Management of Sciatica Pain in Primary and Secondary Settings

Research Article

Austin J Musculoskelet Disord. 2023; 10(1): 1064.

Management of Sciatica Pain in Primary and Secondary Settings

Suresh K*

Family Physician & Public Health Consultant Bengaluru & Visiting Professor of Practice-MPH, Schools of Environmental Science, Public Health and Sanitation Management, Karnataka State Rural Development and Panchayat Raj University (KSRDPRU), GADAG, India

*Corresponding author: Suresh Kishanrao Family Physician & Public Health Consultant Bengaluru & Visiting Professor of Practice-MPH, Schools of Environmental Science, Public Health and Sanitation Management, Karnataka State Rural Development and Panchayat Raj University (KSRDPRU), GADAG, Karnataka India. Tel: 919810631222 Email: ksuresh.20@gmail.com

Received: April 20, 2023 Accepted: May 22, 2023 Published: May 29, 2023

Abstract

Katishoola is the term used in ayurvedic texts which resembles low back pain. The term ‘Kati’ used for lower back arises from the oldest language of human civilization, Sanskrit (4000–5000 BC). In an ancient text, Amarkosha ‘Kati’ has been related to the area of ‘Sroni’ or hip bone. Shoola (Ruja, Vyatha, Yama, or Ruk) is pain or discomfort.

The earliest evidence of back pain outside the Indian subcontinent comes from an ancient Egyptian surgical text called Edwin Smith papyrus (named after Edwin Smith, who bought it in 1862. Sciatica pain is a direct result of pressure on sciatic nerve or sciatic nerve root pathology. The sciatic nerve is made up of the L4 through S2 nerve roots, which coalesce at the pelvis to form the sciatic nerve. About 2cm in diameter, the sciatic nerve is easily the largest nerve in the body. Sciatica pain often is worsened with twisting, bending, or coughing.

In India most practicing doctors across all systems usually determine the cause of Sciatica pain by asking a few questions and a thorough physical examination. Imaging is initially of little value. An MRI or a non-contrast CT scan may be performed to evaluate fracture if plain films are negative. Management of Sciatica traditionally revolves around reducing pain and inflammation, strengthening supportive muscles in lower back, hips, and thighs. Laminectomy or Discectomy are attempted if the surgery is needed to relieve the pressure on the nerve. Of late a New German technology powered based on regenerating new tissue becoming popular.

This article reviews about 5 patients and 6 episodes of Sciatica. Four episodes were common and two un-common conditions, of which only needed laminectomy. Their management by different systems of medical practice are described and review of the literature across the systems adds to the epidemiology, causes and management of Sciatica in India.

Materials & Methods: Four cases, one of them suffering twice after an interval of a decade and traditional management of these cases by allopathic, Unani system, Homeopathy and Yoga exercises, for the core content of sciatica management in Primary and secondary settings. Brief notes on two cases needing surgery and the first-hand information on latest QI based neuromodulation approach update complete the options currently available in India.

Keywords: Backache; Sciatica; Short term Sciatica due to direct pressure/pregnancy; Bugling/herniated disc; Imaging; Ibuprofen; Muscle relaxants and anti-depressants

Introduction

Katishoola is the term used in ayurvedic texts which resembles low back pain (4000-5000 BC). The earliest evidence of back pain outside the Indian subcontinent comes from an ancient Egyptian surgical text called Edwin Smith papyrus (named after Edwin Smith, who bought it in 1862) [1].

Sciatica is a relatively common musculoskeletal disorder with a prevalence ranging from 2–5%, depending on the population. Lifetime incidence is reported to be between 10% to 40% and an annual incidence of 1 to 5% in India. It rarely occurs before age 20 unless secondary to trauma. There is no association with body weight or height except in 50 to 60 age group.

The prevalence of sciatica or radiculitis ranges from 1.2% to 43% worldwide. Slipped discs or Lumbar Disc Herniation (LDH) is common disease in the world, with sciatica pain as the most common related symptom, though not every slipped disc is painful. The typical clinical presentation is pain radiating from the waist to the lower extremities, often accompanied by sensory or motor disturbances. The symptoms usually go away on their own within six weeks in most cases, but many people have back pain that keeps on returning. Any pain that radiates down leg and into foot may be a sign of a slipped spinal disc, or “herniated disc.” In rare cases, numbness in the buttocks or signs of paralysis may develop in addition to the pain & might affect the function of the bladder or bowel, needing immediate treatment [2].

Causes of Sciatica Nerve Pain as we know today [3]:

i. Spinal Stenosis: The narrowing of the spinal canal caused by natural wear and tear of the vertebrae of the spine puts pressure on the roots and cause sciatic nerve pain.

ii. Herniated Disc: A disc is a cartilage and acts as a cushion between vertebrae, allowing flexibility of the spine. A herniated or slipped disc in lumbar region (Lumbar Disc Herniation- LDH) occurs when a disc is temporarily pushed out of place, exerting pressure on the sciatic nerve and pain.

iii. Spondylolisthesis: It is a condition where one of the lower vertebrae slips forward over another, causing a collapse of the disc space between both, resulting in the nerve getting pinched, causing sciatica nerve pain.

iv. Piriformis Syndrome: Piriformis is a muscle found deep inside the buttocks, connects the lower spine to the upper thighbone, running directly over the sciatic nerve. Spasming of this muscle pressurizes sciatic nerve, triggering symptoms of sciatica

v. Sacroiliitis: Sacroiliac joints are the place where the lower spine meets the pelvis and inflammation of one or both joints cause sacroiliitis and give rise to symptoms of sciatica nerve pain in the lower back, buttocks, and legs.

vi. Spinal tumours: Very rarely, tumours growing inside or along the spine may put pressure on the sciatic nerve.

vii. Infection or Injury: Muscle inflammation, infections, fractures, or any other spinal injury may lead to irritation or compression of the sciatic nerve resulting in Sciatica.

viii. Sciatica Pain Due to Pregnancy: Pregnant women’s weight gain, expansion of the uterus, or increased fluid retention or other changes occurring in the body, put pressure on the sciatic nerve and result in sciatica pain temporarily.

ix. Other Causes: Osteoarthritis and fractures caused by osteoporosis may also affect the sciatic nerve, producing symptoms of the sciatica nerve pain. India promotes effective ways to manage sciatica in 2 ways [4].

Self-care treatments:

a) Acupuncture: Acupuncture encourages blood flow and relaxes muscles in the surrounding area, providing relief immediately, but it takes multiple sessions to see a noticeable improvement.

b) Massage Therapy: Massage loosens tight lower back muscles, preventing irritation and encourages the release of pain-fighting endorphins, providing relief from symptoms of throbbing pain in the foot or the burning sensation in the leg.

c) Isometric Exercises: Sitting or standing too long is a trigger for the sciatic nerve, and commonly leads to flare-ups. Isometric exercises are a form of strength training that improve range of motion and prevent further injury by isolating the affected muscles and joints. The result is a strengthened lower back and reduced pain.

d) Anti-Inflammatory Diet: Inflammation is one of the biggest causes of sciatica pain and is the by-product of certain lifestyle choices like being overweight; sitting for long periods of time, and cigarette smoking that can be remedied. Fruits, nuts, and leafy greens are advised as key component of diet.

Health care provider’s interventions: Most primary care doctors when consulted recommend,

a) Medications: Anti-inflammatories such as Ibuprofen, naproxen, diclofenac, and celecoxib muscle relaxants such as Baclofen, Carisoprodol, Methocarbamol and Tizanidine, and certain antidepressants like Amitriptyline, Nortriptyline, Protriptyline, Doxepin, Imipramine, and Clomipramine (or Desipramine may be prescribed to alleviate pain and discomfort.

b) Steroid Injections: Corticosteroids can be injected around the irritated nerve to relieve inflammation, and the benefits last a few months. However, the number of shots a patient can receive is limited due to the risk of serious side effects.

c) Physiotherapy: A comprehensive physical therapy regimen comprises exercises to strengthen supporting muscles in the back, to improve flexibility and correct posture.

d) Surgery: When all other treatments fail, surgery may be recommended to provide pain relief or if the nerve impingement has resulted in a loss of bladder/bowel control or significant weakness of lower limb muscles.

Case Reports

Lumbar Disc Herniation with Radiculopathy`

Sharnu, a 23-year-old rural labourer presented with a three-month history of low back pain and more recently right leg pain. He had presented to outpatient of a Government Medical College Hospital on six occasions since May 2022 for worsening pain. He couldn't recall a single event relating to the onset of his back pain. In the weeks prior to developing back pain, he had been working as a Coolie did find bending over to lift a gunny bag bit difficult and painful. The pain began in his lower back quite centrally and with time is starting to radiate straight down the back of his right thigh and into his calf, stopping at the ankle.

The pain used to be worse in the morning. He felt stiff and crooked in the am, was unable to get out of bed without assistance, and required help to shower and dress. He was waking in the day every 2-3 hours with severe buttock and posterior thigh pain. There were no pins and needles or numbness, but he felt is his right leg heavy. Lying down, sitting down, being still or getting cold aggravated his back and leg pain. Pain increased within 30 minutes of each sustained posture and take up to 2 hours to ease mostly through walking. There was no position or movement that completely reduced Sharnu’s leg pain.

General health & social history: His general health was unremarkable and there were no other red flags. He was working as a labourer but had quit his job due to worsening pain in last 2 months. He had received three sessions of lower back and buttock massage from a private Homeopath. Temporary relief but no sustained improvement in pain and function was reported.

Physical examination: The first thing noticed was the way Sharanu stood. His shoulders were shunted to the left side, his back was extended, and pelvis anteriorly tilted, visible hyper-tonicity of the lumbar para-spinal muscles noticed (Figure 1). Lumbar flexion P2 (right-sided low back pain) R` (upper thigh). Extension P2 (right buttock and leg pain) R` (vertical). Other movements were not assessed day 1 due to severity / irritability.