Most frequent radicular pain syndrome of spinal
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 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
Relieved by lying down.
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
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
NERVE ROOT COMPRESSION
Compression in the vertrebral canal by disc, tumour,
Compression in the intervertebral foramen due to
root canal stenosis because of osteoarthritis ,
spondylolisthesis , facet arthropathy , tumours.
Compression in the buttock or pelvis by
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
Wallet sciatica/fat wallet syndrome
Caused/aggravated by sitting with a large wallet in
the affected side’s rear pocket.
STRAIGHT LEG RAISING TEST IS POSITIVE.
Patient in supine position
Examiner lifts the leg gradually with the knee kept
Between 30 and 70 degree nerve comes into contact
with the prolapsed disc & the patient complaints of
LASEGUE’S SIGN: MODIFICATION OF SLRT.
HIP IS FLEXED & THE KNEE IS ALSO FLEXED AT
THE KNEE IS THEN GRADUALLY EXTENDED BY
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
L3/L4 L4 INNER CALF INVERSION
L4/L5 L5 OUTER CALF
ON OF TOES
L5/S1 S1 SOLE &
CLINICAL FORMS OF SCIATICA
Characterized by severe pain
Patient prefers to remain in bed & is hesitant even to
Specific form : 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
Mild motor deficit.
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.
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.
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
Metastatic leisons or a multiple myeloma can result
in intense refractory sciatic pain.
Infectious sacro illitis
Some disorders can simulate sciatic pain.
Periarthritis of the hip
Most occasions radiographs is normal
Loss of lumbar lordiosis
Reduced intervertebral disc spsce.
Morphologic abnormalities in relation to a
Relative impact on adjacent soft tissues
Any neuroforaminal or extra foraminal
Excellent for assesing the entire sub arachnoid space.
Assesment of spinal stenosis
Disadvantages: headache’s, nausea
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.
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.
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.
When neurological deficit is present
Failure of conservative management