INTRODUCTION:
Sciatica is a medical condition characterized by pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. The pain is often described as shooting. Typically, symptoms are only on one side of the body. Certain causes, however, may result in pain on both sides. Lower back pain is sometimes present. Weakness or numbness may occur in various parts of the affected leg and foot.
About 90% of sciatica is due to a spinal disc herniation pressing on one of the lumbar or sacral nerve roots. Spondylolisthesis, spinal stenosis, piriformis syndrome, pelvic tumors, and pregnancy are other possible causes of sciatica. The straight-leg-raising test is often helpful in diagnosis. The test is positive if, when the leg is raised while a person is lying on their back, pain shoots below the knee. In most cases medical imaging is not needed. However, imaging may be obtained if bowel or bladder function is affected, there is significant loss of feeling or weakness, symptoms are long standing, or there is a concern for tumor or infection. Conditions that may present similarly are diseases of the hip and early herpes zoster (prior to rash formation).Initial treatment typically involves pain management (Rest, Physiotherapy treatment etc). It is generally recommended that people continue with normal activity to the best of their abilities. Often all that is required for sciatica resolution is time; in about 90% of people symptoms resolve in less than six weeks. If the pain is severe and lasts for more than six weeks. surgery often speeds pain improvement, but, its long term benefits are unclear. Surgery may be required if complications occur, such as loss of normal bowel or bladder function. Many treatments, including steroids, gabapentin, pregabalin, acupuncture, heat or ice, and spinal manipulation, have limited or poor evidence for their use.
Depending on how it is defined, less than 1% to 40% of people have sciatica at some point in time. It is most common during people’s 40s and 50s, and men are more frequently affected than women. The condition has been known since ancient times. The first known use of the word sciatica dates from 1451.
Definition
The term “sciatica” usually describes a symptom—pain along the sciatic nerve pathway—rather than a specific condition, illness, or disease. Some use it to mean any pain starting in the lower back and going down the leg. Others use the term as a diagnosis (i.e. an indication of cause and effect) for nerve dysfunction caused by compression of one or more lumbar or sacral nerve roots from a spinal disc herniation. Pain typically occurs in the distribution of a dermatome and goes below the knee to the foot. It may be associated with neurological dysfunction, such as weakness and numbness. The pain is characteristically described as shooting or shock-like, quickly traveling along the course of the affected nerves.
Causes:
Risk factors
Modifiable risk factors for sciatica include smoking, obesity, lower socioeconomic status, and occupation.
Non-modifiable risk factors include increasing age, being male, and having a personal history of low back pain.
Spinal disc herniation
Spinal disc herniation pressing on one of the lumbar or sacral nerve roots is the most frequent cause of sciatica, being present in about 90% of cases. Disc herniation most often occurs during heavy lifting. Sciatica caused by pressure from a disc herniation and swelling of surrounding tissue can spontaneously subside if the tear in the disc heals and the pulposus extrusion and inflammation cease.
Spinal stenosis
Other compressive spinal causes include lumbar spinal stenosis, a condition in which the spinal canal, the space the spinal cord runs through, narrows and compresses the spinal cord, cauda equina, or sciatic nerve roots. This narrowing can be caused by bone spurs, spondylolisthesis, inflammation, or a herniated disc, which decreases available space for the spinal cord, thus pinching and irritating nerves from the spinal cord that become the sciatic nerve. Sciatic pain due to spinal stenosis is most commonly brought on by standing, walking, or sitting for extended periods of time. However, pain can arise with any position or activity in severe cases. The pain is most commonly relieved by rest.
Piriformis syndrome
Piriformis syndrome is a controversial condition that, depending on the analysis, varies from a “very rare” cause to contributing up to 8% of low back or buttock pain. In a small population of people, the sciatic nerve runs through the piriformis muscle rather than beneath it. When the piriformis shortens or spasms due to trauma or overuse, it is posited that this causes compression of the sciatic nerve. Piriformis syndrome has colloquially been referred to as “wallet sciatica” since a wallet carried in a rear hip pocket compresses the buttock muscles and sciatic nerve when the bearer sits down. Piriformis syndrome may be suspected as a cause of sciatica when the spinal nerve roots contributing to the sciatic nerve are normal and no herniation of a spinal disc is apparent.
Pregnancy
Sciatica may also occur during pregnancy, especially during later stages, as a result of the weight of the fetus pressing on the sciatic nerve during sitting or during leg spasms. While most cases do not directly harm the woman or the fetus, indirect harm may come from the numbing effect on the legs, which can cause loss of balance and falls. There is no standard treatment for pregnancy-induced sciatica.
Other
Sciatica can also be caused by tumors impinging on the spinal cord or the nerve roots. Severe back pain extending to the hips and feet, loss of bladder or bowel control, or muscle weakness may result from spinal tumors or cauda equina syndrome. Trauma to the spine, such as from a car accident or hard fall onto the heel or buttocks, may also lead to sciatica. A relationship has been proposed with a latent Propionibacterium acnes infection in the intervertebral discs, but the role it plays is not yet clear.
Pathophysiology
Sciatica is generally caused by the compression of lumbar nerves L4 or L5 or sacral nerve S1. Less commonly, sacral nerves S2 or S3 or compression of the sciatic nerve itself may cause sciatica. In 90% of sciatica cases, this can occur as a result of a spinal disc bulge or herniation. Intervertebral spinal discs consist of an outer anulus fibrosus and an inner nucleus pulposus. The anulus fibrosus forms a rigid ring around the nucleus pulposus early in human development, and the gelatinous contents of the nucleus pulposus are thus contained within the disc. Discs separate the spinal vertebrae, thereby increasing spinal stability and allowing nerve roots to properly exit through the spaces between the vertebrae from the spinal cord. As an individual ages, the anulus fibrosus inevitably weakens and it becomes less rigid; thus, it is subsequently more likely to tear. When there is a tear in the anulus fibrosus, the nucleus pulposus may extrude through the tear and press against spinal nerves within the spinal cord, cauda equina, or exiting nerve roots, causing inflammation, numbness, or excruciating pain. Inflammation of spinal tissue can then spread to adjacent facet joints and cause facet syndrome, which is characterized by lower back pain and referred pain in the posterior thigh.
Other causes of sciatica secondary to spinal nerve entrapment include the roughening, enlarging, or misalignment (spondylolisthesis) of vertebrae, or disc degeneration that reduces the diameter of the lateral foramen through which nerve roots exit the spine. When sciatica is caused by compression of a dorsal nerve root, it is considered a lumbar radiculopathy or radiculitis when accompanied by an inflammatory response. Sciatica-like pain prominently focused in the buttocks can also be caused by compression of peripheral sections of the sciatic nerve usually from soft tissue tension in the piriformis or related muscles.
Diagnosis:
Sciatica is most commonly diagnosed by:
History taking:
o Complaints of radiating pain in the leg, which follows a dermatomal pattern.
o Pain generally radiates below the knee, into the foot.
o Dermatome maps used to locate the distribution of the pain.
o Patients complain about low back pain, which is usually less severe than the leg pain.
o Patients may also report sensory symptoms).
The diagnostic value of patient history and physical examination has not been sufficiently studied. Overall, if a patient reports radiating pain in one leg and has a positive result on one or more neurological tests, indicating nerve root tension or neurological deficit, the diagnosis of sciatica seems justified.
The use of imaging to confirm the diagnosis of sciatica is not very useful. It may be indicated if there are red flags in the acute phase. Imaging may be indicated in patients with severe symptoms who fail to respond to conservative treatment for 6-8 weeks or to find the underlying cause of the sciatica.
Examination
- Neurological testing
o Myotomes
o Reflexes (L4-S3)
o Sensations (Dermatomes)
- Neural tension tests (preferably in a seated position)
o Straight leg raise test
o Crossed straight leg raise test,
o Slump test
o Femoral nerve tension test
- Lumbar mobility assesment
Sciatica is typically diagnosed by physical examination, and the history of the symptoms. Generally if a person reports the typical radiating pain in one leg as well as one or more neurological indications of nerve root tension or neurological deficit, sciatica can be diagnosed.
The most applied diagnostic test is the straight leg raise to produce Lasègue’s sign, which is considered positive if pain in the distribution of the sciatic nerve is reproduced with passive flexion of the straight leg between 30 and 70 degrees. While this test is positive in about 90% of people with sciatica, approximately 75% of people with a positive test do not have sciatica. Straight raising the leg unaffected by sciatica may produce sciatica in the leg on the affected side; this is known as the Fajersztajn sign. The presence of the Fajersztajn sign is a more specific finding for a her
niated disc than Lasègue’s sign. Maneuvers that increase intraspinal pressure, such as coughing, flexion of the neck, and bilateral compression of the jugular veins, may worsen sciatica.
Imaging modalities such as computerised tomography or magnetic resonance imaging can help with the diagnosis of lumbar disc herniation. The utility of MR neurography in the diagnosis of piriformis syndrome is controversial.
Discography could be considered to determine a specific disc’s role in an individual’s pain. Discography involves the insertion of a needle into a disc to determine the pressure of disc space. Radiocontrast is then injected into the disc space to assess for visual changes that may indicate an anatomic abnormality of the disc. The reproduction of an individual’s pain during discography is also diagnostic.
Management:
Sciatica can be managed with a number of different treatments with the goal of restoring a person’s normal functional status and quality of life. When the cause of sciatica is lumbar disc herniation (90% of cases), most cases resolve spontaneously over weeks to months. Initially treatment in the first 6–8 weeks should be conservative. More than 75% of sciatica cases are managed without surgery. Physical activity is often recommended for the conservative management of sciatica for persons that are physically able. However, the difference in outcomes between physical activity compared to bed rest have not been fully elucidated. In persons that smoke who also suffer from sciatica, smoking cessation should be strongly considered. Treatment of the underlying cause of nerve compression is needed in cases of epidural abscess, epidural tumors, and cauda equina syndrome.
Medication
There is no one medication regimen used to treat sciatica. Evidence supporting the use of opioids and muscle relaxants is poor. Low-quality evidence indicates that NSAIDs do not appear to improve immediate pain and all NSAIDs appear about equivalent in their ability to relieve sciatica. Nevertheless, NSAIDs are commonly recommended as a first-line treatment for sciatica. In those with sciatica due to piriformis syndrome, botulinum toxin injections may improve pain and function. While there is little evidence supporting the use of epidural or systemic steroids, systemic steroids may be offered to individuals with confirmed disc herniation if there is a contraindication to NSAID use. Low-quality evidence supports the use of gabapentin for acute pain relief in those with chronic sciatica. Anticonvulsants and biologics have not been shown to improve acute or chronic sciatica.Antidepressants have demonstrated some efficacy in treating chronic sciatica and may be offered to individuals who are not amenable to NSAIDs or who have failed NSAID therapy.
Surgery
If sciatica is caused by a herniated disc, the disc’s partial or complete removal, known as a discectomy, has tentative evidence of benefit in the short term. If the cause is spondylolisthesis or spinal stenosis, surgery appears to provide pain relief for up to two years.
Physical Therapy Management:
In most cases of sciatica, conservative treatment is favored. However, there is still some controversy surrounding it. The evidence does not show that one treatment is superior to the other (LOE 1A). Therefore we will discuss the several treatment options.
A very important part of the therapy can be informing the patient about sciatica and giving him advice(LOE 2A), (LOE 5). But the education of sciatica is not yet investigated in randomized controlled trials (LOE 1A),. During therapy it is very important to give patients necessary information, advice them about staying active and give them information about treatment modalities. It is very important that the patient is physically an active participant in therapy and can take responsibility in the treatment process. The physical therapist also needs to be a coach for the patient (LOE 1A).
Corticosteroid injections and traction are two treatment options that have limited evidence and are therefore not recommended for the treatment of sciatica (LOE 2A), (LOE 1A). If we compare bed rest as a treatment for sciatica with doing nothing at all, there seems to be no difference. On a short term there is no difference regarding overall improvement and pain and disability (LOE 1A), (LOE 1A), (LOE 5).
In a few articles acupuncture has been proven to reduce pain in the back. The practice is centered on the philosophy of achieving or maintaining well being through the open flow of energy via specific pathways in the body. Hair-thin needles are inserted into the skin near the area of pain(LOE 1A) (LOE 2C) (LOE 5). Other articles have found no reduction of pain with acupuncture.
Massage therapy has proven to be useful with the treatment of back pain. It promotes blood circulation, muscle relaxation and the release of endorphins(LOE 1B),(LOE 5),.
Herniated Disc Sciatica Management:
- Extension exercises or press ups are often prescribed; for example, Upper Back Extension(LOE 1A).
Spinal Stenosis Sciatica Management:
- Flexion exercises of the lower back are suggested. Flexing the lower spine opens the spinal canal and allows the irritation or impingement to resolve. Stretching exercises for the back are forward flexion. For strengthening the abdominal muscles Hook-lying March and Curl-Ups excercises are fequently used(LOE 2A).
There is no evidence found for this management. Physical therapists use these exercises since it has been shown to have efficacy for some patients.
Degenerative Disc Disease Sciatica Management:
- A dynamic lumbar stabilization program is recommended. Through this program the patient finds the most comfortable position for the lumbar spine and pelvis and attempts to maintain this position during activities. When performed correctly, this exercise can improve the proprioception of the lumbar spine and reduce the excess motion at the spinal segments. This reduces the amount of irritation at these segments, relieving pain and protecting the area from further damage. Examples of these exercises are; Hook-lying March, Hook-lying March Combination and Bridging(LOE 2A).
Spondylolisthesis Sciatica Management:
- Flexion based exercises and stabilization excercises are included in this program. The objective of this program is to improve the stability of the lumbar spine in flexed positions. A few examples of exercices are: Hooked-lying March; Curl-Ups and Pelvic Tilt(LOE 2A),(LOE 1A).
Piriformis Syndrome Sciatica Management:
- Stretching the piriformis muscle, hamstring muscles and hip extensor muscles may decrease and improve range of motion(LOE 2A).
There is no evidence found for this management. Physical therapists use these exercises since it has been shown to have some efficacy for some patients.
Sacroiliac Joint Dysfunction Sciatica Management:
- This management strategy consists of range of motion exercises for the SI joint; this can help restore normal movement and alleviate irritation of the sciatic nerve. The three most important exercises are: Single Knee to Chest Stretch; Press-Up and Lumbar Rotation(LOE 1A) (non-weight bearing).
Chiropractic treatment is based on the hypothesis that vertebral decompression can be prevented by a flexion-distraction procedure. During this procedure, there is greater intervertebral space and less compression on the vertebral elements: for example, the patient lies on his/her stomach with a little flexion in the spine and due to downward flexion a distraction occurs. It has been proven that this treatment decreases the interdiscal pressure(LOE 1A),(LOE 2C)
A study by Albert et al examined the efficacy of systematic active conservative treatment. Two treatments contained identical information and advice, but differed in the type of exercise program.
- Treatment 1 contained symptom-guided exercises. These consisted of back-related exercises(LOE 1B).
– The patient’s directional preference guided the directional end-range exercise, and
postural instructions (based on the McKenzie method of assessing pain-related-physical impairment).
– Stabilizing exercises, for the transverse abdominis and multifidus muscles
– Dynamic exercises for the outer layers of the abdominal wall and back extensors.
You can see the full treatment strategies and exercises in the link below: treatmentprogram sciatica (→ Link plaatsen)
There is no evidence found for these exercises but physical therapists use these exercises since it has been shown to have some efficacy for some patients.
- Treatment 2 contained Sham exercises. The exercises were not back related and were low-dose exercises to stimulate an increase in systemic blood circulation. Examples of exercises:
– Exercise 1: Squeeze buttocks
The patient lies supine and squeezes the buttocks. Contraction is held for 5 seconds. The exercises are repeated 10 times.
The patient only contracts the gluteal muscles.
– Exercise 2: Swing
The patient is standing with the legs sligthly apart. The shoulders are relaxed and the patient swings the arms loosely
alongside the body. This exercise is repeated 20 times.
You can see the full document of Sham exercises below: Sham exercises (→ Link plaatsen)
There is no evidence found for these exercises but physical therapists use these exercises since it has been shown to have some efficacy for some patients.
The patients had more faith in the Sham exercises but the outcomes of the symptom-guided exercise treatment were better. This cannot be used as an standard procedure because every patient is different and reacts differently to treatment(LOE 1B).
THOSE ABOVE ARE COLLECTED FROM SOME WEBSITES.
THANK YOU,
SRIKUMARAN PHYSIOTHERAPY CLINIC & FITNESS CENTER
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