Cruralgie or Lumbocruralgie

What is cruralgia or lumbocruralgia?

Lumbocruralgia represents pain that originates in the lumbar spine and follows the entire course of the thigh nerve (crural or femoral nerve) . 

It is similar to lumboischialgia , but affects the femoral nerve and not the sciatic nerve.
Symptoms appear in the lumbar region, groin , waist level , and inner front thigh to the knee.

Unlike lumboischialgia , the symptoms of lumbocruralgia do not extend down to the foot . The femoral nerve is the largest nerve of the lumbar plexus and is divided into different branches:

• the muscle trunk innervates the following muscles:   musculus quadriceps femoris , sartorius, pectineus;
• the skin diversion spreads on the anterior, medial and lateral part of the thigh;
• the saphenous nerve runs anteromedially through the thigh and leg;
• Articular branches that innervate the thigh-hip joint.

Pain and other symptoms may result from compression or irritation of the femoral nerve , which is unable to further transmit signals from the spinal cord to and from the peripheral nervous system; the brain interprets this nerve stimulation as pain. The intervertebral disc is located between two vertebrae and consists of a gelatinous mass on the inside (nucleus pulposus) and is surrounded on the outside by fibrous cartilage (fibrous ring or annulus fibrosus).

This ring of fibers is formed from many concentric circles, the fibers of which are differently oriented; it is as if each ring of fibers were made up of layers, each of which serves to support the spine and allow it to move.
If one or more layers are torn, the gelatinous core protrudes a little (bulging) or it penetrates the fibrous ring completely and presses on the spinal cord ( herniated disc ).

The femoral nerve arises from the spinal cord at the level of the nerve roots between L2-L3, L3-L4 and L4-L5 ; compression in this area can cause cruralgia. Lumbocruralgia can be acute or develop slowly, it can be triggered by bending over suddenly, or for no apparent reason.

Lumbocruralgia occurs much less frequently than lumboischialgia; the L5-S1 disc is in a particular position that is subjected to greater stress than the other discs and at this level protrusion and herniation cause lumboischialgia. In the vast majority of cases, the symptoms are unilateral, and bilateral lumbocruralgia is very rare.

Cruralgia is easy to develop during pregnancy because the spinal discs are subjected to increased stress from the weight of the baby and the pressure the uterus puts on the spine.

What are the causes of lumbocruralgia?

There are a variety of causes of cruralgia; First of all, it should be pointed out that these complaints do not only affect patients with a herniated or protruding disc; on the contrary, the cause is usually of a visceral nature or is caused by adherence of the connective tissue, osteoarthritis of the hip, etc. conditional. Patients who have had abdominal surgery in the past may complain of referred pain in the groin and lumbar region; in this case it is not the intervertebral disc that causes the symptoms, but the cause lies in muscles, tendons, ligaments.

What are the causes of femoral nerve compression?

Lumbocruralgia has the following causes:
Overexertion from bending over or lifting too heavy or from intensive physical work.
Incorrect posture , especially when seated, often with a hunched back.
A sedentary lifestyle and sedentary lifestyle: People who do not exercise, are physically inactive, and spend a lot of time sedentary suffer two consequences: stiffness of the spine and loss of tone and trophy of the core muscles, particularly the paravertebral and abdominal muscles.

Then, a simple movement like getting up from a chair is enough to damage the disc and cause compression of the femoral nerve. There are factors that favor the occurrence of this pathology:
Obesity : the heavier a patient is, the greater the pressure exerted on the spine and intervertebral discs.
Age : Protrusion, bulging, and herniated discs typically occur in patients between the ages of 35 and 55; From the age of 55, the gelatinous core of the intervertebral disc tends to dry up, which is why the gelatine fluid no longer escapes.

What are the symptoms of lumbocruralgia?

The symptoms include:

• Back pain and persistent pain on the right or left side up to the gluteus
• pain in the groin and in the inner thigh up to the knee ,
• paresthesia or hypoesthesia,
• stiffness and difficult movements,
• muscle tension ,
• loss of strength and hypotrophy of the quadriceps,
• Loss of Knee Tendon Reflexes.

The pain may be confined to the lumbar spine or the course of the femoral nerve, but in most cases the pain is rooted in the back and radiates to the groin and anteromedial aspect of the thigh.
Depending on where exactly the symptoms occur, it can be deduced whether the nerve root L3 or L4 is affected because they cover a limited region of the body.
A protrusion or a herniated disc at the vertebral level projects the pain in the lumbar region to a lower region (a herniated L3 disc can cause low back pain at the L5 level).
The pain is felt when moving , especially when stretching because the nerve becomes tense.
Sneezing, coughing and straining to have a bowel movement (Malsalva maneuver) also increase the symptoms.
In the acute phase , when the pain is very severe and unbearable, the patient can lie propped up in bed, with knees drawn up to relieve the pain a little and hips flexed so as not to strain the femoral nerve.
After a few days, the lumbocruralgia caused by inflammation slowly subsides and the symptoms subside; once it has completely subsided, the patient is much better. If the compression is caused by the gelatinous core, the pain may persist.

How is lumbocruralgia diagnosed?

The doctor should examine the patient, check his posture, find out whether he is in a relieving posture and how he is walking. The Wasserman test is helpful
in diagnosing lumbocruralgia ; while lying on the stomach with the hip stretched, the painful knee is lifted and bent; in this way the femoral nerve is stretched; if several symptoms appear, the test is positive. The differential diagnosis is made taking into account the fact that the symptoms could also be due to the following causes:

• infectious diseases such as discitis;
• vertebral fractures or spinal falls ;
• neoplasms such as osteoma, osteosarcoma, neurinoma, meningioma, endometriosis or bone metastases ;
• Musculoskeletal disorders such as hip osteoarthritis , piriformis syndrome , pubic arthritis and spondylolisthesis , which, however, are extremely rare between L2 and L3;
• shingles (herpes zoster);
• hernia ;
• Vascular diseases such as femoral artery aneurysm.

The specialist who can diagnose lumbocruralgia is the neurosurgeon or neurologist ; if there is no need for surgery, the patient should consult a physiatrist or orthopedist to initiate conservative management.
The doctor must check the medical history and symptoms, carry out clinical examinations and, if necessary, use diagnostic imaging methods for confirmation: magnetic resonance , CT , as well as laboratory tests to rule out other diseases.

What is the right therapy for lumbocruralgia?

Therapy should be tailored to the patient’s specific symptoms; if he only complains of pain, conservative therapy will probably bring him great benefit and heal him completely:

• The McKenzie method is a mechanical form of therapy in which the intervertebral disc is brought back into its natural position through certain exercises.
• Physiotherapeutic or osteopathic manual treatment.
• Postural rehabilitation exercises.
• Avoid painful movements and walking.
• Nonsteroidal anti-inflammatory drugs such as Dolormin and Voltaren can provide temporary relief.
  When a disc ruptures and internal disc material leaks out, inflammation occurs with a build-up of inflammatory fluid. The fluid can compress the nerve roots; in this case, the pain can be relieved with cortisone preparations because they reduce the inflammation.

If there are also strong neurological deficits, such as paresthesia, hypotrophy, surgical intervention is appropriate.
After surgery, a period of rehabilitation is necessary to relieve pain and regain strength and range of motion.
Time and rest can help resolve the problems of lumbocruralgia because the disc tends to dehydrate, which relieves pressure on the nerve roots; but this can take months or years, and the patient must decide whether he can wait that long or whether he wants to speed healing.

Natural remedies for cruralgia

Natural healing methods include acupuncture, postural gymnastics for back pain, yoga and Pilates.
If the curalgia is caused by a herniated disc, these methods are not appropriate.

How long are the healing times? forecast

The healing times of cruralgia depend on the cause and the type of treatment.
If there is nerve compression, it can take several months to heal.
If the pain is caused by muscles or connective tissue, the tension and adhesions between the connective tissue fibers should be treated appropriately.
There is a risk of the symptoms becoming chronic.

• Spondylarthrosis or spondylosis
• Sciatica or sciatica
• Cervicobrachialgia and herniated disc of the cervical spine