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Extra spinal causes of sciatica and a causes algorithm
- 1. Bahaa Ali Kornah Prof.of Orthopedic Surgery Al-Azhar university , Cairo, Egypt Bahaa Kornah -AlAzhar UN. Cairo Egypt Abstract Number: 52575
- 2. EXTRASPINAL SCIATICA = Non-discogenic sciatica (NDS) Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 3. SCIATICA Sciatica Isa set of symptoms including pain that may be caused by general compression and/or irritation of one of five spinal nerve roots that give rise to each sciatic nerve, or by compression or irritation of the left or right or both sciatic nerves. Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 4. ❖The pain isfelt in the lower back, buttock, and/or various parts of the leg and foot. ❖Numbness, ❖Muscular weakness, ❖Pins and needles or tingling and ❖Difficulty in moving or controlling the leg. Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 5. Sciatica is common,and is frequently caused by lumbar disc herniation(Bickels et al 1999 ) . However, some intraspinal or extra spinal pathologic processes along the sciatic nerve may also cause sciatica. Whereas lumbar spine imaging reveals the causes of intraspinal non-discogenic sciatica (NDS), Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 6. Extra spinal sciaticais often misdiagnosed because routine diagnostic tests focus on the lumbar spine (Dudeney 1998). Extra spinal causes affect the nerve as it progresses distally from the sciatic notch has to be consider. Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 7. Extra spinalSciatica (Extra spinal Radiculopathy) Defined as Pain, sensory disturbance, or weakness by compression or irritation of the left or right or both sciatic nerves. resulting from abnormal changes outside the spinal canal Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 8. ANATOMY The sciatic nerveis the largest nerve of the body and carries contributions from L4 to S3. It passes through the Gluteal region into the thigh, where it divides into its two major branches common peroneal nerve and the tibial nerve. Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 9. Classification No clear classificationwas proposed Extra spinal causes can be differentiated into ❖ Diseases of the lumbosacral plexus and ❖ Lesions of the sciatic nerve or its branches Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 10. Lesions of thelumbosacral plexus usually produce symptoms of more than one segment, and often the pelvic condition responsible for lumbosacral pain overshadows sciatica. ❖ Pelvic tumors (Bickels et al. 1999), ❖ Intrapelvic aneurysm (Dudeney et al. 1998), and ❖ Endometriosis (Dhote et al. 1996). Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 11. Lesions of thesciatic nerve or its branches , Pain is not usually a prominent symptom (Elliott & Schutta 1971). ❖ Compression of the nerve as in hamstring (Puranen & Orava 1991) and piriformis syndromes (Hanania & Kitain 1998), or ❖ by vascular compromise as in diabetes (Naftulin et al. 1993). ❖ A rare cause of sciatica is cervical and thoracic spinal cord compression (Ito et al. 1999). Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 12. EXTRASPINAL SCIATICA CAUSES Kornah Classification Bahaa Kornah-AlAzhar UN. Cairo Egypt
- 13. EXTRASPINAL SCIATICA CAUSES EXTRASPINALSCIATICA Outside thenerve Intra pelvic Extra pelvic Within the nerve Peripheral nerve entrapment Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 14. ➢ INTRA PELVICCAUSES : from neural foramina to greater sciatic notch ➢ Tumors ➢ Hematoma in the psoas muscle ➢ Gynecological causes > Endometriosis ,Tubo-ovarian abscess Intrauterine device after uterine perforation ➢ Pyomyositis ➢ Osteophyte at the sacroiliac joint ➢ Sacroiliitis ➢ Anorectal abscess above the levator ➢ Aneurysm (abdominal aortic aneurysm) EXTRASPINAL SCIATICA CAUSES OUTSIDE THE NERVE Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 15. ➢ EXTRA PELVICCAUSES: distal to greater sciatic notch ➢ Piriformis syndrome ➢ Pseudoaneurysm of the Superior Gluteal Artery ➢ Sciatic Nerve Compression by Gluteal Varicosities ➢ Compression of the nerve by wear debris following total hip replacement ➢ Avulsion fracture of the ischial tuberosity ➢ Tumors ➢ Acetabular paralabral cyst ➢ Surgical Trauma EXTRASPINAL SCIATICA CAUSES OUTSIDE THE NERVE Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 16. CAUSES WITHIN THENERVE ➢Diabetic Radiculopathy ➢Tumor of neural origin ➢Fibrosis of sciatic nerve EXTRASPINAL SCIATICA CAUSES WITHIN THE NERVE Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 17. ➢Common peroneal nerve ➢Posteriortibial nerve EXTRASPINAL SCIATICA ENTRAPMENT OF THE PERIPHERAL NERVE Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 18. . Diagnosis of extraspinal sciatica patient history and clinical examination + Medical history Physical signs Imaging ( X ray – CT scan ,MRI , US.and Magnetic resonance neurography Other diagnostic tests NCT+EMG Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 19. Symptoms INTRA PELVICCAUSES : from neural foramina to greater sciatic notch make irritation to lumbosacral plexus Produce symptoms of more than one segment, and often the pelvic condition responsible for lumbosacral pain overshadows sciatica. Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 20. Symptoms EXTRA PELVICCAUSES: Distal to greater sciatic notch Referred pain is deep, dull, boring and aching. It follows the distribution of the myotomes and sclerotomes (Elliott & Schutta 1971, Bogduk 1997a), Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 21. PIRIFORMIS SYNDROME ➢ Piriformissyndrome is a neuromuscular condition characterized by hip and buttock pain ➢ Delay in diagnosing piriformis syndrome may lead to pathologic conditions of the sciatic nerve Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 22. Piriformis Syndrome Features 1.A chronic nagging ache, pain, tingling, or numbness 2. starts in the buttocks 3. can extend along the course of the sciatic nerve 4. down the entire back of the thigh and calf, and sometimes into the foot 5. Pain worsens when the piriformis is pressed against the sciatic nerve- (eg, while sitting on a toilet, a car seat, or a narrow bicycle seat or while running). Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 23. the relationships between thesciatic nerve and the piriformis muscle PIRIFORMIS SYNDROME Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 24. 1. CLINICAL DIAGNOSIS A.Clinical symptoms & signs B. Clinical tests 1. Freiberg sign 2. Pace sign 3. deep digital palpation of the piriformis muscle PIRIFORMIS SYNDROME Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 25. Freiberg sign Bahaa Kornah-AlAzhar UN. Cairo Egypt Pace sign
- 26. Possible Causes ofPiriformis Syndrome Anatomical variation L/S dysfunction Muscle tightness and/or spasm Overuse Post surgical injury SIJ dysfunction Trauma/fall Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 27. 2. Investigations ❑ Plainradiographs ❑ Magnetic resonance neurography ❑ Neurophysiologic testing PIRIFORMIS SYNDROME Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 28. EXTRAPELVIC CAUSES ❖ Pseudoaneurysmof the Superior Gluteal Artery Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 29. EXTRAPELVIC CAUSES ❖ SciaticNerve Compression by Gluteal Varicosities Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 30. Bursitis IschialTuberosity Bahaa Kornah -AlAzharUN. Cairo Egypt
- 31. Chronic avulsion ofthe ischial tuberosity Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 32. Compression nerve bywear debris following total hip replacement EXTRAPELVIC CAUSES Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 33. EXTRAPELVIC CAUSES TUMORS Bahaa Kornah-AlAzhar UN. Cairo Egypt
- 34. Myositis Ossificans hip BahaaKornah -AlAzhar UN. Cairo Egypt
- 35. Gynecological causes INTRAPELVIC CAUSES HysteromyomaFluid in Douglas Pouch Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 36. Ovarian cyst INTRAPELVIC CAUSES BahaaKornah -AlAzhar UN. Cairo Egypt Iliopsoas abscess
- 37. Osteophyte at thesacroiliac joint INTRAPELVIC CAUSES Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 38. There aretwo potential mechanisms by which Sacroiliitis can generate sciatica: (i) referred pain and (ii) direct involvement of the nerve by inflammatory mediators released from the sacroiliac joint Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 39. Physical examinationsshould include a SI CompressionTest, Gaenslen’s test and a FABER test. The location of the aggravating pain after the FABER test may reflect the pathology. Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 40. CAUSES WITHIN THENERVE DIABETIC NEUROPATHY Diabetes may cause a syndrome of severe lower extremity pain and Weakness. This syndrome usually involves multiple lumbosacral nerve roots but rarely presents as a monoradiculopathy. The precise pathophysiology of diabetic Radiculopathy is controversial with nerve ischemia, inflammation, and metabolic causes implicated Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 41. TUMORS OF NEURALORIGIN ➢ Neurofibroma Posterior thigh pain, palpable mass ➢ Schwannoma Posterior thigh and calf pain ➢ Neurofibrosarcoma Posterior thigh and calf pain, known neurofibromatosis CAUSES WITHIN THE NERVE Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 42. FIBROSIS OF SCIATICNERVEmay be ❖Post traumatic , ❖Post injection , ❖Post inflammatory and ❖Post radiation which lead to affection of sciatic fibers causing symptoms of sciatica CAUSES WITHIN THE NERVE Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 43. ENTRAPMENT OF PERIPHERALNERVES COMMON PERONEAL NERVE traumatic injuries, such as MVA. location along the thigh down to the fibular head region in various forms of trauma, such as lacerations, femoral fractures, bullet wounds, and direct injury. However, most peroneal nerve injuries occur at the region of the fibular head. Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 44. Bahaa Kornah -AlAzharUN. Cairo Egypt
- 45. ENTRAPMENT OF PERIPHERALNERVES POSTERIOR TIBIAL NERVE This entrapment typically occurs within or distal to the tarsal canal, resulting in pain and/or sensory disturbance on the plantar aspect of the foot. Entrapments above the ankle have been reported in the popliteal fossa, where the nerve can be compressed by the tendinous arch of origin of the soleus muscle, a Baker cyst, or other masses that may occur in this region Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 46. Herpes zoster Skin lesions alongthe trajectories of the L3 and L4 nerve roots Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 47. CONCLUSION Sciatica maybe caused by extra spinal bone and soft tissue lesion along the course of the sciatic nerve. Causes of extra spinal sciatica can be within the nerve or outside the nerve which subdivided into Intrapelvic causes extra pelvic causes. The pain pattern is the key to early diagnosis. Special attention should be given to patients with sciatica that had an insidious onset and is constant, progressive, and unresponsive to change in position. Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 48. CONCLUSION . Adetailed patient history, especially focused on pain characteristics, is an important component of patient evaluation. Physical examination of patients with sciatica should include inspection, palpation, and all physical tests to exclude NDS. Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 49. EXTRASPINAL SCIATICA Kornah classification EXTRASPINALSCIATICA Outsidethe nerve Intra pelvic Extra pelvic Within the nerve Peripheral nerve entrapment Bahaa Kornah -AlAzhar UN. Cairo Egypt
- 50. Bahaa Kornah -AlAzharUN. Cairo Egypt Bahaa Ali Kornah bkornah@gmail.com