Disclosures: Jordan P. Orr, MD: No financial relationships or conflicts of interest

Case Description: The patient presented with a three-week history of severe right leg pain and acute left foot drop, eight weeks status-post R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). Physical examination, revealed atrophy in the left anterior tibialis and medial gastrocnemius. Decreased sensation was noted bilaterally over the saphenous, sural, and peroneal nerve distributions, left greater than right. Thoracic dermatomal sensation was intact bilaterally. Upper extremity strength was 5/5 bilaterally. Bilateral lower extremity strength was limited due to pain, but hip abduction, knee flexion, and knee extension appeared to reach 5/5 before pain set in. Right ankle dorsiflexion was 5/5, but left ankle dorsiflexion 0/5. Magnetic resonance imaging (MRI) of her pelvis showed enlargement of the left sciatic nerve and external compression of the right sciatic nerve.

Setting: Tertiary care hospital

Patient: 46-year-old woman with a history of stage IV diffuse large B-cell lymphoma (DLBCL) Assessment/

Results: MRI findings were consistent with bilateral sciatic lesions – left intraneural and right extra-neural lesions. These radiologic and physical exam findings led to PM&R recommending consideration of palliative radiation for symptom control, as well as orthotic and pain medication recommendations.

Discussion: DLBCL is a sometimes aggressive malignancy that can manifest within nerves, or adjacent. A thorough neuromusculoskeletal examination can correlate patient symptoms with imaging to identify symptomatic lesions. The malignancy is radiosensitive, so physiatrists who identify symptomatic lesions should consult with radiation oncology and hematology for treatment. Physiatrists should be familiar with MRI findings of both intra- and extra-neural tumors in DLBCL.

Conclusion: This case outlines the importance of physiatric care in cancer patients, as the cause of her symptoms and pain were unclear to oncology providers until after PM&R evaluation. Based on PM&R recommendations, radiation was initiated and her opioid dosing was decreased due to improved pain control.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/bilateral-sciatic-neuropathies-of-different-causes-in-a-patient-with-lymphoma/