Lower/Lumbar Back Pain and Buttock Pain

Dr Dion Lewis
MBBS (hons) BMedSci (hons)

Case:
There are numerous causes for lumbar back pain and buttock pain. It may feel daunting to treat patients with these conditions. Many have already suffered through long periods of pain with no relief from medical management and numerous other physical and alternative therapies. It is important, therefore, to thoroughly examine and investigate these patients, attempt to locate the anatomical structure or structures causing the pain and then target a treatment plan accordingly. The following examples illustrate the diversity of pathologies found in clinical practice and some of the treatment modalities used to treat these conditions.

1. Patient presents with pain radiating from the lower back all the way down to the foot. Clinical examination reveals L5 weakness and sensory reduction. MRI/CT confirms L5 nerve root compression secondary to right paracentral disc prolapse. L5 nerve root corticosteroid injection may successfully treat this pain.

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2. Patient presents with lumbar back pain and no abnormality on lower limb neurological examination. MRI/CT shows a non-neurocompressive disc prolapse at L4/5. NSAIDs and physiotherapy have not provided relief. An epidural corticosteroid injection may successfully relieve this pain.
3. A patient presents with lumbar back pain with no radiation down either lower limb. MRI/CT shows multi-level facet joint arthropathy bilaterally. Bone scan with SPECT is performed and shows increased activity at the left L3/4 and L4/5 facet joints. Facet joint corticosteroid injection provides initial relief but pain returns. The patient is subsequently referred for median branch block/radiofrequency neurotomy which provides prolonged pain relief.

4. A patient presents with right buttock pain. Lumbosacral and SIJ MRI shows no obvious cause. Clinical examination is suggestive of SIJ dysfunction. Diagnostic local anaesthetic injection into both the membranous and synovial portions of the SIJ confirms origin of pain is from SIJ. Corticosteroid injection, prolotherapy, PRP or radiofrequency neurotomy could be used to treat this pain.
5. A patient presents with morning pain across the buttock and lower back that sometimes warms up by lunchtime and is sometimes there all day. The pain responds to NSAIDs temporarily. Inflammatory markers are elevated, the patient is HLAB27 positive and there are signs of sacroiliitis on MRI of the SIJs. Use of NSAIDs if not contraindicated and referral to a rheumatologist is warranted.