A Family Doctor's Tale - SCIATICA

DOC I HAD A SHOOTING PAIN DOWN ONE LEG

The sciatic nerve is the main nerve going down the leg from the lumbar spine. Any pressure on the nerve can cause the severe pain going down the leg. 
The most common cause is a intervertebral disc prolapse which impinge on the roots of the sciatic nerve. 
The other cause is spinal stenosis which is a narrowing of the outlet of the nerve and resultant pressure on the nerve. 
Many cases are due to frequent usage of the back. 
Many cases are women.

Sciatica is the shooting pain down the leg occurring in the sciatic nerve due to inflammation or pressure on the nerve.


Sciatica occur as a result of pressure on the sciatic nerve as a result of:

1.slipped disc- a prolapsed intervertebral disc which slipped out of the ligaments holding it may press against the sciatic nerve especially in the lumbar vertebrae


2.disc degeneration - flattening of the disc due to degeneration allows the discs above and below it to compress the sciatic nerve


3.Spinal stenosis- narrowing of the spinal canal can cause compression on the sciatic and other nerves


4.sacroiliatis - inflammation of the sacroiliac joint cause swelling of the bones involved in the joint and may compress the sciatic nerve


5.lumbar facet syndrome-the facet bone like any bone in the body can become inflamed, swells and press against the sciatic nerve.


6.Iliolumbar syndrome- the iliolumbar ligament extends from the spine to the iliac crest when inflamed or swollen due to injury can compress the sciatic nerve


7.piriformis syndrome-the piriformis muscle lies on top of the sciatic nerve at the buttock and if inflamed, swells and press on the sciatic nerve.


8.spinal tumor- any tumor in the spine which is near the sciatic nerve may compress it.


Symptoms:
1.pain may be a continuous dull ache in the leg or a shooting pain down the leg


2.pain is present in the buttocks, posterior thigh, and back of outer side of the leg to ankle


3.Pain is usually but not always relieved by rest(lying flat)


4.Pain is aggravated by
a.spinal movements like flexion
b.exercises
c.straining
d.coughing
e.sneezing


5.pain is worse when sitting


6.weakness, numbness, difficulty in moving the leg


Signs:

1.Patient stands with spine rigid.
Sometimes there may sciatic scoliosis to protect the nerve roots on 1 side.


2.Straight leg raising test(SLR) which is normally up to 90 degrees is restricted


3. superficial paresthesia and sensory loss with or without tendon reflexes loss at knee or ankle and muscle weakness depending on severity and site of nerve root compression



4.Xrays of spine and pelvis for osteoarthritis, disc lesions, ankylosing spondylosis, or metastatic tumors


5.MRI of lumbar spine


Electromyogram and nerve conduction studies may give an an indication of the severity of damage to the nerve and the subsequent prognosis


Conservative treatment:

Bed rest with a hard board below the mattress- straighten the back

Pain killers such as NSAID(non-steroidal anti-inflammatory drugs) for pain

Muscle relaxant to relax muscles

Physiotherapy such as traction, massage or expert manipulation of the vertebrae, shortwave diathermy

Wearing a corset to strengthen the back and help the traction of the spinal bones

After the initial phase of pain is over , gradual mobilization and exercises to strengthen the spinal extensor muscles



Surgery:

If conservative methods fail or the pain is too severe, surgical decompression is then considered:
microdiscectomy
laminectomy


Finally treatment of the underlying cause is important!


Prognosis depends on the underlying cause:
Mild inflammation of the muscles, ligaments may recover with conservative methods

More severe inflammation of the nerve due to disc or spinal may become worse with time.


Prevention is by:
Avoidance of postural strain on the back
Wear a corset
Exercises to strengthen the back muscles.