Lumbago with sciatica is a painful attack localized in the lumbar region and the posterior surface of the thigh, developing as a result of lifting weights, awkward turning of the trunk, protrusion of the intervertebral disc. The disease is manifested by sudden pain, forced body position and impaired movement in the lower back and affected limb. The diagnosis is established on the basis of a clinical examination, X-ray examination, CT or MRI, myelography. Analgesics, nonsteroidal anti-inflammatory drugs are used in the treatment; after the inflammation subsides, therapeutic gymnastics is prescribed, physiotherapy procedures are applied. In case of an unfavorable course, surgical treatment is carried out.
ICD 10
M54.4
General information
Lumbago with sciatica is painful sensations in the lower back of varying intensity (from discomfort to powerful intense pain), prone to radiate into the leg, arising from pathological compression and irritation by deformed vertebrae of the spinal roots L4—S3, forming the sciatic nerve. Pain occurs against the background of spinal osteochondrosis, spondyloarthrosis, intervertebral hernias and other diseases accompanied by destructive changes and the formation of osteophytes. The disease accounts for approximately 20-30% of cases among all pathological processes associated with back pain. It occurs most often in people of working age (young and middle age, 25-45 years).
Causes
Lumbago with sciatica is most often of vertebrogenic origin and is caused by reflex “reflection” of pain in intervertebral hernia of the lumbar spine, lumbar spondyloarthrosis and other degenerative changes of the spine. In some patients, it is a manifestation of myofascial pain syndrome involving the muscles of the back and pelvis. Also, pain can be caused by irritation of ligamentous, bone, muscle structures; at the same time, it can be bilateral, with poorly defined localization; the pain reaction is deep and rarely radiates below the level of the knee joint. In the elderly, a common cause of lumbago with sciatica is arthrosis of the hip joint (coxarthrosis), in which pain can radiate to the lower back. The following situations can provoke the development of a painful reaction: sharp turns of the trunk, hypothermia, being in drafts, prolonged being in an uncomfortable, monotonous pose. Less often, pathology develops without any apparent reason.
The risk group for the development of lumbago with sciatica includes people with excess weight, chronic diseases of the spinal column, intervertebral hernias, infectious exacerbations, as well as those patients who work in production, constantly experience increased stress and spend a long time in the same body position.
Pathogenesis
The mechanisms of pain syndrome development in lumbago with sciatica are different, depending on the causes that trigger the pathological process.
Piriformis muscle syndrome. It occurs with osteochondrosis, when areas of the damaged intervertebral disc become a source of pathological impulses. The human nervous system perceives them as pain, doing everything possible to reduce the latter (immobilization of the affected area, increased muscle tone). Muscle tension spreads far from the original source of pain and is transmitted to the piriformis muscle, under which the sciatic nerve passes. Pathological muscle contractions lead to compression of this nerve, and there are symptoms of reflected pain.
Intervertebral hernia. Degenerative processes in intervertebral hernia contribute to narrowing of the lumen of the spinal canal; this, in turn, leads to compression and inflammation (radiculitis) of the roots of the sciatic nerve. As a result, the nerve fibers (sensory and motor) that are part of it are irritated, which provokes the occurrence of reflected pain. The latter can also form with a complicated hernia (its prolapse), leading to an acute narrowing of the spinal canal.
Facet syndrome. It is formed against the background of osteochondrosis, in which either excessive mobility or restriction in the movement of the spinal column appears. This leads to a change in the work of the intervertebral joints, an inflammatory process and the formation of reflected pain.
Symptoms
An attack of pain in the lower back appears suddenly. The pain reaction is burning, shooting or aching. During pressure and / or irritating effects on the spinal nerves at the level from L4 to S3 (with prolonged tension, increased load on the lower back), sharp pain occurs. It leads to reflex muscle contraction, which further increases the pain attack.
The main symptoms of lumbago with sciatica are: pain in the back and back of the thigh, restrictions in the movement of the spine (especially in the lumbosacral region). Painful sensations usually become pronounced when trying to change the position of the body, lift something heavy or straighten up; the patient assumes a forced position (slightly leaning forward, in a half-bent position). Both static and motor skills of the patient change. Standing or walking, he spares one leg, unloading it, and the other becomes the main, supporting one. This leads to a tilt of the trunk towards the healthy (supporting) leg. The muscles of the lumbar region, and often the entire back and even the lower extremity girdle, are tense. Tension prevails homolaterally (that is, on the side of the lesion). The lower back is shackled when walking, scoliosis, flattening of lumbar lordosis, less often hyperlordosis, can be observed. The “tripod symptom” is characteristic when, due to pain, patients either cannot sit at all, or are forced to rest their hands on the edge of the chair. When changing the position, the patient first turns over to the healthy side and often pulls up the sick leg with the help of his hand (Minor symptom).
Diagnostics
Diagnosis of lumbago with sciatica includes a clinical examination, during which a neurologist performs a static and dynamic examination of the spine, checks the symptoms of sciatic nerve tension, and also pays attention to signs of infection or malignant neoplasm. Pathognomonic for lumbago with sciatica is a sharp soreness in response to palpation of the exit point of the sciatic nerve to the thigh. Additionally, with lumbago with sciatica, the pelvic and abdominal organs are examined, which makes it possible to exclude or identify organ lesions, which can also be a source of reflected pain.
Radiography of the lumbar spine reveals a decrease in the height of the intervertebral discs, sclerosis of the closure plates, hypertrophy of the articular processes, osteophytes, uneven narrowing of the spinal canal. The main purpose of this study is to exclude tumors, spondylitis, traumatic and pathological fractures, congenital spinal anomalies, infectious and inflammatory processes. In cases where clinical manifestations give reason to suspect a tumor or spondylitis, and radiography of the spine has not revealed pathology, radioisotope scintigraphy, computer or magnetic resonance imaging are indicated. CT or MRI of the spine, and in their absence – myelography, are indicated when signs of compression of the spinal cord (compression myelopathy) appear. In some cases, a lumbar puncture is performed, according to the results of which it is possible to detect an excess of the amount of protein components. According to the indications, ultrasound examination of the abdominal cavity organs, ultrasound of the kidneys, excretory urography is performed.
Lumbago with sciatica is differentiated from myositis of the back muscles and pathology of the hip joint. For an accurate diagnosis, the doctor carefully examines the anamnesis, examines the patient, evaluates the available objective and subjective clinical manifestations of pathology.
Treatment
In neurology, the elimination of acute back pain is carried out against the background of measures aimed at combating its root cause: intervertebral hernias, lumbosacral osteochondrosis, etc. Treatment of lumbago with sciatica is carried out by a neurologist or a vertebrologist. In the acute stage of a painful attack, it is important to organize high-quality care for the patient. The bed place should be rigid, elastic; analgesics are prescribed to relieve pain, and in particularly difficult cases, blockades are used — injections with painkillers and anti-inflammatory components that are injected directly into the painful focus. Local irritating procedures (the use of pepper plaster, distracting techniques, rubbing) have a good analgesic effect. If therapeutic treatment is ineffective, spinal traction is used. Physiotherapy procedures (mud baths, acupuncture, therapeutic sleep, massage sessions, manual therapy) are recommended.
The complex therapy of lumbago with sciatica, as a rule, includes anti-inflammatory drugs, muscle relaxants, antispasmodics, drugs to improve microcirculation. A positive effect on the patient’s well-being is provided by the intake of vitamins, which contribute to the restoration of tissues, regeneration and nutrition of cartilaginous structures of the spinal column.
Therapeutic massage has an excellent analgesic and restorative effect in the subacute period of the disease. With lumbago with sciatica, special attention is paid to the lumbar and sacral regions. With systematic kneading of this zone, it is possible to improve blood flow, restore metabolism in the spinal column and slow down the progression of osteochondrosis.
If physiotherapy and medication cease to work or are ineffective, surgical treatment is prescribed. Indications for its implementation are: symptoms of compression of the spinal cord; pelvic disorders and lower paraparesis; severe pain syndrome that does not respond to conservative treatment. Surgical treatment of intervertebral hernias is most often recommended. During the operation, the damaged disk may be partially or completely removed. It is possible to perform discectomy, microdiscectomy and endoscopic discectomy. With total interventions, plastic surgery of the damaged intervertebral disc is used.
With frequent recurrences of lumbar pain, special gymnastic exercises are recommended. They allow you to strengthen the muscles surrounding the vertebral column, which significantly reduces the risk of dislocation of the vertebrae and increases their resistance to physical exertion. Physical therapy is recommended to be carried out in a medical institution, under the guidance of an experienced physical therapy doctor. Having no knowledge in the field of physical therapy, you should not experiment with unknown exercises, since with one awkward movement you can stretch the muscles, provoke the appearance of an inflammatory process and strengthen the signs of intervertebral hernias. Gradually, patients get used to the rhythm in which they perform exercises, master new techniques and approaches so that after discharge from the hospital or termination of the active period of treatment, they can continue to use physical therapy, but without outside help.
Prognosis and prevention
In approximately 95% of cases, lumbago with sciatica is benign in nature and, with timely medical care, has a fairly favorable prognosis. With frequent relapses of the disease and lack of treatment, tissue deformities may occur, nodes often form in the depth of the muscles, metabolic processes are disrupted.
Preventive measures for lumbar pain are aimed at timely treatment of spinal diseases and prevention of their progression in the future. It is recommended to avoid prolonged tension of the spine muscles, which leads to stagnation and provokes the appearance of destructive changes in the cartilage tissue of the vertebrae. Correction of the motor stereotype is necessary; it is necessary to avoid performing movements on unprepared muscles; it is necessary to create a muscular corset that will ensure the correct distribution of load on the spinal column. It is also necessary to correct posture disorders with the formation of correct posture, take care of weight loss and give up smoking. In addition, to prevent frequent relapses, it is recommended to undergo sanatorium treatment 1-2 times a year.
