Sciatica is defined as the pain present along the path of the sciatic nerve due to the affectation in any part of the path of the nerve trunk or of the roots that form it. It is perceived as pain in the lower back, buttocks or various parts of the leg and foot. Sciatica is only a symptom, being primordial for the treatment the diagnosis of the cause that originates the affectation of the roots or the nerve.
Sciatica: causes
Sciatica is usually caused by compression of lumbar roots 4 and 5 or sacral roots 1, 2 or 3. The most common cause is compression, which is often accompanied by a significant inflammatory component, originating in a herniated intervertebral disc. Other causes are vertebral alignment defects (spondylolisthesis), canal stenosis caused by osteoarthritis, other degenerative conditions or more peripheral compression of the nerve by muscular structures (pyramidal muscle) or tumors and fibrosis or adhesions occurring after disc herniation surgery.
A pain that is often mistaken for sciatica but is not caused by involvement of this nerve is due to muscular trigger points located in the quadratus lumborum and gluteus medius and gluteus medius minimus.
Sciatica: diagnosis
The diagnosis is based on an adequate review of the clinical history (anamnesis) and physical examination, accompanied when necessary by imaging tests such as simple radiology or magnetic resonance imaging; as well as neurophysiological studies, electromyography, or sometimes scintigraphy. The objective is to assess the origin and extent of the lesion causing the sciatic pain.
Sciatica: types of treatment
The most common initial treatment is anti-inflammatory analgesic drugs. Rest is no better than activity in patients who can remain active. The frequency of associated neuropathic pain is high, with more than 50% estimated to be of mixed origin, so specific drugs are used for this type of pain, such as pregabalin, amitriptyline, gabapentin or muscle relaxants. The role of opioids in the long term is controversial, although new drugs such as tapentadol may improve outcomes by treating both somatic and neuropathic pain. Some pain unit specialists routinely use a combination of blocks in association with oral analgesic therapy that is withdrawn as soon as possible.
In the case of surgery, it accelerates the resolution of pain, but the evidence is not so clear on the long-term benefit and painful post-surgical sequelae are frequent.
Sciatica: studies on treatments
Different international organizations have studied and concluded the outcome of different treatments. The recommendations of the North American Spine Society indicate that lumbar disc herniation surgery, discectomy, provides symptomatic relief more effectively and more quickly than other treatments, although less severe symptoms can be treated conservatively. In addition, patients with psychological problems have been found to have poor results with surgery.
British Pain Society recommendations state that any sign of cauda equina compression requires referral for urgent surgery. Prolonged motor deficits or persistent pain when all non-surgical measures have been exhausted are also indications for surgery.
A study on painful complications after spinal surgery shows that the so-called Failed Back Surgery Syndrome can affect around 20% of patients who have undergone spinal surgery, with persistent pain after surgery. The causes are multiple, ranging from neuropathic pain to epidural fibrosis involving the nerve roots. Treatment consists of epidural corticosteroid infiltrations, pulsed radiofrequency or release of adhesions by epidurolisis. It should be noted that ozone therapy to free the affected roots and reduce epidural fibrosis has been concluded with good results.
A recent review compares the results of surgery versus conservative treatment with infiltration and medication for canal stenosis. It concludes that there is no evidence of better results of surgery over conservative therapy, including epidural corticosteroid infiltrations, while conservative therapy shows hardly any undesirable effects compared to surgery, which has between 10 and 24% of adverse effects and undesirable results.
Epidural blocks are widely used, with efficacy rates equal or superior to surgery. Applying the most recent studies regarding the safety of the technique and the correct choice of drugs used, they are shown to be the first choice alternative with very few adverse effects, especially severe or very severe ones. Specialists use it on a regular basis, often accompanied by ozone infiltrations to increase efficacy and prolong the duration of the effect. On certain occasions, other approaches can be used for blockade in patients with difficult access or high risk, such as the paravertebral approaches, in principle, with the same efficacy rates, or the transforaminal approach in post-laminectomy syndromes.
Other possible techniques are the elimination of compression by percutaneous techniques (nucleolysis by coablation or discectomy with ozone), without surgical intervention, but they are only useful in certain hernias, depending on their position or evolutionary state.
Piriformis syndrome, spasms in the piriformis muscle located in the buttocks area, is treated with stretching and physiotherapy to increase mobility. Injections are sometimes administered into the muscle with fluoroscopic, electromyographic or ultrasound monitoring. Recently, collagen or botulinum toxin infiltrations have been shown to be more effective.
Finally, it should be pointed out that physiotherapy and rehabilitation treatment is not usually resorted to until the epidural or ozone treatment cycle has been completed. Once this has been determined, we assess the use of rehabilitation, osteopathy and postural treatments through a spine school.
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