A fourteen-year-old boy was hit by a car while he was out riding his bicycle. He was dragged 150 feet before the car stopped. And 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.
The boy 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.
The boy’s doctors gave him traditional NSAIDs and opioids for pain. After a month, the medications had not helped much. He couldn’t bear to put any weight through his right leg and needed a wheelchair to get around. His doctors decided to send him to pain-management specialists.
When the pain specialists examined the boy, they noted the wound on his right buttock–an area where the large sciatic nerve is also located. They began to suspect a serious sciatic nerve injury.
As a surgeon who specializes in the treatment of nerve injuries, Dr. Christopher J. Winfree, from the Neurosurgical Pain Center, was called in. He and his colleagues set out to see if the sciatic nerve was the source of this patient’s debilitating leg pain.
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 certain patches of skin and specific muscles.
These nerve branches are like little electrical wires that send messages to and from your brain. Sometimes your brain tells one branch to make certain muscles move–to lift your foot, for example. Other times–say if you cut yourself–the nerve branch will send a message of pain back to the brain.
If these nerves are damaged, then the communication breaks down. Areas become numb or overly-painful, and muscles don’t receive their instructions to move well. It is possible to figure out which nerve is injured by mapping the area of the skin that has changes in sensation, and by testing specific muscles for strength.
Dr. Winfree and the pain specialists tested the strength of the boy’s leg muscles: his right calf showed signs of atrophy, he had a hard time flexing his hip, straightening his knee, and picking up his toes. He also couldn’t move his right foot from side to side.
They tested the boy’s skin sensation: he had some numbness on the outside of his right foot and lower leg, and between his first two toes. The second and third toes of his right foot were extra sensitive to pain.
Based on these patterns, Dr. Winfree and the team knew the sciatic nerve was damaged either in the boy’s knee or buttock. They couldn’t find the exact location of the nerve injury because the extent of the trauma was, in effect, muddying the waters of diagnosis.
Generalized injury or muscle damage to the area surrounding the sciatic nerve could be enough to cause muscle weakness and pain in the area. Doctors had to wait for these things to heal before they could confirm the exact location (or locations) of the nerve injury. Once that was determined, surgery could be planned if needed.
In the meantime, more conservative treatment directed toward helping the nerve heal in general had to begin right away. Dr. Winfree and the team started their patient on a medicine, specifically for nerve pain, called gabapentin. They also prescribed a daily regimen of targeted physical therapy (PT). After a month, he had a noticeable decrease in pain, and he was getting stronger.
Five months after the injury, the boy 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 the buttock wound and no where else.
The nerve had either been over-stretched or cut during the accident. 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 this adolescent had been 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 American Journal of Physical Medicine and Rehabilitation.
Image credit: Sebastian Kaulitzki / Adobe stock
Originally posted on 2/1/10
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