As for the causes of sciatica, many doctors generalize them together without carefully distinguishing the different causes and affected segments, and some even equate sciatica with lumbar disc herniation without distinction. As long as there is low back pain accompanied by pain and numbness in the lower extremities, it is designated as lumbar disc herniation, so that the number of people suffering from lumbar disc herniation is increasing. Especially with the popularization of CT and MRI, patients go for a CT examination at every turn, and then many people are told that the lumbar discs have different degrees of protrusion.
So, what is sciatica all about? The roots of the sciatic nerve originate from the anterior branches of the spinal nerve in the 4 and 5 lumbar segments and the 1, 2 and 3 sacral segments. From the above five anterior branches, it crosses the lumbaris major muscle to form the sacral plexus and descends along this muscle. Most of the nerves of the sacral plexus merge into the sciatic nerve. It descends along the posterior pelvic wall to the inferior foramen of the pear-shaped muscle and passes out of the pelvis into the gluteal region. It descends within the posterior gluteal muscles to the lower mid-thigh where it divides into the tibial and common peroneal nerves.
In this way, the general origin of sciatica is first divided into: radicular, plexiform, and truncal sciatica. At the same time, there are three different types of sciatica, namely, radicular, reflex, and involvement, depending on the site of sciatic nerve involvement and the directness or otherwise of the involvement. It is because of this that the manifestations of sciatica are so varied and complicated that it is like being in a bewildering array, and it is impossible to pinpoint the real cause of the disease, which brings great difficulties to the treatment.
1, radicular sciatica (also known as upper segment sciatica): common causes include lumbar disc herniation, lumbar spinal stenosis, soft tissue compression inflammation at the nerve root outlet and other symptoms. It manifests as numbness, pain, soreness, and coldness in the area innervated by the affected nerve roots. Herniated discs of lumbar 4 and 5 compress the nerve roots of lumbar 5, often manifesting as pain, numbness, soreness, swelling, and coldness in the lumbar region, posterior hip, posterior thigh and anterolateral calf to medial dorsalis pedis, and thumb. And the herniated disc from lumbar 5 to sacral 1 compressing sacral 1 nerve root often manifests as pain, numbness, numbness in the lumbar region, posterior hip, pain, numbness, numbness in the posterior thigh, posterior lateral calf, lateral dorsal foot to the little toe, heel and sole, pain, numbness, acidity, swelling and cold.
2. Plexiform sciatica (also called middle sciatica): It is caused by compression or stimulation of the sacral plexus located in the pelvis. It manifests as numbness and pain, soreness, swelling and coldness in the waist, hip and leg, multiple parts, multiple segments, the whole lower limb, anterior, posterior and lateral, and the dorsal and lateral dorsum of the foot, heel and sole of the foot.
3. Dry sciatica (also known as lower segment sciatica): mainly caused by compression or irritation of the sciatic nerve at the pelvic outlet and the following route of travel.
Here, let’s elaborate on each of them.
1.Root sciatica
The common etiologies are.
(1) lumbar disc herniation.
(2) compression and injury of nerve roots (spinal stenosis, slippage, rheumatoid, tuberculosis, osteoporosis, etc.).
(3) inflammation.
(4) congenital malformation.
Diagnostic points.
(1) Paravertebral pressure pain, percussion pain, and pain on movement. This is due to nerve root compression and posterior nerve root branch involvement.
(2) Flexion neck test (+). Due to pulling on the dural chord and root cuff when doing the movement.
When the lumbar 4 and 5 discs are herniated and the nerve root of lumbar 5 is compressed, the pain manifests as pain and numbness at the hip, posterior thigh, anterolateral calf, and medial dorsum of the foot, while when the lumbar 5 and sacral 1 discs are herniated and the nerve root of sacral 1 is involved, the numbness and pain symptoms are mainly at the posterior lateral side of the ipsilateral calf and the lateral side of the dorsum of the foot and the sole of the foot.
The vicious cycle between degeneration of the cervical disc and secondary changes in the peri-vertebral tissues, as described in the three vicious cycles of cervical spondylosis, also applies to the interpretation of patients with lumbar herniation. When there is lumbar disc degeneration, the anterior branch of the compressed nerve root is involved along with the posterior branch, which innervates the paravertebral muscles, ligaments, and other soft tissues, causing symptoms such as pain and discomfort in these soft tissues. In turn, the soft tissues around the vertebrae, especially the muscles, ligaments and other soft tissues, can also stimulate the posterior branch of the spinal nerve and reflexively cause sciatica symptoms.
Differences between radicular sciatica and reflex sciatica.
Radicular sciatica
Sharp pain Clear route Continuous route
Reflex sciatica
Dull pain Blurred route Interrupted route
In most cases, degeneration of the intervertebral discs is the internal cause, and damage to the soft tissues around the vertebrae caused by external wind, cold, dampness, and strain is the external cause.
(1) Sometimes it is dominated by internal causes and external causes are not obvious, in which some patients do not have obvious symptoms of discomfort of back knocking pain, but only symptoms of lower limbs.
(2) In another part of the cases, external factors play a dominant role, and there are extremely obvious symptoms of lumbar pain and discomfort, accompanied by symptoms of the lower limbs.
(3) In some other patients, the external causes are obvious and the lumbar pain and discomfort persist for a long time, while the internal causes have not yet changed a lot, so there is only lumbar pain without lower limb symptoms.
We found in the clinic that many patients with lumbar synostosis have lower limb symptoms gradually after several years based on trauma and lumbar pain. The changes in these symptoms are also varied and seemingly irregular, but in reality there are patterns, which are just different manifestations of the same disease, i.e. lumbar pain at different stages.
The explanations for this phenomenon are.
(1) In young people, due to acute trauma, the acute onset causes the rupture of the intervertebral disc fibrous ring, and the nucleus pulposus protrudes within a short period of time, compressing the nerve root will appear in the following two situations.
(A) When pain is the main cause and numbness is mild, it means that the fatty tissue around the nerve root is mainly compressed, and the fatty tissue has aseptic inflammation, which stimulates the nerve root and causes severe pain, while the nerve root is not seriously compressed. In cases with peri-vertebral muscle ligament damage and obvious percussion pain, needle and knife stimulation and relaxation or, if necessary, addition of appropriate amount of sacral therapy, can be quickly cured.
(B) When the acute onset is dominated by numbness and muscle atrophy, or when there is numbness in the saddle area and urinary and fecal incontinence, the efficacy of conservative treatment will be reduced, and surgery is the main choice.
(2) In elderly people with low back pain, they often have low back pain first, and the symptoms of the lower limbs appear gradually after several years or even decades. These cases are generally due to pain resulting from strain on the peri-vertebral muscles, ligaments and other soft tissues, and the pain leads to muscle spasm, and the pain and spasm are a vicious circle between the two, constantly aggravating each other’s symptoms. The intervertebral disc under normal conditions bears a physiological load and slowly undergoes physiological degeneration, while the extra load generated by the tense muscles acts on the intervertebral disc fibrous ring for a long time, resulting in accelerated degeneration of the fibrous ring, which finally begins to break down after several years of overload, just like a basketball with a worn-out outer skin, the inner bile protrudes from the weak point and the nucleus pulposus protrudes, compressing the nerve root, thus producing lower limb Sciatica symptoms (radicular symptoms) in the lower extremities.
The sciatic nerve symptoms of such patients are very complex, with various and mixed manifestations, including lumbar symptoms, hip and leg symptoms, radiological neuralgia, reflex and involvement neuralgia, and the treatment of one cause alone often fails to achieve complete healing, but must target multiple causes one by one.
2. Plexiform sciatica (compression or irritation of the sacral plexus located in the pelvis)
Etiology.
(1) chronic pelvic inflammatory disease, adnexitis.
(2) pelvic trauma, injury or inflammation of the iliopsoas and pear-shaped muscles, and sacroiliac arthritis
(3) tumor
(4) prostatitis
(5) diabetes mellitus
(6) Infection
Diagnostic points.
(1) Multi-stem pain, i.e., simultaneous symptoms of multiple nerve trunk involvement
Such as.
A. sciatic nerve radiating pain to the lower extremity
B. femoral N: radiating pain to the anterior thigh
C, supragluteal N: radiating pain to the sacral region
D. inferior gluteal N: radiating pain to the buttocks
E.Closed N: radiating pain to the knee alternately or simultaneously
F. Pubic nerve: radiating pain to the perineum
G, posterior femoral cutaneous nerve: radiating pain to the posterior aspect of the thigh
Among them, B and E are the lumbar plexus, both of which have nerve fibers originating from the lumbar 4 nerve roots.
(2) Percussion pain in the lumbosacral region, and complaints of “comfort”
(3) Knee tendon reflex and heel reflex are both weakened or absent
(4) There are pelvic disorders
3.Stem sciatica (sciatic nerve trunk is mainly compressed at the pelvic outlet and on the walking route)
Key points for diagnosis.
(1) Deep pressure pain at the “ring jump”, with pain and numbness radiating to the lower limbs and feet. 60% of patients have pain at the point of N fossa and common peroneal nerve, and no obvious pressure pain, percussion pain and activity pain in the lumbar region.
(2) Rotation test (+) of the lower limb, about 10% of the pear-shaped muscles were damaged, external rotation test (+).
(3) Dry localization symptoms, manifested as sensory-motor and reflex disorders in the tibial N and common peroneal N innervated areas.
(4) Plantar numbness (more than 90% of cases).
There are 12 etiologies of dry sciatica caused by direct or indirect compression or stimulation of the nerve trunk.
(1) injury to the pear-shaped muscle – causing sciatica
(2) Damage to the gluteus medius muscle — gluteus pear syndrome — sciatica (characteristics: pressure pain and abnormal changes in the gluteus medius muscle, accompanied by the appearance of sciatica symptoms, when, through the It is only through the intermediary of the pear muscle that sciatica symptoms appear. Clinical analysis: 2/3 by the gluteus medius muscle injury resulting in sciatica symptoms, 1/3 by the pear muscle injury resulting in sciatica symptoms.
The above symptoms are typical of radiological sciatica. Another condition: injury to the gluteus medius muscle itself, which is innervated by the superior gluteal N, a branch of the sciatic nerve, and injury to the gluteus medius muscle affects the superior gluteal nerve, thus, reflexively causing sciatica symptoms.
We can imagine the nervous system as the electrical circuit system in the house, when the main circuit is damaged, the branch circuit will be seriously affected, and conversely, when a certain electrical appliance has a problem, other electrical appliances will also be affected to a certain extent, but this effect is smaller, just as sciatica caused by damage to the gluteus medius itself is often atypical and vague.
If we think about this electrophysiological line of thought, then the intricate sciatica and paresthesia symptoms will be gradually sorted out.
(3) Lumbar 3 transverse synovial syndrome: (often accompanied by lumbar 4 and lumbar 2 transverse synovial)
The clinical significance of lumbar 3 transverse synovial syndrome.
A, at the beginning of this sign, it can cause ipsilateral spasm of the gluteal muscles, spasm of the gluteus medius and pear-shaped muscles – sciatica
B, intermittent claudication: the cause is to cause spasm of the gluteus medius muscle – spasm of the gluteus medius and pear muscle – painful spasm of the gluteus medius muscle
This is a kind of arterial ischemic intermittent claudication, different from the intermittent claudication of spinal stenosis, as shown in the following table.
spinal stenosis claudication – short distance to start claudication – sensation to start claudication: radiating numbness and pain along the route of the sciatic nerve or femoral nerve – -relieved posture: must squat completely for a few moments neither sitting nor standing can relieve
ischemic claudication of the superior gluteal artery – long distance to start claudication – sensation to start claudication: muscle soreness and weakness with mild numbness – Posture for relief: sitting, standing, leaning for a few moments can be relieved, as can squatting
Treatment: For patients with lumbar spinal stenosis, sacral therapy is more effective. A high cure rate can be achieved by simultaneously performing nerve root internal and external port release by acupuncture.
For patients with lumbar 3 transverse synovial syndrome, treatment with acupuncture is very effective. Generally one to two times can be cured.
C. Transverse synovial syndrome can cause ipsilateral gluteal muscle atrophy at a later stage.
(4) Damage to three myofascial areas can cause dry sciatica.
A, paracapsular region: B, posterior iliac region: the region at the posterior 1/3 of the iliac crest; C, external gluteal region: the outer edge of the gluteus maximus muscle, slightly behind the greater trochanter. These three zones are subject to large forces, many directions, and frequent activities, and are prone to injury affecting the relevant lumbar gluteal muscles and then affecting the sciatic nerve stem sciatica.
(5) Posterior femoral muscle group subluxation bursitis – sciatica.
The above five symptoms were previously referred to as residual symptoms of lumbar disc herniation. In my opinion, in the case of lumbar herniation, the above 5 diseases are often combined at the same time.
(6) The medial edge of the biceps femoris tendon affects the common peroneal nerve. The foot and ankle cannot be lifted and feel weak.
(7) A small posterior displacement of the head of the fibula affects the common peroneal nerve.
(8) Anterolateral calf discomfort (sinking, swelling, soreness, pain, numbness) symptoms persist, similar to interfascial high compression syndrome.
(9) Pain, swelling, and discomfort in the N fossa and posterior aspect of the calf. caused by the N muscle and the posterior talus affecting the tibial nerve.
(10) Superficial peroneal N fascia outlet entrapment. Location: around the middle and lower 1/3 of the calf, there is a fascial outlet at the fibula, adhesions are tense and stuck in the N. The typical peripheral N entrapment syndrome occurs when the N is pulled.
(11) The medial end branch of the deep peroneal N is stuck. Sensation of numbness, discomfort and pain in the 1st, 2nd or 3rd toe, as well as in the metatarsophalangeal joint and palmar aspect. Location: dorsal aspect of the 1st and 2nd metatarsophalangeal joints, proximal to a vein.
(12) Flexor tenosynovitis: 1st and 2nd toes most often, treated as stenosing tenosynovitis.
Sciatica, starting from it and ending at the toe. Different parts on a journey, different degrees and forms of compression or stimulation can cause different manifestations of sciatica. In clinical practice, it is not feasible to use only monism to explain and guide the treatment of this disease without careful differentiation, and different treatment plans must be formulated for different conditions in accordance with local conditions.
If a treatment method is good, you must have a good idea of what to do before you can make a move like a god. Acupuncture therapy does work wonders in the treatment of sciatic nerve pain, but this knife will work differently in the hands of different people. If the doctor does not know the cause of sciatica in the first place, and still uses the monism of lumbar synostosis of western medicine to guide clinical treatment, he will surely meet with great frustration.
Sciatica is common, but in the end, it is caused by the intertwined and complex relationship between the bones, muscles and nerves in the pelvis. In recent years, the medical profession has come to realize that the majority of people with sciatica suffer from pelvic distortions that cause the pear-shaped muscles to tense and spasm and compress the sciatic nerve, and that a ligament in the buttocks is tense due to the long-term influence of the “pelvic sagging movement” that also compresses the sciatic nerve.
The sciatic nerve becomes congested and edematous due to pressure, causing pain, which is the cause of sciatica. As for cold and chill, they are just some external triggering factors. In Chinese medicine for sciatica there is the method of needling the ring jump point, which is for this area. In chiropractic medicine, the method of pushing the lower part of the sacrum forward and the upper part of the posterior iliac bone forward as well is needed to reduce the effect of the pelvic sagging movement, which often has an immediate effect.
Sciatica can be easily confused with the following conditions.
(1) Acute infectious polyradicular neuritis
(2) Spinal cord disease
(3) varicose veins of the lower extremities
(4) thrombo-occlusive vasculitis