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Lumbosacral Plexus Entrapment Syndrome. Part One: a Common Yet Little-Known Cause of Chronic Pelvic and Lower Extremity Pain

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Lumbosacral Plexus Entrapment Syndrome. Part One: a Common Yet Little-Known Cause of Chronic Pelvic and Lower Extremity Pain 3-A Running head: ANAESTHESIA, PAIN & INTENSIVE CARE www.apicareonline.com ORIGINAL ARTICLE Lumbosacral plexus entrapment syndrome. Part one: A common yet little-known cause of chronic pelvic and lower extremity pain Kjetil Larsen, CES, George C. Chang Chien, D O2 ABSTRACT Corrective exercise specialist, Training & Rehabilitation, Oslo Lumbosacral plexus entrapment syndrome (LPES) is a little-known but common cause Norway of chronic lumbopelvic and lower extremity pain. The lumbar plexus, including the 2 Director of pain management, lumbosacral tunks emerge through the fibers of the psoas major, and the proximal Ventura County Medical Center, sciatic nerve beneath the piriformis muscles. Severe weakness of these muscles may Ventura, CA 93003, USA. lead to entrapment plexopathy, resulting in diffuse and non-specific pain patterns Correspondence: Kjetil Larsen, CES, Corrective throughout the lumbopelvic complex and lower extremities (LPLE), easily mimicking Exercise Specialist, Training & other diagnoses and is therefore likely to mislead the interpreting clinician. It is a Rehabilitation, Oslo Norway; pathology very similar to that of thoracic outlet syndrome, but for the lower body. This Kjetil@trainingandrehabilitation. two part manuscript series was written in an attempt to demonstrate the existence, com; pathophysiology, diagnostic protocol as well as interventional strategy for LPES, and Tel.: +47 975 45 192 its efficacy. Received: 23 November 2018, Reviewed & Accepted: 28 Key words: Pelvic girdle; Pain, Pelvic girdle; Lumbosacral plexus entrapment syndrome; February 2019 Piriformis syndrome; Nerve entrapment; Double-crush; Pain, Chronic; Fibromyalgia Citation: Larsen K, Chien GCC. Lumbosacral plexus entrapment syndrome. Part one: A common yet little-known cause of chronic pelvic and lower extremity pain. Anaesth pain & intensiv care 2019;23(2):124-137 INTRODUCTION entrapment syndrome (LPES), a problem involving entrapment of the lumbosacral plexuses within their Chronic pelvic and lower extremity pain is widespread, emergent passages in the lumbopelvic complex, affecting up to 26,6% of women, thus having a great similar to thoracic outlet syndrome (TOS) in the upper socioeconomical impact.1 Many potential etiologies body. This manuscript aims to outline the existence, have been proposed for chronic pelvic pain, some symptoms, diagnostic criteria and treatment protocol examples being sacroiliac joint dysfunction,2,3 nerve to address LPES. LPES can be treated conservatively root and facet joint referred pain.4,5 However, because with pleasing results if appropriately identified and its symptomology tend to be diffuse in nature, often treated. not compatible with mere sacroiliac, root dermatome or myogenic explanations, the patient’s maladies may LUMBOSACRAL PLEXUS be considered idiopathic or rendered “fibromyalgic”.6 ENTRAPMENT SYNDROME Indeed, several etiologies of pain may be present simultaneously, but it is our impression, after Lumbosacral plexus entrapment syndrome involves numerous examinations of this patient group that entrapment of the lumbar plexus, lumbosacral trunk and proximal sciatic nerve within the psoas major and there is staggering a prevalence of lumbopelvic and piriformis due to chronic weakness or injury of these lower extremity (LPLE) nerve sensitivity amongst the muscles.8 It may result in diffuse but often debilitating majority of LPLE nervous branches, detected with symptoms in the pelvis and lower extremities. Tinel’s test (i.e. provocative pressure applied directly onto the nerve in question),7 suggesting underlying There have been several mentions of lumbar entrapment neuropathy. The etiology of this plexopathy in the literature. However most of these phenomenon is hereby proposed to be lumbosacral are not considered to be of “MSK” territory nor 124 ANAESTH, PAIN & INTENSIVE CARE; VOL 23(2) JUNE 2019 Running head: original article origin. Pregnancy, both antepartum, intrapartum may be elicited, whereas tissues medial or lateral to the and postpartum (compression caused by the fetus),9 nerve tested, are significantly less tender, suggesting hematomas,10,11 aneurysms,12 trauma,13 tumors,13 occult neuralgia rather than fibromyalgia as the abscesses,14 cysts,15 cancer,16,17 and iatrogenesis,18 etiology.8 Just like TOS is notoriously difficult to are all rare, but known causes of this problem. Also diagnose and treat due to its nonspecific presentation, known, but often not considered in clinical practice, 41,42,43,44,45,46,47,48 LPES is a similar condition. LPES is the fact that the entire lumbar plexus including the may frequently present with distal symptoms, likely lumbosacral trunk emerges through the myofascia to mislead the practitioner. For example, similarly, of the psoas major muscle19,20,21 and may become it is known that TOS patients may present with entrapped within it, resulting in various degrees of seemingly unrelated symptoms, such as carpal lumbosacral plexopathy.8 Further, a debated topic, tunnel syndrome,49 chest pain,50 shoulder pain,51 but well-known nonetheless, is the notion that brachialgia,52 or periscapular pain.53 Entrapment- the proximal sciatic nerve may become entrapped induced dysautonomia has also been implicated in underneath the piriformis muscle,22,23,24 and along TOS.54,55 The presentation of LPES may be similar with pre-entrapment of the lumbosacral trunk and in mimicking other, seemingly unrelated pathologies, lumbar plexus, these factors, in tandem, form the such as one or more of the following: rationale for LPES. Empirically, dysfunction of the • Low back pain (dorsal ramus nerves) psoas major and piriformis almost invariably co- develop, especially in non-traumatic incidences. • Groin and testicular/ labial pain (genitofemoral or Thus, for the most part, lumbar and sacral entrapment pudendal neuralgia) plexopathies are viewed as one united problem • Pelvic floor and genital pain (pudendal neuralgia) throughout this article. • Sacroiliac pain (medial cluneal neuralgia) There is scarce literature with regards to myogenic, • Abdominal flank, hypogastric and inguinal pains i.e. myofascially induced lumbar plexus entrapment, (ilioinguinal and iliohypogastric neuralgia) and therefore some jumping between different • Iliac crest/gluteus medius pain (superior cluneal entrapment pathologies is necessary in attempt to neuralgia) demonstrate several important points throughout this article. Further, because TOS is a problem whose • Buttock pain (sciatic & gluteal neuralgias) mechanism is very similar to that of LPES, but is • Hamstring pain (sciatic neuralgia) much more renowned, several references will be • Plantar fasciitis (tibial neuralgia) made to TOS-relevant literature. • Calf pain (tibial neuralgia) LPES may, in fact, be regarded as “the thoracic outlet • Lateral calf pain (peroneal neuralgia) syndrome of the lower body”. It is a “double crush”, • Lateral thigh pain (meralgia paresthetica (lateral 25-34 i.e. multifocal nerve entrapment neuropathy, femoral cutaneous neuralgia)) often resulting in diffuse neuralgic patterns difficult to pinpoint in the LPLE.9,39,40 Other frequently used • Anterior thigh pain (femoral nerve) terms for this problem is “Maigne’s syndrome”,35 • Medial knee pain (saphenous neuralgia) “thoracolumbar junction syndrome”,36 “dorsal ramus • Medial shin pain (saphenous neuralgia) syndrome”,37,38 and “piriformis syndrome”, which • Diffuse dysautonomic symptoms and neuralgias are, in our impression, different perceptions of the can sometimes also occur, such as complex same hierarchical problem, as they are frequently seen in tandem.8 Entrapment of the lumbar plexus regional pain syndrome, bladder incompetence, may cause radiative “aches” in one or several of its overactive bladder, prostate pain, slowed bowel branches, and may also affect the sciatic nerve and movements etc. sacral plexus due to their anastomosis through • Coccydynia (most likely due neuralgic spreading the lumbosacral trunk as well as proximal sciatic to the coccygeal plexus) entrapment by the piriformis muscle. Entrapment occurring at these proximal segments may greatly Understanding the symptoms of LPES is crucial in predispose and sensitize the intermediate and distal order for the practitioner to perform the appropriate nervous branches throughout the LPLE, due to tests, leading to a correct diagnosis. The symptoms of the “double crush” phenomenon, often producing lesser to moderate forms of LPES, as suggested, may seemingly focally originating symptoms. present as seemingly focal and unrelated pathologies which may differ from patient to patient, but the A patient who is severely afflicted by LPES may clinician will still be able to demonstrate severe frequently feel that “everything” hurts or is tender, palpation tenderness upon applying Tinel’s test to and may often be misdiagnosed with fibromyalgia or psychogenicity. However, upon provocative palpation most LPLE branches, suggesting (presuming that of the nerve-passages (Tinel’s test), significant pain other causes have been excluded) subtle (myogenic) plexopathy with secondary peripheral sensitization. ANAESTH, PAIN & INTENSIVE CARE; VOL 23(2) JUNE 2019 125 lumbosacral plexus entrapment syndrome PATHOGENESIS symptomatic side of SIJD, however, and interestingly, after improving gluteal strength, its excess EMG Lumbosacral plexus entrapment syndrome is caused signal output normalized (i.e. reduced), indicating by entrapment of the lumbar plexus, lumbosacral that EMG overactivity may be a sign of muscle trunk
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