Kasus 1: - The cause was likely a herniated disc in the lower back that occurred in a middle-aged person after lifting, causing sudden onset of low back pain radiating down the left leg. The mechanism was likely compression or irritation of the sciatic nerve root from the herniated disc material. Kasus 2: - The cause was likely spinal stenosis or foraminal stenosis from osteoarthritis in the lower spine. This developed gradually over years in an older person. The mechanism was narrowing of the spinal canal and foramina, compressing the nerve roots, especially with prolonged sitting or spine extension.

1. Identifying the Cause
of Sciatica
Aditya Johan Romadhon, SST,Ft, M.Fis

2. Introduction
The remaining 15% of cases of sciatica have many causes
Displacement of a vertebra, spondylolisthesis, occurs in younger people (<30 years).
Osteoarthritis with bony overgrowth, osteoarthritis in older people (>60 years)
Herniated discs, herniated discs occur in middle age people (30–60 years)
There are three major spinal column disorders that cause sciatica
Spinal column disorders account for about 85% of all cases of sciatica

3. Of the common causes
herniated discs,
spondylolisthesis and infection
usually develop rapidly
Whereas osteoarthritis, tumors
and nerve entrapment typically
develop gradually
Sudden onset in a middle aged
person after lifting, straining or
vigorous exercise suggests a
herniated disc
While sudden onset in a young
person after trauma or
vigorous sport suggests
vertebral displacement with
spondylolisthesis

4. Herniated Discs
Each intervertebral disc contains a gelatinous
center surrounded by a fibrous band, which in turn
is surrounded by a strong ligament
The outer ligament is innervated with pain fibers
but there is no innervation to the body of the disc
With trauma and aging, degenerative arthritic
changes occur in the gelatinous center and the
surrounding fibrous disc
Disc protrusions (where the gelatinous center
bulges through the fibrous disc but is held in check
by the annular ligament) occur in more than 50%
of normal people
Pain can result from activation of nerve endings in
the outer ligament, compression of a spinal nerve,
or an inflammatory response triggered by
chemicals released from the bulging disc

5. Spondylolisthesis
Spondylolisthesis can result from
trauma and developmental bony
defects
Fracture of the key stabilizing
elements of the vertebra can lead to
dislocation with forward displacement
of the vertebral body and compression
of spinal nerves causing sciatica
Severe osteoporosis can cause a
sudden collapse of a vertebra

6. Osteoarthritis
Spinal stenosis leads to compression of the cauda equina and commonly causes pain with walking and multiple other
neurological symptoms including leg weakness, numbness and impaired bowel and bladder function
Both conditions tend to be aggravated by bending backward and relieved by bending forward and lying down
Spinal stenosis refers to narrowing of the entire spinal canal
Foramen stenosis refers to a narrowing of the bony canal where the spinal nerves exit the spine
With the aging of the general population and the overall increased life span osteoarthritis has replaced herniated discs
as the most common cause of sciatica
With aging, degenerative arthritic changes not only occur in the discs but also in the vertebral joints, ligaments and
surrounding bone

7. Nerve Entrapment
Sciatica immediately can be due to stretching
of the nerve by prolonged positioning with
the legs in outward rotation, trauma or
entrapment by injured muscles or tendons
near the nerve
As wallets have become stuffed with credit
cards there are reports of sciatica being
relieved by removing a bulging wallet from
the back pocket, so-called credit-carditis
With the piriformis syndrome, the sciatic
nerve is entrapped by muscle or surrounding
tissue as the nerve passes by or through it
Whether the nerve is entrapped by a normal
muscle or by a muscle that has been injured
from running or lunging is often unclear but
probably there are multiple different
mechanisms for the entrapment

8. Sciatica nerve (L4-L5-S1-S2-S3)

9. Branches from L4-L5-S1-S2-S3 become
sciatica nerve and split into two division,
anterior division (tibial nerve) and
posterior division (fibular nerve)
Anterior division (tibial nerve) has
cutaneous branch, it picking up sensation
from posterior aspect of leg, posterior leg
and sole of the foot, and motor supply to
hamstring muscle (biceps femoris
longus), adductor magnus, popliteus,
plantaris, tibialis posterior, flexor
digitorum longus, hallucis longus, triceps
surae (gastroc and soleus)
Posterior division (fibular nerve) has
cutaneous branch to lateral aspect of leg,
and motor supply to short head of biceps
femoris, fibularis brevis and longus
(eversion), extensor hallucis longus,
extensor digitorus longus and tibialis
anterior (inversion and dorsiflexion of
ankle)

12. Kasus 1
• Tuan A, usia 45 tahun, bekerja sebagai tukang bangunan, mengeluhkan nyeri menjalar
pada tungkai sebelah kiri
• awal kejadian, malam hari pasien terbangun dikarenakan nyeri pada punggung
bawahnya, setelah meminum ibuprofen pasien kembali tidur, pagi harinya ketika baru
beranjak dari tempat tidur dan membantu membawa bak cucian istri, pasien
merasakan nyeri pada punggungnya dan menjalar pada tungkai kirinya, pasien
langsung jatuh terduduk dan enggan untuk bergerak, setelah minum ibuprofen pasien
dibantu oleh istrinya kembali ketempat tidur, segera istri menelepon rumah sakit untuk
memperoleh pertolongan, setelah beberapa menit pasien hendak ke kamar mandi
dengan menggunakan bantuan krek, hal ini dikarenakan jika tungkai kiri menumpu
maka nyeri seketika menjadi semakin berat.
• Pada pemeriksaan klinis didapatkan, test SLR positif, tidak ditemukan kelemahan otot
tungkai ataupun hilangnya sensasi, nyeri dilaporkan oleh pasien menjalar kebawah
tungkai bagian lateral sampai ke ujung jempol kaki dan telapak kaki
• Berikan analisis anda apa penyebab dan mekanisme terjadinya serangkaian gejala
tersebut?

13. Kasus 2
• Tuan B usia 62 tahun, merasakan rasa tidak nyaman pada punggung bawahnya dan
berangsur menjadi sensasi nyeri, nyeri punggung yg dirasakan sudah cukup lama
(tahun) dimana akhir-akhir ini nyeri dirasa semakin berat, nyeri dirasakan cenderung
menetap, menjalar pada pantat kanan dan menjalar pada bagian lateral paha, kadang
sampai lateral tungkai bawah, nyeri dirasakan semakin parah ketika duduk lama
sehingga jika nyeri mulai dirasa maka pasien akan berdiri atau berjalan beberapa
menit, pasien tidak ada kelemahan otot tungkai ataupun hilangnya sensasi, pada
pemeriksaan SLR didapatkan nyeri meningkat
• Berikan analisis anda mengenai apa penyebab dan mekanisme terjadinya serangkaian
gejala tersebut

14. Thank
You