A case of conservative treatment for sciatica due to piriform hematoma with <i>jidabokuippo</i>

The two sciatic foramina constitute a complex anatomic site that can be affected by a variety of pathological conditions, including trauma, infection, nerve entrapment, tumor expansion, herniation, and vascular anomalies [1]. Hematoma-induced neuropathy has been identified as a complication of anticoagulant use and trauma [2, 3]. Herein, I report a case of sciatica caused by a pisiform hematoma, which was treated conservatively with jidabokuippo, and the patient was discharged from the hospital early. The patient was an 81-year-old woman with a body mass index of 15.9 kg/m2, who had diabetes mellitus, bronchial asthma, and bilateral femoral neck fractures. On day X − 23, she accidentally fell, and she was transferred to our hospital on day X − 22. Although it was noted that she had fractures of the right sacrum and right sciatic bone without dislocation, she was able to walk with analgesics; she therefore attended the orthopedic surgery department at our hospital. On day X − 1, she started feeling pain in her left buttock from the time she woke up and was unable to get up on her own. The pain worsened when the rehabilitation staff massaged the same area. On day X, she was transferred to our hospital because she had difficulty standing up. Her vital signs were as follows: blood pressure, 146/75 mm Hg; heart rate, 100 bpm; SpO2, 95% (room air); axillary temperature, 36.6°C. No anticoagulants or antiplatelet agents were used. Blood tests showed no abnormal blood cell counts or coagulation abnormalities. There were no sensory disturbance or abnormal tendon reflexes in both lower extremities. However, in the straight leg raising test, no pain was elicited in the right lower extremity at 70°, whereas in the left lower extremity, pain was reported in the sciatic nerve area on raising the left lower extremity up to 30°. On pelvic computed tomography (CT), there were neither an aggravation of the previously noted fracture nor new fractures; however, there was a piriform hematoma. Contrast-enhanced CT revealed no active bleeding or contrast pooling, and no aneurysm formation (Figure 1a). After discussions with radiologists and orthopedic surgeons, the patient was admitted to the hospital for bed rest. After hospitalization, oral acetaminophen (500 mg) was combined with jidabokuippo (http://mpdb.nibiohn.go.jp/stork/) 2.5 g three times daily. On the evening of day X + 1, the pain decreased. On day X + 2, a simple CT scan revealed that the hematoma had shrunk (Figure 1b). It also improved the numeric rating scale from 10 to 2, and the patient was able to walk. On X + 3, the patient was discharged home with no neurological deficits. In addition, the bowel movement observed as an effect of jidabokuippo was only one normal stool on day X + 2, and no diarrhea was observed. In many cases, early surgical removal of hematomas resulting in neurological damage is required, and some reports suggest the need for rehabilitation such as aggressive physical therapy and electrical stimulation afterward [2, 3]. Even in a report of conservative management, it took two months for the pain to completely resolve [4]. Jidabokuippo has also been shown to be effective in treating bruises and bone pain as a blood stasis-resolving formula, and Nakae has demonstrated its usefulness in many cases and clinical trials [5]. To the best of our knowledge, there have been no reports of patients discharged from the hospital on their own after a short period with improvements in the hematoma and neurological deficits. Oral treatment with jidabokuippo is non-invasive and is expected to reduce the treatment duration. None. N/A. Informed consent was obtained from the patient and her family for the publication of this case report and any accompanying images. N/A. N/A.