Sciatica Differential Diagnosis

Manoj Krishna, FRCS, MCh(Orth)Spine Surgeon

www.spinalsurgeon.com

Sensory loss patterns

What happens to the trunk shift?

Chemistry of a disc prolapse

• TNF Alpha• Phospholipase A2• Interleukin 6• Prostaglandin E2• Matrix Metallo-proteinases• Nitric Oxide

Natural History- Disc prolapse and Sciatca. Surgery vs Conservative treatment

• Weber: At 1 yr- op group better. At 4 years, slightly better. At 10 years no difference.

• SPORT Trial: Both groups better at 2 years. Op group slightly better

• 80% of discs show a reduction in size of 50% or more on serial MRI/CT. The largest discs resorb the most.

Different patterns of disc degeneration

CENTRAL DISC HERNIATION ASSOCAITED WITH MORE CHRONICITY AND MORE BACK PAIN ON LOADING

Causes of Leg Pain• Piriformis Syndrome• Spinal Stenosis• Disc protrusion• Synovial Cyst• Tumours: Neurofibroma• Infection: Abscess• DVT• Iliotibial band syndrome

• Hip Arthritis• Psoas Haematoma• Retroperitoneal tumour• Vascular Claudication

Inflammatory radiculopathy

• Diabetes• Sciatic Nerve tumours• Meralgia Paraesthetica

Hip Arthritis can mimic Sciatica!

The hip can give you a slip !

-Anterior thigh pain-Antalgic gait-Positive active SLR .-Hip rotations painful / restricted-Trendelenburg’s positive

65. M. 12m history of moderate back and leg pain. Present even at rest.

6.5cm diameter.No abdominal pain.MRI scan done for Low Back Pain.Needs surgical excision and reconstruction.

Neurofibroma causing Radicular Pain

AM.57 male. Left buttock, and leg pain for 12 months. No postural relief. Widespread Neurofibromatosis.

With Gadolinium

Piriformis syndromeSciatic Nerve Entrapment under Piriformis Muscle

Tender in buttockCant sit on buttockPassive rotation of hip is painfulEMG studiesRx- PhysioRx, Surgical release

Left Hip Pain Caused By L2/3 Disc Prolapse