Sciatica

 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.

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.

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.

CAUSES
 INFLAMMATORY
 NERVE ROOT COMPRESSION

CAUSES
INFLAMMATORY
Sciatic neuritis
arachnoiditis

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.

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.

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.

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.

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
DORSIFLEXI
ON OF TOES
L5/S1 S1 SOLE &
LATERAL
FOOT
PLANTAR
FLEXION
ANKLE

CLINICAL FORMS OF SCIATICA
 HYPERALGIC SCIATICA
 PARALYTIC SCIATICA

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

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 +

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

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.

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

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

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

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

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

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

IMAGING
 DISCOGRAPHY
Often neglected modality
Excellent means of assesing disc pathology

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

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

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.

TREATMENT
 SURGERY
When neurological deficit is present
Failure of conservative management
Chemonucleoloysis
Percutaneous disectomy

REHABILITATION
 THERAPEUTIC EXERCISES

Sciatica

More Related Content

What's hot

Viewers also liked

Similar to Sciatica

More from orthoprince

Recently uploaded

Sciatica