The sciatic or lumbar sciatica is pain along the territory of the nerve or L5 S1 reached at the spine (lumbar spine) or its immediate vicinity.

It must be differentiated from the sciatic nerve, sometimes called “sciatica” and simply born from the union of several nerve roots (including L5 and S1). The cut of the latter causes sciatica.

Etiology

• The herniated disc causes 90% of sciaticaone.
• Tumor (or malignant Benin)
• Infectious process (discitis, epidural)
• Fracture or fracture-vertebral
• Spinal stenosis
• Infectious meningo-radiculitis (Borreliosis, HSV)
• Tumor or pelvic abscess.

It is a common disease: it covers 5-10% of patients with back pain (back pain).

Age, stress, smoking and work involving the movement of the back increase the risk of sciatica.

Symptom

The pain is typically intermittent, one side (unilateral), lumbar spine radiating into the toes, sometimes increased when coughing or defecation relieved by rest lying down or standing.

They can be triggered by the sitting position (including car).

They are sometimes accompanied by a constellation of symptoms such as tingling (parenthesis) located in the leg or toes, a painful perception of certain stimuli (allodynia) or a loss of sensation of part of the leg. A loss (or lessening) of the ankle jerk is another indicator of the sciatic (Only in the case of sciatica S1).

Note that there may be a form hyperdouloure use possibly blocking the lumbar spine called lumbago.

It is reproduced by the maneuver Lasegue: passive flexion of the hip (caused by the examiner), straight leg. The “SLR cross” where the pain is reproduced by raising the other leg, is more specific but less sensitive.

The topography may be indicative of the affected nerve: lateral leg and dorsum of the foot to the big toe (hallux) to the L5 nerve root, posterior calf and sole of the foot to the S1 root.

Diagnoses

The description of pain is sufficient for 90% of cases.

The x-ray standard lumbar spine is necessary if we suspect a cause other than a herniated disc, sciatica or if recurrent or refractory to treatment. It does not, however, view the hernia (the inter-vertebral disc is radio-transparent).

Only the MRI and CT can visualize the spinal hernia. The sensitivity and specificity of these tests is far from absolute: one fifth to one third of patients have a herniated disc and have never suffered from sciatica4.

The sacco-radiculography by direct injection of a contrast material into the spinal canal is a technique abandoned since the 1990s.

Biological tests are useful in certain situations (Sedimentation velocity and Blood count).

The Electromyogram is unnecessary in typical forms (with the differential diagnosis)

Differential Diagnosis

The suffering of the piriformis muscle or pyramid, which originates on the sacrum within the pelvis and runs out to the hip to fix the upper femur, also called grand trochanter, may be responsible for pain suggestive of sciatica but the cause and treatment are different. Indeed, the fate of the piriformis muscle pelvis through the greater sciatic notch, which contrary to what its name suggests, is not very wide. The sciatic nerve also goes through the notch between the piriformis muscle and other muscles or for a small percentage of the population (less than 15%) directly inside the pyramid5. This muscle, which is external rotator of the thigh, is very busy during running and cycling, and prone to overwork. Furthermore, it may suffer from ischemia partial if one stays too long on a seat that compresses, which may be the case among cyclists. More rarely, a pyramid of suffering can occur without exercise sport among people who keep too long a position putting the muscle in a state of ischemia (head pressing hard in the wrong place) and keep their (s) leg (s) in a stretch position or bending continuous muscle.

The ensuing painful contraction can compress or irritate the sciatic nerve causing sciatica6. In principle, the SLR maneuver does not cause pain revealing nerve compression in the vertebrae. Are usually recommended rest, stretching specific muscle, possibly as part of physiotherapy. Anti-inflammatory drugs may be prescribed. In case of failure of these treatments, infiltration of the muscle can be proposed, based on anti-inflammatory and / or corticosteroids and / or botulinum toxin, or a combination of three. It is sometimes argued that the results are better when the muscle is infiltrated internal shutter, which play a role in this disease, and, even, would form a syndrome with the internal obturator muscle.

Evolution

It is favorable in most cases spontaneously. It can sometimes be prolonged or recur. In rare cases, it is complicated by a syndrome of the cauda equina with onset of paralysis and sphincter disorders, under an urgent surgery.

Treatment

It was traditional to prescribe bed rest on a hard surface during access of sciatica. This attitude has not proven its effectiveness8. Similarly, administration of analgesics (pain medication) or non-steroidal anti-inflammatory is not better than placebo.

The injection of corticosteroids in the lumbar spinal canal (epidural) appears to have a beneficial effect although it remains controversial.

Wearing a corset and physiotherapy sessions may be prescribed.

Massages and other practices (chiropractic, traction …) are of questionable effectiveness.

The use of traditional Chinese medicine such as acupuncture can alleviate pain.

Therefore, patient preferences appear to be an important factor in the clinical management of sciatica.

Surgical treatment

It is to remove the herniated disc. It should be proposed that in three cases: motor weakness or sphincter dysfunction, pain despite the morphine treatment regimen are, or disease duration than three months despite treatment.

Chemonucleolysis

It involves the injection into the inter-vertebral disc of a substance enzyme, the chymopapain, which will dissolve the core “nucleus pulposus” reducing the hernia. This technique is aimed at small disc herniations and whose walls are not broken. It is no longer permitted in France.

Author: Nouman Umar