Sciatica and back pain

Sciatica is pain that radiates along the sciatic nerve. Sciatica is usually caused by compression of the lumbar nerve roots. The most common causes are disc pathology, osteophytes, and narrowing of the spinal canal (spinal stenosis). Symptoms of sciatica include pain radiating from the buttock to the foot. Diagnosis involves MRI or CT. Electromyography and nerve conduction velocity testing can help to determine the level of damage. Treatment includes symptomatic therapy and sometimes surgery, particularly if there is a neurological deficit.

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Causes of sciatica

Sciatica is usually caused by compression of the nerve roots, usually due to a herniated disc, bone deformities (osteoarthritic osteophytes, spondylolisthesis), a tumor or abscess in the spinal canal. Compression can occur in the spinal canal or intervertebral foramen. Nerves can also be compressed outside the spine, in the pelvic cavity or in the buttock area. The most commonly affected nerve roots are L5-S1, L4-L5, L3-1.4.

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Symptoms of sciatica

The pain radiates along the sciatic nerve, most often to the lower part of the buttock and the back of the leg below the knee joint. The pain is usually burning, shooting, stabbing. It may be combined with lumbar pain or be without it. The Valsalva maneuver may increase the pain. Compression of the roots may cause sensory, motor, or more objective findings - reflex deficit. A herniated L5-S1 disc may cause a decrease in the Achilles reflex, a herniated L3-L4 disc - a decrease in the knee reflex. Raising a straightened leg more than 60 ° (sometimes less) can cause pain radiating to the foot. This is typical of sciatica, but pain radiating downward in the raised limb in combination with pain arising in the contralateral leg (crossed syndrome) is more specific for sciatica.

Diagnosis of sciatica

Sciatica may be suspected based on the characteristic algic picture, and testing of sensation, muscle strength, and reflexes is necessary. If neurologic deficits or symptoms persist for more than 6 weeks, neuroimaging (MRI) and electroneuromyography (if necessary) are necessary. Structural abnormalities causing sciatica, including spinal stenosis, are well diagnosed by MRI (preferred) or CT. Electromyography may be performed if radicular compression persists or worsens to exclude conditions that mimic sciatica, such as polyneuropathy and entrapment neuropathies. This test may help clarify whether there is a single or multiple levels of nerve involvement and whether there are clinical correlations with MRI findings (especially before surgery).

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Treatment of sciatica

Acute pain may be treated with bed rest for 24 to 48 hours with the head of the bed elevated 30° (semi-Fowler position). NSAIDs (eg, diclofenac, lornoxicam) and acetaminophen, and adjuvants (tizanidine) may be used. Improvement may also occur with drugs to treat neuropathic pain, such as gabapentin or other anticonvulsants or low doses of tricyclic antidepressants. Caution is needed when prescribing sedatives to elderly patients, as they increase the risk of falls and arrhythmias. Muscle spasm may be reduced by tizanidine, as well as heat or cooling, and physical therapy. Corticosteroids are debatable in acute radicular pain. Epidural corticosteroids may hasten pain resolution, but should probably be reserved for severe or persistent pain. The epidural method of glucocorticosteroid administration ensures local creation of a high concentration of the drug, and, accordingly, minimization of side effects associated with their systemic action. However, the literature data on the effectiveness of glucocorticosteroids with epidural administration are still insufficient and in some cases are contradictory.

The presence of pain with subsequent changes in the habitual motor stereotype can lead to a more or less rapid formation of MTZ, which will contribute to the overall algic picture. The presence of radicular compression accelerates the formation of MTZ. Treatment of MTZ is carried out according to the above principles, with the exception of kinesitherapy, which in case of discogenic pain can cause an increase in the discogenic conflict in the spinal canal.

Indications for surgical treatment may include obvious disc herniation with muscle weakness or progressive neurological deficit, as well as treatment-resistant pain that interferes with professional and social adaptation in an emotionally stable patient and is not cured within 6 weeks by conservative methods. Epidural corticosteroids may be an alternative for some patients.