Sciatica (or sciatica) is “a set of symptoms that originate from the nerve root of a lumbar or sacral vertebra and occur throughout the course of the sciatic nerve to the foot.” 
If the nerve is compressed it should trigger symptoms in all regions of the body it crosses.

Real sciatica pain is rare, unfortunately I often see patients who are misdiagnosed just because they feel localized pain between the back and the knee .

In fact, pain originating from the lumbar spine or the hip and extending  along the back of the thigh without affecting the calf and foot is not caused by a protrusion of the intervertebral disc .
True sciatica is usually an inflammation of the sciatic nerve caused by hernia, ie a part of the intervertebral disc moves posteriorly and presses on the spinal cord or a nerve root .
If the disc presses on an osteophyte  (that is to say the osseous calcification due to the arthrosis) it is a hard hernia. We talk about low back painacute in the first 2/3 days after onset, after this time the symptoms should subside until they disappear, but in a good percentage of patients the pain remains and the disorder becomes a chronic low back pain.
The pain should be persistent from the first day because the pressure on the nerve is continuous.

Lateral view of the lumbar vertebral column with hernia or Schmorl nodule, ie the disc ruptured the cartilage and the subchondral bone, penetrating the vertebra.

If the vertebrae are crushed, as patients and doctors often report , it means that the disc is dehydrated, meaning that it has lost the liquid contained in the nucleus pulposus.
In some cases there is a sacralization or hemisacralization of L5 which is a congenital malformation of the bone in which the physiological space between the two vertebrae has disappeared and the transverse processes of the last lumbar vertebra are joined to the sacrum.
The nerve roots that leave the vertebral foramen merge and form one of the nerve trunks.
The sciatic nerve is formed by the union of the nerve roots of the last three lumbar vertebrae and the first three sacral.
The nerve conducts sensory signals (sensibility) and those  contractile (for muscle contraction), if it is compressed by the disc protrusion, its functioning is compromised, so it feels:

Lumbar cystitis usually occurs on a single limb, rarely  bilateral.

From a study published in pubmed in 36 healthy individuals, 80% have at least one bulging of the  intervebral disc and about 30% have  a protrusion, but they do not present symptoms because the nerve compression is not significant, in addition about more of these 75% have at least one broken intervertebral disc.
The most affected intervertebral discs are between L5-S1 and L4-L5 ie between the fifth lumbar vertebra and the first sacral or between the fourth and fifth lumbar vertebrae.
It is rare to find a hernia at levels above L4, in this case instead of causing sciatica, if you feel the symptoms of a cruralgia , that is a pain in the inguinal regionand in the anterior part of the thigh to the knee, along the course of the crural nerve.
The pregnancy increases the load on the spine and may cause excessive pressure on the intervertebral disk, with movements in flexção can fracture the intervertebral disc.

Pseudo sciatica or false sciatica 

This type of disorder consists of pain along the sciatic nerve that does not pass beyond the knee.

What is the cause of sciatica?

Modified Lasegue Test

The cause of herniated disc is a strong pressure on the intervertebral discs that breaks the fibrous ring at the back and pushes the nucleus pulposus to the nerve root.
When it flexes forward without bending the knees, the weight that is carried in the vertebrae increases by up to 600%, the vertebrae are approaching anteriorly and gain distance posteriorly by pushing back the intervertebral disc.
One of the most common causes of herniated disc is lifting a weight off the floor with your legs stretched out.
Even poor posture when sitting with your back leaning forward and with your legs crossed for too long can cause neuralgia.
One of my overweight patients spent a period of time in which he always worked sitting from morning to night, one day when he got up, felt a severe pain in his foot.
Obesity along with paravertebral muscle atrophy (for a sedentary lifestyle) favors the formation of a hernia.
A minor cause of disc herniation can be a trauma, such as a car accident, even though it is much more likely to cause a cervical hernia.
Sport in general does not cause sciatic pain, but excessive force can cause excessive pressure on the disc and if it is already weakened it may break.

 

What are the symptoms of sciatica?

Forward bending exercise of the spine

Patients with sciatic pain caused by disc herniation should experience unbearable and persistent pain along the nerve, loss of sensation and strength beyond tingling in the foot.
Depending on the type of disc herniation, the patient may walk limping and could remain permanently tilted  to one side.
The pain should be continuous and constant, it may worsen with certain movements or in certain positions.
These patients have difficulty even biking.
Many patients ask me: How can I have a herniated disc if I do not have spinal pain ?

  • I answer that patients are often found with nonspecific pain that part of the buttocks  and radiates vertically in the posterolateral region of the thigh to the knee, in this case it is not sciatic pain but of piriformis muscle syndrome and external rotators of the hip.
    In these individuals, the sciatic and femoral nerve tests are negative (Lasegue and Wassermann test), ie lying in the supine position, it is possible to lift the extended leg without pain in the spine, but there are some movements that are impossible to do, especially the crossing of the legs ” like a man “.
    Além desta área, a dor pode ser sentida na virilha, na frente e atrás da coxa ou verticalmente até a perna, afetando os músculos antagonistas do piriforme (e a rotação lateral do joelho ), ou seja, os rotadores internos.
  • There is another type of patient who frequently comes to the clinic with nonspecific pain in the gluteus and the posterior region of the thigh, that is, at the level of the hip flexors, which over time can also move over the region of the antagonistic muscles, or be the quadriceps.
    They are patients who struggle to lift the knee toward the chest and in severe cases fall during the normal activities of daily living because they can not support the weight on the leg.
    The test done in such cases is to kick forward and backward, this movement usually increases pain, but the test for sciatic nerve compression is negative.
    In the lying position with the legs raised and the knees flexed, the patient can not keep the hips bent if the therapist pushes to extend it.
  • The third, rarer type of patient has nonspecific pain outside the buttock and thigh in the abductor area; after a few weeks it may extend to the instep or thigh, in the region of the adductor muscles of the hip ( gracile, long adductor, short adductor).
    It is not sciatica pain, but if the pain is too strong, it can be felt at night and especially when waking up in the morning. These individuals fail to give a lateral kick with the leg and even a slow side kick with the healthy limb because they have to carry the weight on the diseased limb to maintain balance. This disorder is muscular or fascial, the Lasegue and Wassermann tests (of the femoral nerve) are negative.

Patellar reflex test to assess whether lumbar pain affected reflexes.

In these cases therapy to reduce disc herniation fails because it is not the hernia (or protrusion) of the intervertebral disc that causes the symptoms.
The patient suffers from sciatic pain if the pain is along the sciatic nerve, although the spine is not painful neither palpation nor during movements.
I have noticed that these often non-specific pains affect individuals who have undergone surgery, even the physiotherapists who invented manual therapies take into account past surgery.
In very rare cases, patients report bilateral symptoms, but a feeling of weight and weakness in both legs. The chances of suffering from sciatic pain on the left side are the same as a sciatic pain on the right side.
Some patients report that after many examinations, visits and tests, the doctor suspects that the cause of the pain is psychosomatic and either refer the patient to the neurologist or prescribe antidepressants, often without benefit.

Testing Achilles tendon reflexes

Sciatica, also known as “sciatica” should cause symptoms in a particular region of the spine and lower limbs.
The difference between this and the pain syndromes described above is that the herniated disc causes symptoms that radiate along the nerve, such as a rope, while the piriformis syndrome and other muscle problems cause widespread pain.
In case of inflammation of the sciatic nerve, the patient feels pain in the spine , pain in the leg , gluteus , behind the knee , in the calf , ankle and foot .

If the disc protrusion is at the L5-S1 level, the pain is felt in the buttock, the posterior-central area of ​​the thigh and leg, the external area of ​​the ankle, and the foot to the fifth finger.
If the affected root is L4-L5, the symptoms are felt in the lateral region of the gluteus, thigh and leg up to the middle of the calf and then radiates anteriorly over the instep to the middle of the foot both dorsal and plantar.
The nerves of the lumbosacral plexus cross the pelvic region: testicles, ovaries, bladder, etc.
Patients with herniated disc may suffer from fecal or urinary incontinence , but it is a very rare event.

The pain of the nerve is horrible, the worst along with that bone and the periosteum, the patient has a discomfort similar to a burning sensation .
In the case of sciatic pain, in the acute phase patients remain in bed and have difficulty getting up.
The worst times are to turn around in bed, lean over to wear socks and shoes, change positions (sitting, standing or lying down) and hold the same position for a long time.
The activities of daily living are painful and almost impossible.
Rotations or tilting on one side are usually more painful than the other.
Sciatica does not cause a fever , even if the pain is very strong.

 

How to diagnose sciatica?

It is not enough to look at the magnetic resonance of the lumbar spine to diagnose sciatica, but if there is a protrusion or disc herniation on the dural sac (pressing on the dura), it is possible that a nerve compression causes the symptoms of a sciatica.

There are important tests like Lasegue that consist of lifting the extended leg with the patient in the supine position, or walking on the heels.
In the consultation, the patient should inform what symptoms they feel and in which part of the body, it is crucial to exclude non-orthopedic pathologies, that is, oncological, systemic, rheumatologic, etc.
The patient should inform the physician if he has made incorrect movements or if he has suffered a trauma.
If the cause of the pain is not a herniated disc, but is non-specific, or if the patient does not have a hernia, specific motion tests are performed because some movements cause pain or show excessive weakness.
In this case we no longer speak of sciatica, but of a change in connective tissue, that is, the production of new collagen typical of the repair processes.
As a result, among muscle fibers, collagen bridges are formed that can cause radiated pain, lead to loss of strength and pain that sometimes feels even when standing still .

 

What to do? What is the treatment for sciatica?

If the patient has nonspecific pain not due to sciatic pain, treatments for herniated disc fail because he tries to treat a non-existent or non-painful injury.

There are guidelines or a standard protocol for treating this health problem, but depending on the type of patient will decide the most appropriate therapy.
Surgery and ozone therapy should be performed only in patients with unequivocal symptoms of disc herniation.
Unfortunately, there are many cases of operated individuals who continue to experience low back pain, so a good neurosurgeon looks at the patient well and does not just look at the resonance.

After the surgery, the rehabilitation is quite long, to return to normal it takes about 2 months of treatment.
Another mistake I see often is the sciatic pain patient who performs an abdominal muscle strengthening program in the gym or at home, these exercises should be avoided until the pain disappears.
Patients often ask me if it is better to apply cold or heat to the painful area, in case of acute sciatica it is better to avoid thermotherapy or cryotherapy, in the following days the heat relieves contractures and can provide relief to the patient.

Physiotherapy works with excellent results in cases of protrusion or bulging of the disc, that is, if the fibers of the fibrous annulus are not completely broken.
If the hernia is expelled, ie a part of the nucleus pulposus leaves its anatomical site and moves beyond the fibrous ring, the patient feels a lot of pain, we can act with laser treatment with ozone injections  or surgery.

Today, only about 400 patients with herniated disc are operated, in all other cases, physical therapy or other treatments are sufficient.
If sciatica is caused by a protrusion, the most appropriate treatment is Mckenzie , which consists of relaxation and over-pressure exercises of the patient and the therapist.
This treatment is used to push the intervertebral disc into its anatomical location.

After being cured, to prevent relapses, the best therapy is postural gymnastics and stretching, it is necessary to avoid travel until the sciatic nerve is inflamed.

Instrumental treatment such as  TECR ® and laser treatment may reduce the intensity of the symptoms, but the improvement may be transient and does not solve the problem.
If pain is caused by sciatic nerve compression, to eliminate the cause of this symptom, I prefer osteopathic manual therapy or myofascial manipulation of L. stecco.
This method serves to dissolve the collagen that trap the nerve and causes pain, is a technique of manipulation and massage in certain points of the body for 5-10 minutes to remove excess collagen points.
Any therapy should be accompanied by improved posture, if the pain is at night or in the early hours of the morning, it may be helpful to change the mattress or bed base, it is also important to control the posture on the chair and the sofa.
The intervertebral disc does not return intact, but the patient may stop feeling pain.

The  instrumental treatment can help relieve inflammation and contractures, but can not put the disc back in its place, then a mechanical therapy is needed

Usually the doctor prescribes anti-inflammatories (such as Alivium or Voltaren) because they are very light and advises cortisone .
The drugs based on cortisone (Betnelan ®, Depo – Medrol, etc.) will act to resolve the inner inflammation or swelling caused by rupture of the intervertebral disc in some cases eliminates the compression of the nerve, but does not remove the source of disturbance.

The doctor also usually recommends muscle relaxants (eg, Muscoril) for muscle contractions.
The problem with these medications is the numerous contraindications and side effects .
Anti-inflammatory drug patches are slow-release medicines to keep on the skin for many hours, but it is an ineffective type of treatment, while cortisone infiltrations give better results.

L4-L5 lumbar infiltrates, guided by fluoroscopy

 

Natural Remedies for Sciatica

Among natural or alternative treatments, shiatsu can attenuate contractures because it has an energy-balancing effect, but it does not resolve the cause of the disorder and does not eliminate the symptoms.
Some people are turning to homeopathy or buying products in herbal medicine, but the effects are not scientifically proven.
Often your doctor prescribes vitamin supplements for a faster cure, especially B12.
In the acute phase it is not recommended to walk for a long time because it increases the pressure on the disc, after the first few days it is allowed to do some walking, but in moderation.
Swimming is a great sport, when performed properly tends to pull the spine and strengthen muscles, may help relieve symptoms, but it is not a definitive therapy.
After recovery, we recommend a fitness course with specific exercises in the gym, yoga or pilates, but always respecting the limit of pain.

 

What is the healing time? How long does the pain last?

There is no recovery time of the disease with precise dates, each person responds differently to therapy, some patients heal within a few days because the cause is only the inflammation caused by intervertebral disc fracture.
If the protrusion or osteophytes cause pain, the prognosis may be a few months.

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