Sciatica and Lower Back Pain

Sciatica and Lower Back Pain

Low back pain can be put into two categories: chronic and acute. However, the two types of low back pains are different. Most pains in the lower back can be naturally cured in six to seven weeks, but 10% of low back pains do not resolve in this time period. The evolution of pain from acute to chronic can be separated into three categories with subcategories. They are:

  1. Neurophysiological
    • peripheral
    • peripheral to central
  2. Psychological
    • behavioral
    • cognitive-affective
    • psychophysiological
  3. Barriers to recovery
    • medical
    • surgical
    • neuropsychological
    • social
    • physical

The barriers to recovery are further broken up, but those will be presented later on.


Peripheral mechanisms can reinforce the stimulation if the pain is persistent at the source. Chronic low back pain can cause the nerves to continuously fire, and that may cause the nerves to be over sensitive to normal stimuli, or the mild stimuli that may have otherwise resulted in a light or mild pain.

Peripheral-to-central pains, on the other hand, can be self-sustaining. They usually are such, to be honest, and also have continuous loops of pain in the spinal cord that causes the self-sustaining loop. The signal from the nerves reverberates and there it is. The inhibition or dampening of such a signal could be less or not present at all if the myelinated fibers are damaged, malfunctioning, or diseased.

A theory for this kind of pain was proposed by Wall and Gutnick and is called ectopic impulse generation. The damaged nerves produce signals that are too strong. This hypersensitivity can then cause chronic misfiring patterns in the neurons.

Signal bias can occur in three places: the spinal cord, brainstem, or in the cortex of the brain. This directs attention to the CNS and the attention of the CNS either away from or towards the peripheral or central stimuli.

Recovery Barriers

These recovery barriers stem from three different categories: premorbid factors, posttraumatic factors, or traumatic factors. Chronicity and prognosis can be impacted by these, and therefore can make a patient a poorer or better candidate for rehab or surgery.

The capacities for exercise differ in each patient. Reduction of physical activity due to the chronic low back pain can create deconditioning syndrome. This means that the muscle strength, mobility of the joints, and even fitness in the cardiovascular system can be reduced over time. This could be part of a self-sustaining cycle of illness in the musculoskeletal system.

Recovery barriers could include:

  1. Premorbid factors
    • depression
    • personality disorders/traits
    • childhood sexual abuse
    • psychosis
    • a predisposition to somatoform pain disorder
    • dysthymia and
    • anxiety disorders and panic disorder
  2. Traumatic factors
    • fear
    • a loss of control
    • abnormal dependencies
    • anxiety
    • pain
    • psychophysiological responses
  3. Posttraumatic factors
    • depression
    • Post Traumatic Stress Disorder (PTSD)
    • anger
    • hostility
    • disability mindsets
    • somatoform pain disorder
    • panic
    • anxiety
    • symptom magnifications
    • time since injury
    • latrogenic substance abuse

Personality disorders are a large factor in determining a prognosis. Borderline personalities will act differently than those who are narcissistic. Antisocial personalities can have more difficulties than others. Somatizing factors or hypochondriacs are the least likely to even respond to treatments. Chronic pains could also be influenced by avoidance, passive-aggressive, or paranoid disorders as well.

Role models might have an effect as well. A tendency to selectively attend, overgeneralize, personalize, etc. could be extremely influential in how successful the treatments could be. These kind of responses could also be affected by nightmares, headaches, fatigue, and other conditions. They usually feel as if they have lost control and depend on others in abnormal ways.

The more barriers a person has, the less clear the prognosis will be. Pre Existing factors or those that become active after the injury are part of the problem. Cognitive function that is limited could also limit the ability to make decisions on the patient’s end.

Other barriers to recovery can include:

  • family or spousal conflicts
  • financial security
  • age
  • education
  • brain injury
  • unemployment compensation
  • legal influences

In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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