The main back disorders
disc herniation and sciatica
True sciatica is very rare, unfortunately I often see patients who are diagnosed erroneously because they feel pain located between the back and knees.
In fact, the pain starts from the lumbar spine or from the hip and runs down the leg side or rear, without affecting the calf and the foot is not caused by a protrusion of the intervertebral disc.
The sciatic is a set of symptoms that arise from the nerve root of one or more lumbar vertebrae and occur throughout the course of the sciatic nerve to the foot.
The pain must be experienced without interruption from day one because if the nerve is compressed does not work well in any of the body regions it crosses.
True sciatica is usually caused dall'ernia disc disease, which is a part of the intervertebral disc moves back and goes to press on the nerve root.
If the disc presses on osteophytes, or bone calcification due to arthrosis of hernia talking tough.
Lateral view / posterioredella lumbar spine with herniated disk (red) that presses on nerve roots L3-L4 (Yellow).
If the vertebrae are crushed, how often refer patients and doctors, it means that the disc is dried, the liquid that is lost in the nucleus pulposus or expelled.
In some cases you may have a emisacralizzazione or sacralization of L5, which is a congenital bone malformation in which the space between two vertebrae physiological disappeared last lumbar vertebrae and transverse processes are joined to the sacrum.
The sciatic nerve is formed by nerve roots that emerge from the holes of the last three lumbar vertebrae and the first three sacral.
the nerve carries sensory stimuli (sensitivity) and the contractile (for muscle contraction), if it is compressed by the disc protrusion its operation is compromised, then: a loss of strength and sensitivity, as well as pain and tingling to foot.
The lumbar sciatica is almost always on one leg, are the most unique and rare cases where it is bilateral.
point out that a study published on PubMed in 36 healthy subjects, 80% had at least a bulging disc and about 30% of a protrusion, but do not experience symptoms for nerve compression is not significant, also more than 75% of these has at least one intervertebral disc broke.
What is the cause?
posture with her back arched forward, his legs crossed the pelvis rotated.
The cause of the herniation of the intervertebral disc is a strong pressure on the intervertebral disc annulus fibrosus that fissure the rear and pushes the nucleus pulposus to the nerve root.
When you bend forward without bending your knees, the weight is loaded on the vertebrae increases up to 600%, the vertebrae before they approach and move away after pushing back the intervertebral disc.
One of the most common causes of disk herniation is lifting a weight from the floor with legs relaxed.
too bad posture while sitting with her back arched forward and his legs crossed may lead to long this problem.
One of my overweight patients spent a period in which he was working a lot more sitting around 12/16 hours a day, getting experienced a sharp pain to the foot; obesity united all'iportofia paravertebral muscle arising from the sedentary life has caused the herniated disc.
A cause minor herniated disc can be a trauma like a car crash, although it is much more likely to cause a herniated cervical.
What are the symptoms?
The patient with low back sciatica dall'ernia caused the disc must feel pain along the nerve, loss of sensitivity and strength as well as tingling in the foot.
The pain must be continuous and constant, it can get worse with certain movements or assuming certain positions.
Many patients ask me: How do I get the herniated disc if I do not have back pain?
specify that you often come across patients with nonspecific pain that starts from the buttock and radiates vertically in the posterior-lateral thigh to the knee, in this case is not about low back sciatica, but piriformis syndrome and external rotation of the knee. In these subjects the test of femoral and sciatic nerve were negative, that is, lying in a supine position is able to raise the extended leg without back pain, but there are some movements that fail to do, first of all the overlapping "men" of the legs while sitting or test Faber. From this condition, the pain may travel in the front and inner thigh or vertically to the leg, affecting antagonists piriformis and external rotation of the knee, ie the external rotators.
Another type of patient who had surgery often occurs in non-specific pain in the buttock region and in the center rear of the thigh, ie at the level of the hip flexors that with the passage of time can also move about the region of the antagonists, namely the quadriceps. Patients who are struggling to lift the knee toward your chest and in severe cases occurring during the normal activities of daily life for the failure of the leg. The test is done in these cases is to give a kick in the back and a kick back from that position, usually exacerbates the pain, but the test for the compression of the sciatic nerve is negative. From a lying supine with legs raised and knees bent, the patient will be unable to resist pressure to relax the lower limb.
The third type of patient is rare, has non-specific pain outside of the buttock and thigh area of \u200b\u200bthe hip abductors after a few weeks can be extended to instep or inside of the thigh in the region of the antagonistic muscles: hip adductor muscles (gracilis, adductor longus and short). Although not lumbo-sciatica, the pain is very strong, can be felt during the night and especially in the morning after getting up. These individuals fail to give a side kick with the affected leg and even a slow side kick with the healthy limb because the load on the limb to compensate sick outside, brings great pain. Again the test Lasègue and femoral nerve were negative.
In these cases, treatment for disk hernia reduction inevitably fail because even if the patient has a protrusion of the intervertebral disc, is not what causes the symptoms.
I noticed that often these non-specific pain affecting people who have undergone surgery, including physical therapists who invented the manual therapies take account of past transactions.
In very rare cases, patients report bilateral symptoms, but some feel heaviness and weakness in both lower limbs.
Some patients report that after many tests, examinations and tests, doctors suspect that the cause of the pain is psychosomatic and send them to the neurologist or prescribing antidepressants, often without benefit.
The Lombo Sciatica is also known as "sciatica" symptoms should be given in a particular region of the back and lower limbs.
What makes it different from any of the three pain syndromes described above is that the hernia symptoms that radiate like a spiral vortex, while the piriformis syndrome and other nonspecific pain spread vertically and symmetrically in relation to the starting point.
If the disc protrusion is at the level of L5-S1 pain through the buttock, the rear central area of \u200b\u200bthe thigh and leg, the outside of the ankle and foot to the toes.
If the subject is L4-L5 root symptoms are felt in the lateral region of the buttock, thigh and leg up mid-calf, then radiates the front and on the instep to the central part of the foot is plantar to dorsal.
The nerve pain is terrible, the worst along with bone, the patient feels a burning sensation.
In the case of sciatica, the first day, patients are stuck in bed and can barely stand up.
The worst moments are turned in bed, bending to put on her socks and shoes, getting up from sitting or lying down and maintain a long position.
activities of daily life are painful and almost impossible.
rotations or lateral inclination on the one hand are generally stronger than the other.
How to diagnose sciatica?
diagnose sciatica simply by looking at the MRI of the lumbar spine is not sufficient, but if there is a protrusion or herniated disc that impression on the dural sac means that you can trigger a nerve compression symptoms of low back sciatica
There are tests that are as Lasègue which is to raise the extended leg with the patient lying supine, or walking on toes or heels.
In the visit, the patient should report symptoms such as feeling and in what regions of the body, medical history is essential to exclude non-orthopedic diseases: causes attributable to cancer, systemic, etc..
Patients should tell their doctor if he performed movements of incorrect or if you have experienced trauma.
MRI of the lumbar spine with L5-S1 herniation highlighted.
If pain is not caused dall'ernia disk, but is nonspecific or occurs in patients without disc herniation, the engine will run tests because certain movements cause pain or are carried out with excessive weakness.
In this case no longer speak of sciatica, but a connective tissue disorder, ie the deposition of neocollagene that is typical of granulation tissue repair processes.
then the bridges are formed between collagen muscles going to strangle or entrap a nerve, this results in loss of strength and pain that is felt in some cases even when standing still.
What is the treatment?
If the patient has a pain not due to nonspecific low back sciatica, treatment for the herniated disk will fail because it tries to treat a lesion that is not or is not the cause of pain.
Ozone therapy and surgery should be performed on patients who have symptoms suggestive certainly herniated disc because there are many cases of people continue to feel that surgery pain before, so the neurosurgeon good visit and analyze the patient well, is not limited only to look at the resonance.
Another mistake I see often is the patient with sciatica who runs a program for strengthening the abs in the gym or at home, it is essential to avoid these exercises until the pain disappears.
The Tecar therapy equipment such as lasers and can decrease the intensity of symptoms, but improvement may be temporary and unlikely to solve the problem.
I use myofascial manipulation of L. Stick, a method that dissolves the collagen bridges that trap the nerve and cause pain, this will eliminate the cause of the disorder.
consists of an intense massage on the points involved in the disorder for 5 / 10 minutes to remove the bridges of excess collagen.
Top view of an intervertebral disc with disc herniation.
Physical therapy works with excellent results in cases of protrusion or bulging disc, that is, if the outer fibrous annulus fibers are not completely broken.
If the hernia is expelled and migrated, a part of the nucleus pulposus is out of its anatomical location and has moved beyond the annulus fibrosus, if the patient is experiencing much pain, you can do with lasers, ozone therapy or surgery.
Today, only one patient out of 400 with a herniated disc will work in all other cases, physical therapy or other treatments are inadequate.
In the case of lumbo-sciatica caused by a disc protrusion, the best treatment is the McKenzie method, which positions held by, or free-body exercises with the over-pressure of the patient and the therapist encourages the mobilization and nucleus pulposus within its anatomical site enough to not have pain.
Any therapy must be accompanied by improving posture, possibly by changing the mattress or the bed of the network and the control of sitting posture.
The intervertebral disc not return intact, but the patient ceases to feel pain. The instrumental
therapy can help in removing the inflammation and any contractions, but they can not put the disk back in its place, you need a mechanical therapy.
Once cured, it is advisable to follow a fitness program with specific exercises in the gym or yoga.
facet joint syndrome
What is this?
The joints between the posterior processes of the vertebrae are called zigoapofisarie.
If the bones undergo degenerative changes with age due to arthritis of the articular surfaces are asymmetrical and the bones do not slide on each other without friction or restriction.
The consequences are excessive degradation of articular cartilage and in some cases, the posterior subluxation and a distraction of the facet joint capsule of the L5-S1.
E 'possible to find the presence of cysts communicating with the joint.
This process leads to irritation of the joints zigoapofisarie.
What are the symptoms?
The symptoms are pain in the data side of the spine, in the groin and gluteal area over the back of the thigh.
The symptoms increase with hyperextension with contralateral tilt and rotation, in addition to prolonged standing. There is an improvement
lying in bed and leaning forward to move away because joint rear area as if you pull on one vertebra over the other.
How to get the diagnosis?
lumbar facet joint syndrome can be diagnosed by taking into account the symptoms, diagnostic imaging should show advanced arthritis of the joints zigoapofisarie well as a possible cyst.
Tests that may show degeneration of the joints and the formation of osteophytes are CT and MRI. The classic test
Lasègue and femoral nerve are both negative.
There are no tests or other tests to confirm with certainty this syndrome, the only thing that can demonstrate is the anesthetic block of the facet joint is suspected.
What is the best treatment?
Conservative treatment consists of physical therapy such as laser or Tecar combined with the repositioning of the facet joints by moving back together to pressure targeted vertebral performed by an experienced physiotherapist.
E 'shall also be provided with physical therapy and muscle strengthening exercises in flexion.
The infiltration of anesthetic drugs and cortisone in the joints zigoapofisarie is used only in case of failure of conservative treatment and only in selected cases.
There is an experimental therapy that was successful for many patients: percutaneous neurotomy is a new technique of treatment which consists of denervation of sensory nerve fibers of the facet joint radiofrequency.
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