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  • 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 DORSIFLEXI ON OF TOES L5/S1 S1 SOLE & LATERAL FOOT PLANTAR FLEXION ANKLE
  • 14. CLINICAL FORMS OF SCIATICA  HYPERALGIC SCIATICA  PARALYTIC SCIATICA
  • 15. HYPERALGIC SCIATICA  Characterized by severe pain  Patient prefers to remain in bed & is hesitant even to move slightly.  Specific form : myalgic sciatica
  • 16. 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 +
  • 17. 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.
  • 18. 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.
  • 19. 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
  • 20. Differential diagnosis  Metastatic leisons or a multiple myeloma can result in intense refractory sciatic pain.  Infectious discitis  Infectious sacro illitis
  • 21. PSUEDOSCIATIC SYNDROMES  Some disorders can simulate sciatic pain.  Periarthritis of the hip
  • 22. IMAGING  RADIOGRAPHY Most occasions radiographs is normal Loss of lumbar lordiosis Scoliosis Reduced intervertebral disc spsce.
  • 23. IMAGING  CT Morphologic abnormalities in relation to a herniated disc. Relative impact on adjacent soft tissues Any neuroforaminal or extra foraminal encroachment.
  • 24. IMAGING  MYELOGRAPHY Excellent for assesing the entire sub arachnoid space. Assesment of spinal stenosis Disadvantages: headache’s, nausea
  • 25. IMAGING  DISCOGRAPHY Often neglected modality Excellent means of assesing disc pathology
  • 26. Magnetic resonance imaging  STUDY OF CHOICE for recurrence following disectomy, to differentiate recurrent herniation from peri neural fibrosis.  Detect other leisons.
  • 27. 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
  • 28. 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.
  • 29. TREATMENT  SURGERY When neurological deficit is present Failure of conservative management Chemonucleoloysis Percutaneous disectomy
  • 30. REHABILITATION  THERAPEUTIC EXERCISES
  • 31. THANK YOU