a feeling of “being crushed” in the second and third toes of his right foot. Worse than that, however, was an unbearable “shooting” pain that happened three to four times a day and would last up to 30 minutes. His doctors gave him traditional NSAIDs and opioids for pain. After a month of no relief, his doctor sent him to pain-management specialists. At this point Timmy was in a wheelchair because it hurt so much to put any weight through his right leg.

When the pain specialists examined Timmy, they noted the cuts on the front of his right shin and ankle and the wound on his right buttock. This part of the buttock is where the large Sciatic nerve is found. The sciatic nerve comes out of the spinal cord in the low back, travels across the buttock and down the back of the leg, all the way to the toes. Along the way, it branches out into ever smaller nerves that feed specific tissues, including certain patches of skin and a number of muscles. These branches are like little electrical wires that send messages to and from our brain. Sometimes the brain tells one branch to make certain muscles move, to lift our leg for example. Other times, like if we cut ourselves, the branch itself will send a message of pain back to the brain. If these wires are damaged then the communication breaks down. Areas become numb and muscles don’t receive their instructions to move. Because the same nerves operate on the same patches of skin and within the same muscles from person to person, it is possible to figure out which nerve has a problem by mapping the area of the skin that has less feeling or more pain, and testing specific muscles for strength.

That is how the pain specialists were able to figure out that, in Timmy’s case, nerve damage was likely. They looked at Timmy’s muscles: his right calf was noticeably smaller than his left, he had a hard time flexing his hip, straightening his knee, and picking up his toes, and he also couldn’t move his right foot from side to side. They tested Timmy’s skin sensation: he had some numbness on the outside of his right foot and lower leg, and between his first two toes, and the second and third toes of his right foot were extra sensitive to pain.

Based on these patterns, the pain specialists figured it was either a nerve in the knee or buttock that was damaged. The problem in the case of an accident like Timmy’s, is that so much gets damaged it isn’t easy to pinpoint where, and even if, there is a nerve injury at first. Damage to the muscle itself or even generalized pain in surrounding areas can be enough to cause muscle weakness in an area. Doctors had to wait for these things to heal before they could confirm the actual nerve injury.

Treatment had to begin right away, though. They started him on a drug called gabapentin, a medicine specifically for nerve pain and a daily regimen of physical therapy (PT). PT was particularly important in Timmy’s case because he had to get out of that wheel chair and be kept as strong and flexible as possible while he healed. After a month of taking the gabapentin and doing physical therapy Timmy had a noticeable decrease in pain and he was getting stronger.

Five months after the injury, Jimmy had healed enough for the exact location and extent of the nerve damage to be assessed. Doctors confirmed that the damage had occurred to the Sciatic nerve in an area that corresponded with Timmy’s buttock wound and no where else. The nerve had either been over stretched or actually cut during Timmy’s accident. His recovery depended on several factors: discovery of the underlying nerve injury through nerve mapping, the use of a nerve specific pain medication, and aggressive physical therapy.

Six months after Timmy was hit by the car he showed all the signs that his nerve was healing and he wouldn’t have to have it repaired surgically. His pain had decreased enough for his doctor to begin lowering his dosage of gabapentin and he had returned to the normal activities of school and family.

This case report can be found in the July, 2007 issue of the American Journal of Physical Medicine & Rehabilitation