Back and Lateral Hip Pain
Here you can see that the hips are normal- reflecting the normal log roll test.
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Axial of the L1 vertebral body where the herniated disc is seen on the right behind the pedicle.
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MRI of lumbar spine- note the extruded HNP behind the body of L1 from the L1-2 Disc. There is multi level DDD and an old HNP at L5-S1.
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Patient is a 60 year old police officer who had seen us 6 years before for long standing significant lower back pain (LBP). The patient was not a surgical candidate and we sent him for rehabilitation. He continued with manageable LBP. He came back to the office 5 years later with new onset lateral right hip pain, mild groin pain with increased lower back and sacroiliac pain after helping a motorist change a tire. The pain in the hip was increased with sleep and would awaken him at night. This pain was tolerable during the day but increased with standing and prolonged sitting.
Pain with standing could be from a disc but normally, standing pain originates from a stenotic condition (narrowing) of the spinal canal. This patient had a normal log roll test for hip symptoms which doesn’t rule out hip pathology but puts it lower on the differential diagnosis scale.
There is one clue here of the potential pathology. The sensory exam noted decreased sensation in the right anterior thigh. Of course, this could be meralgia paresthetica (compression of the lateral femoral cutaneous nerve in the groin) but this area is also the dermatome of the L1 or L2 nerve.
A herniated disc (HNP) at L1 can affect the genitofemoral nerve and refer pain into the hip, groin and sacroiliac joint. Looking at the history of bending and lifting with new onset of pain makes a herniated disc more likely. HNPs can also cause more pain at night from positional swelling of the nerve root. See the MRI to note the HNP at the L1-2 level.
