actually sciatica is a symptom which has more causes, i collect general info about sciatica

2. Nangarhar university teaching
hospital
Surgical ward
Presenter
Abdullah ihsaas
TMO of GS 2nd year
Topic
SCIATICA
Guider
Ass prof Dr th Basir Mangal

3. Topic to discus
• Lower extremities peripheral nerve
• Short anatomy of vertebral column and sciatic nerve
• Sciatica
• Causes
• Clinical presentation
• Sensory testing
• DDx
• Diagnosis
• Special tests
• Treatment

4. Lower extremities peripheral nerves
1. Peroneal nerve
2. Tibial nerve
3. Sciatic nerve

5. Short Anatomy of vertebral column and
sciatic nerve
Vertebral column is the central pillar of the body
Vertebral column protect the spinal cord and also supports the Wight of the
head and the trunk.
The vertebral column is flexible because it is segmented and made of
vertebrae , there joints, and pads of fibrocartilage called intervertebral discs,
which made ¼ of the length of the column.
1. Cervical 7
2. Thoracic 12
3. Lumbar 5
4. Sacral 5 fused to form the sacrum
5. Coccygeal 4 the lower three commonly fused

6. General characteristics of a vertebra
Typical vertebra has a round body anteriorly and a vertebral arch
posteriorly
Vertebral foramen :
Space enclosed by body and arch

7. Arch :
• Consists of a pair of cylindrical pedicles and pair of flattened lamiae
• Arch gives rise to seven processes one spinous ,two transverse
And four articular
Inter vertebral foramina :
• Consist from ( superior and inferior vertebral notch ) which transmit the
spinal nerves and vessels.

8. Important foramina
Greater sciatic foramen
• Pisiformis muscle
• Sciatic nerve
• Posterior cutaneous nerve of the tight
• Superior and inferior gluteal nerves
• Nerves to obturator internus and quadratus femoris muscles
• Pudendal nerve
• Superior and inferior gluteal arteries and vein
• Internal pudendal artery and veins
Lesser sciatic foramen

9. Sciatic nerve
• The sciatic nerve also called ( ischiadic nerve, ischiatic nerve )
• The largest , Longest and widest nerve in human body
• Sciatic nerve formed by the lumbosacral plexus ( L4 - L5 - S1 - S2 - S3 )
which leave vertebral canal trough the intervertebral foramen
• it passes out of the pelvis
• and into the gluteal region through the greater sciatic foramen
• The nerve appears below the piriformis muscle and is covered by
the gluteus Maximus muscle.
• and it enters the posterior compartment of the thigh.
• In the lower third of the thigh ( and occasionally at a higher level )
• it ends by dividing into the tibial and the common peroneal nerves.

11. SCIATICA
Synonyms : sciatic neuritis , sciatic neuralgia , lumbar radiculopathy
• Sciatic nerve pain commonly called sciatica.
• or sciatica is a medical condition characterized by pain going down the leg
from the lower back.
• Pain is associated with injury or compression of sciatic nerve or spinal
nerve that form it.
• Its most common during peoples 40’s and 50’s
• Men are more frequently affected than women

12. Causes of sciatica
Two groups
1.Spinal causes
2.Non spinal causes

13. 1.Spinal causes
A. Intervertebral disc herniation: cause about 90 % of sciatica
( poor posture , trauma, strong rotational movement can cause it )
may occur in different levels of lumbosacral vertebrae , but the
most common are L5 or S1

14. B. Spinal stenosis : Narrowing of spinal canal or
intervertebral foramen , due to degenerative
bone disorders , trauma , inflammatory
disease e.g. rheumatoid arthritis
C. Spondylolisthesis : Vertebra become
displaced due to trauma, surgery or degenerative
spinal disease
D. Growths (spinal canal ): e.g. tumors , cysts
abscess

15. 2.Non spinal causes
Occur out side the spinal region cause compression or damage to
sciatic nerve
A. most common is piriformis syndrome
piriformis muscle inflammation or spasm can compress the sciatic nerve
B. Wallet sciatica ( credit – carditis )
C. Gynecological causes
D. Trauma to leg
E. Pelvic tumors

16. Clinical presentation
Aching & sharp leg pain :
The hallmark symptom from sciatica.
Most people describe a deep, severe pain that starts low on one side of the back and then shoots down ( electric shocks ) the buttock and
the leg with certain movements.
A. Below knee : pain follows dermatome distribution
B. Could begin suddenly :
 Disc herniation
 piriformis syndrome or
 trauma
 and infection
C. Develop slowly or gradual onsite :
 tumor
 spinal stenosis
 rheumatoid arthritis
 inflammatory arthropathy
 spondylosis
 spondylolisthesis
D. Typically unilateral
E. Bilateral can occur :
 Central disc herniation
 lumbar stenosis
 spondylo listhesis

17. Sensory and motor dysfunctions or true nerve root sign
A. Radiculopathy
B. Motor or sensory deficit
C. paresthesia's or numbness
D. Motor weakness or absent deep – tendon reflexes
a. S1 spinal nerve compression  Ankle jerk reflex
b. l4 nerve compression  Knee jerk reflex

18. Aggravating Factors:
Coughing, sneezing (↑ intrathecal pressure) → herniated disc
Activity/brisk walking → stenosis , vascular claudication
Relieving Factors
Pain relieved by activity → ankylosing spondylitis
Pain relieved by sitting/flexion → spinal stenosis

19. Sensory Testing
The sensory distribution of lower limbs and trunk should be tested.
Each spinal nerve is in charge of the sensation from a specific area of the skin
( dermatomes )
• L1 - Inguinal
• L2 - Groin/anteromedial thigh
• L3 - Anterior thigh
• L4 - Anteromedial leg
• L5 - Lateral leg/dorsum foot
• S1 - Sole /lateral foot
• S2 - Back of thigh
• S3 - Buttock
• S4 - Perineum
• S5 - Perianal

20. Cauda equina syndrome : is a serious neurologic condition in which
there is acute loss of function of the lumbar plexus causes
Bowel or Bladder Dysfunction

21. DDx
• Non specific low back pain
• Piriformis syndrome ( MRI no spinal causes )
• Muscular problems ( sprine , spasm …)
• Vascular problems ( claudication, compartment syndrome )
• Chronic edema
• Shingles

22. Diagnosis
• Clinical features & character of pain
• Classic physical exam findings (special tests)
• Investigation
• Imaging
• X ray
• MRI
• CT scan

23. Special tests
• Lasegus sign ( straight leg raise test )
• Bragard’s sign
• Neris test
• Lasegu’s differential sign
• Lasegu’s Rebound test
• Slump test

25. Rebound test

26. Lesage's deferential sign

28. Deyerle sign

29. Cox sign

30. What is the bowstring test?
With the patient supine, fex their hip with approximately 20° knee flexion and apply
pressure to the popliteal fossa. Reproduction of pain is suggestive of sciatic nerve
etiology.

31. Heel / toe walk test
Assessment for L5 or S1 nerve root motor deficiency

32. Treatment
Rest and conservative medication
• Ice or heat applications on affected area for 20 min
• Pain & anti inflammatory medication
• Muscle relaxant
• Little evidence for steroid, ether by epidural or by pill
• Low evidence Gabapentin or pregabalin for chronic sciatica
• Physical therapy
• All that is required is time - in about 90 % of people the problems go away in
less then six weeks,

33. Surgery
• If the pain is sever and least more than six weeks then surgery may be an
option
• Or Surgery required if complication occur
• Surgery often speeds pain improvement, long term benefits are unclear
• Lumber discectomy
• Laminectomy

34. Conclusion
Short video

35. References
Internet :– physiotour – physiopedia