SPINE, amber 15, pp 1736-1949 ©1997, Lippincort-Raven Publishers ® Groin Pain Associated With Lower Lumbar Disc Herniation Yasutsugu Yukawa, MD,* Fumihiko Kato, MD,* Gakuji Kajino, MD.t Shigeru Nakamura, MD,t and Hiroyuki Nitta, MDt ‘Study Design. Retrospective clinical and magnetic, resonance imaging study of patients with groin pain associated with lower lumbar disc herniation. ‘Objectives. To demonstrate the clinical features and, ‘magnetic resonance imaging findings of these patients, ‘Summary of Background Data. Patients with lumbar disc herniation sometimes report groin pain. Little men- tion has been made, however, regarding the clinical fea- tures of groin pain stemmed from lower lumbar disc herniation until now, with only Murphey referring to groin pain in disc disease. Methods. A total of 512 patients were diagnosed with singular lower lumbar disc herniation (L¢-L5 and 15-S1) at Kakegawa City General Hospital between July 1990 and December 1993. Of these patients, 21 (4.1%) reported groin pain. The characteristic clinical features and magnetic resonance imaging findings of the 21 pa- tients were investigated and compared with the features and findings of patients with no groin pain. Results, Patients with groin pain had a higher mean age and lower rate of low back pain, and L4-LS discs were more likely to be involved than L5-S1 discs. In their magnetic resonance images, herniation tended to bbe more central than in patients with no groin pain. Conclusions. Elderly patients with L4-L5 protruding herniation of the anulus fibrosus were most likely to experience groin pain. The sinuvertebral nerve that in: nervates the posterior anulus fibrosus, the posterior longitudinal ligament, and the dura was indicated as the afferent nerve of groin pain. [Key words: groin pain, lumbar disc herniation, magnetic resonance imaging, referred pain, sinuvertebral nerve] Spine 1997:22;1736— 1740 Patients with lumbar disc herniation sometimes report obscure pain that differs from nerve root pain or lower back pain. Groin pain is often present in such patients (Figure 1). On questioning, these patients often describe this pain asa dull aching, which they usually find difficult to localize with any degree of accuracy. The patient fre~ quently contends that this pain lies deep beneath the skin, Althe igh the patient often reports pain and numb From the “Department of Orthopaedic Surgery, Chubu Rosai I tal, Nagoya, Japan, and the {Department of Orthopaedic Su Kakegawa Ciy, General Hospital, Kakegawa, Japan. Acknowledgment date: April 18, 1996 First revision date: July 17, 1996, Second revision daie: December 31, 199%. Acceptance date: February 17, 199 1736 ness, on physical examination the orthopedist is often unable to discern any objective findings such as tender. ness, muscle weakness, or hypesthesia, except perhaps occasionally a slight hyperalgesia. The groin area is in nervated by the genitofemoral or ilioinguinal nerves, which are terminal branches of the L1 or L2 spinal nerves. In contrast, the affected nerves in lower lumbar disc herniation (L4-LS and LS-S1) are LS or SI nerves Groin pain therefore is considered to be referred pain, distinct from nerve root pain Little mention has been made, however, regarding the clinical features of groin pain associated with lower lum bar disc herniation until now, with only Murphey! re ferring to groin pain in disc disease. In addition, some reports of studies have described that diagnostic spinal trations to the disc, posterior longitudinal ligament, facet, interspinous ligaments, and other structures pro- ts, but the clinical fear duced groin pain in some pati tures of groin pain are unclear. In the present study, the clinical features and magnetic resonance imaging (MRI) findings of patients with groin pain associated with lower lumbar disc herniation were investigated ™ Patients and Methods A total of 512 patients were diagnosed between July 1990 and December 1993 with singular lower lumbar disc herniation (L4-L5 and L5-S1) with no recurrent herniation o¢ lumbar spinal canal stenosis, based on symptoms and MRI findings The patients were diagnosed at Kakegawa City General Hos pital. Of these patients, 21 (group G) reported geoin pain with out ip disease. Nine patients were men, and 12 were wore with a mean age of 45.7 years (range, 28~77 years). Sex 286 disc level, rate oflower back pain (LBP), results ofa straightleg raising test (SLR), and Japanese Orthopaedic Association scores for assessment of treatment for lower back pain JOA score; with the exception of activities of daily living retectioy full score = 15) were examined in this group and in the remait ing 491 patients (group NI}. Magnetic resonance images of 21 patients with groin pat (group G) also were compared with those of 21 patients lected at random from 491 patients with no groin pain (grOUP N2). There were no significant differences in sex, age, dsc leveh the presence of LBP, the results of the SLR test, or the JOM score between groups N2 and Ni Location of herniation within the spinal canal, degeneration of the dises, extent of herniation in the anterior or lateral diFigure 1. Groin pain associated with lower lumbar disc hernia- tion. rection, and absence of the low-signal peripheral line around the herniation (black line) were evaluated using MRI by one radiologist who did not have access to clinical information. In axial images, the location of herniation was graded as central ‘when the top of the herniation was in the central half of spinal ‘anal. In T2-weighted images, degeneration of the discs was graded as I through V, according to the classification system of Pearce et al.® In sagittal images, the extent of herniation in the anterior direction was graded as 1) no anterior herniation, 2) Grade I (protrusion), or 3) Grade II (extrusion). In axial im- ages, the extent of herniation in the lateral direction was graded 48 1)no lateral herniation, 2) Grade I (border unclear between dise and psoas major muscle), and 3) Grade II (disc clearly protruded into the psoas major muscle) 1 Results Of the 512 patients diagnosed with singular lower lum- bar disc herniation (L4-LS and LS-S1), 21 patients (4.1%) reported groin pain. The average age was 45.7 + 13.4 years in group G and 39.1 = 13.8 years in group NI, with a statistically sig- nificant difference (P < 0.05, t = 2.15 > 1.97). The incidence of herniation at L4-LS was 86% in group G and 65% in group N1, a statistically significant differ- ence (P < 0,05, x° = 3.98 > 3.10). The rate of lower back pain was 67% in group G and 86% in group Ni, also a statistically significant difference (P < 0.05, x° = 6.11 > 4.66). Twelve of 21 patients (57%) in group G and 209 of 491 (43%) in group N1 were women, with the former showing a slightly higher rate of lower back Pain, although not statistically significant. The mean JOA score was 9.7 * 3.0 in group G and 8.8 = 2.7 in group Ni. The SLR test showed a mean value of 67.4 degrees in group G and 60.7 degrees in group N1. These diferences were not statistically significant (Table 1). Surgery was performed on five patients (24%) in group Gand on 133 (27%) in group N1. Groin pain was not the chief symptom of these patients at surgery, and in Groin Pain Associated With Lower Lumbar Disc Herniation * Yukawa et al_ 1737 Table 1. Clinical Features of Group G and Group Nt Group 6 Group NI (n= 2) (v= 491) Sex a, F12 ze, F209 Age (yr) 467 = 134" 312 138 L-LS Ino. (% 18 68)" 31765), Low back pain [no (%)) 1467" 4266) SUR test (") 674306 wo7r= 29 JOA score 9730 8827 305 two of the patients in group G, groin pain disappeared before surgery. In the other three group G patients, groin pain was present at surgery, but disappeared afterward. A posterior discectomy with partial laminectomy was performed. ‘On axial MR images, there were 15 central hernia- tions (71%) in group G and eight (38%) in group N2, a statistically significant difference (P < 0.05, x* = 4.71 > 3.46). There were 14 cases of Grade II and seven cases of Grade III dise degeneration in group G, and there were nine cases of Grade Il, 11 cases of Grade III, and one case of Grade IV disc degeneration in group N2. There were six cases of Grade I and six cases of Grade Il herniation in the anterior direction in group G, and there were seven cases of Grade I and six cases of Grade II herniation in group N2. There were six cases of Grade I and three cases of Grade I herniation in the lateral direction in group G, and there were five cases of Grade I and seven cases of Grade I herniation in the lateral direction in group N2. There were five cases in group G and seven cases in group N2 showing an absence of a black line. No significant difference was seen in degeneration of discs, extent of herniation in the anterior or lateral direction, or absence of black line on MRI between group G and group N2 (Table 2; Figures 2 and 3) ® Discussion Patients with lumbar disc herniation sometimes report groin pain, which is considered to be a referred pain. Table 2, Magnetic Resonance Ima G and Group NZ Findings of Group Group. Group N2 (@=2) (n= 2) Central herniation 1s(7i%I —8(38%) Grade of disc degeneration lag iis {arading by Pearce) 7 in Wa Absence of black line 5 7 Grade ofthe herniation inthe 16 ia ‘anterior direction is us Grade of the hemiaion in the lateral direction 16 15 3 uy += 008Spine + Volui 22+ Number 15 + 1997 Figure 2. Magnetic resonance image of L4-L5 central disc her fiation in a 65-year-old woman She came to hospital with a chief symptom of right buttock and Gfoin pain. Groin pain increased with hip extension. No abnormal findings were seen in a radio graph of the hip. With conserva. tive management, the groin pain decreased, but the right buttack pain remained, Posterior discec: tomy was performed, The re moved partion was a protrusion After surgery, the right buttock pain and the groin pain, which had remained slightly at surgery, disappeared Until now, little mention has been made regarding clin cal features and source of groin pain associated with data and MRI findings of patients with groin pain were investigated in lower lumbar disc herniation, Clinica the present study. Groin pain is derived not only from lumbar dise herniation, but also from other diseases of the hip and sacroiliac joint.'*" Patients with hip dis cases were excluded from this study, but examination of the sacroiliac joint condition was not possible because of the retrospective nature of this study In this study, patients with groin pain had a signif: cantly higher mean age, higher JOA score, weaker ten: , and lower rate of LBP than patients with no groin pain. The groin pain also was found to be transient Surgery was performed on five group G patients (24%), but groin pain was not the chief symptom at time of On MR ima ents with groin pain, No significant difference was es, more central herniation was noted in pa Figure 3. Magnetic resonance image of L4-L5 central disc her niation in a 45-year-old man. He came to the hospital with a chief symptom of right sciatica and lower back pain. He also re ported groin pain associated th weight-bearing in the right leg. Range of motion in the right hip joint was normal, and no ten: derness in the groin area discernable. Nonsurgical trea ment in the hospital for 1 month Produced no effect, so a poste: Fior discectomy was performed. The remaved portion was a sub: ligamentous extrusion, His right sciatica, lower back pain, and groin pain disappeared com: pletely after surgery s seen in degeneration of the discs, extent of herniation in the anterior and lateral direction, or absence of a black line between those with and without groin pain Taking both features and MRI findings into account, elderly patients with protruded herniation of the anulus fibrosus are considered to be more likely to experience groin pain, with the rate of L4=L5 disc involvement be ing higher than that of LS-S1 involvement. These results support conclusions drawn from Murphey’s study": 1) groin and testicular pain are rare with LS-S1 disc dis: ease, but are fairly common with L4=LS disc diseases 2) the rupture of the anulus is incomplete; and 3) conserva tive course should be followed for a considerable period consideration of su of time befor cry in a patient with unilateral sacroiliac, hip and/or groin pain, Posterocentral herniation, rather than anterior or lat eral herniation, was noted to be significantly more prev alent in patients with groin pain in the present study. The posterior anulus fibrosus, the posterior longitudinal lig: