Sciatica or sciatica

The definition of sciatica (or sciatica as it is called) is as follows: “a series of symptoms which originate in the nerve root of a lumbar or sacral vertebra and spread throughout the course of the sciatic nerve  to the foot” because when a nerve is compressed is, the symptoms must appear in all parts of the body through which it passes.

True sciatica is very rare; unfortunately, I often meet patients who have been misdiagnosed with it simply because they feel pain between their back and knees.
In reality, pain that originates in the lumbar spine  or hip and extends into the back of the thigh without involving the calf and knee is not due to disc protrusion .

True sciatica is usually herniated  disc damage, ie, part of the disc moves backwards and presses on the nerve root; If the intervertebral disc presses on the osteophytes, which are calcium deposits on the bone caused by arthrosis , this is referred to as a hard herniated disc. The first 2-3 days after the occurrence is called acute sciatica , after which the symptoms should subside until they disappear completely, but in many patients the pain persists and chronic sciatica develops .

If the pain persists from day one, there is continuous pressure on the nerve .

If the vertebrae are flat , as is often reported by patients and doctors, this means a dehydrated disc, ie it has lost the fluid contained in the gelatinous core and expelled it. In some cases there is sacralization or hemisacralization of L5, ie a congenital malformation of the bone where the natural space between two vertebrae is missing and the transverse processes of the last lumbar vertebra are fused to the sacrum.

The nerve roots emerging from the intervertebral foramina fuse with each other, forming nerve trunks; the sciatic nerve is formed from the union of the nerve roots of the last three lumbar and first three sacral vertebrae.

The nerve conducts sensitive (sensibility) and contractile (for muscle contraction) stimuli; if it is compressed by a disc protrusion, its functionality is limited, the following symptoms appear:

Sciatica occurs practically only on one extremity, the appearance on both sides is extremely rare.
I would like to refer to a study published in PUBMED, according to which, of 36 healthy people, at least 80% have disc bulging and about 30% have protrusion , but do not experience any discomfort because the compression of the nerve is not significant; moreover, more than 75% of people have at least one ruptured disc.

The most commonly affected intervertebral discs are between L5-S1 and L4-L5, ie between the fifth lumbar and first sacral vertebrae and between the fourth and fifth lumbar vertebrae. A herniated disc above L4 is less common, in which case sciatica is not caused, but symptoms of lumbocruralgia are felt, i.e. pain in the groin and in the inner front of the thigh up to the knee, along the thigh nerve (Nervus cruralis or femoralis) . Pregnancy increases the load on the spine, which could put undue pressure on the disc Bending movements may then lead to a rupture of the intervertebral disc.


In this case, the pain occurs along the sciatic nerve and does not extend beyond the knee.


What is the cause of sciatica?

The cause of a herniated disc is a strong pressure exerted on the disc, which tears the fibrous ring (anulus fibrosus) at the back and pushes the nucleus (nucleus pulposus) to the nerve root. If you bend forward with your legs straight, increases the weight unloaded on the vertebrae by 600%, the vertebrae approach each other in front and distance themselves in their posterior area, pushing the intervertebral disc backwards.

One of the most common causes of a herniated disc is lifting a weight off the floor with your legs straight.
Poor sitting posture , with your back bent over and your legs crossed over time, can also trigger this neuralgia over time. One of my overweight patients used to do a lot of seated work for a while, from morning to night; then one day, when he got up, he felt a severe pain down to his foot.

Obesity combined with hypotrophy of the paravertebral muscles , which are the result of a sedentary lifestyle with a sedentary lifestyle, have favored disc herniation.
A less common cause of a herniated disc can be a

Represent trauma , such as a traffic accident, even if it would more likely result in a herniated cervical disc.
Exercising doesn’t usually cause sciatica, but excessive stress can put a lot of pressure on the disc, and if damaged, it could rupture.

What are the symptoms of sciatica?

The patient with sciatica caused by a herniated disc complains of unbearable pain along the entire nerve, loss of sensitivity and strength, and tingling in the foot.

Depending on the type of disc herniation, the patient may limp or always bend to one side.
The pain is continuous and constant, it can increase with certain movements or positions.
These patients also have difficulty riding a bicycle.
Many patents ask me: How can I have a herniated disc if I don’t suffer from back pain ?

  • I would like to specify that I often encounter patients with non-specific pain that originates in the gluteus maximus and radiates down to the posterior aspect of the thigh to the knee; in this case it is not sciatica, but syndrome of the pear muscle (musculus piriformis) and the external rotators of the hip.
    In these patients, the tests for the sciatic and femoral nerves are negative (Lasègue and Wassermann tests), ie in the supine position the straight leg can be raised without feeling pain in the back; but there are movements that cannot be performed, especially the ‘male’ crossing of the legs: the Faber test.
    Outside of this area, the pain may radiate to the groin , the inner front of the thigh , or radiate vertically down the leg, affecting the antagonists of the pear muscle (and the extrarotators of the knee), i.e. the internal rotators.
  • Another group of patients has non-specific pain in the gluteus maximus and in the posterior mid-thigh, ie, at the level of the hip flexors; over time they can also shift to the area of ​​the antagonist, that is the four-headed thigh muscle (musculus quadriceps femoris).
    These patients have trouble bringing their knees up to their chests, and in severe cases, they fall down while carrying out their usual daily activities because their leg gives out.
    In this case, a test of kicking back and forth is done, and the pain usually gets worse; but the test for compression of the sciatic nerve is negative.
    In the supine position, with the legs raised and bent, the patient cannot keep the hip flexed as the therapist pushes it away for extension.
  • A less common third group of patients has non-specific pain external to the gluteus and thigh , in the area of ​​the hip abductors; after a few weeks they can extend to the instep of the foot or the inner thigh in the area of ​​the hip adductors (musculus adductor longus, brevis, gracilis).
    This is not sciatica, but the pain is very severe and is felt at night and especially in the morning as soon as you get up.
    Patients cannot side kick with the affected leg or with the sound leg because the weight is shifted to the affected leg to maintain balance. These complaints are of muscular or fascial origin, Lasègue and femoral nerve tests are negative.

In these cases, therapy to reduce the herniated disc inevitably fails because neither herniated disc nor protrusion are the cause of the symptoms.
The patient suffers from sciatica when the pain follows the course of the sciatic nerve, even if the back does not hurt on palpation or during movement.
I’ve noticed that this non-specific pain is common in patients who have had surgery ; also physiotherapists who have developed manual therapies take into account the operations performed in the past.
In very rare cases, patients complain of bilateral symptoms , heaviness and weakness in both lower extremities.

The probability of suffering from left-sided sciatica is just as great as suffering from disease on the right side.
Some patients report that after many examinations and tests performed, physicians suspected that the cause of the pain was psychosomatic and referred the patient to a neurologist or prescribed antidepressants, often without much benefit.

Sciatica, also known as “ sciatica ”, produces symptoms in a specific region of the back and lower extremities.
What distinguishes it from the three previously described pain syndromes is that disc herniation involves symptoms that radiate along the nerve course like a ribbon , while piriformis syndrome and the other muscle disorders cause diffuse pain.
Inflammation of the sciatic nerve causes pain in the back, leg, gluteus, back of the knee , calf, ankle and foot .
With disc protrusion at the L5-S1 level, the pain traverses the glutes, posterior medial thigh and leg, external ankle and foot to the fifth toe.

If the affected nerve root is at L4-L5, the pain is felt in the lateral region of the gluteus, thigh and leg, up to mid-calf; then they radiate forward to the instep to the middle of the foot, both the dorsum and the sole of the foot.
The nerves of the lumbar-sacral plexus (plexus lumbosacralis) also pass through the pelvic area: testicles, ovaries, bladder, etc.
The patient with a herniated disc may also suffer from urinary or fecal incontinence, but this is relatively rare. Nerve pain is terrible , worst pain ever, along with bone and periosteal pain; the patient feels a burning sensation.

In the case of sciatica, patients in the acute phase are blocked in bed and have difficulty getting up. The worst movements are turning in bed, putting on stumps and shoes, changing position (sitting, standing, lying), and staying in one position for an extended period of time.
The usual daily activities are very painful and almost impossible.
Twisting or bending sideways is usually more painful to one side than the other. Sciatica does not cause a fever even when the pain is severe .

How is sciatica diagnosed?

It is not sufficient to evaluate lumbar spine magnetic resonance  to diagnose sciatica; when a protrusion or herniated disk compresses the dural sac, compression of the nerve can trigger the symptoms of sciatica. There are important tests, such as Lasègue ‘s , which consists of lying on one’s back and raising one’s straight leg, or walking on one’s heels. When visiting the doctor, the patient must describe the nature and location of the symptoms precisely; The medical history is particularly important to rule out non-orthopaedic causes, such as those of an oncological, systemic, rheumatological, etc. nature.
The patient must tell the doctor if he performed improper movements or traumahas suffered.
If the cause of the pain is not attributed to a herniated disc but is of a non-specific nature or the patient simply does not have a herniated disc, motor tests are performed because some movements cause pain or excessive weakness is evident.
In this case, one no longer speaks of sciatica, but of an alteration of the connective tissue , ie the production of new collagen, typical of the repair processes. As a result, collagen bridges
form between the muscle fibers , pinching or constricting a nerve ; this leads to a loss of strength and pain, which in some cases is felt even when standing still.

What to do? Which is the right therapy?

If the patient complains of non-specific pain that cannot be traced back to sciatica, the therapies for a herniated disc are doomed to fail because they are trying to heal an injury that does not exist or causes no pain.
There is no guide or standard protocol for curing these ailments, therapy must be tailored to each patient type. Ozone therapy and surgical intervention may only be used in patients who show the distinctive symptoms of the herniated disc. Unfortunately, there are a large number of patients who continue to experience low back pain after surgery; therefore, a good neurosurgeon will thoroughly examine and analyze the patient, and not just look at the resonance images.

The rehabilitation after the operation is quite lengthy, it takes about 2 months of therapy to get back to normal. Another mistake I often see is when the sciatica sufferer does an abdominal strengthening program at the gym or at home; the remedy here lies precisely in avoiding such exercises until the pain goes away.
We are often asked by patients whether heat or cold treatment of the painful areas makes sense; in acute sciatica, both heat and cold therapies are better avoided; in the days that follow, heat relieves the contracturesand can bring relief to the patient.
Physiotherapy can  achieve excellent results in disc protrusion or bulging, ie when the fibers of the outer fibrous ring are not completely torn.

If the disc is ejected and migrated, that is, if part of its gelatinous core has emerged from its anatomical seat and displaced beyond the annulus fibrous, the patient may be treated with laser, ozone therapy, or surgery if the pain is severe . Today, only one in 400 patients with a herniated disc is operated on; in all other cases, physiotherapy or other forms of therapy are sufficient.

If the sciatic syndrome is caused by a disc protrusion, the McKenzie method is best suited ; The intervertebral disc is pressed back into its anatomical position by maintaining certain positions, performing calisthenic exercises or by pressure from the patient and therapist.

After healing, the best therapy to prevent recurrence is postural exercises and stretching, but walking should be suspended until the inflammation of the sciatic nerve subsides.
Instrumental therapies such as Tecar ® and laser can lessen the intensity of symptoms, but improvement is temporary and the problem is difficult to solve.

If the pain is not triggered by the compression of the sciatic nerve, I prefer manual therapies such as osteopathic therapy or myofascial manipulation by L. Stecco to eliminate the cause .
This method is designed to dissolve the collagen bridges that are pinching the nerve and causing pain. It consists of a 5 to 10 minute massage or manipulation technique on certain points of the body to remove excess collagen bridges. Any therapy must be accompanied by posture correction, and a new mattress can help with pain that occurs at night or in the early morningor a new jump frame might be helpful; a controlled sitting position on a chair, armchair or sofa is also important. The intervertebral disc does not heal, but the patient no longer feels pain.

Instrumental therapies can help to heal inflammation and possible tension , but they cannot put the disc back in place, mechanical therapy is needed for this.
Usually the doctor does not prescribe nonsteroidal anti-inflammatory drugs (such as Dolormin or Voltaren) because their effect is too weak, but rather cortisone preparations .

Drugs containing cortisone (Bentelan, Orudis, Feldene, etc.) act by eliminating the inflammation or internal swelling caused by the herniated disc; in some cases, the compression of the nerve is relieved but not the cause of the discomfort.
The doctor also often recommends muscle relaxants (muscle relaxants) such as Muscoril to combat muscle tension.
The problematic thing about these drugs are the numerous contraindications and side effects.
Anti-inflammatory patches are slow-release drugs that stay on the skin for several hours, but this treatment is too gentle and not effective enough;Cortisone shots show better results.

Natural healing methods

Of the natural and alternative treatments, Shiatsu can relieve muscle tension because its action aims at energetic rebalancing, but it does not solve the root cause of the symptoms. Some patients consult a  homeopath or buy medicinal plant products , but there is no scientifically proven benefit.
Doctors often prescribe vitamin supplements (especially vitamin B12) to speed up healing.

In the acute phase, prolonged walking should be avoided because the pressure on the intervertebral disc increases; moderate walks can be taken after a few days. Swimming is an excellent sport; when done correctly, the spine is contracted and the muscles strengthened; Swimming can help relieve symptoms but is not definitive therapy.
After healing, a fitness program with special exercises, yoga or Pilates should be practiced in the gym, but always taking into account the pain threshold.

 How long does the healing take? How long does the pain last?

There is no exact time information on the length of the disease , each person responds differently to the therapies; some patients heal in a few days because the pain is only caused by inflammation caused by the ruptured disc. If protrusion or osteophytes are the cause of the pain, healing can take several months.

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