Sciatica: diagnosis and medical treatment

2021-07-20 12:27 AM

The most common cause is a herniated disc. Medical treatment is key. However, if persistent pain significantly affects mobility, surgery should be considered.

The sciatic nerve is a large nerve in the body made up of nerve roots from the lumbar vertebrae L3, L4, L5, S1. Sciatica is a common manifestation, the most severe manifestation in the general condition of low back pain. This expression often appears suddenly, can disappear after a few weeks but can also last for many months, many years, greatly affecting the ability to work and quality of the spine.

The most common age is from 30 to 60 years old with a male/female ratio of 3/1.

The most common cause is a herniated disc. Medical treatment is key. However, if persistent pain significantly affects mobility, surgery should be considered.

Physical symptoms

Low back pain, radiating to the buttocks, hamstrings, and lower legs along the path of the sciatic nerve. Contraction when the pain is dull but often severe, pain increases when coughing, sneezing, bending. Pain increases at night decrease when lying still on a hard bed and the pillow is flexed. It may be accompanied by a tingling, numbness, or pins-and-needles sensation on the outside of the foot across the instep to the big toe (lumbar root 5), heel, or little toe (sacral root 1).

Some patients have pain in the lower part and pain during defecation due to extensive lesions invading the roots of the cauda equine plexus.

Physical symptoms

Spine: muscle spasticity reaction next to the spine, spine losing physiological curves, crooked due to anti-pain posture, broken spine line...

Symptoms of root compression: positive Lasegue sign, Walleix (+). Examine reflexes, sensations, movements, and muscle atrophy to locate damaged roots.

L5 root: normal tendon reflexes, reduced or absent feeling in the thumb (may increase in the excitatory phase), heel inability, atrophy of the anterolateral calf muscle group, the dorsal muscles.

S1 root: reduced or cool heel reflex, decreased or lost sensation on the little toe side, inability to walk on the toes, atrophy of calf muscles, the plantar fascia.

Image analyzation

Routine X-ray: evaluate the morphology of the spine and vertebrae to rule out other causes such as tumors, vertebral collapse, disc spondylitis, sacroiliitis...

Contrast-enhanced discography to detect disc damage is not currently used.

Nerve root sheath scan: When there are signs of spinal cord compression, nerve roots are rarely used.

Computed tomography of the spine when there is a suspicion of damage to the bone structure, spinal canal...

Magnetic resonance imaging (MRI): can evaluate soft tissue structures such as discs or muscles, paraspinal ligaments, and bones to detect tumors. Allows early and sensitive diagnosis, can detect 30% of lesions without clinical symptoms. However, there may be no correlation between clinical symptoms and MRI findings.

Electromyography: to detect damage of nerve origin, locate the damaged nerve.

Tests and investigations may be needed to rule out other causes (depending on the individual case)

Basic tests: peripheral blood cells, erythrocyte sedimentation rate, c-reactive protein (CRP).

Cerebrospinal fluid examination: protein is usually slightly elevated if root compression is present.

Biochemical tests such as calcium, phosphorus, alkaline phosphatase, if there is suspicion of metabolic diseases or cancer.

Bone scintigraphy: to detect metastatic cancer or inflammatory disc-spondylitis, osteomyelitis.

Biopsy, cytology, histopathology...

Medical treatment of sciatica due to disc herniation

Non-drug treatment

Immobilization during acute pain:

Reasonable movement in the following stages.

Physical exercise and physical activity strengthen the health of the spinal muscles.

Physiotherapeutic and reflexology therapy: using heat, irradiation, acupuncture, acupressure, chiropractic, pulsed electricity, shortwave, acupuncture.

Stretch the spine.

Drug treatment:

Pain relief chooses one of the drugs according to the pain ladder of the World Health Organization: acetaminophen (paracetamol, Efferalgan), Efferalgan codeine, morphine. For example, take 0.5g paracetamol tablets with a dose of 1 - 3g/day. Depending on the pain condition, adjust the dose accordingly.

Non-steroidal anti-inflammatory drugs when the patient is in great pain:

Choose one of the following drugs (note absolutely do not combine drugs in the group because they do not increase the treatment effect but have many side effects):

Diclofenac (Voltaren) 50mg x 2 tablets/day divided into 2 or 75mg x 1 tablet/day after a full meal.

75mg/day intramuscular injection can be used for the first 2-4 days when the patient is in severe pain, then switch to oral.

Meloxicam (Mobic) 7.5mg x 2 tablets/day after eating or as an intramuscular injection 15mg/day x 2-4 days if the patient has a lot of pain, then switch to oral.

Piroxicam (Felden) 20mg tablet or tube, take 1 tablet per day orally after meals or intramuscularly 1 ampoule per day for the first 2-4 days when the patient has a lot of pain, then switch to oral.

Celecoxib (Celebrex) 200mg tablets, dose 1 to 2 tablets / day after a full meal. Should not be used in patients with a history of cardiovascular disease and with greater caution in the elderly.

Muscle relaxants:

Choose one of the drugs:

Mydocalm: 150mg x 3 tablets/day (if muscle contractions are high) or mydocalm 50mg 4 tablets/day.

Myonal 50mg x 3 tablets/day.

The drug is effective in reducing pain caused by nerve causes.

Use one of the following:

Neurontin 0.3 g tablets orally 1 -3 tablets/day, can be increased to 6 tablets/day.

Lyrica 75mg orally 1-3 tablets. Take 1 pill on the first day, the next days can increase by 1 pill per day.

Trileptal: 0.3g 1-3 tablets/day.

Vitamin B12: methyl cobalt: 500mcg x 2 times/day (oral) or intramuscularly 500mcg x 3 times/week.

Combination of sedatives, antidepressants when necessary:

Amitriptyline tablets 25mg x 1-2 tablets/day (should be taken in the evening).

Epidural injection with hydro cortisol, acetate course of 3 injections, every 3 days.

Surgical treatment

Indications: When medical treatment is unsuccessful (usually after 3-6 months of proper medical treatment, the patient does not have pain relief and/or has muscle atrophy). Patients present with signs of root compression such as circular muscle disorders, paraplegia, or rapid muscle atrophy.