Acute Sciatica - need suggestion

Hi.. there is this patient of mine with acute sciatica, an x ray reveals L2-L3 space narrowed. she has pain in the lateral aspect of the left lower leg.the moment she lies on the bed either prone or supine she has severe pain for ten mins after which she is relieved and is able to turn around in lying. passive extension of the lumbar spine causes a sharp pain. after a few sessions of traction the pain seems to have disappeared from her lumbar region. now pain is only in d lower leg. lumbar flexion causes no pain at all. SLR negative. she has numbness on the dorsum of foot. she does not tolerate exercise well, have made her do extension exercises.few days she is alright. then there is pain again. i teach her flexion exercises. again a few days later her pain is a bit more.bending to the right causes recurrence of pain in the left leg. i am not sure as to proceed with extension, flexion or lateral flexion exercises for her. Please send in your suggestions.

You dont say how long she has had her problems and whether she has shown signs of improving, or being static since onset of her problems, and start of your sessions with her

she has been having it now for 4 months.but she did have a similar episode about a year ago which just subsided by itself.. and yes she says her pain has reduced by 60% since the start of physio sessions 2 weeks ago.

kps,

Seems you are dealing with the patient based on Mecknezie technique ,am i correct ?

Cheers
Emad

tried mckenzie n also williams flexion exercises.. she finds flexion painless

Hi kpc_23,

You seem to be assuming that the problem is a disc herniation. But you only have a narrowed disc space at L2-3 to go off which BTW doesn't correspond to your patient's reported area of pain.

Some interesting findings on her examination though:
1. Lying in bed supine or prone gives sharp pain - doesn't sound like disc to me, more like a joint or something?
2. LF right gives left leg pain - that is a stretch pattern of pain and is consistent with left sided disc problem but can also be stretching of the joint capsule etc.
3. extension exercises gives pain but does standing in extension provoke the symptoms?
4. flexion seems ok. What about F + LF left and right in standing?
5. What about other joints? SIJ? Hip?

Just some thoughts. Let us know...

Your pt case presentation is not fully complete. Describe it in a little bit more detail. It will be better to use the McKenzie Assessment approach, so that the condition of your patient is better analysed. An example of McKenzie assessment approach is given below to follow. Have a look over that.

Date--------------
Name--------------------------- Sex M / F
Address---------------------------------
Telephone-----------------------------
Date of Birth---------------------------- Age-----------------------
Referral: GP / Orth / Self / Other-------------------------
Work: Mechanical Stresses-----------------------
Leisure: Mechanical Stresses------------------------------
Functional Disability from present episode--------------------
Functional Disability score---------------------------------------
VAS Score (0-10)------------------------------------------

HISTORY

Present Symptoms---------------------------------------
Present since--------- Improving / Unchanging / Worsening-----------
Commenced as a result of------------- Or no apparent reason-----------
Symptoms at onset: back / thigh / leg----------------------------------
Constant symptoms: back / thigh / leg--------------------------------- Intermittent symptoms: back / thigh / leg-----------------------------

Worse: bending Sitting / rising standing walking l ying
am / as the day progresses / pm when still / on the move
other

Better: bending sitting standing walking lying
am / as the day progresses / pm when still / on the move
other

Disturbed Sleep Yes / No

Sleeping postures: prone / sup / side R / L
Surface: firm / soft / sag
Previous Episodes 0 1-5 6-10 11+
Year of first episode
Previous History--------------------------------------
Previous Treatments-----------------------------------

SPECIFIC QUESTIONS

Cough / Sneeze / Strain / +ve / -ve
Bladder: normal / abnormal
Gait: normal / abnormal
Medications: Nil / NSAIDS / Analg / Steroids / Anticoag / Other------------
General Health: Good / Fair / Poor--------------------
Imaging: Yes / No---------------------------------------------
Recent or major surgery: Yes / No ---------------
Night Pain: Yes / No---------------------
Accidents: Yes / No ----------------------
Unexplained weight loss: Yes / No---------------------

POSTURE

Sitting: Good / Fair / Poor Standing: Good / Fair / Poor Lordosis: Red / Acc / Normal Lateral Shift: Right / Left / Nil
Correction of Posture: Better / Worse / No effect------------- Relevant: Yes / No------------------
Other Observations:--------------------

NEUROLOGICAL

Motor Deficit Reflexes
Sensory Deficit Dural Signs

MOVEMENT LOSS

Movement Loss Maj Mod Min Nil Pain

Flexion
Extension
Side Gliding R
Side Gliding L

TEST MOVEMENTS Describe effect on present pain – During: produces, abolishes, increases, decreases, no effect,
centralising, peripheralising. After: better, worse, no better, no worse, no effect, centralised, peripheralised.

Mechanical Response
Symptoms During Testing Symptoms After Testing
Rom Rom No
Effect
Pretest symptoms standing:
FIS
Rep FIS
EIS
Rep EIS
Pretest symptoms lying:
FIL
Rep FIL
EIL
Rep EIL
If required pretest symptoms:
SGIS – R
Rep SGIS - R
SGIS - L
Rep SGIS- L

STATIC TESTS

Sitting slouched---------------------- Sitting erect---------------------
Standing slouched---------------- Standing erect-----------------------
Lying prone in extension--------------- Long sitting--------------------

OTHER TESTS--------------------------------------------------

PROVISIONAL CLASSIFICATION

Derangement Dysfunction Posture Other
Derangement: Pain location------------------------------------

PRINCIPLE OF MANAGEMENT

Education------------------- Equipment Provided------------------------
Mechanical Therapy: Yes / No--------------------------------------
Extension Principle:------------------- Lateral Principle:--------------------
Flexion Principle:---------------------- Other:------------------------
Treatment Goals:----------------------------------------------------

McKenzie forms are as an attachment. Have a look over that.

thanks a lot for the suggestions wil c into these n reply back

From history it seems to a postero-lateral disc protution. No mateer where it is. There is no single reliable test which conferms it.

So, u can persorm simple stretch (Rotation) manipulation for the lumbar region at side lying position maintaining painful side above. (According to Cyriax System of Orthopaedic Medicine)

Osman Gony
BPT; PG. Dip. Orthopaedic Medicine.