Introduction

Lumbosciatica refers to the combination of low back pain (pain in the lower back) and sciatica (pain radiating down a leg along the path of the sciatic nerve). They are most often due to a herniated disc or osteoarthritis of the lumbar spine, which irritates or compresses a nerve root. This is an extremely common reason for consultation:  low back pain is the leading cause of work absence worldwide. Although the majority of episodes resolve within a few weeks, some cases of lumbosciatica can reveal a serious pathology requiring urgent care.

If you have lower back pain radiating down your leg, first contact your primary care physician. If they are unavailable, Docadom offers an emergency consultation by a doctor at home : call 021 845 45 45 or use our app available on the App Store and Google Play.

Who is at risk of suffering from it?

The risk factors are multiple: carrying heavy loads, poor professional postures, sedentary lifestyle, prolonged sitting or standing, overweight, history of low back pain, pregnancy, weak abdominal and back muscles, lumbar osteoarthritis, herniated disc, osteoporosis, poor physical condition, smoking (which impairs the nutrition of the intervertebral disc), psychosocial factors (stress, depression, anxiety). Men and women are equally affected, with the peak incidence between 30 and 50 years old.

Symptoms of lumbosciatica

The symptoms combine lumbar pain and radicular pain of a specific distribution.

Main symptoms

• Low back pain : pain in the lower back, sometimes mechanical (worsened by exertion, relieved by rest) or inflammatory (night waking, morning stiffness).

• L5 sciatica : pain radiating down the postero-lateral aspect of the thigh, leg, to the top of the foot and the big toe.

• S1 sciatica : pain radiating down the posterior aspect of the thigh and leg, to the heel and the little toe.

• Cruralgy : pain radiating to the anterior aspect of the thigh, in case of damage to the L3-L4 roots.

• Paresthesias (tingling, numbness) in the territory of the affected root.

• Muscle weakness, sometimes motor deficit (extension of the big toe, walking on tips of toes or heels).

• Worsening by coughing, sneezing or defecation (indicative sign of radicular compression).

• Stiffness, limitation of movements of the lumbar spine.

When to consult urgently?

An emergency consultation is necessary in the following situations ("red flags"):

• Cauda equina syndrome : sphincter disorders (incontinence or urinary or fecal retention), saddle anesthesia, motor deficit in both legs — call 144.

• Rapid and significant motor deficit of a leg.

• Low back pain associated with fever (suspicion of spinal infection).

• Pain occurring after a major trauma.

• Low back pain in a patient with a history of cancer, osteoporosis, or taking corticosteroids.

• Intense night pain, weight loss, deterioration of the general state.

• Patient aged > 50 years with new-onset low back pain.

What to do before calling Docadom? Avoid strict bed rest (which worsens the situation), move gently and contact your primary care physician first. If they are unreachable or if you need a doctor at home outside of opening hours, call Docadom at 021 845 45 45 or make your request directly from our smartphone application (App Store and Google Play). In case of neurological signs (loss of strength, sphincter disorders, saddle anesthesia), dial 144 without delay.

Causes of lumbosciatica

Mechanical causes (the most common)

• Herniated disc : this is the most common cause of sciatica in young adults.

• Lumbar osteoarthritis and degenerative disc disease : more common after age 50.

• Spinal stenosis : neurogenic claudication of the elderly.

• Spondylolisthesis : slipping of one vertebra over another.

• Traumatic muscle or ligamentous injuries.

Inflammatory, infectious and tumor causes

• Ankylosing spondylitis and other inflammatory rheumatisms.

• Infectious spondylodiscitis (rare but serious).

• Vertebral metastases from cancers (breast, prostate, lung, kidney).

• Myeloma, primary tumors.

• Vertebral compression fracture due to osteoporosis.

Diagnosis of lumbosciatica

The diagnosis is essentially clinical. Imaging is only indicated in case of a red flag, persistent pain or before an interventional procedure.

Diagnostic methods

• Anamnesis : onset circumstances, Pain characteristics, associated signs, medical history.

• Clinical examination : search for Lasègue's sign, neurological examination of the lower limbs (strength, sensitivity, reflexes), spine examination.

• Radiographs of the lumbar spine: not very useful in acute, ordinary low back pain, useful in case of red flags.

• Lumbar MRI : gold standard examination in case of persistent sciatica, neurological deficit, or before surgery.

• CT scan in case of contraindication to MRI.

• Laboratory workup (CBC, CRP, protein electrophoresis) in case of suspicion of inflammatory, infectious, or tumor etiology.

• Electromyogram (EMG) in case of doubt regarding nerve root involvement.

Alternative diagnoses

• Coxarthrosis or hip pathology, which can sometimes be misleading.

• Piriformis syndrome.

• Diabetic or other peripheral neuropathies.

• Peripheral artery disease of the lower limbs (arterial claudication).

• Abdominal aortic aneurysm in elderly subjects.

• Pelvic pathologies (gynecological, urological).

Treatment of lumbosciatica

Management combines medical treatment, maintaining adapted activity, and rehabilitation.

Medical treatment

• Paracetamol as first-line treatment.

• NSAIDs (ibuprofen, ketoprofen, diclofenac): highly effective on inflammation, for a short duration.

• Muscle relaxants (thiocolchicoside, tetrazepam should be avoided): useful if marked muscle spasms are present.

• Level 2 analgesics (tramadol, codeine) if necessary.

• Oral corticosteroids in a short course: sometimes used in hyperalgic sciatica.

• Epidural or foraminal injections: in case of persistent sciatica.

• Strong opioids must be avoided in the long term.

Non-drug measures

• Maintaining an adapted physical activity : strict bed rest is harmful.

• Physiotherapy : stretching, muscle strengthening, core training, back school.

• Application of heat or cold depending on preferences.

• Ergonomic advice for work and daily life.

• Regular physical activity (walking, swimming, cycling) once the acute phase is past.

• Management of psychosocial factors.

Surgical treatment

Surgery is indicated in case of cauda equina syndrome (emergency), significant motor deficit, or persistent sciatica after 6 to 8 weeks of well-conducted medical treatment. Techniques include microdiscectomy,  laminectomy, and sometimes arthrodesis.

Prevention of lumbosciatica

• Regular muscle strengthening (abdominal, back, core).

• Regular physical activity : walking, swimming, cycling, yoga, pilates.

• Good postures at work (station ergonomics, screen at eye level).

• Learning to lift loads by bending knees and keeping the back straight.

• Avoid sedentarity, change position regularly.

• Maintaining a healthy weight.

• Smoking cessation (impairs disc nutrition).

• Management of stress and sleep disorders.

• Adjustment of the mattress and pillow.

Possible complications

The majority of lumbosciatica cases heal without sequelae. Some can progress to chronic low back pain, a source of prolonged disability. The most serious complication is cauda equina syndrome, an absolute neurosurgical emergency. Other complications include recurrences, neurological sequelae (motor or sensory deficit), chronic neuropathic pain, and professional and psychosocial impact (prolonged work absences, depression).

When to contact a doctor for lumbosciatica

Any new or persistent lumbosciatica deserves medical advice. Here is the course of action to follow:

• First-line recourse : contact your primary care physician, who can evaluate the situation, prescribe an appropriate treatment, and refer to a specialist if necessary.

• If your primary care physician is unavailable (evening, weekend, vacation), Docadom offers an emergency consultation by a home doctor. Call 021 845 45 45 or make your request via our mobile app, available for free on the App Store and Google Play.

• In case of signs of severity (rapid motor deficit, sphincter disorders, saddle anesthesia, fever, history of cancer), dial 144 without delay.

Conclusion: keep moving, do not immobilize herself

Lumbosciatica is a common condition, mostly benign but sometimes disabling. It is characterized by lumbar pain associated with radiation into the leg along the territory of a nerve root, which can lead to complications like cauda equina syndrome, a neurological deficit or disabling chronicity. Treatment relies on painkillers, maintaining activity and physiotherapy, sometimes on surgery.  Prevention through muscle strengthening, ergonomics, and physical activity remains the key.

In case of severe or persistent pain, first contact your primary care physician. If they are not available, Docadom provides you with an emergency doctor at home 7 days a week: call 021 845 45 45 or use our mobile app (App Store, Google Play) to request an emergency consultation.