Sciatica

1. SCIATICA

2. Most frequent radicular pain syndrome of spinal origin. Occurs due to irritation of a spinal nerve root associated with disc herniation at L4-L5 OR L5-S1. Pain usually begins in the lower back radiating to the sacroiliac regions, buttocks,thighs,calf & foot. Sciatica is a symptom , NOT A DIAGNOSIS.

3. ONSET Onset is often traumatic. Exertion or a forced movement results in acute low back pain, followed by referral to the leg. Exacerbated by standing, sitting, exertion, coughing and sneezing. Relieved by lying down.

4. TOPOGRAPHY It’s referral pattern follows that of L5 or S1 territory: L5:buttock, anterior aspect of thigh, lateral malleolus, dorsum of foot, great toe or the medial 3 toes. S1:buttock,posterior aspect of thigh, knee,leg & heel, to the sole or lateral side of the foot upto the fifth toe. In the distal limb, pain may be replaced by tingling or numbness.

5. TOPOGRAPHY

6. CAUSES INFLAMMATORY NERVE ROOT COMPRESSION

7. CAUSES INFLAMMATORY Sciatic neuritis arachnoiditis

8. CAUSES NERVE ROOT COMPRESSION Compression in the vertrebral canal by disc, tumour , TB. Compression in the intervertebral foramen due to root canal stenosis because of osteoarthritis , spondylolisthesis , facet arthropathy , tumours . Compression in the buttock or pelvis by abscess,tumours,hematoma .

9. CAUSES PIRIFORMIS SYNDROME Neuromuscular syndrome that occurs when the sciatic nerve is compressed/irritated by the piriformis muscle causing pain, tingling & numbness in the buttocks & along the path of sciatic nerve. Wallet sciatica/fat wallet syndrome Caused/aggravated by sitting with a large wallet in the affected side’s rear pocket.

10. CAUSES

11. CLINICAL EXAMINATION STRAIGHT LEG RAISING TEST IS POSITIVE. Patient in supine position Examiner lifts the leg gradually with the knee kept straight. Between 30 and 70 degree nerve comes into contact with the prolapsed disc & the patient complaints of pain.

12. CLINICAL EXAMINATION LASEGUE’S SIGN: MODIFICATION OF SLRT. HIP IS FLEXED & THE KNEE IS ALSO FLEXED AT 90 DEGREES THE KNEE IS THEN GRADUALLY EXTENDED BY THE EXAMINER. IF NERVE STRETCTH IS PRESENT: PATIENT WILL EXPERIENCE PAIN IN THE BACK OF THIGH OR LEG.

13. SIGNS IN LUMBAR ROOT COMPRESSION DISC LEVEL ROOT SENSORY LOSS WEAKNESS REFLEX LOSS L3/L4 L4 INNER CALF INVERSION OF FOOT KNEE L4/L5 L5 OUTER CALF & DORSUM OF FOOT DORSIFLEXION OF TOES L5/S1 S1 SOLE & LATERAL FOOT PLANTAR FLEXION ANKLE

14. CELLULO-TENO-PERIOSTEO-MYALGIC MANIFESTATIONS Cellulalgic manifestations, trigger points & teno periosteal tenderness are located in the territory of involved nerve root. Trigger points are constant in the gluteal muscles. Biceps femoris (inferior part) S1 SCIATICA

15. CELLULO-TENO-PERIOSTEO-MYALGIC MANIFESTATIONS In 50% of cases,a cellulagic zone is found overlying the post calf S1 sciatica. Trochanteric tenderness is frequent in L5 sciatica.

16. CLINICAL FORMS OF SCIATICA HYPERALGIC SCIATICA PARALYTIC SCIATICA

17. HYPERALGIC SCIATICA Characterized by severe pain Patient prefers to remain in bed & is hesitant even to move slightly. Specific form : myalgic sciatica

18. Myalgic sciatica Seen most commonly in disc heerniations affecting S1 nerve root. Neuralgic pain is associated with intense & often continous muscular pains and cramps affecting the biceps femoris , triceps surae & ocasionally the gluteal muscles. Mild motor deficit. Fasciculations +

19. PARALYTIC SCIATICA Slight motor deficit can be detected. More frequent in L5 sciatica Most often paralytic L5 sciatica leads to foot drop, which forces t he patient to modify the gait pattern.

20. DIFFERENTIAL DIAGNOSIS SPONDYLOARTHROPATHY Usually seen in the young. Pain does not refer distal to the knee. Bilateral or alternating occuring episodically. Not modified by activity. Nocturnal pain is common. Diagnosis: PA Views of pelvis or specialized hibbs view of the sacro illiac joints. ESR is elevated. Rapid respone to medication.

21. DIFFERENTIAL DIAGNOSIS INTRAMEDULLARY TUMOURS(GLIOMAS) Nocturnal pain is common Patient will stand or walk to bring relief. Physical activity has no influence on the pain. Spine is sometimes very stiff. Radiograhic studies are normal Diagnosis : ct / myelography Surgery relieves the patient

22. Differential diagnosis Metastatic leisons or a multiple myeloma can result in intense refractory sciatic pain. Infectious discitis Infectious sacro illitis

23. PSUEDOSCIATIC SYNDROMES Some disorders can simulate sciatic pain. Periarthritis of the hip

24. IMAGING RADIOGRAPHY Most occasions radiographs is normal Loss of lumbar lordiosis Scoliosis Reduced intervertebral disc spsce .

25. IMAGING CT Morphologic abnormalities in relation to a herniated disc. Relative impact on adjacent soft tissues Any neuroforaminal or extra foraminal encroachment.

26. IMAGING MYELOGRAPHY Excellent for assesing the entire sub arachnoid space. Assesment of spinal stenosis Disadvantages: headache’s, nausea

27. IMAGING DISCOGRAPHY Often neglected modality Excellent means of assesing disc pathology

28. Magnetic resonance imaging STUDY OF CHOICE for recurrence following disectomy , to differentiate recurrent herniation from peri neural fibrosis. Detect other leisons .

29. TREATMENT CONSERVATIVE MANAGEMENT Intermittent bed rest with movement for short periods in between. Patient should lie on a firm mattress, in the position that feels most comfortable. Rigid lumbar orthosis can shorten the duration or obviate the need for bed rest. Heat/cold application

30. TREATMENT ANALGESICS & ANTI INFLAMMATORY DRUGS In hyperalgic forms, intrathecal injection of steroids by LUCHERINI’S technique can produce a remarkable reduction in pain Epidural analgesia in severe cases.

31. TREATMENT SURGERY When neurological deficit is present Failure of conservative management Chemonucleoloysis Percutaneous disectomy

32. REHABILITATION THERAPEUTIC EXERCISES

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