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546 - Sitting on Symptoms: How a Toilet Break Led to Ischemic Sciatic Neuropathy

Friday, February 28, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

MP

Matthew J. Prevost, N/A, BS

Medical Student (MS4)
Oakland University William Beaumont (OUWB) School of Medicine / Corewell Health William Beaumont University Hospital
Royal Oak, Michigan, United States

Co-Author(s)

DS

David J. Spiteri, MD

Physiatrist
Corewell Health William Beaumont University Hospital / OUWB School of Medicine
Royal Oak, Michigan, United States

Case Diagnosis: Ischemic sciatic neuropathy is an uncommon condition characterized by sciatic nerve injury resulting in sensory changes and weakness. It can arise from vasculitis, trauma, malignancy, or prolonged nerve compression. Accurate diagnosis and differentiation between central versus peripheral etiologies of painless weakness are crucial for effective management.

Case Description: A 57-year-old male presented with neck pain radiating down his left arm, accompanied by paresthesias and shooting sensations. He was diagnosed with cervical radiculopathy and prescribed gabapentin with physical therapy. A week later, he visited the emergency department due to severe dizziness and nausea, ruled out as central causes by a normal head CT and attributed to gabapentin. At follow-up, he reported improvement in C6 radicular symptoms but developed new-onset weakness in left foot dorsiflexion and painless numbness on the dorsum of his left foot, suggestive of L5/peroneal nerve involvement. He denied low back pain, trauma, or loss of bowel and bladder control but mentioned constipation. A brain MRI and carotid doppler excluded central causes of weakness. An EMG was scheduled three weeks post-onset to assess peripheral causes, during which he revealed he had strained for three hours on the toilet. This suggested pressure-induced ischemic sciatic neuropathy, which EMG confirmed.

Discussions: This case underscores the importance of a thorough history and timeline in differentiating neurologic causes of weakness. The initial symptoms suggested left sided cervical radiculopathy, characterized by neck pain and left arm paresthesias indicating root involvement. The later, new-onset painless left leg numbness and weakness in a sciatic nerve distribution pointed to a peripheral nerve injury, likely from prolonged sciatic nerve compression while straining on the toilet as a result of constipation.

Conclusions: Seemingly benign activities can contribute to nerve issues, highlighting the need for obtaining a detailed history and timeline of symptoms in evaluating painless weakness.