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Pains along the sciatic nerve apparently have numerous possible causes (18 of them according to this article).

Now, given the following facts, what would be appropriate differential-diagnostic measures/procedures/tests to determine the exact cause (or combination of causes) of such pains?

Relevant qualifying facts:

  • Adult, but not elderly, male subject.
  • Pain manifests only on one side of the body (the left side).
  • Pain centered around the gluteal muscles (Piriformis?), occasionally shooting upwards or downwards.
  • Pain intensity varies with time and posture; usually low intensity.
  • Symptoms persist for over a year (but do not worsen).
  • No relevant impact trauma.
  • Regime of relevant physical exercise has little (and no lasting) effect.

Notes:

  • I've tried to follow the guidelines in this answer and keep this question on-topic; if you believe it isn't, please comment and help me edit it accordingly.
  • If you believe the cause(s) are obvious based merely on the facts above, an explanation why that is would be a valid answer of course.
  • @JohnP: Oh yeah, you're right! I remember now that that's a thing. I even remember the House episode now.... – einpoklum - reinstate Monica May 30 at 19:59
  • Just an off the wall question....how thick is the patients wallet and which pocket is it kept in? – JohnP May 30 at 19:59
  • @JohnP: Do you mean that in a metonymous sense, or in a literal sense? In both cases, not thick. And it is usually not kept in a pocket. And when it is, it's a front pocket and it alternates between right and left. – einpoklum - reinstate Monica May 30 at 20:26
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    @einpoklum - Cool. Was just a random thought, I had a friend that had hip problems brought on by an overly thick wallet that was habitually in the same rear pocket. – JohnP May 30 at 20:43
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    @Carey Gregory Thanks I understand. – Gordon May 31 at 0:03
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DIFFERENTIAL DIAGNOSIS

Differential diagnosis in an adult man with a unilateral pain in the gluteal area lasting for over a year and not worsening, without a history of trauma, infection or inflammatory arthritis or other conditions (an incomplete list):

  • Degenerative disc disease (DDD) with bulging or herniating disc(s) pressing upon the spinal nerve root(s) in the lower back (lumbosacral radiculopathy)
    • Often runs in families; can be caused by acute or repetitive injury
    • Pain triggers: coughing, bending and certain other moves
    • Pain relievers: walking, lying down (not always)
    • Other common symptoms: tingling, numbness, leg weakness
    • In most cases heals/improves on its own in weeks/months
  • Hip conditions with pain radiating to the gluteal area
  • Piriformis syndrome
    • Caused by repetitive running, climbing stairs, sitting
    • Pain is typically worse during sitting ("sitting intolerance")
  • Ischial bursitis
    • Caused by prolonged sitting
    • Pain worse during sitting
  • Sacroiliac joint dysfunction (sacroiliitis)
    • Pain in the hip and buttock
    • Worse during prolonged standing or running
  • Spinal tumor
    • Pain can persist during the night
  • Postherpetic neuralgia - inflammation of the nerve (neuritis) due to Herpes zoster infection
    • Typically (but not always) preceded by burning rash
    • Constant burning pain lasting for months/years

DIAGNOSTIC PROCESS

1) History

A doctor will likely ask detailed questions about the pain location, its triggers and relievers (coughing, sitting, walking, lying down).

2) Physical examination (examples of tests)

3) Investigations

  • Blood tests to exclude inflammatory conditions (specific antibodies in ankylosing spondylitis and rheumatoid arthritis, sedimentation rate, C-reactive protein...)
  • X-ray is often the first imaging investigation, which can detect broken vertebra, decreased space between vertebra (suggesting degenerative disc disease) and gross changes (spurs, deformities) due to inflammation
  • CT or MRI of the lower spine or the hip is done when a problem with the discs or hip joint is suspected.
  • There is no specific investigation for piriformis syndrome

NOTE: This is not a complete differential diagnosis of sciatica-like pain; it is a list of causes adjusted to the "case." The list of 18 causes linked from the question is grossly repetitive.

  • 1. Could an inflammatory condition really last a year without improving/worsening? 2. Can you be a bit more specific about which blood tests? Also - thank you for the detailed and informative answer. Although I have more details, I will not add them to the question. – einpoklum - reinstate Monica May 31 at 12:15
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    Yes, OK, everything can be discussed here in the comments. Inflammation of the spine (ankylosing spondylitis) can last for several years, but I did not include any inflammation in my list because it's not really typical for the described case. I added few details about blood tests, but that part is not really important for the answer. My instict (because the pain is pretty constant) is that the cause is "mechanical" - something pressing on the nerve. – Jan May 31 at 12:23

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