Sciatica or sciatic neuralgia is a commoncondition in which one of the spinal nerve roots of the sciatic nerve is compressed resultingin lower back, buttock and leg pain. Sciatic nerve is a large nerve derived from 5 spinalnerve roots: L4, L5, S1, S2 and S3. It runs from the lumbar spine through the buttockdown the leg and the foot on the posterior aspect. There is one sciatic nerve on eachside of the body. Typically, only one side of the body is affected.A typical sciatica pain is described as a sharp shooting pain in the lower back, downthe buttock, thigh and leg on one side of the body. There may also be numbness, burningand tingling sensations. The pain can get
worse with sitting, moving, sneezing, or coughing.The patterns of pain depend on which nerve root is compressed, and follow the dermatomedistribution. The most common cause of sciatica is a herniatedspinal disc. The spinal disc is a soft elastic cushion that sits in between the vertebraeof the spine. With age, the discs become rigid and may crack, the gellike center of thedisc may protrude out and become a herniation outside the normal boundaries of the disc.Disc herniation presses on the nerve root as it exits the spine.In majority of the cases the condition resolves by itself after a few weeks of rest and conservativetreatment. Pain relief, nonsteroidal antiinflammatory
drugs and muscle relaxants may be prescribed.Stretching exercises and physical therapy may be recommended.Surgery may be needed if the pain doesn't go away after 3 months or more of conservativetreatments. The herniated disc may be removed in a procedure called discectomy. Or, in anotherprocedure called laminotomy, part of the bone of the vertebrae may be cut to make room forthe nerve.
Saphenous and Sural Nerve Injury Following Laser How to Avoid
Saphenous Nerve and Sural nerve injuries area potential complication of all endothermal treatments both endovenous laser and radiofrequencyablation. This presentation discusses this problem. It is mainly of concern to s,nurses and vascular technologists, but members of the public mainly also find it of interest.My own interest in this subject was stimulated by colleague and friend Ted King in Chicago.Ted has done a lot of al research on the saphenous nerve and sural nerve and theiranatomical relationship to the great saphenous vein and the small saphenous vein. Ted haskindly helped to direct my reading of the medical literature and he has generously sharedthe findings of his own research that was
presented to the European Venous Forum inJune 2010. Nerve injury may occur in over a third oflaser treatments of the great saphenous vein and nearly one in twenty small saphenous veintreatments. A recent study from Germany has even suggestedthat saphenous nerve injury is more likely after endovenous laser than after surgicalstripping. The study authors have proposed that in some cases the nerve may have beeninjured by the needle during administration of the tumescent local anaesthetic.Here are the mechanisms by which the nerve might possibly be injured. Firstly, the nervemight injured by the needle during the cannulation
of the vein itself. This is probably veryrare but it is possible that the nerve could be transected by the needle. Similarly, aneedle stick injury might occur during the administration of local anaesthetic causinga neurotemesis. Finally, the thermal ablation could cause the direct transfer of heat energyto the nerve causing a thermal neuropraxia a burn injury.These are the possible strategies to avoid nerve injury. Firstly, the nerve and veincan be imaged in transverse section to identify a site of cannulation where the nerve andvein are sufficiently far apart to minimise the risk of thermal energy transfer. Secondly,the vein and nerve can be imaged in transverse
section during the cannulation to ensure thatthe vein is cannulated directly and that the needle tip does not impinge on the nerve.Thirdly, the nerve, vein and needle tip can be kept in view during tumescent anaestheticadministration by scanning in transverse section at all times. Lastly, the needle should bewithdrawn immediately and the thermal ablation terminated immediately if pain is felt inthe sensory distribution of the nerve at risk. In fact, performing these treatments underlocal anaesthetic is much safer than under general anaesthetic for this very reason.When pain occurs, the treatment should be terminated or the needle withdrawn, makingthe possible risk of nerve injury less likely.
Here you can see that the saphenous nerveand the great saphenous vein are very close and in contact in the distal calf. The twolie within the saphenous fascia superficial to the tibia. In this case the nerve liesanterior to the vein. This would not be a good site for cannulation. Even if the needletip is kept in view and the vein is cannulated cleanly by which I mean the needle tip isnot allowed to stray near the nerve, it is likely that the nerve would be injured byadministration of local anaesthetic fluid. As this tutorial clip shows, distally the nerveand vein and nerve are in contact as the probe moves more proximally, the vein and nerveare separated by 10mm or more. The vein can
be easily identified by the fact that it collapsesflat with pressure from the transducer probe. The probe is moved proximally and distally. Here once again we can see the probe moving more distally, and the vein and the nervecoming into contact with each other the vein collapsing on pressure.Here is the appearance of the Sural Nerve in relation to the small saphenous vein. Theanatomy and ultrasound appearance of the sural nerve have been very nicely described by Ricci.This tutorial clip shows that further proximally the vein and nerve are separated by 10mm ormore. As the probe moves more distally, the vein and the nerve are in close contact. Thevein here is collapsing on light pressure