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The Skeletal SystemLumbago and Sciatica Clinical features, Diagnosis, Management, Prognosis, Low
back pain (lumbago) is felt in the low lumbar, lumbosacral, or sacroiliac
region. It is often accompanied by sciatica,
pain radiating down one or both buttocks and/or legs in the distribution of
the sciatic nerve. Low back pain may be related to acute ligamentous (sprain)
or muscular (strain) problems, which
tend to be self-limited, or to more chronic osteoarthrotic or ankylosing
spondylitic processes of the lumbosacral area. Causes of chronic low back pain
may also include:
back
strain due to poor posture (e.g., obesity, pregnancy, certain occupations)
localised
or generalised fibromyalgia (discussed later)
a
protruding or ruptured intervertebral disk with subsequent herniation of the
nucleus pulposus into the spinal canal, causing nerve root pressure
traumatic
ligament rupture, stress microfracture or muscle tear commonly occurring, mild congenital defects of the low lumbar and upper sacral spine, such as abnormal intervertebral facets, sacralisation of L-5 vertebrae (fusion of L-5 and S-1) Clinical features: < BACK TO TOP >
The
circumstances leading to onset, the character, and the precise location of the
pain vary with the underlying condition.
Pain may
be localised to certain area (e.g., tenderness, as in sprain or strain),
arising from deeper-lying tissue (e.g., in chronic osteoarthrosis of the lumbar
spine); radicular following the nerve distribution (as in sciatica).
There is
often limitation of back motion because of pain and increased tone of the
paravertebral muscles.
Low back
pain is usually worse after physical exercise, bending and lifting, except in
inflammatory conditions such as ankylosing spondylitis where the pain tends to
diminish during physical activity.
Sciatica
(pain radiating along the course of the sciatic nerve, most often down the
buttock and the posterior aspect of the leg to below the knee) may accompany
low back pain, but may be more severe and may occur alone. Limitation of straight-leg lifting, diminution or loss of reflexes, and sensory change (numbness) are more characteristic of conditions affecting spinal nerve roots and the sciatic nerve. Diagnosis: < BACK TO TOP >
Carefully
taken history and physical exam often give indications about possible cause,
but even then differential diagnosis is often difficult
X-ray
can show structural changes in the spine (e.g., spondyloarthrosis, narrowing of
the intervertebral foramina or intervertebral spaces).
Spinal
cord compression and nerve root compression are better seen on CT and MRI. Injury to soft tissues (connective tissue and muscles) unfortunately can’t be visualised and the diagnosis of these causes is essentially clinical. Management < BACK TO TOP >
Recovery
from a single acute attack of low back pain is common, but attacks may recur or
symptoms may become chronic in all conditions.
Acute
low back pain following unusual strain or activity is treated first by
relieving muscle spasm with bed rest in a comfortable position with hips and
knees flexed, local heat, gentle massage, oral NSAIDs and oral muscle relaxants
such as baclofen [Lioresal, Clofen] or benzodiazepines.
Manipulation
(massage, physiotherapy) may be helpful if the pain is due to muscle spasm
alone, but may aggravate arthritic pain, ligament, muscle or disk injury.
Diathermy
(deep heat) techniques may be helpful in reducing muscle spasm and pain after
the acute stage.
Abdominal
muscle-strengthening exercises and lumbosacral flexion exercises are indicated,
when symptoms permit, to strengthen the supporting structures of the back and
decrease the likelihood of the condition becoming chronic or recurrent.
Chronic
low back pain treatment is directed toward alleviating the cause such as weight
reduction in the obese, improving muscle tone and strength, and improving
posture, with added analgesics.
Sometimes
treatment can be difficult like in chronic spondyloarthrosis or ankylosing
spondylitis.
Soft
tissue injection with corticosteroids can be effective in relieving disabling
tender points. Surgery is indicated if a compression syndrome is detected (removal of the nucleus pulposus or the whole intervertebral disk). Prognosis < BACK TO TOP >
(source :
Dr Zoran Pletikosa) |
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