Ciatalgia: Definition, Symptoms, Causes, Pathophysiology, Diagnosis, Management and Treatments

Also known as sciatica, it is a medical condition characterized by pain that descends down the leg from the lower back.

symptom

This pain can go through the back, the outside or the front of the leg.

The onset is often sudden after activities such as lifting heavy objects, although a gradual onset may also occur. Typically, the symptoms are only on one side of the body. Certain causes, however, can cause pain on both sides.

Lower back pain sometimes, but not always present. There may be weakness or numbness in various parts of the affected leg and foot.

About 90% of the time the sciatica is due to a herniated spinal disc pressing on one of the lumbar or sacral nerve roots.

Other problems that can cause sciatica include spondylolisthesis, spinal stenosis, piriformis syndrome, pelvic tumors, and compression of a baby’s head during pregnancy. The straight leg elevation test is often useful for diagnosis.

The test is positive if, when the leg is raised while a person is face up, the pain shoots below the knee. In most cases, medical images and x-rays are not necessary.

The exceptions to this are when the bowel or bladder function is affected, there is a significant loss of sensation or weakness, the symptoms are of long duration, or there is the concern of a tumor or infection.

The conditions that can occur in a similar way are diseases of the hip and early shingles before the eruption appears.

The treatment initially is typically with analgesics. In general, it is recommended that people continue with the activities in the best possible way.

Often, all that is needed is time, in approximately 90% of people, the problem disappears in less than six weeks. If the pain is severe and lasts more than six weeks, surgery may be an option.

Although surgery often accelerates the improvement of pain, the long-term benefits are not clear. Surgery may be required if complications occur, such as bowel or bladder problems.

Many treatments, including steroids, gabapentin , acupuncture , heat or ice, and spinal manipulation, have little evidence of their use.

Depending on how it is defined, 2% to 40% of people have sciatica at some time. The condition is known since antiquity.

Definition of sciatica or sciatica

The term “sciatica” describes a symptom-pain along the sciatic nerve pathway, rather than a specific disease, disease or condition. Some use it to indicate any pain that begins in the lower back and descends down the leg.

Others use the term more specifically to refer to a nerve dysfunction caused by the compression of one or more lumbar or sacral nerve roots of a spinal disc hernia . Although in this second use it is a diagnosis (that is, it indicates a cause and effect).

Pain usually occurs in the distribution of a dermatome and goes below the knee to the foot. It may be associated with a neurological dysfunction, such as weakness. The pain is characteristically a type of shot, traveling quickly along the nerve.

Causes

Spinal disc herniation

The herniated spinal disc that presses on one of the lumbar or sacral nerve roots is the most frequent cause of sciatica, being present in approximately 90% of cases.

The herniated disc is usually due to the degeneration related to the age of the outer ring, known as the fibrous ring, although there have also been involved injuries, injuries by lifting or straining.

The tears are almost always posterolateral (on the back of the sides of the body) due to the presence of the posterior longitudinal ligament in the spinal canal.

This rupture in the disk ring can cause the release of chemicals that cause inflammation, which can cause severe pain even in the absence of compression of the nerve root.

Disc hernias are usually a posterior development of a previously existing disc protrusion, a condition in which the outermost layers of the fibrous ring are still intact, but may bulge when the disc is under pressure.

In contrast to a hernia, no central part escapes beyond the outer layers. Most minor hernias heal within several weeks.

Anti-inflammatory treatments for pain associated with disc herniation, protrusion, bulging or tearing of the disc are usually effective. Severe hernias may not heal on their own and may require surgery.

The condition can be called a sliding disc, but this term is not precise since the spinal discs are firmly attached between the vertebrae and can not “slip” out of place.

Spinal stenosis

Other compressive spinal causes include lumbar spinal stenosis, a condition in which the spinal canal (the spaces through which the spinal cord passes ) narrows and compresses the spinal cord, the horse’s tail or the roots of the sciatic nerve .

This narrowing can be caused by bone spurs, spondylolisthesis, inflammation or a herniated disc, which decreases the space available for the spinal cord, pinching and irritating the nerves of the spinal cord that travel to the sciatic nerves.

Lumbar spinal stenosis (EEL) is a medical condition in which the spinal canal narrows and compresses the nerves at the level of the lumbar vertebrae. This is usually due to the common occurrence of spinal degeneration that occurs with aging.

It can also sometimes be caused by a spinal disc herniation, osteoporosis, a tumor or trauma. In the cervical (neck) and lumbar region (lower down the spine) it can be a congenital condition in varying degrees.

It is also a common symptom for those who suffer from several skeletal dysplasias, such as pseudoachondroplasia and achondroplasia at an early age.

Spinal stenosis can affect the cervical or thoracic region, in which case it is known as cervical spinal stenosis or thoracic spinal stenosis. In some cases, it may be present in all three places in the same patient.

Lumbar spinal stenosis can cause low back pain, abnormal sensations and the absence of sensation (numbness) in the legs, thighs, feet or buttocks or loss of control of the bladder and bowel.

Piriformis syndrome

Piriformis syndrome is a controversial disease that is believed to be the result of compression of the sciatic nerve around the piriformis muscle.

According to the analysis, it varies from a “very rare” cause to contribute up to 8% pain in the lower back or buttocks.

In 17% of the population, the sciatic nerve runs through the piriformis muscle instead of below it. When the muscle shortens or has spasms due to trauma or excessive use, it is postulated that this causes compression of the sciatic nerve.

It is known colloquially as “wallet sciatica” since a wallet carried in a back pocket of the hip compresses the muscles of the buttocks and the sciatic nerve when the wearer sits down.

Piriformis syndrome causes sciatica when the nerve root itself remains normal and there is no spinal disc herniation.

Symptoms may include pain and numbness in the buttocks and leg. Symptoms often get worse when sitting or running.

Causes may include trauma to the gluteal muscle, spasms of the piriformis muscle, anatomical variation or an overuse injury. However, few cases in athletics have been described.

The diagnosis is difficult since there is no definitive test. Several physical examination maneuvers can be supportive. Medical images are typically normal. Other conditions that may occur in a similar manner include a herniated disc.

Treatment may include avoiding activities that cause symptoms, stretching, physical therapy, and medications, such as nonsteroidal anti-inflammatory drugs. Injections of steroids or botulinum toxins can be used in those that do not improve.

Surgery is usually not recommended. The frequency of the condition is unknown, with different groups arguing that it is more or less common.

The pregnancy

Sciatica or sciatica may also occur during pregnancy as a result of the weight of the fetus pressing on the sciatic nerve during the session or during spasms in the legs.

While most cases do not directly harm the fetus or the mother, the indirect effect can cause indirect damage to the legs, which can cause loss of balance and fall. There is no standard treatment for sciatica induced by pregnancy.

Other

Sciatica or sciatica may also be caused by tumors that affect the spinal cord or nerve roots.

Severe back pain that spreads to the hips and feet, loss of control of the bladder or bowel, or muscle weakness may be the result of spinal tumors or horsetail syndrome.

A trauma to the spine, such as a car accident, can also cause sciatica. A relationship with a latent infection of Propionbacterium acnes in the intervertebral discs has been proposed, but the role it plays is not yet clear.

Pathophysiology

Sciatica or sciatica is usually caused by compression of the lumbar nerves L4 or L5 or the sacral nerves S1, S2 or S3, or compression of the sciatic nerve itself.

When sciatica or sciatica is caused by compression of a dorsal nerve root (radix), it is considered a lumbar radiculopathy (or radiculitis when accompanied by an inflammatory response).

This may occur as a result of a spinal disc bulge or a herniated spinal disc (a herniated intervertebral disc), or of roughness, enlargement or misalignment (spondylolisthesis) of the vertebrae, or as a result of degenerated discs that may reduce the diameter of the disc. the lateral foramen (natural hole) through which the nerve roots leave the spinal column.

The intervertebral discs consist of a fibrous annulus, which forms a ring that surrounds the internal nucleus pulposus.

When there is a rupture in the fibrous annulus, the nucleus pulposus (pulp) can be extruded through the tear and press against the spinal nerves inside the spinal cord, the horse’s tail or leave the nerve roots, causing inflammation, numbness or pain unbearable.

Inflammation of the spinal canal can also spread to adjacent facet joints and cause lower back pain and / or referred pain in the posterior thigh (s).

However, many herniated discs do not cause pain or discomfort, only occasionally a herniated disc causes sciatica.

Diagnosis

Sciatica or sciatica is usually diagnosed by a physical examination and history of symptoms.

In general, if a person reports the typical pain irradiated in a leg, as well as one or more neurological indications of nerve root tension or neurological deficit, sciatica can be diagnosed.

The most applied diagnostic test is the elevation of the stretched leg to produce the Lasègue sign, which is considered positive if pain is reproduced in the distribution of the sciatic nerve with passive flexion of the leg stretched between 30 and 70 degrees.

Although this test is positive in approximately 90% of people with sciatica, approximately 75% of people with a positive test do not have sciatica.

Imaging tests such as computed tomography or magnetic resonance imaging can help with the diagnosis of lumbar disc herniation. The utility of magnetic resonance imaging in the diagnosis of piriformis syndrome is controversial.

Management and treatments

When the cause of sciatica or sciatica is lumbar disc herniation, most cases resolve spontaneously for weeks or months.

The best treatment for each person will depend on the root cause of the pinched nerve. Since it can come from a wide variety of different problems, it is important to determine what is the cause before deciding a treatment plan with your doctor.

Many patients have great success with more conservative treatments such as physical therapy or chiropractic treatment, which often allows them to avoid taking severe pain medications or resorting to surgery.

Initially, the treatment in the first 6-8 weeks should be conservative.

There does not seem to be a significant difference in the results between the tips to stay active and the recommendations for bed rest. In the same way, physical therapy (directed exercise) has not been found better than bed rest.

Medication

Medications are commonly prescribed for the treatment of sciatica, but the evidence for pain medications is poor.

Specifically, low quality evidence indicates that non-steroidal anti-inflammatory drugs do not seem to improve immediate pain and all nonsteroidal anti-inflammatory drugs appear to be equivalent.

There is also a lack of evidence on the use of opiates and muscle relaxants by the usual means. In those with sciatica due to piriformis syndrome, botulinum toxin injections can improve pain and / or function.

There is little evidence of steroids, either epidural or per pill. Low quality evidence supports the use of gabapentin for the relief of acute pain in those with chronic sciatica.

Surgery

Surgery for unilateral sciatica involves the removal of a part of the disc, which is known as a discectomy. While it results in short-term benefits, the long-term benefits seem to be equivalent to conservative care.

The treatment of the underlying cause of compression is necessary in cases of epidural abscess, epidural tumors and horsetail syndrome.

alternative medicine

Evidence of low to moderate quality suggests that spinal manipulation is an effective treatment for acute sciatica. For chronic sciatica, the evidence is poor.

Spinal manipulation has generally been found safe for the treatment of disc-related pain; however, case reports have found an association with horsetail syndrome, and is contraindicated when there are progressive neurological deficits.

Physiotherapy

Physiotherapists use a combination of various stretching, strengthening and aerobic conditioning exercises as their main part of almost any type of treatment plan to relieve sciatic pain. By participating regularly in gentle exercises, patients can recover faster from their pain.

Exercise “pose of pigeon”

One of the most effective exercises to relieve sciatic symptoms is known as pigeon posture. This exercise, which is used in yoga, involves a flexion of the back that requires a large amount of extension in the dorsal column.

It is named for the way the chest is pushed towards the ceiling, which resembles an inflated pigeon. The pigeon pose is exceptionally effective in relieving symptoms on both sides of the hips.

In addition to relieving sciatic pain, this exercise stimulates the internal organs, stretches the deep buttocks and can even improve urinary problems.

Stretch from knee to chest

Another major exercise for sciatica is the “one knee to chest” stretch, which helps stretch the hamstring, lower back and gluteal muscles.

Lying on your back, strips a knee to your chest, while using your hands to hold the leg for 10 seconds.

The process is repeated in the other knee and leg. It is usually performed as a warm-up before exercising to avoid injury to an overheated body.

Stretching of the pyramidal, or piriform muscle

The piriformis muscle, which is located deep in the hip, extends near the sciatic nerve.

When this muscle swells or tightens, the sciatic nerve can become irritated, which can cause sciatic pain, along with numbness and a tingling sensation that can sometimes even radiate down the leg and foot.

The stretching of the pyramidal muscle is done with the knees bent while lying on your back. It involves crossing the affected leg over the other knee and then holding the knee unaffected. This is done when you pull towards your chest until you feel a stretch in your butt.

In addition to treating sciatic symptoms through stretching and other exercises, physiotherapy treatments can also be helpful in discovering the cause of your sciatic pain.

During your physical therapy appointment, your physical therapy doctor will ask you specific questions about your symptoms so that the appropriate treatment plan can be developed.

Wait for questions about when your pain started and where it is located. You will be asked to rate your pain on a scale that varies from 1 to 10, where 10 represents the highest level of pain.

Your physical therapist may also want to know about any medication or exercise you have used to treat the pain and whether it has been effective.

Epidemiology

Depending on how it is defined, 2% to 40% of people have sciatica at some time. It is more common during people in their 40s and 50s and men are affected more often than women.