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.

TOPOGRAPHY

CAUSES

INFLAMMATORYNERVE ROOT COMPRESSION

CAUSES

INFLAMMATORYSciatic neuritisarachnoiditis

CAUSES

NERVE ROOT COMPRESSIONCompression 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 SYNDROMENeuromuscular 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 syndromeCaused/aggravated by sitting with a large

wallet in the affected side’s rear pocket.

CAUSES

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 DEGREESTHE 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

DORSIFLEXION OF TOES

L5/S1 S1 SOLE & LATERAL FOOT

PLANTAR FLEXION

ANKLE

CLINICAL FORMS OF SCIATICA

HYPERALGIC SCIATICAPARALYTIC SCIATICA

HYPERALGIC SCIATICA

Characterized by severe painPatient 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 sciaticaMost often paralytic L5 sciatica leads to foot

drop, which forces the patient to modify the gait pattern.

DIFFERENTIAL DIAGNOSIS

SPONDYLOARTHROPATHYUsually 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 commonPatient will stand or walk to bring relief.Physical activity has no influence on the pain.Spine is sometimes very stiff.Radiograhic studies are normalDiagnosis : ct/myelographySurgery relieves the patient

Differential diagnosis

Metastatic leisons or a multiple myeloma can result in intense refractory sciatic pain.

Infectious discitisInfectious sacro illitis

PSUEDOSCIATIC SYNDROMES

Some disorders can simulate sciatic pain.Periarthritis of the hip

IMAGING

RADIOGRAPHYMost occasions radiographs is normalLoss of lumbar lordiosisScoliosisReduced intervertebral disc spsce.

IMAGING

CTMorphologic abnormalities in relation to a

herniated disc.Relative impact on adjacent soft tissuesAny neuroforaminal or extra foraminal

encroachment.

IMAGING

MYELOGRAPHYExcellent for assesing the entire sub

arachnoid space.Assesment of spinal stenosisDisadvantages: headache’s, nausea

IMAGING

DISCOGRAPHYOften neglected modalityExcellent 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 MANAGEMENTIntermittent 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

SURGERYWhen neurological deficit is presentFailure of conservative managementChemonucleoloysisPercutaneous disectomy

REHABILITATION

THERAPEUTIC EXERCISES

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