CHAPTER IV: LUMBAGO AND

SCIATICA

Faculty
Dr Francis B. MPIMPA
Definition
 The term “lumbago” originates from the latin word
“lumbus” meaning loin.
 Lumbago refers to low back pain
LOW BACK PAIN
Epidemiology
 60m-90% of adults experience back pain at some points
in their life.
-  incidence age 35- 55 y.o.
- 90% resolve in 6 weeks
- 7% become chronic
- M/ F equally affected
 85% never given precise patho-anatomical Dx
• 5th Leading reason for medical office visits
• 2nd to respiratory illness as reason for symptom-related
MD visits
Causes of LBP

The most common cause of LBP is muscles spasm (somatic dysfunction). But also,
any dysfunction involving the thoracic or lumbar spine, the sacro-iliac joints or the hip
can create LBP. In order of frequency, causes of LBP are:
 Lumbar “strain” or “sprain” – 70%

 Degenerative changes (Lumbar OA) – 10%

 Herniated disk – 4%

 Osteoporosis compression fractures – 4%

 Spinal stenosis – 3%

 Spondylolisthesis – 2%

 Spondylolysis, diskogenic low back pain or other instability – 2%

 Traumatic fracture - <1%

 Congenital disease - <1%

 Cancer – 0.7%

 Inflammatory arthritis – 0.3%

 Infections – 0.01%
Lumbar Spine Conditions
• Low Back Muscle Strain
– Acute (Overextension) and Chronic (Faulty posture)
• Facet Joint Dysfunction
– Dislocation or Subluxation (Acute or Chronic)
• Low Back fracture
– Compression, Stress, or Spinous and Transverse Processes
• Herniated Disc
– Protrusion, Prolapse, Extrusion, and Sequestration
– Local and Radiating Pain
• Classic term “Sciatica”
Cont’d
• Spondylolysis
– Unilateral defect in the pars interarticularis
• Spondylolisthesis
– Bilateral defect in the pars interarticularis
which causes forward displacement of
vertebra.
• Spina Bifida Occulta
– Congenital condition – spinal cord is exposed
= delays in development.
Sacroiliac Joint Conditions
(note this is advanced)
• Sacral torsion
– Forward or Backward torsion
• Ilium torsion, upslip, downslip, outflare,
inflare
• Piriformis strain/trigger points
Common Patho-anatomical Conditions of the Lumbar Spine

.
Red Flags
 History of cancer
 Unexplained weight loss
 Intravenous drug use
 Prolonged use of
corticosteroids
 Older age
 Major Trauma
 Osteoporosis
 Fever
 Back pain at rest or at
night
 Bowel or bladder
dysfunction
Evaluation of a patient with LBP
• Start with a detailed history – your best diagnostic tool.
– Get an idea of the severity.
– Look for the “red flags” of serious causes (Cancer, infections,
Sciatica, Cauda equina syndrome, ankylosing spondylitis).
• Fever – possible infection
• Vertebral tenderness - not specific and not reproducible between
examiners
• Limited spinal mobility – not specific
• If sciatica or pseudoclaudication present – do straight leg raise
• Positive test reproduces the symptoms of sciatica – pain that
radiates below the knee (not just back or hamstring)
• Ipsilateral test sensitive – not specific: crossed leg is insensitive but
highly specific
• L-5 / S-1 nerve roots involved in 95% lumbar disc herniations
• Keep in mind:
– Most of the time you won’t have a definitive diagnosis.
– Imaging rarely changes initial treatment.
Cauda Equina Syndrome
• Caused by massive midline disc herniation or mass
compressing cord or cauda equina.
– Rare (<.04% of LBP patients).
– Needs emergent surgical referral.
• Symptoms: bilateral lower extremity weakness,
numbness, or progressive neurological deficit.
• Ask about:
– Recent urinary retention (most common) or
incontinence?
– Fecal incontinence?
Ankylosing spondylitis
• Ankylosing spondylitis is one of many
forms of inflammatory arthritis, the most
common of which is rheumatoid arthritis.
Ankylosing spondylitis primarily causes
inflammation of the joints between the
vertebrae of the spine and the joints
between the spine and pelvis (sacroiliac
joints).
Differential Diagnosis of LBP ( for your general
cultivation)
Investigations
 FBC, ESR

 X-Ray Lumbar and sacral spine A/P and Lateral

views: sometime gives better information than CT
Scan
 CT Scan

 MRI : best describes lesions

Treatment
 Medical: NSAIDs, Myorelaxant, topical NSAIDs
cream, opioid pain killers (e.g Tramadol)
 Physiotherapy: massage, exercises, ultrasound

 Lumbar corset, lumbar support, lumbar brace

SCIATICA
 The sciatic nerve is the longest and largest nerve in
human body. It originates in the lower spine as nerve
roots exit the spinal cord and extends all the way down
the back of the legs to the toes.
 The term “sciatica” refers to the pain that radiates along
the path of this nerve – from the back down the buttock
and leg.
Etiology

 Disc Herniation: may occur in different level of

lumbosacral spine, but most common are L5 or S1
 Spinal stenosis: narrowing of the vertebral foramen,
usually due to aging pressure on spinal cord
 Spondylolysthesis
 Irritation of the nerve from adjacent bone, muscle
(pyriform muscle syndrome), tumors, internal
bleeding, infections, pregnancy
Symptoms and Signs

 Pain: most common symptom. Pain is made worse

with coughing, laughing, sneezing, leaning
backward,
 Sometimes weakness of the leg or foot along with
pain
 Numbness
 Walking difficulty
Physical examination of the patient include
 Observation
 Palpation

 Determination of the range of motion of the

spine
 Root tension test (e.g valsalva)

 Evaluation of the neurological status of the

lower limb
Assessment of the functions

 98% disc herniations: L4-5; L5-S1

Impairment: Motor and Sensory L5-S1
– L5: Weakness of ankle and great toe
dorsaflexion
– S1: Decrease ankle reflex
– L5 & S1: Sensory loss in the feet
 Testing of the dorsiflexion strength of the
ankle and the big toe with weakness
suggesting mainly L5 dysfunction
 Testing of ankle reflex to evaluate S1 root
dysfunction
 Testing of light touch sensation in the medial
(L4), dorsal (L5) and lateral (S1) aspects of
the toe
. The straight leg
raise test is
positive if pain in
the sciatic
distribution is
reproduced
between 30° and
70° passive flexion
of the straight leg.
Dorsiflexion of the
foot exacerbates
the pain
Investigations

 The most helpful is MRI

 CT Scan

 X-Ray to see losing of lumbar lordosis

Treatment
 Medical: If there is no neurological defect
 NSAIDS

 Bed rest

 Physiotherapy

 Muscle relaxant

 Surgery: if neurological defects 

laminectomy, discectomy, lumbar fusion,…
 Thanks
.