Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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C.H. Li et al.
steroid injections and surgery. Injections have increased in popularity in
recent years, but their efficacy has been controversial [ 32 ]. Surgical
versus nonsurgical approaches have recently been evaluated by the
Spine Patient Outcome Study (SPORT) [ 33 ]; the authors concluded that
patients with degenerative spondylolisthesis treated with surgery had
significantly better outcomes at four years compared to those who were
managed noninvasively. The outcomes for patients with stenosis without
spondylolisthesis were not as clearly defined.
Herniated Disc
Herniated discs are one of the most common discogenic causes of
groin pain. The most common sites of herniation are at the L4–5 and
L5–S1 levels. Additionally, other sites of herniation that will manifest as
groin pain include the L1/L2 and S3/S4 levels. S3/S4 involvement likely
is not due to direct S3/4 disc herniation, rather by S3/4 nerve root
compression by more rostral disc herniations (i.e., L4–5 or L5–S1). L1/
L2 disc herniation will localize to the inner thigh, while a herniation that
affects the S3/S4 level will localize to the scrotal region. It is believed
that decreased hydration of the annular disc leads to decreased ability of
the disc to cushion load. This dehydration can be due to age, genetics,
and environmental factors. A sharp stabbing pain that radiates down to
the extremities below the knees is highly suggestive of herniation [ 34 ].
On physical exam, increased pressure on the annular fibers of the disc
will help distinguish herniation from low back pain, which is typically
made worse by twisting motions of the lower back muscles. The straight
leg raise is usually indicative of a pinched nerve or nerve root.
Nonsurgical approaches to the management of a herniated disc are
similar to those for other forms of disc degeneration. These approaches
include physical therapy, focused exercises, and epidural injections. The
natural history of lumbar herniated disc is that a majority of patients will
resolve their symptoms without intervention given enough time. Surgery
may be indicated in severe cases that cause significant pain or disability
and also in cauda equina syndrome [ 34 ].
Spondylolisthesis
Spondylolisthesis refers to anterior subluxation of the vertebral body
that is caused by a defect in the pars interarticularis [ 35 ]. Spondylolisthesis
falls into three categories: spondylolysis, isthmic, and degenerative [ 36 ].