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Psoas Mass

Exit forum ID Forum Discussion Psoas Mass

This topic contains 2 replies, has 2 voices, and was last updated by   William Brady, DC June 19, 2018 at 1:59 pm.

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  • #5373

    Andrew Wengert
    Participant

      30 year old female. Consistent R sided low back and right anterior and lateral hip pain when back gets really bad.  Currently an achy dull 2/10 but gets up to a sharp stabbing 9/10.  Provocative is lumbar extension, also abdominal training, and sitting for 3+ hours hip flexion after leg day is also painful.  Palliative is laying on her stomach and child’s pose.

      Patient has had this pain for 9 years.

      All level one tests are 100% with the exception of QLF which is 60% 11112.  SLPF also brings on tension in the right side of the low back and right posterior thigh, patient can touch the floor.

      Patient came to me with an MRI and a neurosurgical referral.  

      MRI findings:

      At L2-3 there is a large right sided cystic mass within the right psoas muscle measuring 5×4.5x3cm and protrudes into the right L2 neural foramen. Radiologist believes this is a psoas abscess, and states that a cystic neural tumor would be extremely rare.

      Patient went for neuro consult today and neurosurgeon ordered an MRI with contrast to better visualize the mass he believes it is a cystic schwannoma.  She follows up with him next week after the imaging and he has put the option of surgery clearly on the table.

      The MRI also shows an L4-5 annular bulge.

      Diagnosis at this point:

      1-Right psoas mass causing L2 foramen crowding

      2-Adhesion in bilateral multifidus, Longissimus muscles

      3-L4-5 annular bulge

      My question is, “Is now the right time for my treatment?” 

      Using reverse compatibility some data points go toward disc and some go toward this mass.  So I feel treatment is warranted at this time even though it likely wont effect the priority problem.

      #5374

      Christopher Stepien
      Participant

        I agree, your smoking gun here appears to be the cystic mass (disc pain tends to be more episodic and less consistent, esp. over 9 year period) . If it’s your #1 priority in your diagnosis, any treatment for #2 and #3 could distract the patient from attending to #1.

        I wouldn’t treat her yet.

        If she gets #1 resolved, it’s like teeing up the golf ball perfectly so that when you do deliver treatment, you’ll get her better as quickly and permanently as possible (thus becoming a better referring patient). You’ll also know exactly how much of her problem was caused by the cyst because hopefully, her symptoms will be relieved by some %.

        I’m curious, she’s provoked by lumbar extension (weight-bearing) and relieved by laying prone (no gravity). Both put her spine in extension. I assume lumbar extension provokes her at the end range and not in the first 25% of motion (suggesting more disc involvement in this test)?

        If the pain is provoked in the 1st 25% of motion, I’d prioritize adhesion a bit higher on the list (although not higher than the cyst) because the same spinal orientation expressed different symptoms in weight-bearing vs. not weight-bearing.

        #5375

        William Brady, DC
        Participant

          That is a very large mass. Do not let her get distracted. No treatment at this time. Continue with neurosurgeon.

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