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ment; a cough, sneeze, or strain is intolerable The patient is usually most comfortable lying on his or her back with legs exed at the knees and hips and the shoulders raised on pillows to obliterate the lumbar lordosis For some patients, a lateral decubitus position is more comfortable Free fragments of disc that nd their way to a lateral and posterior position in the spinal canal may produce the opposite situation, one whereby the patient is unable to extend the spine and lie supine When the condition is less severe, walking is possible, though fatigue sets in quickly, with a feeling of heaviness and drawing pain Sitting and standing up from a sitting position are particularly painful The pain is usually located deep in the buttock, just lateral to and below the sacroiliac joint, and in the posterolateral region of the thigh, with radiation to the calf and infrequently to the heel and other parts of the foot Radiation of pain into the foot should at least raise the suspicion of an alternative cause of nerve damage It is noteworthy and surprising to patients that a lumbar disc protrusion sometimes causes little back pain, although in these circumstances there is often deep tenderness over the lateral process or facet joint adjacent to the protrusion Pain is also characteristically provoked by pressure along the course of the sciatic nerve at the classic points of Valleix (sciatic notch, retrotrochanteric gutter, posterior surface of thigh, head of bula) Pressure at one point may cause radiation of pain and tingling down the leg Elongation of the nerve root by straight-leg raising or by exing the leg at the hip and extending it at the knee (Lasegue ma` neuver) is the most consistent of all pain-provoking signs, as discussed earlier When sciatica is severe, straight-leg raising is restricted to 20 to 30 degrees of elevation; when the condition is less severe or with improvement, the angle formed by the leg and bed widens, nally to almost 90 degrees, in patients with exible backs and limbs During straight-leg raising, the patient can distinguish between the discomfort of ordinary tautness of the hamstring and the sharper, less familiar root pain, particularly when asked to compare the experience with that on the normal side Many variations of the Lasegue maneuver have been described (with numer` ous eponyms), the most useful of which is accentuation of the pain by dorsi exion of the foot (Bragard sign) or of the great toe (Sicard sign) The Lasegue maneuver with the healthy leg may evoke pain, ` but usually of lesser degree and always on the side of the spontaneous pain (Fajersztajn sign) The presence of this crossed straightleg-raising sign is strongly indicative of a ruptured disc as the cause of sciatica (56 of 58 cases in the series of Hudgkins) With the patient standing, forward bending of the trunk will cause exion of the knee on the affected side (Neri sign); the degree of limitation of forward bending approximates that of straight-leg raising Sciatica may be provoked by forced exion of the head and neck, coughing, or pressure on both jugular veins, all of which increase the intraspinal pressure (Naffziger sign) Marked inconsistencies in response to these tests raise the suspicion of psychologic factors With the patient in the upright position, the posture of the body is altered by the pain He or she stands with the affected leg slightly exed at the knee and hip, so that only the ball of the foot rests on the oor The trunk tends to tilt forward and to one side or the other, depending on the relationship of the protruded disc material to the root (see above) This antalgic posture is referred to as sciatic scoliosis and is maintained by re ex contraction of the paraspinal muscles, which can be both seen and palpated In walking, the knee is slightly exed, and weight bearing on the painful leg is brief and cautious, giving a limp It is particularly painful for the patient to go up and down stairs. asp net mvc show pdf in div How can display . pdf file in view MVC . - CodeProject
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