Attending Physician JFK-Johnson Rehabilitation Institute Edison, New Jersey, United States
Case Diagnosis: 79-year-old female with history of childhood polio, osteoporosis, abdominal and thoracic aortic aneurysms with thoracic aneurysm repair found improvement of groin pain after epidural spinal injection (ESI) at L4-L5.
Case Description: Patient presented to acute care hospital with worsening low back and left hip/groin pain with difficulty bearing weight on the left lower extremity. The patient had acute functional decline from post-polio syndrome, and sharp pain in the left hip was severely limiting their ability to participate in therapies. MRI revealed no abnormalities except L4-L5 disc bulge dorsolateral to the left with central disc protrusion encroaching on the left neural foramen and subarticular recess. Patient failed conservative pain treatments, including cortisone and trochanteric bursal injections, while having a low tolerance for side effects from pain-relieving medications. MRA of the aorta showed a stable abdominal aortic dissection, unchanged. ESI of the left inter-laminar space at L4-L5 was performed. After injection, patient reported improvement of left groin pain and was able to participate in rehabilitation therapies again.
Discussions: Groin pain is classically associated with L2-L3 herniations. In this case ESI was performed targeting L4-L5, and the patient found relief leading to increased participation in rehabilitation therapies, functional gains, and a successful discharge to home. One study showed that elderly patients with L4-L5 herniation of the anulus fibrosus experienced groin pain. The pain was attributed to the sinuvertebral nerve that innervates the posterior anulus fibrosus, the posterior longitudinal ligament, and the dura, and was indicated as the afferent nerve of groin pain.
Conclusions: This case report supports that geriatric patients who experience groin pain, should be considered for an ESI to alleviate the pain and advance these patients functionally, when all other causes have been ruled out. Physicians caring for this population should note that disc levels associated with groin pain may vary in elderly patients.