David Spence's NeuroMOOC final project

1. My NeuroMOOC 2015 Project
Hello and welcome to my project, which will be
focusing on my mother's struggle with sciatica
and how NeuroMOOC has helped me help her
understand her condition and choose a
therapeutic intervention. Please bear with me as
this is the first slide presentation I've ever made!
--David Spence

2. What is Sciatica?
Sciatica is a collection of symptoms that follow
the path of the sciatic nerve, with varying
causes, that generally involves pain, numbness,
tingling and/or burning sensations, and
sometimes muscle weakness running from the
lower back down one side into the leg, along the
sciatic nerve, which we'll be talking about in
detail shortly.

3. What is Sciatica?
Sciatica is usually acute and resloves itself in 6-
8 weeks. It is treated with bed rest or physical
therapy. Chronic sciatica may indicate an
underlying problem, as proved the case with my
mother. Often in these cases a structrual
problem causes irritation of part or all of the
sciatic nerve. So what is the sciatic anyway?

4. The Sciatic Nerve
As we have learned, nerves are collections of
the axons of neurons. The sciatic nerve is
formed from a collection of spinal nerve roots
that are part of the cauda equina below the
terminus of the spinal cord, specifically those
numbered L4 down to S3, which join as the
sciatic nerve as seen in the following diagram:

5. The Sciatic Nerve
● [from: sciaticapainreliefathome.com]

6. The Sciatic Nerve
As you can see the unified sciatic is a large
nerve, in fact it is the largest in the human body.
It is a mixed nerve, so it not only innervates
muscles in the leg but also sensations in the
skin of the foot, lower leg, and back of the thigh.
This is why irritation or compression of the
sciatic nerve or its constituent fibers causes
symptoms affecting those areas. How might
such compression occur?

7. Intervertebral Foramen
In the diagram in slide 5, you can see that spinal
nerve roots exit the vertebral column through
small gaps, called foramen. The size of this
opening depends on the structure around it, and
one problem that can develop is that a disc that
separates the vertebrae can degenerate and
cause the foramen to shrink so much that the
nerve roots are pinched as they exit, as in the
next slide diagram:

8. Pinched Spinal Nerve
● [from: www.precisionhealth.com.au]

9. Foraminal Stenosis
As the diagram shows, the degenerated disc
causes a severe narrowing of the foramen
opening. This narrowing is called stenosis, and
this is what my mother was diagnosed with right
in the middle of our NeuroMOOC course.

10. My Mother's Case
Her sciatica symtoms came on suddenly several
months ago. Her primary symptom was severe,
shooting pain from her tailbone down her left leg
into her foot. While there were also
uncomfortable sensations along that route as
well, including a pins-and-needles feeling called
parethesia, the pain has been the majority of the
problem.

11. Pain
Normally, pain is a process that begins where
pain receptors called nociceptors are located in
tissue. When these are activated they send a
signal up an axon into the spinal cord where
they are relayed to the thalamus and finally the
cerebral cortex, resulting in the perception of
pain.

12. The Pain Pathway
● [from: www.mydr.com.au]

13. Compressed Nerve Pain
But the pain caused by a pinched nerve, like my
mother and many with sciatica have, is the
result of the compression causing a dysfunction
in the sensory (afferent) signals so that pain
shoots through the area that nerve services.
This route of pain that follows a pinched nerve is
called its dermatome and depends on the
nerve(s) affected:

14. Dermatomes
● [from: drwolgin.comx]

15. Dermatomes
As you can see from the previous slide, the pain
of sciatica makes a great deal of sense in this
context. When I showed it to my mother, she
said that the L5 and S1 dermatomes exactly
matched where she felt symptoms down her left
leg. Not only does pain disrupt a patient's life
because of the obvious—it hurts—pain affects
how we move.

16. Adjusting to Pain
Just about all of us have had to change the way
we walk for some period of time while we're
injured. Because of her sciatica symptoms, my
mother has had to do this for months. Her
activity has been severely hampered but she
can still get around, albeit more slowly, because
of the adaptability of her cerebellum.

17. The Cerebellum
As we've learned, the cerebellum modulates
movement. And when it has to, it adjusts those
movements via associative learning, so that my
mother's “new” gait favors the painful left side as
well as the numb part of the outside of that foot.
Similarly it will have to adjust back once she
begins to get better.

18. Getting Treatment
My mother first sought treatment at her primary
physician. After bed rest and a course of oral
steroids didn't help, she was sent to a specialist
who sent her to physical therapy. At first this
relieved some of her pain because the
therapists used a technique that stretched her
vertebrae apart.

19. Getting Treatment
After a short time, though, the pain returned as
the vertebrae settled to their normal position.
This told her specialist that her sciatica likely
had a structural component and ordered a
lumbar MRI.

20. The Diagnosis
The doctor reviewed her MRI and found that at
the L4-L5 juncture there was “moderate to
severe right neural foramina stenosis” and at the
L5-S1 juncture “moderate to severe left neural
foramina stenosis”--so two places where nerve
roots that become the sciatic nerve are being
compressed. Here's what that looks like:

21. The MRI
● [Used with permission]

22. The MRI
The previous slide is one image from my
mother's MRI (with identifying info cropped from
the top), which I've marked up to the best of my
understanding to show the lumbar areas where
nerve roots are being crowded, if not all
compressed. Even though there are several
spots, her symptoms are from the left foraminal
stenosis located at the L5-S1 junction.

23. More Treatment
Solving back problems is often a long and
frustrating journey for patients. My mother's
case has not been an exception to that. Doctors
suggested that the next step be a cortisone
injection into the back in the hope it would
reduce any inflammation there and ease the
nerve compression. This was done, but did not
work.

24. Time For Surgery
After the cortisone shot didn't relieve her
symptoms, my mother and I met with her
neurologist (who is a neurosurgeon) and
discussed where to go from there. He
suggested a procedure I had found online in my
own research called a foraminotomy, which is
where the foramen is enlarged by removal of
bony material so the nerve root isn't
compressed.

25. Lumbar Foraminotomy
This procedure is minimally invasive and
involves use of an arthoscope or endoscope to
image the affected nerve root exit followed by
shaving of surrounding material, possibly
including the facet joints which connect the
vertebrae and lie alongside the foramen.

26. Arthoscopic Foraminotomy
● [from: www.joint-surgeon.com]

27. Endoscopic Foraminotomy
● [from: www.aopmhealth.com]

28. The Journey From Here
After some deliberation, my mother has decided
to have the foraminotomy done. I feel that the
info from NeuroMOOC helped me aid her in
better understanding both the sciatica and this
procedure. For example I was able to tell her
that the surgery is below where her spinal cord
stops, somewhat alleviating her anxiety of an
operation on her back.

29. The Journey From Here
She has made an appointment for the middle of
June 2015 for her procedure. The recovery time
is expected to be relatively short and the pain
relief immediate since the nerve root shouldn't
be compressed anymore. It may take longer for
normal sensation to return, and she'll have to
use that cerebellum again to readjust her
posture and walk. But, hopefully, the
foraminotomy will mark the beginning of real
healing from this painful problem.

30. Final Note
Thanks for your patience viewing this. I know it
wasn't visually stunning :)
Please see the last slides for image sources
and references.

31. Image Sources
● “The Sciatic Nerve”:
http://www.sciaticapainreliefathome.com/wp-
content/uploads/2014/01/Where-is-the-
Sciatic-Nerve1.png
● “Pinched Spinal Nerve”:
http://www.precisionhealth.com.au/images/def
ault-source/neurosurgery-and-spinal-
surgery/spinal6.png?sfvrsn=1

32. Image Sources
● “The Pain Pathway”:
http://www.mydr.com.au/files/images/categori
es/pain/painpathway2.gif
● “Dermatomes”:
http://www.drwolgin.com/SiteImages/dermato
mes-netter2.jpg
● “The MRI”: Used by permission of patient

33. Image Sources
● “Arthoscopic Foraminotomy”: http://www.joint-
surgeon.com/orthopedic-joint-surgeon/spine-
specialist/minimalinvasive-spine-surgery.jpg
● “Endoscopic Foraminotomy”:
http://aopmhealth.com/wp-
content/uploads/2013/07/treatments-
endoscopicforaminotomy.jpg

34. Reference Material
● http://www.precisionhealth.com.au/services/p
ain-management/conditions-treated/spinal-
conditions/sciatica
● http://www.drwolgin.com/pages/foramstenosis
.aspx
● http://www.chirogeek.com/003_CT-
Axial_Tutorial.htm

35. Reference Material
● http://www.mydr.com.au/pain/pain-and-how-
you-sense-it
● www.setonbrainandspine.com/treatment/spin
e/sciatica-diagnosis-and-treatment
● www.spine-health.com/conditions/spine-
anatomy/all-about-l5-s1-lumbosacral-joint
● en.wikipedia.org/wiki/Sciatica
● en.wikipedia.org/wiki/Spinal_nerve

36. Reference Material
● www.drwolgin.com/pages/foraminotomy.aspx
● www.drwolgin.com/pages/foramstenosis.aspx