Lumbar ischialgia is a term denoting pain in the lower back with irradiation into the buttock, into the leg, along the back of the leg. Pain may be accompanied by numbness and tingling in the area of innervation of the sciatic nerve. The term lumboischalgia (synonymous with lumbosacral radiculitis) refers only to pain syndrome and is not a diagnosis.
Luboischialgia is characterized by one or more symptoms:
- Constant pain only in the buttock or thigh on one side (less often in both legs)
- Pain worsens when sitting
- Burning or tingling sensation spreading down the leg
- Weakness, numbness, or loss of movement in the leg
- Constant pain on one side
- Severe pain that may make it difficult to stand or walk
Pain syndrome with lumbar ischialgia can be of varying intensity depending on the underlying disease that led to the development of lumbar ischialgia. Symptoms of lumbar ischialgia are caused by irritation of the sciatic nerve.
The sciatic nerve is the largest nerve in the torso and is made up of individual nerve roots that originate in the lumbar spine (at L3) and collectively form the “sciatic nerve.” The sciatic nerve runs from the lumbar spine to the leg. Parts of the sciatic nerve then branch in each leg and innervate specific parts of the leg - buttocks, thighs, calves, feet, toes.
Symptoms of lumbar ischialgia (lumbosacral radiculitis) such as pain in the leg, numbness, tingling, weakness may vary depending on where the nerve compression occurs.
The incidence of lumboischalgia (lumbosacral radiculitis) increases in middle age. Lumbar ischialgia rarely occurs under the age of 20; such pain syndromes are most likely at the age of 40-50 years, and in the older age group the likelihood of lumbar ischalgia decreases.
Often, specific events or injuries do not cause inflammation of the sciatic nerve, but over time the damage leads to the development of sciatica. In most patients, conservative treatment can be quite effective, and the pain syndrome decreases significantly within a few weeks, but in a certain number of patients the pain syndrome may be persistent.
Causes
There are 6 most common causes of lumbar ischialgia:
Herniated disc in the lumbar spine.
A herniated disc occurs when the soft inner core of the disc (nucleus pulposus) protrudes through the fibrous outer ring, affecting nearby nerve roots.
Osteochondrosis
Degenerative changes in the intervertebral discs are a natural involutional process that occurs as the body ages. Degenerative changes in the discs can lead to irritation of the roots and the development of pain.
Spondylolisthesis
This condition occurs when the vertebral arches are damaged (spondylolysis), resulting in the sliding of one vertebra in relation to another. Displacement of the vertebra causes damage and displacement of the intervertebral disc, which together can lead to irritation of the nerve roots and irritation of the sciatic nerve.
Spinal stenosis of the lumbar
This condition usually causes inflammation of the sciatic nerve due to narrowing of the spinal canal. Spinal stenosis in the lumbar region is most often associated with natural involutional changes in the spine and occurs in patients over 60 years of age. The condition usually results from a combination of one or more of the following factors: enlargement of the facet joints due to bony overgrowth, soft tissue overgrowth (ligamentous tissue), and disc bulging (herniated disc).
Piriformis syndrome
Irritation of the sciatic nerve can occur in the area in the buttock under the piriformis muscle. If there is a spasm of the piriformis muscle or other changes in this muscle, the sciatic nerve may be affected with the development of pain. And although this syndrome is an independent disease, pain in the leg can be similar to lumbar ischialgia.
Sacroiliac joint dysfunction
Irritation of the sacroiliac joint can also cause irritation of the L5 root, which exits at the top of the sacroiliac joint, and if there is a problem in this joint, inflammation of the sciatic nerve and pain may occur. Pain in the leg can be similar to that which occurs with lumbar ischialgia (lumbosacral radiculitis).
Other causes of lumbar ischialgia
A number of other conditions and diseases can cause inflammation of the sciatic nerve, including:
- Pregnancy. Changes in the body that occur during pregnancy, including weight, a shift in center of gravity, and hormonal changes, can cause inflammation of the sciatic nerve during pregnancy.
- Presence of scar tissue. If scar tissue presses on nerve roots, it can irritate the sciatic nerve
- Crick. In some cases, inflammation associated with muscle strain can put pressure on the nerve roots and cause inflammation of the sciatic nerve.
- Spinal tumors. A tumor in the spine (most often of metastatic origin) can have a compressive effect on the sciatic nerve.
- Infections. Infections rarely occur in the spine, but can also cause an impact on the roots with the development of inflammation of the sciatic nerve.
Diagnosis of the causes of pain in the buttocks and their treatment
Most often, diseases in this area are dealt with by surgeons, orthopedists, neurologists, traumatologists, and dermatologists. Initially, you can contact a general practitioner - a therapist, who will refer you to the appropriate specialist.
To diagnose the cause of pain in the buttock, use:
- general analysis, biochemical blood test;
- tissue biopsy;
- examination of synovial fluid;
- physical examination;
- radiography;
- magnetic resonance imaging;
- computed tomography;
- ultrasonography;
- electromyography;
- testing reflexes and strength in the lower extremities;
- tuberculin test.
Based on the results of the selected diagnostic complex, the patient may be prescribed:
Symptoms
As a rule, with lumbar ischialgia, symptoms occur on one side, and the pain starts from the lower back and goes down the back of the thigh down to the foot.
- Pain in the lower back is usually less intense than in the leg.
- Pain, as a rule, on one side of the lower back with irradiation into the buttock or thigh along the sciatic nerve - along the back of the thigh, lower leg and foot.
- The pain decreases when the patient lies down and when walking and intensifies when standing or sitting.
- The pain is acute and burning in nature.
- Some patients may describe a feeling of tingling, numbness, or weakness in the leg.
- Weakness or numbness when moving your leg.
- Severe or shooting pain in the leg that may make it difficult to stand or walk.
- Depending on the location of the effect on the sciatic nerve, pain may also occur in the foot and toes.
Symptoms of lumbar ischialgia depend on where the root compression occurs.
For example:
- L4 root - Symptoms will usually appear on the hip. Patients may experience weakness when straightening the leg and possibly a decreased knee reflex.
- L5 root – symptoms may occur in the big toe and ankle. Patients may feel pain or numbness in the top of the foot (between the big and second toe).
- S1 root – symptoms may appear on the outer part of the foot, radiating to the toes and little toe. Patients may experience weakness when lifting the foot or trying to stand on tiptoes. There may also be decreased ankle reflexes.
When several roots are compressed, a combination of symptoms is possible.
There are a number of symptoms that deserve special attention, as they require emergency medical attention, sometimes even surgical intervention. These symptoms are:
- Symptoms that continue to worsen rather than improve may indicate possible nerve damage, especially if neurological symptoms have progressed (eg, weakness in the leg).
- Symptoms of lumbar ischialgia occur in both legs and there are signs of bowel or bladder dysfunction, which may be a sign of cauda equina syndrome. For cauda equina syndrome, emergency surgery is indicated.
If you have these symptoms, you should immediately seek medical help.
Why do my buttocks hurt?
Traumatic injuries
The most common traumatic cause of the development of the symptom is a bruise.
The injury occurs as a result of a fall on the buttocks and is more common in winter. It is characterized by moderate pain, gradually subsiding over several days, swelling, and bruising. Movements are not impaired or slightly impaired. With severe bruises or impacts with a hard object on the gluteal region, hematomas are formed. The pain is initially pressing and aching, later bursting, and increases with continued bleeding into the hematoma cavity. During the examination, local dense edema is detected. Subsequently, the pain decreases and a fluctuating formation forms.
Local infectious processes
In the buttock area, superficial and deep pyoderma are often detected. This area is a common localization of ecthyma vulgaris. With superficial pyoderma, the pain is insignificant or moderate, combined with itching and burning. The buttock swells, phlyctens, bullous rashes or pustules form on it. Purulent foci open with the formation of erosions, the pain becomes raw. A secondary infection may occur with the development of a severe purulent process.
Of the deep pyodermas on the buttocks, boils and carbuncles are most often found. They are accompanied by rapidly growing pain, which after 1-2 days becomes tugging, bursting, throbbing, and deprives sleep. The degree of disturbance of the general condition depends on the size of the purulent focus. A limited dense swelling of a purple hue with one or several rods in the center is determined. After the abscess has matured, the rod is surrounded by a yellowish rim. Palpation is sharply painful, fluctuation is detected.
The buttock area is the most common location for post-injection abscess. The onset of a purulent process may go unnoticed, since after an injection a painful infiltrate normally forms. A distinctive feature of an abscess at the initial stage is the intensification, rather than subsidence, of pain. Subsequently, the injection site turns red, swells, and the pain becomes twitching and pulsating. It becomes impossible to sit on the buttock. Symptoms of intoxication and general hyperthermia are revealed.
Pararectal dermoid cysts are sometimes localized in the buttock area. In the absence of infection, the disease is asymptomatic or manifests itself as minor pressing pain. When suppuration occurs, the pain becomes sharp, bursting, pulsating, disrupts night sleep, and is accompanied by weakness, fatigue, hyperthermia, and symptoms of intoxication. Palpation reveals sharp pain.
Purulent bursitis develops when the mucous bursa located between the gluteus maximus muscle and the posterior surface of the greater trochanter becomes infected. It manifests itself as symptoms of a deep abscess: increasing pain, increased temperature, deterioration of general condition, limitation of movements. Due to the deep localization of the bursa, it may be difficult to determine the type of abscess.
In bedridden patients, bedsores form on the buttocks. Pain syndrome is noted already in the initial stages of bedsore formation, but due to its insignificant severity, it often goes unnoticed. Possible burning, itching, discomfort, increased local sensitivity.
Buttock pain
Joint diseases
The symptom is often observed with arthritis of the hip joint. The disease develops gradually. Initially, patients are bothered by dull aching pain in the buttock, groin area, and on the outside of the joint. Subsequently, pain becomes the cause of limited movements, gait disturbances, and the appearance of lameness. The pain intensifies after being in a stationary position. The following pathologies may be the cause of pain:
- Specific infections
: tuberculosis, brucellosis, syphilis, gonorrhea. - Secondary aseptic arthritis
: Crohn's disease, SLE, psoriasis. - Reactive arthritis:
after urogenital (mycoplasmosis, ureaplasmosis, chlamydia) and intestinal (yersiniosis, dysentery, salmonellosis) infections.
Dull, transient pain can be observed in various forms of seronegative spondyloarthritis, including ankylosing spondylitis, Reiter's disease, Behçet's syndrome, and chronic intestinal diseases. Soreness in the upper outer quadrant of the buttock is typical of inflammation of the sacroiliac joint. Features of the symptom are determined by the type of sacroiliitis:
- Purulent
. There are sharp, rapidly growing pains in the buttock, abdomen and lower back, intensifying with hip extension. The body temperature is elevated, the condition is serious. - Aseptic
. Identified in rheumatic diseases. Accompanied by moderate or mild pain in the buttock, radiating to the thigh, worsening at rest, weakening during movement. - Tuberculous
. Moderate pain without clear localization, stiffness, and local hyperthermia are detected. Over time, a leaky abscess often forms on the thigh.
Soft tissue pathologies
Myalgia in the gluteal muscle area develops after significant exercise, usually during sports training. They have a tugging, sometimes burning character. They sharply intensify at the beginning of movements, subside a little after warming up, a light massage, or a short warm-up. They persist for 2-3 days and gradually disappear.
Biceps tendonitis is more common in runners. Accompanied by deep pain in the buttock, radiating down the back of the thigh. At first, the symptom bothers you only during intense exercise; later it occurs with any movement, and is sometimes observed at night. With enthesopathy of the ischial tuberosity, pain is localized at the point of attachment of the muscle to the bony protrusion, initially mild, and subsequently progressive.
Bursitis of the ischial bursa of the gluteus maximus muscle is manifested by pain in the projection of the buttock, which intensifies when sitting on a hard surface or bending forward. It develops with repeated trauma (falls on the buttocks, pressure and blows to the buttocks), and is more often diagnosed in figure skaters and people involved in equestrian sports.
Neurological diseases
Pain in the buttock is typical of radicular syndrome, which is observed in a number of spinal diseases. It has an aching, burning, baking, shooting character, depends on the position of the body, is combined with paresthesia, in severe cases - with paresis, hyporeflexia, and sensory disturbances. Detected in the following diseases:
- Degenerative
: lumbar osteochondrosis, disc hernias and protrusions, spondyloarthrosis, spondylosis. - Developmental anomalies
: sacralization, lumbarization. - Injuries
: conditions after fractures of the lumbar vertebrae, traumatic spondylolisthesis. - Tumors
: primary and metastatic neoplasms.
The cause of radicular syndrome can also be infectious processes: tuberculosis, syphilis, spinal osteomyelitis, spinal meningitis. In addition, burning, shooting, pulling, cerebral, baking pain in the buttock, radiating along the back surface of the limb, is found in such neurological pathologies as:
- sciatic nerve neuropathy;
- lumbosacral plexitis;
- gluteal muscle syndrome.
Other pathologies
Other diseases associated with pain in the gluteal region include:
- Positional compression syndrome.
Occurs when sleeping for a long time in an uncomfortable position while under the influence of drugs or alcohol. It can cause the development of acute renal failure, which is life-threatening due to a significant array of damaged gluteal muscles. - Chronic pelvic pain syndrome (CPPS)
. Painful sensations in the buttock are radiating in nature and are observed in many diseases of the female genital organs: oophoritis, adnexitis, salpingitis, endometritis, myoma, ovarian cyst. Sometimes they are diagnosed with urological pathologies and gastrointestinal diseases: cystitis, urolithiasis, colitis. - Leriche's syndrome.
At first, the pain in the buttocks is minor, nagging. Subsequently, intense pain occurs during walking and causes intermittent claudication. In the final stages, pain is noted even at rest. - Dercum's disease.
Along with the buttocks, stabbing, burning or aching pain appears in the hips, shoulders, and abdomen. Multiple lipomas are detected. - Mental disorders
. Soreness in the gluteal area can be detected in hysteria, depression, certain diseases accompanied by senestopathies, sensory hallucinations.
Treatment
In most cases, conservative treatment of lumbar ischialgia is quite effective. The range of treatment methods for lumbar ischialgia is wide and is aimed at reducing compression of the nerve roots and reducing pain. The most effective is the use of an integrated approach to the treatment of lumbar ischialgia and the use of a combination of various treatment methods (physiotherapy, massage, manual therapy, drug treatment, acupuncture and exercise therapy).
Drug treatment . The use of anti-inflammatory drugs (ibuprofen, naproxen, voltaren), COX-2 inhibitors (Celebrex) can reduce inflammation, which leads to a decrease in pain.
Epidural injections . If severe pain is present, an epidural steroid injection may be given. Epidural steroid administration differs from oral steroid administration in that the drugs are injected directly into the painful area around the sciatic nerve, which can quickly reduce inflammation and relieve pain. The effect of such a procedure is usually temporary, but it helps to relieve severe pain quite quickly.
Manual therapy
Modern gentle manual therapy techniques make it possible to restore the mobility of the motor segments of the spine, remove muscle blocks, improve the mobility of the facet joints and can sometimes significantly reduce compression of nerve fibers.
Acupuncture also helps reduce pain and restores conduction through nerve fibers.
Massage
Therapeutic massage methods can improve microcirculation, relieve muscle spasms, and also increase the body's production of endorphins.
Physiotherapy . Existing modern methods of physiotherapy (cryotherapy, laser therapy, ultrasound, electrophoresis) can reduce inflammation, improve blood circulation and thus reduce pain.
Exercise therapy . Physical exercises, which need to be included after pain has been reduced, allow you to restore the muscle corset and normalize the biomechanics of the spine, improve blood circulation in the motor segments. Physical exercises include both mechanotherapy (exercises on machines) and gymnastics, which allows you to develop both muscles and strengthen the ligamentous apparatus. Exercises for lumbar ischialgia must be selected with a physical therapy doctor (instructor), since independent exercises often lead to a relapse of symptoms.
Surgery
Indications for surgical treatment are the following factors:
- Severe pain in the leg that lasts for more than 4 to 6 weeks.
- Lack of effect from conservative treatment and persistence or worsening of neurological symptoms.
- Pain syndrome significantly impairs the patient's quality of life and the patient's ability to participate in daily activities
Urgent surgery is usually only necessary if there are progressive neurological symptoms (increasing weakness in the legs or sudden loss of bowel or bladder function).
Diagnosis of piriformis syndrome
In addition to the examination, checking tendon reflexes, posture and gait, the doctor prescribes instrumental research methods to the patient. Among them, the most informative is considered to be radiography of the spine in the lumbar region, as well as the joints of the sacrum with the pelvic bones. In addition, comprehensive results can be obtained by magnetic resonance scanning of the lumbar and sacral area. Radioisotope scanning is used in cases of suspected cancer or infection in the area of the piriformis muscle and nearby organs.
A clear confirmation of piriformis syndrome is the diagnostic injection of an anesthetic solution into the muscle, which can be done under the guidance of an x-ray or computed tomography. If the pain disappears after the injection, then the diagnosis is made without doubt.