Lumbar Spine and Pelvis

6 Lumbar Spine and Pelvis

Complex Pain

Lumbago

Indications

Pain conditions in lumbago and coxalgia

Irritation of the gluteus maximus and the long back extensors

Affections of the superior iliolumbar ligaments

Tightening of the paravertebral muscles, as well as pseudoradicular symptoms

Differential Diagnoses

Blockage of the sacroiliac joint and the L 5 facet

Inflammation of the sacroiliac joint

Radicular symptoms in herniated vertebral disks

Radiating complaints originating in disorders of the ureter and the bladder

Referred pain originating in segmental processes (head zone T 11)

Tumors in the lower abdomen

Instability at the lumbosacral transition

Material

Local anesthetic: 5–10 mL

Needle: 0.8 × 80 mm

Technique

The superior pelvic crest is palpated 2–3 finger widths paraspinally, at the level of the fifth lumbar vertebral body. The needle is inserted vertically until bone contact is made (transverse process of L 5). A local anesthetic (2 mL) is injected. The needle is then retracted 1–2cm and advanced toward the pelvic crest until bone contact is made. Here, the needle is retracted 2–3 mm and 2–3 mL of a local anesthetic is injected. The needle is inserted again, 2–3 finger widths inferior to the first injection site. The procedure of the first injection is repeated. This results in an almost isosceles triangle being formed.

Complementary injections may be performed 1finger width paraspinally next to L4/L 5, L 5/S1, and S 1/S 2, comprising a subcutaneous quaddle and an injection close to the bone. Equilateral injection at the greater trochanter is recommended if muscles connecting the pelvis and the greater trochanter are involved.

Risks

Bone contact safeguards unintentional excessive advancement of the needle. If the needle is advanced too far centrally and drops after initial resistance, aspiration has to rule out unintentional administration near the spinal cord (liquor!).

Direct infiltration between bone and periosteum should be avoided owing to its extreme painfulness.

Concomitant Therapies

Dysfunctions of the sacroiliac joint are nearly always present; therefore, mobilization or manipulations of the sacroiliac joint are recommended.

Relaxation techniques and muscular balancing by stretching the quadratus lumborum and muscles connecting the pelvis and the greater trochanter have been proven useful. The patient can repeat the exercises at home.

Medical exercise therapy and physical therapy to relax the musculature.

! +++

R2–3 times a week, up to 8 weeks

MM, ThE, MET, PhysApps, Chiro

Piriformis Syndrome

Indications

Frequently, pseudoradicular symptoms in terms of sciatica. Patients complain about pain on the side of the hip when they are lying down at night.

Tendinopathy of the greater trochanter

Concomitant treatment of sacroiliac joint dys-functions

Differential Diagnoses

Sciatic irritations

Affections of the gluteus medius

Material

Local anesthetic: 5 mL

Needle: 0.8 × 80 mm

Technique

The greater trochanter is located. At its tip and 2 cm apart, along its posterior edge, the needle is inserted vertically until bone contact is made. After the needle has been retracted 1–2 mm, 1 mL of a local anesthetic is injected at each site.

At the center, between the greater trochanter and the sacroiliac joint, the trigger point of the piriformis can be found. This is usually a painful area, including a rough palpable myogelosis. The needle is inserted 4 cm and 2 mL of the injectable is administered.

Risks

If the needle is advanced excessively, the sciatic nerve may be anesthetized; therefore, the needle must be retracted if radiating, flashlike sensations are reported.

Concomitant Therapies

Manual therapy in functional disorders of the sacroiliac joint

Physical therapy in terms of stretching of the piriformis, including postisometric relaxation and instructions for self-mobilization. Differences in the length of the legs must be observed!