Sciatica – Everything You Need To Know – Dr. Nabil Ebraheim Dr. Ebraheim’s educational animated video describing disc herniation of the lumbo sacral spine, the etiology, signs and symptoms, diagnopsis, and treatment options. It explains the anatomy of the spine the structure of the disc and types ,site ,level of disc prolapse bulge herniation L4_L5 AND L5-S1 are the most common levels causing sciatica and positive SLR OR STRETCH TEST . It is a condition in which the sciatic nerve or one of its roots or branches is compressed resulting in pain in the lower back and buttock, and sharp shooting pain in the leg, usually on one side. The sciatic nerve is a large nerve that comes from the lumbosacral plexus. The sciatic nerve arises from 5 nerve roots: L4, L5, S1, S2, and S3. There are five nerve roots and each one has its own dermatomal distribution. When a nerve is compressed, it gives pain and symptoms in a specific area. In the video we see an example of the compression of the L5 and L4nerve root compression. The dermatomes are really important in knowing which level is the herniated disc. For the diagnosis of sciatica this is not very important for a non-medical person, because what matters is the presence of pain that is shooting down the buttock and leg. What is the course of the sciatic nerve? It runs from the lumbar spine through the buttock, down to the leg and foot. The nerve runs predominantly in the posterior aspect of the buttock and the lower extremity. Symptoms and signs: A sharp shooting pain down the buttock, the thigh and the leg. Usually on one side of the body, with numbness, tingling and burning. The area of symptoms and pain usually depends upon the nerve that is involved. Sitting can aggravate the pain, almost like you are doing a straight leg raising sign, you are tensioning , stretching and lengthening the nerve. Also coughing, sneezing, or moving can aggravate the pain. The pain will improve with standing. Provocative tests: •straight leg raising sign: tension sign L5, S1 nerve roots, with the patient either sitting or supine, raising of the leg will produce the pain and paresthesia at 30°-70° of hip flexion. It really help to identify if the patient is a good candidate for surgery, if the patient has a positive tension sign, they will get better with surgery. • Lasegue’s test: the straight leg raising pain is aggravated by forced ankle dorsiflexion. What are the causes of sciatica? Usually it is a herniated disc of the lumbar spine. What is a disc herniation, and what is a disc? It is an elastic soft cushion between the vertebrae together of the spine. It links the vertebrae together and gives stability to the spine. It links the vertebrae together and gives stability to the spine, allowing the spine to move. The intervertebral disc has two parts: • Annulus Fibrosus: fibrous outer layer. • Nucleus Palposus: soft inner layer. The soft inner material leaks out or herniates through a tear in the fibrous outer layer, becoming a disc herniation. So a tear of the disc may allow the gel like material in the center of the disc to protrude, causing a herniation of the disc which process into the nerve root as it exits the spine. This irritates the close by nerve root. Sciatica is one of the most common symptoms of lumbar disc herniation. Treatment: • Rest/ Conservative: - Anti- inflammatory medication. - Muscle relaxation. - Physical therapy. - Usually the condition resolves itself in a few weeks. • Surgery is done if the pain does not improve after 6 weeks of the initiation of conservative treatment. Usually done to remove the intervertebral disc and relieve the pressure placed on the nerve. There will be a good outcome from surgery if: - The patient has leg pain. - Positive straight leg raise pain. - Neurological deficit. - The clinical findings correspond with the MRI findings. - Surgery is usually called: discectomy or laminotomy. Periformis syndrome can also cause sciatica like symptoms, and this needs to be differentiated from sciatica that is caused by herniated disc. Both may have the same symptoms, but have different causes. Diagnosis of periformis syndrome should be done by exclusion of any possible spine problems which could be compressing the spinal nerve roots and causing true sciatica. If the patient complain of sciatica and the MRI does not show that there is disc problem, then the patient probably has periformis syndrome.