lumbosacral plexus and sciatica

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LUMBAR & SACRAL PLEXUS

LUMBAR & SACRAL PLEXUSSciatic Nerve

Peripheral nerves in lower quadrantThe lumbosacral plexus terminates in three primary peripheral nervesThese are responsible for innervating the tissues of the lower extremityLumbar plexus Femoral & obturator nerves Sacral plexus Sciatic nerve

Nerve Muscle affected with nerve injuryCommon sites of nerve Compression / tension or causes of nerve injuryDeformity / symptomsPrimary functional lossFemoral (L2 L4)Illiacus Sartorius Pectineus Quadriceps Pelvic or upper femur fractureDuring reduction of DDHPressure during forceps delivery Atrophy in anterior thighWeakness or inability to flex thigh and extend kneeGait and weight bearing disturbances: unable to control knee flexion during loading response

Nerve Muscle affected with nerve injuryCommon sites of nerve Compression / tension or causes of nerve injuryDeformity / symptomsPrimary functional lossObturator (L2 L4)Obturator externusAdductor muscle groupsPelvic or upper femur fractureDuring reduction of DDHPressure during forceps deliveryPressure from gravid uterus and difficult labour Atrophy in medial thighDifficulty in crossing legsImpaired adduction & external rotation of thigh

Nerve Muscle affected with nerve injuryCommon sites of nerve Compression / tension or causes of nerve injuryDeformity / symptomsPrimary functional lossSciatic (L4 S3)Hamstring groupAdductor magnusCompression from tight piriformisHip dislocation # of femurSciatica Pain radiating in posterior thigh and legAtrophy posterior thigh , leg & footAtrophy in calfWeak knee flexion and loss of ankle and foot control affecting all phases of gait

Nerve Muscle affected with nerve injuryCommon sites of nerve Compression / tension or causes of nerve injuryDeformity / symptomsPrimary functional lossTibial (L4 S3)

Distal to ankleMedial and lateral plantar nerves Plantar flexorsPopliteus Tibialis posterior Flexor digitorum longus Flexor hallucis longus

Distal to ankleAbductor hallucisFlexor hallucis brevis Lumbricales Interossei Quadratus plantae -

Ankle and footCompromise in tarsal tunnelIrritation from pes planus or pes cavus -

Foot deformitiesPes cavus Claw toes Foot strainPainful heelInability to plantar flex ankle or flex the toesGait impairment in terminal stance

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Nerve Muscle affected with nerve injuryCommon sites of nerve Compression / tension or causes of nerve injuryDeformity / symptomsPrimary functional lossCommon peroneal (L4 S2)

Deep peroneal nerve

Superficial peroneal nerveAnkle dorsiflexors Toe extensors Peroneus tertius

Peroneus longus and brevisCompression from crossing legs Injury from # at head/neck of fibula

Foot dropMay develop pes valgus

May develop equinovarusGait impairment during the loading response with foot slap and during swing phase with excessive flexion ( steppage gait ) to clear the toes

Sciatic NerveSciatica

Introduction The sciatic nerve is the thickest nerve in the human bodyIn its upper part, it forms a band about 2 cmIt begins in the pelvis and terminates at the superior angle of popliteal fossa by dividing in to the tibial and common peroneal nerves

Origin and Root valueThis is the largest branch of sacral plexusRoot value L4, L5, S1, S2, S3It is made up of 2 parts, the tibial part and common peroneal partThe tibial part is formed by the anterior primary rami of L4, L5, S1, S2, S3The common peroneal part is formed by the dorsal division of the anterior primary rami of L4, L5, S1, S2

Course Pelvis The nerve lies in front of the piriformis, under cover of its fasciaGluteal region The nerve enters the gluteal region through the greater sciatic foramen below the piriformis It runs downwards and passing between the ischial tuberosity and the greater trochanter Thigh Enters back of the thigh at the lower border of the gluteus maximusIt runs vertically downwards up to the superior angle of the popliteal fossa, at the junction of the upper two third and lower one third of the thigh, where it terminates by dividing in to the tibial and the common peroneal nerves

RelationsGluteal region: Medial:Inferior gluteal nerve and vesselsSuperficial or posterior:Gluteus maximus Deep or Anterior:Body of the ischiumTendon of obturator internus with the gemelliQuadratus femoris, obturator externusThe capsule of the hip jointThe upper, transverse fibres of the adductor magnus

Thigh: Small companion artery branch of inferior gluteal arterySuperficial / Posterior:Crossed by long head of biceps femorisDeep / Anterior:Lies on the adductor MagnusMedial:Semimembranosus & SemitendinosusLateral: Biceps femoris

Muscles & Nerve Supply Semitendinous TSSemimembranosus TSBiceps femoris LTS SCPAdductor magnusCP

SCIATICAItis a common type of pain affecting the sciatic nerve, a large nerve extending from the lower back down the back of each leg.

Causes Sciatica is caused by irritation of the root(s) of the lower lumbar and lumbosacral spine.Lumbar spinal stenosis(narrowing of the spinal canal in the lower back)Degenerative disc disease(breakdown of discs, which act as cushions between the vertebrae)Spondylolisthesis(a condition in which one vertebra slips forward over another one)PregnancyOther things that may make yourback painworse include being overweight, not exercisingregularly, wearing high heels, or sleeping on a mattress that is too soft.

Symptoms Pain in the rear or leg that is worse when sittingBurning or tingling down the legWeakness, numbness, or difficulty moving the leg or footA constant pain on one side of the rearA shooting pain that makes it difficult to stand upSciatica usually affects only one side of the lower bodyThe pain extends from the lower back all the way through the back of the thigh and down through the legDepending on where the sciatic nerve is affected, the pain may also extend to the foot or toes

In Severe cases lower extremity weakness, numbness in the upper thighs, and/or loss of bladder or bowel control.Loss of knee flexion due to weakness of hamstring group of muscles

Risk factors Age.Age-related changes in the spine, such as herniated disks and bone spurs, are the most common causes of sciatica.Obesity.By increasing the stress on your spine, excess body weight may contribute to the spinal changes that trigger sciatica.Occupation.A job that requires you to twist your back, carry heavy loads or drive a motor vehicle for long periods may play a role in sciatica, but there's no conclusive evidence of this link.Prolonged sitting.People who sit for prolonged periods or have a sedentary lifestyle are more likely to develop sciatica than active people are.Diabetes.This condition, which affects the way your body uses blood sugar, increases your risk of nerve damage.

ComplicationsAlthough most people recover fully from sciatica, often without any specific treatment, sciatica can potentially cause permanent nerve damageLoss of feeling in the affected legWeakness in the affected legLoss of bowel or bladder function

Tests During the physical exam, your PT may check your muscle strength and reflexes. For example, you may be asked to walk on your toes or heels, rise from a squatting position and, while lying on your back, lift your legs one at a time straight in the air. Pain that results from sciatica will usually become worse during these activities.

Investigations X-ray.An X-ray of your spine may reveal an overgrowth of bone (bone spur) that may be pressing on a nerve.Magnetic resonance imaging (MRI). MRI produces detailed images of bone and soft tissues such as herniated disks

Management Medical :The types of drugs that might be prescribed for sciatica pain include:Anti-inflammatoriesMuscle relaxantsNarcoticsTricyclic antidepressantsAnti-seizure medications

Physical Therapy

Once your acute pain improves, your physical therapist can design a rehabilitation program to help you prevent recurrent injuries. This typically includes exercises to help correct your posture, strengthen the muscles supporting your back and improve your flexibility.To reduce compression Traction To reduce pain Ultrasound therapy & TENS or IFT

Alternative MedicineAcupuncture.In acupuncture, the practitioner inserts hair-thin needles into your skin at specific points on your body. Some studies have suggested that acupuncture can help back pain, while others have found no benefit. Chiropractic.Spinal adjustment (manipulation) is one form of therapy chiropractors use to treat restricted spinal mobility. The goal is to restore spinal movement and, as a result, improve function and decrease pain. Spinal manipulation appears to be as effective and safe as standard treatments for low back pain

Surgery

This option is usually reserved for times when the compressed nerve causes significant weakness, bowel or bladder incontinence or when you have pain that progressively worsens or doesn't improve with other therapies. Surgeons can remove the bone spur or the portion of the herniated disk that's pressing on the pinched nerve.

Home RemedyCold packs.Initially, you may get relief from a cold pack placed on the painful area for up 20 minutes several times a day. Use an ice pack or a package of frozen peas wrapped in a clean towel.Hot packs.After two to three days, apply heat to the areas that hurt. Use hot packs, a heat lamp or a heating pad on the lowest setting. If you continue to have pain, try alternating warm and cold packs.

Stretching.Stretching exercises for your low back can help you feel better and may help relieve nerve root compression. Avoid jerking, bouncing or twisting during the stretch and try to hold the str

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