Sciatica | Spinal stenosis | Disc prolapse

Question 1

Sciatica
Definition and Summary

Answer 1

Sciatica is radiating pain from the butts down the lower extremity, usually on the posterior or lateral of the thigh.
Usually caused by irritation of Sciatic nerve, compression of nerve, injury to the nerver or compression of the nerve roots leaving the cord.

Based on etiology, diagnosis and management protocol is changed. The most likely etiology of sciatica involves:
- Muscoloskeletal causes [Hip dislocations, fractures, hamstring injury, piriformis syndrome]
- Neuropathic [Diabetes, Zooster]
- OBGYN related
- Pressure neuropathy
- Spine related [Degenerative disc disease, Spondylolisthesis, Lumbar spinal stenosis, Mass effect, Arachnoid matter inflammation]

Question 2

Sciatica
Etiology

Answer 2

Spinal causes: [compression related]
- Disc herniation/Disc displacement
- Spondylolisthesis
- Lumbar Spinal Stenosis [Spinal Ortheoarthritis]
- Mass effect [Neurofibroma, Arachnoid cyst, Facet joint synovial cyst]
- Arachnoid matter inflammation [irritation and compression]

Non-spinal causes: [mostly impigement and irritation related]
- Piriformis syndrome/Hip fracture, dislocation/Hamstring injury
- Diabetes radiculopathy/Zooster sine herpete
- Endometriosis/Ovarian cysts/Uterine enlargements in pregnancy/Prolonged lithotomy position
- Lumbosacral plexitis/Vascular impingement/Pressure neuropathy/Iatrogenic

Question 3

Sciatica
Clinical Features

Answer 3

Clinical features depend on the causative agent of nerve irritation/compression

• Radiating Pain to posterior/lateral thigh +/- Lower back pain
• Parasthesias, Numbness +/- weakness
• Hyporeflexia, muscle wasting, atrophy, weakness [LMN signs ~ Herniated disc]
• Bowel +/- urine problems + pain + LMN/UMN signs [~ compression myelopathy = emergency]
• Pain with postural changes [~ spinal stenosis]

Question 4

Sciatica
Diagnosis

Answer 4

• Detailed Patient history about pain
• Myotomes/Dermatomes testing
• Leg raise tests [Straight leg raise/Bragard sign same as straight leg + dorsiflex giving pain]
• Imaging only needed if conservative treatments do not work or pain gets worse [MRI spine without contrast/CT lumbar spine/MRI pelvis/CT pelvis]

Dx is Clinical

Pain with Sitting = usually herniated disc
Pain relieved with Sitting = usually spinal stenosis

Question 5

Sciatica
Treatment

Answer 5

Conservative:
- Physical Therapy +/- NSAIDS +/- Bracing +/- Corticosteroid injections [Epidural or oral]
- Most sciatica tend to resolve spontaneously within 3 months

Surgery:
- Indications are persistent pain for 3-6 months with conservative management, progressive neurologic deficits, dx is spinal stenosis of lumbar
- Wide pedicle-to-pedicle Decompression
- Degenerative spine disroders causing sciatica, dx is spinal stenosis of lumbar
- Wide pedicle-to-pedicle Decompression + Instrumented fusion
- Degenerative disc disease is Dx
- Discectomy

Question 6

Spinal Stenosis
Definition and Summary

Answer 6

Spinal stenosis is characterized by the narrowing of the central spinal canal, intervertebral foramen, and/or lateral recess within the cervical spine, thoracic spine, or lumbar spine, resulting in progressive nerve root compression

It is commonly caused by degenerative joint disease. Lumbar spinal stenosis is the most common form and causes load-dependent lower back pain that radiates to the buttocks and legs

Cervical and thoracic spinal stenosis are less common and patients typically present with symptoms of myelopathy

Lumbar stenosis is the most common form, Thoracic is the rare. Mostly middle aged to elderly population affected

Question 7

Spinal Stenosis
Etiology

Answer 7

• Degenerative Joint disease [most common]
  Spondylolisthesis/Disk space narrowing from osteoarthritis/Facet joint hypertrophy/Disk bulging
• Iatrogenic [post spinal surgery]
• Systemic diseases like Pagets, AS, tumours
• Others [Trauma/Lig flavum calcification/congenital manifestations]

Question 8

Spinal Stenosis
Clinical Features

Answer 8

• Pain [Gradual onset/chronic/subacute]
• Acute pain due to exacerbation of chronic process
• Radiculopathy [Pain + LMN from nerve root compression]

Lumbar Spinal Stenosis:
- Load dependent lower back pain, worsens with walking
- Neuropathic claudication from postural changes [worsens with lumbar extension, relieves with lumbar flexion]
- Unsteady wide gait
- Hyporeflexia of lower extremities
- Mild motor weakness

Cervical Spinal Stenosis:
- Neck pain
- Gait and balance disturbances
- UMN and LMN signs
- Pain, parasthesia and/or anesthesia at/below stenosis level
- Lhermitte sign [Neck flexion triggers shooting electrical sensation travels down spine; typical in MS and other demylenating diseases]

Question 9

Spinal Stenosis
Diagnosis

Answer 9

• Patient history and clinical features
• Confirm above with imaging
• MRI spine without contrast/CT myelogram/CT spine
• Electromyogram for mild to moderate symptoms + stenosis signs on above
• Imaging will reveal spinal stenosis signs
• URGENT MRI spine for cord compression signs [rapidly focal neuro deficits + pain + bowel/urine disturbance]

Treatment similar to Sciatica