Sciatica Causes and Relief

Sciatica SOS

This ebook teaches you an often-ignored trick that the medical industry refuses to acknowledge to get rid of sciatica pains. This trick comes from the mountains of Nepal; it is natural remedy that gives you all of the pain relief that you need to feel better, just like you deserve. You don't have to succumb to the horrible pains that sciatica will bring you; you can instead feel the relief that comes to people who carefully follow this treatment plan. Your nerves are often too sensitive to put up with much pain or discomfort of any kind; now, you will be able to get rid of that pain and reclaim your manhood; you can do all of the things that you used to be able to do, but now you can do them without fearing that you are going to trigger horrible, debilitating pain in your body! More here...

Sciatica SOS Overview


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Continuous Sciatic Nerve Infusion

Medtronic Quattro Lead Fluoro Image

The sciatic nerve is formed from the nerve roots of L4 to L5 and S1 to S3. After formation at the sciatic notch, the nerve passes through the gluteal region between the greater trochanter and the ischial tuberosity. In the buttocks, it runs posterior to the gemelli and the obturator internus. It lies anterior to the piriformis muscle as it descends to the thigh, as first described by Labat in 1923. My approach is based on the identification of the piriformis muscle and the placement of the catheter on the sciatic nerve in the gluteal region. Figure 16-5 Drawing depicting the landmarks to be identified by fluoroscopy. A, Posterior superior iliac spine. B, Greater trochanter. C, Ischial tuberosity. (From Racz G, Raj P, Lou L, et al Posterior sacral approach to the sciatic nerve for continuous lidocaine infusion A new technique. Presented at 1997ASA Annual Meeting, San Diego, CA.) Figure 16-5 Drawing depicting the landmarks to be identified by fluoroscopy. A, Posterior superior iliac...

Sciatic nerve block Anatomy

The sciatic nerve (L4, 5, SI 3) arises from the sacral plexus, passes through the great sciatic foramen and descends in the posterior thigh to the popliteal fossa, where it divides into the tibial and common peroneal nerves. In the thigh, it supplies muscles and the hip joint. The posterior cutaneous nerve of the thigh (SI 3) may run with the sciatic nerve or separate from it proximally this nerve supplies the skin of the posterior thigh and upper calf. The tibial and common peroneal nerves, together with the saphenous nerve, supply all structures below the knee.

Lateral Approach To The Sciatic Nerve

The patient position is supine and if possible, the leg is slightly rotated externally. The point of puncture is located on the lateral aspect of the thigh, 1 to 2 cm, below the greater trochanter, depending on the patient's age. The needle is inserted perpendicular to the long axis of the limb in the horizontal plane and directed toward the position bordering the femur and the ischial tuberosity. If the needle touches bone, it is withdrawn and reinserted more dorsally under the femur. The depth at which the sciatic nerve is found depends on the patient's age. Lateral sciatic nerve block is simple and there is no need to immobilize the child.

Posterior Approach To The Sciatic Nerve

The posterior approach to the sciatic nerve identifies the sciatic nerve at the same level as the anterior approach described earlier. In this setting, the patient is placed in the lateral position, with the upper leg flexed at the hip. At the midpoint of a line drawn from the ischial tuberosity to the greater trochanter, a short bevel needle is inserted with a nerve stimulator attached (length 25 mm under 10 kg, 50 mm until 25 kg, 100 mm over 25 kg). The depth at which twitches are seen depends on the patient's age (between 16 and 60 mm). When the chosen end point is found, the injection of 1 mL of local anesthetic abolishes the stimulation of muscle activity (i.e., dorsal flexion of the foot and eversion Figure 21-9 Cross-sectional diagram of the sciatic nerve and its relation to the lesser trochanter of the femur for anterior and posterior approaches. Figure 21-9 Cross-sectional diagram of the sciatic nerve and its relation to the lesser trochanter of the femur for anterior and...

Anterior Approach To The Sciatic Nerve

The anterior approach to the sciatic nerve relies on the path of the sciatic nerve between the ischial tuberosity and the greater trochanter of the femur ( Fig. 21-9 ). The patient lies supine with the leg in a neutral position. After a sterile preparation and drape, two parallel lines are drawn with a perpendicular dropped between them. The first line follows the inguinal ligament from the anterosuperior iliac spine to the pubic tubercle. A perpendicular line is drawn from the intersection of the medial third and the lateral two thirds of the first line. The second line is drawn from the greater trochanter parallel to the inguinal ligament until it intersects the perpendicular. At this point, a short-bevel needle is inserted until the surface of the femur is reached. The needle is then withdrawn and redirected to pass behind the lesser trochanter until it enters the neurovascular sheath containing the sciatic nerve, the sciatic artery, and the inferior gluteal veins. The use of a...

Sciatica The Nerve of It

Developing sciatica is unfair because you rarely get a break from its pain. The pain is present when you sit, stand, and even while you're lying down. Sciatica is the familiar term for pain that travels along the sciatic nerve, which starts in the middle of your butt, runs down the back of your leg, and sometimes extends to your foot. The farther down you feel the characteristic pain, burning, or numbness, the more pressure is being put on the root of the nerve in your butt. Oriental Medicine categorizes sciatica according to how you feel. The diagnostic category of wind is used for pain that moves around, while dampness characterizes the often stiff, heavy ache in the hip muscles. In traditional Chinese medicine terms, cold, stuck Qi and blood cause the sharp stabbing pain of sciatica. During the past 15 years of my practice, I've felt that I've been most successful helping patients with sciatica get some relief. Patients will walk in leaning to one side to relieve the pressure on...

The sciatic nerve Commentary

The sciatic nerve is the largest peripheral nerve in the body and it is accessible from a number of sites. Sciatic nerve block provides good analgesia for much lower limb surgery, and the variety of possible approaches provides an appropriate test of applied anatomy. As always with questions which include practical procedures, it will help greatly the credibility of your answer if you can convince the examiner that you have undertaken some of these blocks. You will not, however, be expected to be familiar with every single approach.


The word sciatica has been in use from Greek times, and is derived from ischias or pain around, or coming from, the hip and thigh. It was only with modern ideas of pathology that it came to mean pain in the distribution of the sciatic nerve. Hippocrates (460-370 bc) noted that ischiatic pain mainly affected men aged 40-60 years. In younger men it usually lasted 40 days. Contrary to modern ideas, radiation of pain to the foot had a good prognosis but pain that stayed in the hip was dreaded. (This was probably tuberculosis or other serious disease of the hip joint.) Areteus (150 ad) first distinguished nervous and arthritic schiatica. He blamed nervous sciatica on an excess of cold and suggested that the remedy was local heat - spas, soothing ointments, counterirritants, and cautery. Hippocrates first mentioned cautery and it appears throughout the ancient writings (Fig. 4.4). Dung cautery was in use by 100 ad and probably came from Arabic use of goat's dung. Albucasis (1100 ad)...

Sciatic Nerve

The sciatic nerve can be blocked by a variety of approaches. The block can be done in conjunction with blocks of the femoral nerve, the obturator nerve, and the lateral femoral cutaneous nerve to provide lower extremity anesthesia or postoperative analgesia. Block failure can be a significant problem. Ecchymosis or hematoma may occur and nerve injury with persistent dysesthesia has been noted. These side effects may occur whether the block is done in the anterior, posterior, or lithotomy position.

Degenerative Mechanics

Asymptomatic but can cause neurological symptoms when the degree is severe. Symptoms may include intractable neck or lower back pain or radiculopathy due to compression of the neural foramen. Osteoarthritic changes of the facet joints can also exacerbate other deformities of the spine, including degenerative scoliosis, as these joints serve as a stabilizing influence on spinal alignment.

Reason Of Pain In Lower Anterior Teeth And Lip After Rftc And Mental Block

Blockade of the SPG is used in the treatment of many painful medical syndromes involving the face and head. Sluder was the first to describe in the literature a unilateral facial pain at the root of the nose, which sometimes spread retro-orbitally toward the zygoma and extended back to the mastoid and occiput.13 The pain was commonly associated with parasympathetic features such as lacrimation and rhinorrhea, with or without mucosal congestion.13 Sluder called this pain syndrome sphenopalatine neuralgia. He believed the the cause of this pain was the spread of infection from the paranasal sinuses, which caused irritation of the SPG. This was initially accepted as a possible causal mechanism but was questioned when other syndromes, such as low back pain, sciatica, and dysmenorrhea, were attributed to irritation of the SPG. In the early 1940s, Eagle13 sought to revive interest in sphenopalatine neuralgia when he presented his thesis to the American Laryngological, Rhinological, and...

Table 175 Summary Of Differences Between Insulated And Uninsulated Needles

Two sets of experiments were performed. In the first, the needle was advanced toward the sciatic nerve in the thigh, and stimulation of the nerve was assessed by twitches of the tibialis muscle attached to a force transducer. In the second, the saphenous nerve was used and the compound action potential recorded distal to the stimulation. In both cases, the needle was mounted on a mechanical platform that enabled its exact position to be determined. The minimal current needed to produce stimulation by a 100 microsecond pulse delivered by a Grass S-88 stimulator was recorded at various distances from the nerve. The current was measured by recording the voltage drop across a known resistance by a Tektronic 564B storage oscilloscope. The effect on the twitch of a small injection of saline was investigated at various positions of the needle. At the end of each experiment, a cutdown was performed to verify the exact position of the needle in relation to the nerve. Results. The graph shows...

Autonomic Dysfunction Secondary to Focal Central Nervous System Disease

Hyperhidrosis may be generalized or localized. Localized hyperhidrosis is rare and may occur with injury to the spinal cord (e.g., in syringomyelia), peripheral nerves (e.g., with partial median or sciatic nerve injury), or eccrine sweat glands. Perilesional hyperhidrosis may surround an anhidrotic region produced by a lesion of the sympathetic ganglia or rami. The axillary eccrine sweat glands are activated by thermal stimuli, whereas the palmar and plantar glands are activated by emotional stimuli. Primary or essential hyperhidrosis affects the axillary, palmar, and plantar regions and may be familial. Generalized hyperhidrosis may be secondary to infections, malignancies, or neuroendocrine disorders (e.g., pheochromocytoma, thyrotoxicosis, acromegaly, carcinoid, anxiety, hypotension, hypoglycemia, and cholinergic agents).y

Clinical Presentation

MPNSTs usually afflict adults in their third to sixth decade of life however, the mean age is a decade younger in NF1-associated cases. The medium and large nerves are more likely to be affected than small nerves. The buttock, thigh, brachial plexus, and paraspinal regions are the most common sites. The sciatic nerve is the most commonly affected nerve.52 No nerve, however, is immune, including, in rare examples, cranial nerves, especially the trigeminal nerve.7,54

What is lifting capacity

Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation 10 year results from the Maine lumbar spine study. Spine 2005 30(8) 927-35. 6. Malanga G, Wolff E. Evidence-informed management of chronic lower back pain with trigger point injections. Spine J 2008 8(1) 243-5.

Rotational And Torsional Sports

Because golf is not an aerobic sport, aerobic conditioning should be included in any effective lower back rehabilitation program. Fairbank et al1 showed that higher aerobic fitness shows a strong negative correlation with the incidence of both lower back pain and disk herniation. Exercise results in increased aerobic metabolism in the outer annulus and the central portion of the nucleus pulposus, bringing about reduction of lactate concentration.26 A key aspect of a pitcher's rehabilitation is not only the resolution of the back problem the secondary inflammatory effects of referred pain can produce the same biomechanical abnormalities in the pitching motion, thus leading to further injury. Indeed, the pain itself may prevent proper pitching and performance and thus cause additional injury. True sciatica and muscle weakness in a leg result in a critically important dysfunction in a pitcher severe abnormalities of pitching motion that place the arm, shoulder, and elbow in jeopardy....

Classifications of Complementary and Alternative Medicine

Sciatic nerve Sciatic nerve Each meridian has an entry and exit point energy enters through the entry point and flows through to the exit point. There are 12 primary meridians of the body, each running vertically, bringing qi and the other four essential substances to specific parts of the body. No part of the body is without qi a blockage causes an imbalance in the flow of the life force. In Figure 4-2, a male model demonstrates where the meridians and acupuncture sites are indicated. Figure 4-3A depicts the clinician placing an acupuncture needle in the buttocks of a man with sciatica Figure 4-3B shows all the needles in position. Figure 4 3 Acupuncture. A, Physician inserting needles into a patient with sciatica. B, Needles in position. Moxibustion is a specific form of acupuncture in which herbs are burned to stimulate specific acupuncture sites. If a disease fails to respond to traditional acupuncture, moxibustion is used. Moxa leaves (Artemisia chinensis) are either rolled into...

Endoneurial Fluid Dynamics

Of a proximodistal flow of fluid was demonstrated in rat and guinea pig sciatic nerve (56). As indices of fluid movement, endoneurial injections of dyes, crystals, and radioactive mineral salts were used, with conclusions based on comparisons of proximodistal spread of the indicators in dead and living tissue. The two major limitations of this study are (1) the use of injection volumes no smaller than 100 mL and (2) the use of small hydro-philic tracers that could have migrated down the nerve by entering the vascular compartment and later reentering the endoneurial space. Therefore, they were unable to calculate a precise rate of convective fluid flow from their data but suggested an approximate rate of 3 mm per hour, similar to results by others studying traumatized chicken sciatic nerves (57). Low (58), injecting 10 ml of tetrodotoxin into the endoneurium and monitoring the rate and spread of inactivation, concluded that convective fluid flow is about 4-8 mm per hour. Morphological...

Accreditation Commission for Acupuncture and Oriental Medicine AGAOM

228-229 sciatica, 86 shiatsu, 23-24 sinusitis, 60 stress, 203 techniques, 104 tennis elbow, 71-74 tinnitus, 230-231 uterine fibroids, 179-181 weight management, 233-234 wony, 205-206, 211 acu-pros, 4, 10-13, 18-20, 39-40, 59, 239, 244-246, 250 acupuncture, 39-40 allergies, 116-117 228-229 sciatica, 86 sinusitis, 60, 128-131 skin, 199-200 smelling, 15 stress, 203 strokes, 108-112 tennis elbow, 71-74 tinnitus, 230-231 uterine fibroids, 179-181 visits, 239-241 vomiting of milk, 144-145 weight management, 233-234 worry, 205-206 acu-woman, 25 228-229 reflexology, 24-25 safety, 17 sciatica, 86 shiatsu, 23 sinusitis, 128-131 skin, 199-200 stationary pressure, 33-34 stress, 203 strokes, 109-112 supporting pressure, 33-34 techniques, 35-36, 109-112 tennis elbow, 72, 74 tinnitus, 230-231 treatments, 18 vertical pressure, 33-34 weight management, 233 Acupressure-Acupuncture Institute, 277 safety, 17-18 sciatica, 86 back pain, 82 bursitis, 70-71 neck pain, 64 ovarian cysts, 179-180 sciatica, 86...

Obstetrical and Gynecological Procedures and Surgery

The saphenous nerve can be injured by pressure from leg braces when the patient is in the lithotomy position. The sciatic nerve can be injured when the patient is placed in stirrups on the obstetrical table or with a misplaced deep intramuscular injection. Clinically, the patient experiences sensory loss over the lateral leg and the whole foot, weakness of both dorsal and plantar flexion of the foot, and of the extension of the knee, and loss of the ankle jerk. Isolated tibial injury is uncommon. The common peroneal is usually compressed at the head of the fibula from the leg braces with the patient in the lithotomy position. y Clinically, the patient has footdrop and inversion and sensory loss on the lateral aspect and the dorsum of the foot. Sciatic nerve injury can occur as a result of sacroiliac fossa bleeding, intramuscular injections, and the sacrospinus vaginal vault suspension procedure. Obturator nerve injury has been associated with pelvic surgery and specifically with...

Electrical Characteristics Of Peripheral Nerve Stimulators Currently Available In Clinical Practice

Peripheral Nerve Stimulator Diagram

To monitor evoked muscle twitches produced by the PNS, the sciatic nerve-tibialis muscle preparation of the cat was chosen as a model. The superficial tendons of the tibialis muscle on the dorsal surface of the right hind paw were exposed. After clamping the quadriceps muscle and the paw to immobilize the leg, the most lateral tendon The needle (6.3 cm*22 gauge G spinal needle, uninsulated) was mounted in a one-dimensional manipulator and aligned to approach the sciatic nerve through the hamstring muscle. The needle was advanced through the At the conclusion of this experiment, with the needle 1 to 2 cm beyond the sciatic nerve, a cutdown to the nerve revealed how closely the needle approached the nerve ( Table 17-4 ). By withdrawing the needle until the tip was again even with the nerve, the depth of the nerve was determined. A repeat series of measurements was made 2 to 3 cm distally on the nerve.

Surgery Hip Arthroscopy

Hip Arthroscopy Positioning

The perineal post is heavily padded and lateralized against the medial thigh of the operative hip (Fig. 45-1). This aids in achieving the optimal traction vector (Fig. 45-2) and reduces pressure directly on the perineum, lessening the risk of neurapraxia of the pudendal nerve. Neutral rotation achieves a constant relationship between the topographic landmarks and the joint. Slight flexion may relax the capsule, but excessive flexion should be avoided as this places undue tension on the sciatic nerve and may block access for the anterior portal. Typically, about 50 pounds of force is needed to distract the joint. In general, the goal is to use the minimal force necessary to achieve adequate distraction and keep traction time as brief as possible. Two hours is usually recognized as a reasonable limit for traction. Figure 45-4 The relationship of the major neurovascular structures to the three standard portals is demonstrated. The femoral artery and nerve lie well medial to the anterior...

Posterior Division Of The Sacral Plexus

Tensor Fascia Lata Nerve

Exits the pelvis via the greater sciatic foramen and travels inferior to the piriformis, providing motor innervation to the gluteus maximus muscle. Common fibular (peroneal) nerve (L4-S3). Is the smallest division of the sciatic nerve (half the size of the tibial nerve). The common fibular nerve exits the pelvis via the greater sciatic foramen to enter the gluteal region inferior to the piri-formis muscle. The nerve descends along the posterior aspect of the thigh, providing motor innervation to the short head of the biceps femoris muscle. The common fibular nerve descends to the popliteal fossa and curves laterally around the neck of the fibula to bifurcate into the superficial and deep fibular nerves, providing motor innervation to the lateral and anterior compartments of the leg, respectively. Furthermore, the superficial fibular nerve provides sensory innervation to the anterolateral region of the leg and the dorsum of the foot. The deep fibular...

The dynasty of the disk

Bone Setting

Reports of major trauma and disk damage causing paraplegia. Luschka (1858) first described two cases of prolapsed intervertebral disk with a connection from the nucleus pulposus through the posterior longitudinal ligament to the protrusion. Later Schmorl (1929) and Andrae (1929) made postmortem studies of large series of spines and described both posterior disk protrusions and protrusions into the vertebral bodies (Schmorl's nodes). They considered that most were asymptomatic in life However, although pathologists saw these disk lesions, no one related them to the clinical symptom of sciatica. Despite these reports, clinicians remained unaware of the disk. Middleton & Teacher (1911) then reported a case of fatal paraplegia from a central disk prolapse. They related it to the sprains and racks of the back and did a crude experiment to produce a disk prolapse. Goldthwait (1911) described a case of paresis after manipulation of the back for a displaced sacroiliac joint. Harvey Cushing...

Spondylolysis and Spondylolisthesis

One of the most common causes of lower back pain in the young athlete involves a stress fracture of the pars interarticularis. The pars interarticularis is stressed with lumbar extension. Athletes who participate in activities involving repetitive extension (e.g., gymnasts, ballet dancers, divers, baseball pitchers) are at increased risk to suffer a pars stress fracture. Once a pars fracture has occurred, particularly if it occurs bilaterally, the athlete may go on to develop a spondylolisthesis. This is when one vertebral body moves in relation to the adjacent one. The degree of spondylolisthesis can be graded (Table 8.1). Patients may complain of a history of mild lower back pain that has become worse and progressive to the point that participating in activities that require lumbar extension is not tolerated. Often, the patient may report participation in gymnastics, swimming, football, or soccer. The pain may refer to the buttocks and posterior thighs.

By Robin McKenzie And Stephen May

This edition explains the centralisation and peripheralisation phenomena the use of exercre to induce changes in pain location and intensity the means of detecting the most effective direction in which to apply therapeutic exercise differentiation displacement, pain of contracture and pain arising from normal tissue how to differentiate the pain of nerve root adheience from entrapment and sciatica.

217 Gaj Pilot Ka Naksha

Chase AW Medical recipes Sciatica cured with electricity a very cheap, simple battery how to make and use. In Dr. Chase's Receipt Book and Household Physician, 3rd ed. Detroit, FB Dickerson, 1892, pp 36-37. 12. North RB, Kidd DH, Zahurak M, et al Specificity of diagnostic nerve blocks A prospective, randomized study of sciatica due to lumbosacral spine disease. Pain 65 77-85, 1996. 104. Koes BW, Scholten RJ, Mens JM, et al Efficacy of epidural steroid injections for low-back pain and sciatica A systematic review of randomized clinical trials. Pain 63 279-288, 1995. 122. Stanley D, McLaren MI, Euinton HA, et al A prospective study of nerve root infiltration in the diagnosis of sciatica. Spine 15 540-543, 1990. 151. Kuslich SD, Ulstrom CL The tissue of origin of low back pain and sciatica A report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop Clin North Am 22 181-187, 1991. 162. Yeoman, W The relation of arthritis of the...

Selective Cervical Nerve Root Block

Figure 28-13 A, Computed tomography (CT) scan through the pelvis. The dotted line corresponds to the area where the pudendal nerve is blocked. B, CT-guided pudendal nerve block. The pudendal nerve is located just medial to the apex of the falciform process. The sciatic nerve is located just lateral to the falciform process. The needle is advanced transgluteally toward the pudendal nerve near the ischium, medial to the falciform process between the sacrotuberal and sacrospinal ligaments. The final needle position is verified by injecting 0.3 mL of contrast, which should be distributed in the territory of the pudendal nerve. (From Calvillo O, Skaribas I, Rockett C Computed tomography guided pudendal nerve block. A new diagnostic approach to long-term anoperineal pain A report of two cases. Reg Anesth Pain Med 25 420 423, 2000.) Figure 28-13 A, Computed tomography (CT) scan through the pelvis. The dotted line corresponds to the area where the pudendal nerve is blocked. B, CT-guided...

Endoneurial Homeostasis

Changes in endoneurial wet weight to dry weight ratio in desheathed rat sciatic nerve following a crush injury is shown. Data are presented as mean SEM. The SEMs of normal, and 6, 8, and 18 weeks are smaller than the size of the symbol (Weerasuriya, unpublished data). Fig. 6. Changes in endoneurial wet weight to dry weight ratio in desheathed rat sciatic nerve following a crush injury is shown. Data are presented as mean SEM. The SEMs of normal, and 6, 8, and 18 weeks are smaller than the size of the symbol (Weerasuriya, unpublished data).

Muscles Of The Posterior Compartment Of The Thigh

Hamstrings Muscles Posterior Thigh

Attaches proximally to the ischial tuberosity and the medial surface of the proximal tibia (pes anserinus). The semitendinosus muscle extends and medially rotates the thigh at the hip joint. In addition, the muscle flexes and medially rotates the leg at the knee joint. The tibial division of the sciatic nerve (L5-S2) innervates this muscle. Semimembranosus muscle. Attaches proximally to the ischial tuberosity and the medial tibial condyle. The semi-membranosus muscle flexes and medially rotates the leg at the knee joint and extends and medially rotates the thigh at the hip joint. The tibial division of the sciatic nerve (L5-S2) innervates this muscle.

Lower Motor Neuron Syndromes

It is less likely to be injured by trauma than the brachial plexus, but pelvic hematomas in the psoas muscle resulting from anticoagulation and surgical trauma are more common. Lesions of the lumbar segments produce weakness of all movements of the thigh with reduction or loss of the patellar tendon jerk. Lesions of the sacral portion of the plexus result in a weakness of the foot and flexion of the knee with reduction or loss of the ankle jerk. Because most of the motor output of the lumbar portion of the plexus is contained in the femoral nerve and the output of the sacral portion is found in the sciatic nerve, it may be difficult to distinguish lumbosacral plexus lesions from lesions of their respective major peripheral nerves. To distinguish a lumbar plexus lesion from a femoral neuropathy, a diligent search should be made for weakness of the adductor muscles innervated by the obturator nerve or of sensory loss in the inguinal region or over the...

Structural Components of the BNB

The perineurium circumscribes the endoneurium in concentric cellular layers, each one cell thick. In larger nerve fascicles, the perineurium consists of as many as 15 cellular layers, with fewer layers in smaller fascicles and only one cell layer in the vicinity of sensory and motor end-organs. Perineurial collagen fibrils, which are smaller in diameter than those in the epineurium (12), are interposed in the extracellular space between cell layers arranged in circular, longitudinal and oblique bundles along with occasional elastic fibers (9) and likely provide the perineurium with its passive compliance properties. Perineurial cells are flattened squamous cells with a serrated polygonal border considered by some to be epithelial cells (5, 13) but later shown to have a fibroblast origin (14). As in the root sheath, perineurial cells lack a polarized architecture and are bounded on both sides by basal laminae (15, 16), which distinguishes perineurial cells from epineurial and...

Neurologic and Neuromuscular Diseases

Altered myelin sheaths (Monaco, 1990). More direct evidence for the role of MAC in causing myelin alterations was obtained in a rabbit model of peripheral neuropathy induced by injecting anti-MAG antibodies into the sciatic nerve, which caused marked demyelisation associated with deposition of MAC (Monaco, 1995). These antibodies had no effect when injected into C6 deficient rabbits.

Lower Motor Neuron Pool

The lumbosacral plexus is derived from the anterior primary rami of the twelfth thoracic through the fourth sacral levels and is contained within the psoas major muscle. Although many more roots contribute to the lumbosacral plexus, it is somewhat simpler than the brachial plexus. Two major nerves, the femoral nerve and the sciatic nerve, are formed from the plexus (see Fig 15-7 ).

Blockade Of The Obturator Nerve

The obturator nerve has both motor and sensory components. The anterior division provides sensory innervation to the medial aspect of the distal thigh. The posterior division provides sensation to the medial aspect of the distal thigh as well as to the hip and knee joints. The obturator nerve also provides motor innervation to the thigh adductors. Clinical applications of obturator block include use as an adjunct with lateral femoral cutaneous, femoral, and sciatic nerve blocks for surgical procedures on the lower extremity. The obturator block is also used as a diagnostic adjunct in the treatment of pain syndromes involving the hip, because the articular branch of this nerve is involved in pain transmission from the hip. Obturator block is also used to relieve adductor spasms of the hip.

Myxopapillary Ependymoma

Myxopapillary ependymomas do occur in children, albeit rarely, and tend to have longer symptomatology, which tends to focus more on an exacerbation of long-standing lower back pain. Treatment consists of a reasonably aggressive surgical excision with radiation therapy reserved for local treatment in the event of a subtotal resection. Further surgical resection for recurrences has been successful, as has radiation therapy for later related intracranial masses. At this time chemotherapy or further experimental therapy play a questionable role in management.

Polyarteritis Nodosa Churg Strauss and Overlap Syndromes

CSS usually begins with upper respiratory symptoms such as sinusitis and rhinitis. Symptoms of systemic vasculitis involving skin, heart, and peripheral nerves follow. In a series of 42 patients with CSS, 62 percent had nervous system involvement, almost entirely restricted to PNS. Mononeuropathy multiplex (58.6 percent), distal symmetrical polyneuropathy (24.1 percent), asymmetrical polyneuropathy (3.5 percent), and one patient with a lumbar radiculopathy (3.5 percent) were included. Three of the patients in the series (10.3 percent) had cerebral infarctions. y Inflammatory myopathy has also been described in other series.

Inflammatory Pseudotumor of the Peripheral Nerve

Inflammatory pseudotumor, also described as nodular lymphoid hyperplasia, plasma cell granuloma, and fibrous xanthoma, are all reactive and non-neoplastic processes that can mimic a peripheral nerve mass lesion. Inflammatory pseudotumors are characterized by chronic infiltration of inflammatory cells, primarily the T-cell population, as well as extensive fibrosis and collagen deposition. The etiology is unclear, but the inflammation may be triggered by various stimuli such as physical, biologic, or chemical factors. Five cases of inflammatory pseudotumor involving peripheral nerves (median nerve, facial nerve, sciatic nerve, radial nerve, and greater auricular nerve) have been reported in which the inflammatory cells penetrate the nerve fascicles.95 The differential diagnosis often includes other non-neoplastic processes such as amyloidoma of the peripheral nerve and tuberculoid leprosy, all of which may mimic peripheral nerve tumors.130 In general, inflammatory pseudotumor of the...

Clinical Case Examples

Sciatica Healing Plan

MC, a 66-year-old woman with medical contraindications to open surgery, was treated with SRS for a spinal schwannoma. She initially presented with a chronic cough and generalized weakness. Routine laboratory studies showed pancytopenia, and flow cytometry was consistent with acute lymphocytic leukemia. The diagnosis was confirmed by bone marrow biopsy. While undergoing chemotherapy in December 2008, she developed lower back pain with subjective right leg weakness. A 10-by 7-mm epidural lesion,

Components of the tract and their innervation

Structure Corpora Cavernosa

Fig. 10.22 Diagram of the innervation of the penis. The sympathetic outflow arises from segments T9 to L2 of the spinal cord (SC) and runs to the prevertebral ganglia (coeliac plexus CP and superior hypogastric plexus SHP) via the splanchnic nerves, and from thence via the hypogastric nerves to the pelvic plexus (PP). Parasympathetic input comes from segments S2 to S4 of the sacral cord, and travels to the pelvic plexus via the pelvic nerves (PEL). The autonomic nerves then travel to the penis in the cavernous nerves (CN). The sensory output from the penis travels in the perineal nerves (PN) and the dorsal nerve of the penis (DNP) to the pudendal nerve (PUD), which enters the cord through the S2-S4 roots. (SN) sciatic nerve.

The interpretation of leg pain

One of the most common mistakes is to assume that all leg pain is sciatica, and must be due to a disk prolapse pressing on a nerve. That is false logic. Leg pain may be nerve root pain due to a disk prolapse pressing on a root, but more often it is not. Most leg pain is not nerve root pain, and has nothing to do with a disk prolapse. There is so much confusion about the term sciatica that it is better not to use it. Sciatica is pain in the distribution of the sciatic nerve, but different doctors and therapists use the term differently, varying from any leg pain It is nearly 60 years since Kellgren (1939) showed that stimulation of any of the tissues of the back can cause pain down one or both legs. Seventy percent of patients with back pain have some radiation of pain to their legs. This referred pain can come from the fascia, muscles, ligaments, periosteum, facet joints, disk, or epidural structures. It is usually a dull, poorly localized ache that spreads into the buttocks and...

Lower Limb Peripheral Nerve Blocks

Spinal or epidural anesthesia is usually chosen when regional anesthesia is being considered for lower limb surgery. An alternative to central neural blockade is the combined femoral and sciatic nerve block. The sciatic nerve block component is technically more difficult, and, therefore, it is not widely used. In a study of 40 patients undergoing unilateral total knee replacement, Lau and coworkers1901 (Taiwan) compared spinal anesthesia with combined femoral (3-in-1) and sciatic nerve block. The two techniques were comparable for surgery, intraoperative blood loss, and time to first postoperative analgesia. Ten of the 20 patients in the spinal group developed postoperative urinary retention, whereas none had this complaint in the femoral sciatic group. Urinary retention and subsequent bladder catheterization can be a potential source of infection in patients with an implant. Combined femoral sciatic nerve block was shown to be a good alternative to central neuraxial blockade. It can...

Physician beliefs and patient satisfaction

Battie et al (1994) found that only 8 of physical therapists in 1990 felt well prepared and ready to manage low back pain when they first entered practice. Even experienced therapists had doubts about their ability to affect recovery. Seventy-five percent felt that they could help patients with acute sciatica. Only 50-65 felt that they could help patients with acute, recurrent, or chronic low back pain without sciatica. Half the therapists agreed that Patients with low back pain often have unrealistic expectations about what therapists can do for them. I often feel frustrated by patients with low back pain who want me to fix them.

Muscles Of The Medial Compartment Of The Thigh

Consists of an adductor part and a hamstring part. Proximally, the adductor part attaches to the ischiopubic ramus, and the hamstring part attaches to the ischial tuberosity. Distally, the adductor part of the muscle attaches on the linea aspera, and the hamstring part attaches on the adductor tubercle. The adductor magnus muscle is the largest and deepest muscle of the muscles of the medial compartment of the thigh. It adducts and medially rotates the thigh at the hip joint. The obturator nerve (L2-L4) innervates the adductor part of the muscle, and the tibial division of the sciatic nerve (L4) and the obturator nerve (L2 and L3) innervate the hamstring part of the muscle.

Anterior Division Of The Sacral Plexus

Nerve to the inferior gemellus and quadratus femoris muscles (L4-S1). Exits the pelvis via the greater sciatic foramen, inferior to the piriformis, and travels along the deep surface of the superior gemellus muscle and the obturator internus tendon, providing innervation to the inferior gemellus and quadratus femoris muscles on their deep surface. Tibial nerve (L4-S3). The tibial nerve (a division of the sciatic nerve) exits the pelvis via the greater sciatic foramen to enter the gluteal region inferior to the piriformis muscle. The nerve descends along the posterior aspect of the thigh, providing motor innervation to the hamstring muscles (excluding the short head of the biceps femoris muscle) and a hamstring head of the adductor magnus muscle in the medial compartment of the thigh. The tibial nerve descends through the popliteal fossa and enters the posterior compartment of

Treatment Indications for Acute Symptoms

The almost immediate relief of symptoms that occurs in some instances indicates that the condition is basically one of tight muscles and fascia. (These treatment reactions differ from those in sciatica. The same procedures applied to the painful area along the hamstring muscles in cases of sciatic irritation would give rise to increased pain.)

Randomized Controlled Trials

Dilke and associates193 conducted a double-blind, randomized trial on 100 patients with degenerative disc disease and unilateral sciatica with neurologic deficit. Patients received either 80 mg of methylprednisolone in 10 mL saline, or 1 mL of normal saline injected into the interspinous ligament. Patients from these comparable groups who received epidural steroids manifested improvement judged by decreased use of analgesics. A significantly larger number of patients had clear pain relief at timed post-treatment assessments. These patients required fewer surgical referrals and had a significant reduction in time to return to work. There was no difference with respect to neurologic deficit and straight leg raise test. More recently, Carette and associates193 conducted a blinded, placebo-controlled trial in 158 patients with sciatica caused by herniated nucleus pulposus. Patients were randomized to receive injections with either 2 mL of methylprednisolone in 8 mL normal saline or...

What is the incidence of recurrent disc herniation after microsurgical lumbar discectomy

Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation 10 year results from the Maine Lumbar Spine Study. Spine 2005 30 927-35. 2. Carragee EJ, Han MY, Suen PW, et al. Clinical outcomes after lumbar discectomy for sciatica the effects of fragment type and anular competence. J Bone Joint Surg 2003 85A 102-8.

Describe the prevalence and natural history of lumbar disc herniations How do they differ from the prevalence and

The lifetime prevalence of a lumbar disc herniation is approximately 2 . The natural history of sciatica secondary to lumbar disc herniation is spontaneous improvement in the majority of cases. Among patients with radiculopathy secondary to lumbar disc herniation, approximately 10 to 25 (0.5 of the population) experience persistent symptoms. These statistics are in sharp contrast to low back pain, which has a lifetime prevalence of 60 to 80 in the adult population. Although the natural history of acute low back pain is favorable in the majority of patients, successful management of patients with chronic symptoms remains an enigma.

Sacroiliac Joint Pain

The sacroiliac joint is believed to be the source of up to 10 of chronic lower back pain. In sports, with the repetitive movement and torsional forces placed on the spine, the sacroiliac joint suffers repetitive stress and this may predispose to injury. It is thought that in addition to repetitive stress, sacroiliac joint pain may be due to muscle imbalances.

Functional Assessment

Patients respond to different classes of NSAIDs for unknown reasons, and no NSAID appears superior to others in efficacy. Treatment is largely empiric. Most clinicians start with a low dose and titrate upward if needed. An adequate trial of an NSAID requires that the patient take a maximum dose for 3 weeks before changing to a different NSAID, although many patients will expect a change in medication before this. It is usually best to switch to an NSAID from a different class. There is no benefit to combining nonsalicy-late NSAIDs. All COX-1 NSAIDs can cause dyspepsia and GI toxicity, interfere with platelet function, and prolong bleeding times. Other common side effects include renal toxicity and central nervous system (CNS) symptoms such as drowsiness, dizziness, and confusion. A 2004 Cochrane review of NSAIDs for lower back pain concluded that the various types of NSAIDs (e.g., COX-2 inhibitors) are equally effective, and selection of an NSAID for OA should be based on relative...

Special clinical considerations

Failure to remember that the vaginal artery is a separate branch of the hypogastric artery, rather than a branch of the uterine artery, may lead the surgeon into the pitfall of an unnecessary and ineffective hysterectomy for control of bleeding. Injury to the external iliac artery from retractors or mistaken ligation of this vessel can lead to lower limb amputation. Also, accidental ligature of one or both ureters would lead to renal function impairment. Accidental incorporation of the anterior division of the sciatic nerve may lead to foot drop (Figure 1b).

History of illness behavior in daily life

These methods of assessing pain, behavioral symptoms and signs, and overt pain behavior are all measures of illness presentation in the context of a clinical history and examination. They provide useful information, but may be peculiar to the health care situation and may be colored by patient-professional communication. We now have several other powerful measures of illness behavior in daily life. These are all illness behaviors in chronic back pain and sciatica. They are of much less significance for a few days in an acute attack. They are obviously not a matter of illness behavior in patients with serious spinal pathology or widespread neurology.

Sensorimotor Impairment Scales

The Hoffman's reflex (H-reflex) has been used in clinical settings.41,42 The amplitude of the H response compared to the motor (M) response (Hmax Mmax ratio) measures the excitability of the soleus motoneurons that respond to supramaximal stimulation of the sciatic nerve. Tested at rest, the ratio tends to increase with spasticity, but studies have not shown it to correlate with the intensity of spasticity. The ratio and H-reflex amplitude increase significantly approximately 3 months after a clinically complete spinal cord injury.43 The hyperactive H-reflex was not consistently modulated during ambulation in spastic paretic subjects, unlike normal subjects, so its usefulness as a measure of reflex abnormality may be limited.44 The gain of the H-reflex in some spastic patients may already be so high that the response cannot rise with stimulation.

Vascular Anatomy On Imaging

On angiographic images, the inferior gluteal artery is seen as descending laterally and extending lower than bony pelvis. The importance of this artery gives off the sciatic branch which supplies the sciatic nerve. Therefore, the accidental embolization of the inferior gluteal artery could result in transient or long-term injury to the sciatic nerve.

Facet Joint Procedures

Over the past 40 years, our understanding of the innervation of facet joints and their potential as pain generators has greatly expanded.2 We now know that even referred leg pain and hamstring tightness can be associated with facet joint pain and thus mimic features of sciatica. Cervical facet joints may refer pain to the head, neck, and shoulder areas and have well-described referral pattern maps, whereas thoracic facet joints may produce mid back pain with accompanying neuropathic symptoms as well.22 Along

Demyelination and Wallerianlike degeneration

Demyelination and axonal transport One potential mechanism by which demyelination can lead to axonal degeneration is disruption of axonal transport through demyelinated segments (Rao et al., 1981 Guy et al., 1989 Munoz-Martinez et al., 1994 Kirkpatrick et al., 2001). This is more apparent in the optic nerve system where local injections of very small quantities of anti-Gal-C antibody can lead to focal demyelination and abnormal axonal cytoskele-ton and axonal transport through the demyelinated segment (Zhu et al., 1999). Similarly, in animal models of experimental allergic neuritis, there are axonal transport deficits in the optic nerve (Rao et al., 1981 Guy et al., 1989). The issue is less clear in the PNS demyelination in the sciatic nerve induced by focal injection of a neurotoxin from K. humbold-tiana causes slowed fast axonal transport (Munoz-Martinez et al., 1994), but demyelination induced by intraneural injection of anti-galactocerebroside does not have any effect on fast...

Wallerian degeneration

Wallerian degeneration is an active process The concept that the axon depends day-to-day on materials received via axonal transport was implicitly challenged by the increasing data that some proteins can be synthesized within the axon and by observations that axons survive at least for many days in the face of apparently complete blockade of axonal transport. The most dramatic basis for reconsideration was the identification of profoundly retarded Wallerian degeneration in a substrain of mice (C57Bl Ola, now called Wlds) (Lunn et al., 1989 Perry et al., 1990a Perry et al., 1990b Glass et al., 1993). In this spontaneously occurring substrain degeneration of the transected axons is significantly slower. In a wild-type animal, transection of the sciatic nerve results in loss of electrical conductivity in the distal portion within a day or two, followed by dissolution of the axoplasm. In contrast, a transected axon in a Wlds mouse continues to conduct electricity for up to 2 weeks (Lunn...

Vaccine Administration

Most immunizations must be given by deep intramuscular (IM) or subcutaneous (SC) injection. IM injections should be given in the anterolateral thigh for infants or the deltoid muscle of the arm for older children. The sciatic nerve may be injured by deep intragluteal injections. Although acetaminophen (paracetamol) administered for 24 hours has been demonstrated to decrease mild to moderate reactions, such as temperature of 38 C (100.4 F) or greater, it may reduce antibody responses to some vaccine antigens (Pry-mula et al., 2009). Topical local anesthetics, sweet-tasting solutions, and breastfeeding may decrease injection pain for childhood immunizations (HELPinKIDS, 2009).

Physical activity and low back pain

Low back pain is pain, muscle tension or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). About 85 of low back pain cases are non-specific, not attributable to recognizable pathology. The poorly defined pathophysiology and mechanism of pain explain to a large degree the difficulties of prevention and treatment of low back pain.

Electro Auricular I Hear Its All in the

Paul Nogier began observing successful treatments of sciatica using ear acupuncture in his hometown of Lyon. He began to do more studies and experiments until he finally developed an electro-auricular non-needle acupuncture device. When it comes to treating plantar fasciitis, hikers and dancers who once suffered from the condition are now up and around and can attest to its effectiveness. V Nagging sciatic nerve pain can be shut down with acupuncture and deep pressure on acu-points.

Elbow Your Pain Out of the

The sciatic nerve is located deep in the muscles of the buttocks, so the acupressure techniques used to reach the affected area need to penetrate through layers of muscles. If you used your fingers or thumbs, you'd be sore in a very short time. That is why acu-pros use their elbows or tools to stimulate the points and put an end to your pain. Elbowing the way to the sciatic nerve.

Direction the viva may take

You may be asked to describe one method of blocking the sciatic nerve. A line is drawn from the greater trochanter to the ischial tuberosity. The nerve can be located just medial to the mid-point of this line at a depth of around 6 cm. The depth clearly varies with the size of the patient. The needle is inserted at right angles to the skin, attached to a nerve stimulator. A twitch in the lower limb (usually dorsiflexion of the foot) elicited at about 0.5 mA is a sign of accurate placement, and 20 ml laevobupivacaine 0.5 is injected. The stimulator technique and drug dose apply to the other proximal approaches to the sciatic nerve. It is worth noting that in a proportion of patients (about 15 ) the sciatic nerve lies immediately posterior to the femur at this point and is therefore inaccessible to the anterior approach. The sciatic nerve can be blocked in the popliteal fossa before it divides into its tibial and common peroneal branches. If dorsiflexion is elicited it may be the common...

Orthopedic principles

Early orthopedics was mainly about childhood deformities, and orthopedics first took an interest in sciatica because of sciatic scoliosis. From these roots, orthopedics expanded in the second half of the 19th century to include all musculoskeletal problems. Interest in spinal deformities spread to sciatica and back pain, and focused on the spine. Previously, back pain and sciatica were regarded as separate diseases. From now on, they were linked in the spine. Ever since, failure to distinguish our ideas and treatment of back pain and sciatica has caused much confusion, which continues to this day. The discovery of X-rays opened up a whole new perspective. For the first time it was possible to visualize the spine during life. Soon, every incidental radiographic finding became an explanation for back pain and sciatica. Different authors blamed lumbosacral anomalies, facet joint degeneration, and sacroiliac disease. The 1920s and early 1930s saw operations to correct these anomalies by...

Early spiritual beliefs

Actually, the word animal derives from anima or soul in Latin. Observing the movements and autonomy of animals fascinates everybody, especially children. This is probably why Walt Disney's animated cartoons became so popular, and today animation is used in television, not only in advertisements for children, but also for adults. The existence of animal spirits, however, was disproven in the 1700s, when the Italian physician Luigi Galvani (1737-1798) was able to produce movements in the legs of recently sacrificed frogs by applying electrical discharges to the frogs' sciatic nerve.

The Long List of Inventions and Observations that Led to the Pacemaker

In 1783 Luigi Galvani was dissecting frog legs on the same table where he had previously done work on static electricity. When an errant spark from a scalpel hit the sciatic nerve, the frog leg moved. Later observations, both with frog legs and later hearts, showed that electricity could stimulate muscle. He published these observations in 1791 as Commentary on the Effect of Electricity on Muscular Motion.7 This may in part have served as an inspiration for Mary Shelley's novel Frankenstein 8

Clinical Case 1 Degenerative Lumbar Spondylolisthesis

Figure 13-1 presents lumbar magnetic resonance imaging (MRI) of a 67-year-old woman with a 30-year history of progressive lower back pain. This pain was exacerbated by activity and relieved by rest. She reported no associated radicular symptoms. Past medical history was significant for morbid obesity, diabetes, and osteoarthritis. Physical exam did not reveal

Lumbosacral Plexus And Its Branches

Minimal monitoring should include continuous regulation of blood pressure, ECG, and level of consciousness. If the patient receives any sedative or narcotic medications during the block, a pulse oximeter should be used. A peripheral nerve stimulator can greatly enhance the success rate of a sciatic nerve block by helping to avoid significant patient discomfort. The extent of the block can be assessed by examining motor function, which is primarily governed by a somatic nerve.

Electrophysiology Of Peripheral Nerve Stimulators

The relationship between the strength and the duration of the charge needed to stimulate a nerve can be expressed by the familiar strength-duration curve. Figure 17-1 shows such a curve obtained from a preparation of cat sciatic nerve. The rheobase is the minimum current required to stimulate the nerve with a long pulse width, whereas the chronaxy is the duration of stimulus required to just stimulate at twice the rheobase. Generally, strength duration curves follow this formula

Stressful Life Events

In a study of 892 adult psychiatric outpatients, Sack et al. (2007) found that compared with non-traumatized patients, sexually traumatized patients reported a significantly higher incidence of somatic complaints pertaining to pain or discomfort in sexual organs or sexual indifference. In their study of women with headache and lower back pain, Yucel et al. (2002) found that physical abuse and neglect were the most commonly reported types of childhood maltreatment.

Table 172 Distancevoltage Relationship

To confirm that the needle tip was within 5 mm of the nerve, Raj and coworkers112 performed the following experiment in a group of five anesthetized dogs. Three spinal needles were introduced toward the sciatic nerve at the gluteal region via electrical stimulation. After it appeared that the muscle contraction was maximal at the lowest voltage with all of the needles, one needle was left undisturbed. The second needle was pulled back 1 cm proximally, the third needle was pushed 1 cm deeper, and 0.2 mL of methylene blue stain was injected through each needle. With the needles in place, the stained areas were explored through careful dissection. It was found that the needle that was presumed to be on the nerve, did, in fact, stain the nerve sheath. The other needles, 1 cm distal or proximal to the nerve, stained tissues similar distances away from the nerve.

Patient Encounter 1 Part 1

A 25-year-old Caucasian woman presents to the university student clinic with complaints of intermittent crampy abdominal pain and four to five loose stools per day. She describes some visible mucus and blood in the stool and states that these symptoms have been present for 6 to 8 weeks. She also has intermittent lower back pain, fatigue, fever, and a 4.5-kg (10-lb) weight loss. The back pain started about the same time as her Gl symptoms. She denies any sick contacts and has not eaten any takeout

Neurological Disorders

Disturbances of Vayu were thought to create many neurological diseases. These included Dhanustam-bha (literally a pillar curved like a bow) or tetanus. Other conditions caused by disturbed Vayu included convulsions, the two types of which may well have been descriptions of petit mal and grand mal epilepsy paralysis of one lower extremity paraplegia sciatica brachial palsy and facial palsy. Other diseases that we now do not think of as being neurogenic are also ascribed to disturbed Vayu. These include one that appears to be synovitis of the knee joint, another that seems suggestive of paresthesias of the feet, and still another that seems to have been bowel obstruction. Dumbness, nasal speech, and indistinct speech were also seen to stem from the same cause.

Clinical Manifestations and Pathology

That virus traveled up the sciatic nerve at 2.4 mm per hour. Postmortems reveal that lesions in the CNS can be discrete and separate, suggesting that virus enters at numerous endplate junctions of motor neurons in the muscles and reaches the CNS at many different places. The time taken to reach the CNS from any muscle depends on the length of the nerve to be traveled, during which time the virus would be shielded from antibody. Virus could enter a nerve at any time from about the second to the ninth day. Virus entering from a foot muscle on the ninth day in a tall adult would reach the CNS about 18 days later. This model would account for the incubation of about 3 to 28 days. As viremia ends about the ninth day, the BBB model requires the virus to be 18 days in the CNS before producing symptoms.


Low back pain that may be referred to the buttock. Activity usually aggravates pain. May present with associated spasms of the erector spinae or hamstring muscles. Sciatica in the young patient is sometimes observed in grades III and IV. Sciatica from disk and facet joint degeneration or hy-pertrophic tissue in the pseudarthrotic defect is sometimes observed in adult patients.

What is SEP testing What is its value in the investigation of radiculopathy

SEPs are waveforms recorded over the scalp or spine following electrical stimulation of a mixed or sensory nerve in the periphery. SEPs are conducted in the posterior columns of the spinal cord, which represent nerve fibers carrying joint position and vibratory sensation. These nerve fibers usually remain unaffected in radiculopathy. SEPs are used successfully in monitoring spinal cord function during spinal surgery, and prolonged SEP latency can be the earliest sign in extensive multiroot lesions. However, this modality is of limited value for the diagnosis of cervical or lumbar radiculopathy. The range of normal SEP values is broad, and the test has poor sensitivity and specificity for assessing nerve root function.

What are the most common presenting symptoms of spinal tumors

Pain is the most common presenting symptom. Pain is frequently described as persistent, progressive, and not typically associated with activity. Pain at night is a characteristic symptom. Subjective weakness, radiculopathy, objective neurologic deficit, and bladder or bowel dysfunction may develop over time. Other presenting symptoms include a palpable mass or painful spinal deformities. Pelvic girdle malignancies, including chordoma, osteosarcoma, chondrosarcoma, and malignant fibrous histiocytomas, may present with back pain and sciatica. Always remember to evaluate the pelvis if the spine appears normal or the degenerative lesion does not fit the patient's degree of pain or neurologic involvement.

What are nerve root tension signs

Tension signs are maneuvers that tighten the sciatic or femoral nerve and in doing so further compress an inflamed nerve root against a lumbar disc herniation. The supine straight leg raise test (Lasegue's test) and its variants (sitting straight leg raise test, bowstring test, contralateral straight leg raise test) increase tension along the sciatic nerve and are used to assess the L5 and S1 nerve roots. The femoral nerve stretch test (reverse straight leg raise test) increases tension along the femoral nerve and is used to assess the L2, L3, and L4 nerve roots.

How is spinal impairment evaluated

Specific spinal impairment may or may not be related to patient's symptoms or functional abilities. For example, there is weak or nonexisting correlation between spinal range of motion and functional ability. However, decreased trunk extensor endurance correlates with back pain recurrence, chronicity, and first-time episodes of lower back pain symptoms.

Imaging Studies

Plain radiographs are still the most common imaging studies done for evaluation and management of rheumatic diseases. Techniques such as magnetic resonance imaging (MRI) and radionuclide scintigraphy (bone scan) are being used more often, although costly and often unnecessary. Many arthritides have characteristic radiographic findings, but these techniques are not indicated for most patients with acute and new symptoms of SLE, gout, mechanical lower back pain, or RA, because radiographs are usually normal early in the course of the disease. Normal radiographs also do not rule out OA. In established RA, the physician might see periarticular osteoporosis, soft tissue swelling, and marginal erosions. Gouty erosions cause characteristic overhanging edges because of reparative changes. (See also Chapter 31.) The severity of radiographic changes in association with severe symptoms can help guide the aggressiveness of treatment. Overreliance on radiographs, however, can lead to...

Relative Indications

Axial back pain from facet is 50 with leg pain 50 in general Patients received previous benefit from medial branch block, plus transforaminal epidural block. The patient has a strong desire for relief of axial back pain more permanently with a minimally invasive procedure, while intermittent sciatica is tolerable.

Physical therapy

Li & Bombardier (2001) tried to assess the impact of the AHCPR (1994) guidelines in a survey of Canadian physical therapists in 1998. They presented three vignettes a healthy young woman with acute low back pain for 1 week the same patient if she did not respond after 4 weeks' physical therapy and a 35-year-old man with severe low back pain and sciatica for 4 days. Almost all physical therapists said they would give all three patients education on back care and back exercises, including exercises to do at home. Eighty percent would give advice on work modifications. About a third would use spinal mobilization but only 3-5 manipulation. A quarter would advise the patient with sciatica to have a few days' bed rest but very few would advise bed rest for back pain alone. Up to 80 would use passive modalities and up to 30 would use traction. After 4 weeks, 80 would use mobilization, 50 would refer to a community exercise program, and 40 to a back school. But 65 would also continue...

Neuraxial Techniques

Evidence regarding the use of epidural drug therapy for chronic pain comes primarily from studies of epidural steroid injection (ESI) for low back pain and sciatica, and long-term epidural catheter use in the treatment of cancer-related pain. Recent meta-analyses have done little to dispel controversy over the efficacy of ESI in low back pain and associated radiculopathy. Watts and Silagy reviewed 11 randomized controlled studies (207 patients) of ESI in the treatment of sciatica these studies were deemed to be of good quality. They calculated an odds ratio of 2.61 for ESI versus control in providing short-term (up to 60 days) relief, and an odds ratio of 1.87 for long-term (up to 12 months) relief. No difference was noted in efficacy between caudal and lumbar injection, and no long-term adverse events were noted. In contrast to these findings, meta-analysis of 12 studies by Koes and associates123 and a critical appraisal by Rozenberg and colleagues123 of 13 trials failed to...

Other Neuropathies

Magnetic resonance imaging of the nerves involved by a focal compressive or inflammatory lesion may provide insight into the best physical therapy approach based upon anatomic detail. Figure 12-1, for example, delineates the edema and demyelination affecting a femoral nerve and lumbar plexus caused by a postin-fectious inflammatory neuropathy. Paresthesia and pain from a thoracic outlet syndrome or from compression of the sciatic nerve by the pyriformis muscle can be identified by similar imaging and aid the planning of a trial of stretching and exercise prior to more invasive management. Figure 12 1. Magnetic resonance neurography shows patchy hyperintensities of the lumbar plexus (upper arrow) and especially within the femoral nerve (lower arrow). These regions were 30 -50 wider than the unaffected nerve in the other leg. The patient presented with severe right hip and thigh pain and fluctuating, progressive paralysis of the quadriceps group, sparing the iliopsoas and hip adductors,...


Proponents claim that bee and other insect venom can treat chronic pain, rheumatoid arthritis, multiple sclerosis, lower back pain, migraines, and some dermatologic conditions. Bee pollen consumed internally is also claimed to increases one's energy, endurance, and overall performance. Although practitioner and client testimonials praise bee-product therapies, no studies document the ability of bee products to cure any ailment or to increase endurance or energy.

Facet Joint Syndrome

The facet joints in the back are paired synovial joints. They allow the spine to flex and extend and help prevent anterior and posterior displacement. Trunk extension and oblique extension in particular loads the facet joints. Just like any other synovial joint (e.g., knee), the facet joints can become arthritic and painful. In fact, as much as 40 of chronic lower back pain in older individuals, and 20 of younger individuals is thought to be due to facet joint disease. Sports that involved repetitive trunk extension (e.g., tennis, throwing sports, swimming, gymnastics) may predispose to facet joint disease. Typically, patients present with complaints of gradually progressive lower back pain that is worse with extension and made better with sitting. The pain may refer into the lower extremities but rarely extends beneath the knees. If the facet joints have hypertrophied and are impinging a nerve root, the patient may complain of radicular symptoms.

Preoperative Tests

Treating Lipomas Naturally

Gadolinium-enhanced magnetic resonance images of a lesion in the right buttock growing rapidly, producing severe neuropathic pain and progressive sciatic neuropathy, in a woman with neurofibromatosis 1. The tumor, which shows regions of signal inhomogeneity and enhancement, is located deep to the gluteal muscle mass adjacent to or involving the sciatic nerve. gadolinium-enhanced magnetic resonance images of a lesion in the right buttock growing rapidly, producing severe neuropathic pain and progressive sciatic neuropathy, in a woman with neurofibromatosis 1. The tumor, which shows regions of signal inhomogeneity and enhancement, is located deep to the gluteal muscle mass adjacent to or involving the sciatic nerve.


Glutaeus Max Med Min

This information is contrary to what many people believe or have been taught. In the analysis of low back problems and sciatica, however, this concept is important. sciatica, in which clinical findings suggest a disk lesion, but the fluctuation of symptoms suggest that the protrusion is not constant. Conservative treatment of many such cases has brought about effective relief of symptoms without surgery. In instances when, for some reason, the patient declines operation or the doctor does not elect to perform surgery, conservative treatment becomes the necessary alternative. Albert Freiberg described the piriformis muscle and its relation to sciatic pain, and furnished an interesting explanation for a possible cause of sciatic symptoms (21). Although there may be numerous cases in which sciatic pain is associated with a contracted piriformis, as he described, it is the opinion of the authors that irritation of the sciatic nerve by the piriformis muscle is often associated with a...

Individual Sports

As we move from the motion sports, those sports that require tremendous amounts of flexibility (in addition to strength) and involve large degrees of changes in range of motion, we go to the heavier sports. These sports require strength, lifting, and high body weight. Of course, the most common would be weight lifting. The incidence of lower back pain and problems in weight lifters is estimated to be 40 .24 The tremendous forces exerted on the lumbar spine by lifting weights over the head produce a tremendous lever arm effect and compressive injury to the spine. The three most important things in performing weight lifting are technique, technique, technique. Squats and dead lifts can be done, but the technique must be perfect in order to decrease the risk of a disk injury. For example, a dead lift requires erect posture, lumbar lordosis, and balance of the weight on the heels. Most lifts are begun with the spine in tight,


Manipulation of the spine by a chiropractor often makes people feel better. Manipulation may correct a dislocation and solve the problem of chronic lower back pain. Chiropractic therapy may improve posture, relieve headaches and tension, and successfully address other discomforts eased by manipulation or massage. Similar benefits may be obtained by treatments given by physical therapists.


Innervated, producing tremendous pain and reflex spasm when the annulus tears. The spasm and pain are mediated through the sinuvertebral nerve with anastomosis through the spinal nerve to the posterior primary ramus. As the herniated material extrudes and produces pain from the traversing or exiting nerve root itself, the patient may develop sciatica or radiculopathy. Intravesical infiltration of the granulation tissue adds increased potential for painful sensation in the annulus. The annulus, with time, can heal, although the healing annulus will not retain the same biomechanical function capability as the original intervertebral disk.

Embolic material

Embolic material should not be infused into the inferior gluteal artery for the reason described above. In spite of this, there are reports where infusion of gelatine particles into the inferior gluteal trunk either did not result in sciatic nerve symptoms3 or only in a minority of instances2. It is assumed that the amount of embolic material infused is the key factor as to whether sciatica presents or not. Even if superselective catheterization is achieved, care needs to be taken to minimize overflow of embolic material. As embolization of a branch approaches completion, some overflow is usually unavoidable. Particular caution is necessary when liquid embolic material is used, such as cyanoacrylate, alcohol and its derivatives.

Normal Anatomy

Neurofibroma Cross Section

Magnetic resonance neurography (MRN) used to assess the resectabil-ity of a peripheral nerve tumor. MRN images of a 69-year-old-female patient with a right sciatic nerve neurofibroma in the lower thigh. A, Coronal fat-suppressed T1 spin echo (SE) image after administration of gadolinium showing heterogeneous enhancement of a multilobulated and cystic mass lesion (white arrows) in the posterior thigh. B, Coronal short tau inversion recovery (STIR) fast spin echo (FSE) image showing high signal within the multilobulated lesion (white arrows). C, Axial T1 SE image after administration of gadolinium. D, Axial T2 FSE image showing discrete demarcation of the fascicular structure of the sciatic nerve (white arrow) along the posteromedial circumference of the tumor. E, Intraoperative photograph showing Penrose loops elevating the sciatic nerve from the multilobulated neurofibroma (black arrows). F, Intraoperative photograph after removal of the neurofibroma. Note the splitting of the distal...

Sciatic Neuropathy

The sciatic nerve arises from the sacral portion of the plexus. It leaves the pelvis through the sciatic notch and divides into the tibial and peroneal nerves at the popliteal fossa. The sciatic nerve provides sensation to the perineum, posterior thigh, lateral calf, and foot. It innervates the thigh extensors, hamstrings, and all the muscles of the lower leg and foot. Pain, weakness, and sensory changes caused by injury of the sciatic nerve or one of its two branches can be caused by trauma from gunshots, hip fracture or dislocation, compression from surgery or prolonged sitting on a hard edge, tumor, endometriosis, lipoma, aneurysm of the gluteal artery, or improper intramuscular injection into the gluteus. Symptoms of sciatic nerve compression can mimic L5-S1 radiculopathy. Again, EMG is helpful in these clinical situations.

Clinical examination

If the lateral curve remains on forward flexion, this suggests that the scoliosis is fixed or structural. A rib hump confirms the diagnosis (Fig. 6.5.18). Is the range of forward flexion limited Measure fingertip-floor distance. What is the cause of the limitation thoracic kyphosis, low back pain or short hamstring muscles In a patient with a complaint of sciatica, forward flexion may provoke pain down the leg by increasing tension of the ischiadic nerve, the hamstring muscles or the deep gluteal muscles. Patients with low back pain often present with a dysfunctional movement pattern clearly demonstrated as they assist by using their arms and legs to straighten up from the forward flexed position. It should be kept in mind that measurements of range of motion as well as muscle strength in patients are always affected by the patient's pain and motivation. Therefore assessment of pain intensity and psychological tests can add information that assists interpretation of the results from...


Pain from entrapment of the sciatic nerve is called sciatica. Patients with sciatica describe pain, burning sensation, or aching in the buttocks radiating down the posterior thigh to the posterolateral aspect of the calf. Pain is worsened by sneezing, laughing, or straining at stool. One of the tests for sciatica is the straight leg raising test. The patient is asked to lie supine while the examiner flexes the extended leg to the trunk at the hip. The presence of pain is a positive test result. The patient is asked to plantarflex and dorsiflex the foot. This stretches the sciatic nerve even more. If sciatica is present, this test reproduces pain in the leg. The test is illustrated in Figure 20-40. Another test for sciatica is the sitting knee extension test. The patient sits off the side of the bed and flexes the neck, placing the chin on the chest. The examiner fixes the thigh on the bed with one hand while the other hand extends the leg. If sciatica is present, pain is reproduced as...

Desmoid Tumors

Desmoid tumors, also known as aggressive or deep-seated fibromatosis, are benign fibrous tumors of mesenchymal origin usually located in muscle, particularly in the abdominal wall. When located at extra-abdominal sites such as in the neck, shoulder, or limbs, they often compress, envelop, or infiltrate peripheral nerves such as the brachial plexus, peroneal nerve, radial nerve, and sciatic nerve. Desmoid tumors are considered benign, because they do not metastasize to other parts of the body. However, they are often locally invasive to surrounding tissues, especially soft tissues such as peripheral nerves and surrounding vascular structures, and therefore they can be very difficult to treat surgically. They can also adhere to and intertwine with surrounding structures and organs. Patients often have symptoms that include a painless swelling or lump, pain or soreness caused by compressed nerves or muscles, pain and obstruction of the bowels, or limping or other difficulty using the...


No well-designed clinical trials of phenol blocks to muscle or nerve have been reported214 and no functional gains are evident. Blocks with phenol as a 2 -10 solution and ethyl alcohol have been used for over 30 years.215 The nerve or motor point is most often located by percutaneous electrical stimulation via a hypodermic needle cathode, but an intraneural injection by an open procedure is also advocated.216 An initial injection of a long-acting local anesthetic such as bupivacaine helps predict the efficacy of a subsequent phenol block. The most commonly injected nerves include the posterior tibial nerve to decrease equinovarus positioning of the feet and to decrease clonus, the obturator nerve to reduce adductor scissoring with gait but mostly to improve skin care management for immobile patients, and the sciatic nerve to allow better positioning of a patient with very spastic paraplegia. In the upper extremity, blocks of the musculocutaneous, median, or ulnar nerves may improve...

Stephen may

This edition explains the centralisation and peripheralisation phenomena the use of exercise to induce changes in pain location and intensity the means of detecting the most effective direction in which to apply therapeutic exercise differentiation between the pain of displacement, pain of contracture and pain arising from normal tissue how to differentiate the pain of nerve root adherence from entrapment and sciatica.


Impermeable to ionic lanthanum, but the endoneurial capillaries are not (13, 24). Intravascular perfusion with a hyperkalemic solution inactivates peripheral nerve much more rapidly than when it is bathed by the same hyperkalemic solution (26). Histamine increases the permeability of endoneurial capillaries to macromolecular tracers, but is without effect on the perineurium (27, 28). In leprosy, the endoneurial blood vessels become permeable to ferritin, whereas the perineurium remains impermeable to this tracer (29). In the frog sciatic nerve as well as rat tibial and sciatic nerve, where perineurial permeability has been measured independently, the endoneurial capillaries are more permeable (2, 3, 28, 30-32). During the second to sixth week of Wallerian degeneration, while the perineurial permeability increases about fourfold, the permeability-surface area product (PS) of the frog sciatic nerve decreases by more than 60 reflecting the greater sensitivity of PS to permeability of the...

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