Low Back Pain or Low Back ache with special reference to Sciatica:
Considerations of Low Back Pain:
Changing of life style of modern human being has created several disharmonies in his biological system. As the advancement of busy, professional and social life, improper sitting posture in offices, factories, continuous and over exertion, jerking movements during travelling and sports – all these factors create undue pressure to the spinal cord and play an chief (important) role in producing low back pain and Sciatica. Likewise, progressive disorders affecting the pelvis and nearer structures are also precipitating this condition. In this way, this disease is now becoming a significant threat to the working population. Backache which was known as an ancient curse is now known as a modern international epidemic. 80% of the populations are affected by this symptom at sometimes in life.
Synonyms of Low Back Pain:
Low back pain, Low backache, Backache, Backpain, Sciatica, Katishula,
Gridhrasi (In Ayurvedic term)
Definition of Sciatica:
1) Sciatica is a neuralgia of the hip and thigh; a pain in the sciatic nerve.
2) Sciatica is a neuralgia along the course of the sciatic nerve, most often with pain radiating into the buttock and lower limb, most commonly due to herniation of a lumber disc (Dorland’s Dictionary).
3) In sciatica there is pain in the region of the hips or along the course of the nerve at the back of the thigh (Merriam-webster Dictionary).
4) Sciatica is a swelling of the sciatic nerve, usually marked by pain and soreness along the thigh and leg. It may lead to a wasting of the muscles of the lower leg (Mosby’s Medical Encyclopedia).
5) Shooting pain along the cutaneous distribution of the sciatic nerve and its terminal branches (chiefly the common peroneal) is known as sciatica. Pain usually begins in the gluteal region or even higher, and radiates along the back of the thigh, and the lateral side of the leg, to the dorsum of the foot. This is usually due to compression and irritation of one or more nerve roots forming the sciatic nerve (Chaurasia B. D, 1995)
In short, Sciatica is a symptom not a diagnosis. It is a non-specific term commonly used to describe symptoms of pain radiating downward from the buttock over the posterior or lateral side of the lower limb. It is usually assumed to be caused by compression of a nerve but this is not necessarily so. It is often assumed that there is sciatic nerve root entrapment, resulting in the compression of the nerve. Pain and symptoms being transmitted or referred from the low back to one of the buttocks and down the back of the leg along the pathway of the sciatic nerve. Hence the term sciatica.
Definition of Gridhrasi (According to Ayurveda):
1) Gridhra is bird called as vulture in English. This bird is fond of meat and he eats flesh of an animal in such a fashion that he deeply pierce his beak in the flesh then draws it out forcefully, exactly such type of pain occurs in Gridhrasi and hence the name.
2) Another meaning is a man who is striving after meat greedily like Gridhra (vulture) is prone to get it and hence the name Gridhrasi.
3) Further as in this disease the patient walks like the bird Gridhra and his legs become tense and slightly curved so due to the resemblance with the gait of a vulture, Gridhrasi term might have been given to this disease.
Structures involved in Sciatica:
- Vertebral bodies
- Intervertebral discs
- Posterior intervertebral joints
- Ligaments and small intevertebral muscles
- Posterior longitudinal ligament
Sciatica origins: Spine –> Pelvis —> Leg
The sciatic nerve is formed from the L5 and S1 nerve roots in the spinal canal and the union of these nerves becomes the sciatic nerve in the pelvis. The sciatic nerve continues through the pelvis into the buttock and back of the upper thigh to the back of the knee where it splits into nerves coursing into the calf.
There are many structures in the lower back that can cause severe pain. These includes – muscles, ligaments, tendons, bones and facet joints.
There is severe pain in the leg caused by compression, irritation or inflammation of the sciatic nerve.
Symptoms of Sciatica:
Symptoms play most important role in proper diagnosis of the disease. Curability and incurability of the disease depends upon the severity of the presenting symptoms.
In general radiating pain emerging from lumber region and radiating towards buttock and goes down to the foot and along the course of Gridhrasi Nadi i.e. sciatica nerve, is a cardinal symptom of Gridhrasi.
On the basis of symptoms Gridhrasi can be equated with the disease Sciatica in modern parlance, which occurs because of spinal nerve irritation and characterized by its distinct nature of pain in distribution sciatic nerve and often it is associated with lumbago.
Waist, hip, posterior of the thigh, knee, calf and foot are affected respectively in Gridhrasi.
According to Ayurveda, the symptoms of Gridhrasi…
In Vataja type:
- Stambha (stiffness)
- Ruka (pain)
- Toda (pricking sensation)
- Muhuspandanam (tingling sensation)
In Vata-kaphaja type:
- Tandra (Giddiness)
- Gaurava (Feeling of heaviness in the body)
- Arochaka (Anorexia)…
are three additional symptoms found (Ref: Ch. Chi. 28/56-57).
Special Test of Sciatica:
- SLR (Straight Leg Rising) – Test :
- Bowstring test:
- Suspected prolapsed intervertebral disc :
- Look for further evidence of neurological involvement.
- Femoral Nerve Stretch Test (Revere SLRT)
- Muscle Wasting : Note the extensive wasting, A) thigh, B) calf and peronei, C) sole of foot and D) drop foot.
- Modifications of SLR – Test are Lasegue test, Biickling sign, Sicard’s test and Fajerstazan’s test.
- Well Leg Rising Test
- Bilateral Straight Leg Raising Test
- Popliteal Compression Test
- Sitting Test
Investigaions of Sciatica:
Radiography of the back is not very reliable as normal findings are observed in 7% – 46% of the cases. Disc space is reduced in old cases but in acute cases it is maintained. Oblique view is recommended to rule out spondylolysis.
Myelography. It consists of injecting radio-opaque dye (Myodil was used earlier; now it is the water soluble Iopamiro 300 which is being used) into the spinal canal and taking radiographs of the back. It is helpful in detecting the intra-spinal lesions, spinal stenosis and cases of previously operated backs. It is also indicated when the diagnosis is in doubt. It is an invasive procedures like CT scan and MRI.
CT Scan. It is a very useful non-invasive, painless outpatient procedure. It gives a cross-sectional study of the pathology. If however fails to detect intraspinal lesion, arachnoiditis and scar from disc herniation. It helps to detect the foraminal stenosis and the lateral disc prolapse.
MRI. This is also an extremely useful, painless, non-invasive outpatient procedure. It helps to detect the intraspinal lesion, helps to examine the entire spine and identifies degenerative disc. However, it is expensive and hence prohibitive.
Discography. After identifying the disc correctly, through a needle, a radio-opaque dye is injected into the space. This reproduces the pain experienced by the patient previously and is relieved by injecting Xylocaine. This confirms the diagnosis. It is a painful procedure and
can introduce infection into the disc. Hence it is less practiced.
Other Tests of diagnostic importance are bone scans, EMG, routine laboratory studies, injection studies etc.