Synonyms in the wider sense
Ischialgia, sciatica, back and leg pain, radiculomyelopathy, nerve root pain, back pains
Definition
Lumbar sciatica is not an illness diagnosis, but rather a description of a decisive and indicative symptom of back pain, which proceeds into the leg.
Abstract concept
Lumbar sciatica consists of the terms lumbago = back pain in the area of the lumbar vertebrae together with sciatica = pain in the legs that is transmitted via the sciatic nerve.
Complaint cause
Lumbar sciatica can originate from different causes. The most frequent cause of the complaint is a slipped disk (discusprolaps) in the lumbar vertebrae. The affected vertebral disk that protrudes in the direction of the spinal cord leads to a chemical and mechanical irritation of the efferent nerve roots. Hereby, a nerve root pain (radiculomyelopathy) is evoked, which proceeds along the affected corporal nerve (peripheral nerve) in the body. In that the lower spinal nerves of the lumbar spinal column, the sciatic nerves, unite to form the largest nerves of the human body, the pain is transmitted along the sciatic nerve over the buttocks, the back-side of the thigh and over the calf to the foot. Thereby, a relationship exists between the strength of the stimulation of the nerve root in the area of the lumbar vertebrae and the extent of the pain in the leg. Corresponding to the strength of the irritation (stimulus) of the nerve root, the pain will be transmitted along the sciatic nerve to the leg. Very strong irritations of the nerve roots lead accordingly to leg pain until the foot; less strong stimuli of the nerve roots lead to leg pains, which can terminate in the thigh or lower leg area. Normally, the back-leg pain that is caused by a slipped disk is experienced by the patient more strongly in his leg than in his back.
Less frequent causes for lumbar sciatica are restrictions of the neural outlet openings on the spinal column that are worn out (degenerative spinal column disease), spinal joint cysts or inflammations of the sciatic nerve itself.
Pseudoradicular pains must be differentiated from lumbar sciatica. By this, one understands simulated nerve root pains, which can be caused by different illnesses. Pseudoradicular back pains also extend to the leg; however they never reach the foot and they cannot be allocated to any nerve root. The following illnesses can cause a pseudoradicular back pain:
- Facet syndrome
- Diseases of the sacroiliac joint (ISG joint)
- Blockages of the lumbar spinal column
- Sprained muscular conditions
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- Vertebra
- Intravertebral disk
- Nerve root
- Anterior spinal nerve ramification (Ramus ventralis)
- Posterior spinal nerve ramification (Ramus dorsalis)
- Facet joint / vertebral joint
- Merging of spinal cord nerves into solar plexus nerve (e.g. sciatic nerve).
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Diagnosis
The complaint described by the patient and the physical examination determine, whether a lumbar sciatica is evident and if further diagnostic measures are required.
The symptom according to Laseque can be viewed as a characteristic investigative feature for lumbar sciatica (Lasegue Test). Hereto, the patient lies on his back. The pain-afflicted leg will then be brought into an extended position by the doctor and slowly raised with a bending of the hip joint. Hereby the patient should not assist in any manner, but remain as relaxed as possible. As a symptom of vertebral irritation, the patient will quickly determine a pain intensification of his lumbar sciatica. The background for this is the extension of the sciatic nerve caused by raising the leg, which in turn is transmitted to the irritated nerve root. Then the Lasegue Test is designated as positive. If the doctor wishes to extend the sciatic nerve even stronger, then he pulls on the toes of the patient’s elevated leg. The lumbar sciatica is further accentuated (Bragard Test: positive).
The symptom according to Lasegue is only positive with characteristic lumbar sciatic form of pain that is indicated by raising the leg until approximately 45°. If pain first occurs upon raising the leg even further, then the Lasegue Test is no longer regarded to be positive, because some of the other diseases that were mentioned above can lead to such a complaint indication: thus it is no longer certain that one is dealing with leg pain that is caused by a spinal cord nerve root. In this instance, the Lasegue Test is negative. Sometimes, such an investigative result can also be designated as a positive „Pseudo-Lasegue“ test.
Should the nerve root pain be demonstrated in a procedure that provides an image, then the magnetic resonance imaging (MRI) is most suitable hereto. By this means, the nerve roots of the spinal cord and eventually a slipped disk can be made visible.
Therapie
Quite different therapeutic approaches are suitable for a symptomatic therapy of lumbar sciatica. Under a symptomatic therapy, one understands a therapy that is orientated towards illness symptoms (symptomatic). A truly, causal therapy, such as the removal of a slipped disc is not performed initially.
Support / suspension
By means of a graduated suspension, the lower back (lumbar spinal column) will be relieved and the sciatic nerve will also be relieved by bending the knees.
Physical therapy
The goal of physical therapy for acute lumbar sciatica is the relief of the mechanically irritated nerve root. For example, the sling table treatment is suitable, by which the patient is brought to a weightless, floating position and the efferent nerve openings (neural foramen) are expanded. Thus, the impinged nerve root in the area of the efferent nerve openings receives a possibility to recuperate.
Electrotherapy
The application of therapeutic, effective types of current belongs to the scope of physical therapy and it is being written in the medicament ordinance for physical therapy. Different types of current function in an anti-inflammatory manner and they reduce pain.
Medicine
Classical medicines for anti-inflammation and pain reduction are Non-Steroid-Antirheumatica (NSAR) and Cortisone. Their application is possible in pill form or as medicament for injection. The primary goal is the reduction of pain via an anti-inflammatory treatment in the nerve root.
Pregabalin (Lyrika®) can also be implemented as an accompanying therapy of chronic lumbar sciatica. Lyrica® acts to sooth neuropatholgical pains (nervous pain) of multiple types.
Local Infiltrations
The most effective therapy of lumbar sciatica occurs through local, exactly targeted infiltrations to the affected nerve roots. This type of injection therapy is also known as periradicular therapy (PRT). In order to apply infiltrations precisely to the nerve root, a procedure is required that provides an image. Computerized tomography (CT) is especially suitable hereto as support, which provides an image. A mixture of a local anesthetic and cortisone is usually used as the content of the injection.
Infiltrations in the area of the spinal cord have also be implemented with great success, such as the epidural infiltration or the sacral infiltration (sacral blockage, sacral flooding). On the basis of possible side effects, such as a temporary weakness in the legs and a resultant hazard of falling, these infiltrations are preferably administered under stationary control.
Operation
If the lumbar sciatica cannot be adequately treated conservatively due to the severity of the causative illness, e.g. on the basis of a very significant herniated vertebral disc, then surgical therapeutic measures will be implemented, whereby the herniated vertebral disk will be removed (microsdiscectomy, endoscopic discectomy) and/or the efferent neural openings will be expanded (decompression, foraminotomy).
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