Date post: | 02-Nov-2014 |
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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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