SCIATICA: SYMPTOMS, CAUSES, AND TREATMENTS
What is sciatica?
Sciatica is a term that describes low back and radiating leg pain that travels past the knee. The term in and of itself does not refer to any specific cause of the pain, but it can have multiple causes which will be discussed later. Hippocrates is sometimes credited as being the first to use the term "sciatica" which derives from the Greek ischios, meaning hip. Since the early to mid 20th century, we have come to understand that this type of pain more commonly results from a lumbar spine issue rather than a hip condition.
What are the symptoms of sciatica?
Sciatic pain usually starts in the low back and then travels down the leg.
The most common symptom of sciatica is back and leg pain, as previously mentioned. This pain can vary in intensity, from mild to excruciating. Other symptoms may include numbness, tingling, or a pins-and-needles sensation in the leg or foot. Some individuals may also experience weakness in the affected leg, making it challenging to stand, walk, or lift the leg. The symptoms of sciatica can be intermittent or constant and are often aggravated by activities such as sitting, standing, or bending, usually depending on the specific cause. All of these symptoms stem from irritation or compression of the sciatic nerve or its roots.
Can sciatica occur down both legs?
Yes, sciatica can occur down both legs, although it is relatively less common than sciatica that affects only one leg. Bilateral symptoms can occur if there is compression of the nerve roots within the central part of the spinal canal. Each sciatic nerve originates from several nerve roots in the lower back and travels down through the buttocks, hips, and legs. In the central spinal canal, the nerve roots to each side are in close proximity to one another.
How can I tell if pain in my hip is a hip issue or sciatica?
This question can be a complicated one, and a good healthcare provider would best be able to help you sort it out. As described below, determining the cause of the pain involves a thorough history and examination, appropriate diagnostic testing, and assessment of response to treatment. All of these factors can help determine if the pain is related to a hip issue or sciatica.
Risk factors for sciatic nerve pain
Several risk factors can increase the likelihood of developing sciatica. Age is one of the most common unmodifiable risk factors. As people age, the intervertebral discs in the spine can degenerate, leading to disc herniation or narrowing of the spinal canal, which can put pressure on the sciatic nerve roots. Excess body weight is another risk factor as it puts added stress on the spine and can contribute to disc degeneration and herniation, increasing the risk of sciatica.
Jobs that involve prolonged sitting or heavy lifting can strain the lower back and increase the risk of developing this condition. At the same time, lack of regular physical activity can weaken the back and core muscles, making the spine more vulnerable to injury and compression of the sciatic nerve roots. Accidents or injuries that affect the lower back can damage the spinal structures, including the sciatic nerve roots.
It is important to note that while these risk factors can increase the likelihood of sciatica, not everyone with these factors will develop the condition, and it can occur in individuals without any apparent risk factors as well. Maintaining a healthy lifestyle, including regular exercise, proper posture, and weight management, can help reduce the risk of developing this condition and other spine-related issues.
What causes sciatica?
Sciatica generally does not actually refer to sciatic nerve impingement, but rather refers to pain in the distribution of that nerve. It is usually caused by compression of one or more lumbosacral spinal nerves, prior to these nerves joining to form the sciatic nerve. The most common causes include:
Herniated discs (herniated disk): A herniated disc (herniated disk) occurs when the soft inner material of an intervertebral disc pushes through its outer layer and puts pressure on the adjacent spinal nerves, including the roots of the sciatic nerve.
Degenerative disc disease: With age and wear and tear, the intervertebral discs in the spine can degenerate, leading to a reduction in disc height and narrowing of the space between vertebrae, causing compression of the roots of the sciatic nerve.
Lumbar spinal stenosis: This condition involves the narrowing of the spinal canal, which can put pressure on the nerves as they travel through that space..
Spondylolisthesis: This occurs when one vertebra slips forward over the adjacent vertebra, causing narrowing of the space where the nerves travel and compression.
Trauma or injury: Accidents, falls, or sports-related injuries can cause direct trauma to the lower back, leading to sciatica.
Tumors or growths: Abnormal growths in or near the spine can put pressure on the roots of the sciatic nerve.
Piriformis syndrome: The piriformis muscle, located in the buttocks, can sometimes irritate or compress the sciatic nerve. This is one case in which sciatica does not emanate from the lumbosacral spine but actually from compression of the specific nerve.
Exams and Tests
To diagnose sciatica and determine its underlying cause, healthcare professionals may use various tests and diagnostic tools. These tests aim to assess the source of pain, identify any nerve compression or inflammation, and rule out other potential conditions.
The healthcare provider will first take a detailed and complete medical history, asking about the patient's symptoms, their onset, duration, and any factors that exacerbate or relieve the pain. During the physical examination, the healthcare provider will assess the patient's reflexes, muscle strength, and sensation in the affected leg. They may also perform specific tests that reproduce the sciatic pain, such as the straight leg raise test.
After the history and examination, the healthcare provider may order imaging studies which can include x-rays, magnetic resonance imaging (MRI), or computed tomography (CT). Plain X-rays of the lumbar spine can help identify any structural abnormalities or degenerative changes, such as bone spurs which may hint at a particular cause of sciatica. MRI scans provide detailed images of the spinal structures, including the intervertebral discs, nerves, and soft tissues. This helps to visualize any herniated discs, nerve compression, or other abnormalities. CT scans can offer cross-sectional images of the spine and are sometimes used in conjunction with MRI to provide more detailed information about bony structures. Ultrasound imaging can be used to visualize the soft tissues, such as muscles and tendons, and may assist in identifying sources of compression, especially in a case of piriformis syndrome as described above.
MRI of the Lumbar Spine may help determine the cause of sciatica.
Electromyography (EMG) and Nerve Conduction Studies (NCS) can assess the function of the nerves and muscles, helping to determine if there is nerve damage or dysfunction. These tests can sometimes identify the exact location of nerve compression and the severity of nerve involvement.
In some cases, diagnostic injections of local anesthetics or corticosteroids may be used to temporarily numb or reduce inflammation around specific nerves. If the injection provides relief from pain, it may help pinpoint the source of the problem.
It is essential to note that a combination of these tests and clinical evaluation is typically used to diagnose sciatica accurately. The goal is to identify the cause of the sciatic pain and develop an appropriate treatment plan tailored to the individual's specific condition and needs.
What are the complications of sciatica?
Sciatica, if left untreated or not managed properly, can lead to several complications and adverse effects on the affected individual's health and well-being. Some of the potential complications include:
Without effective treatment, this condition can become chronic, leading to persistent and debilitating pain in the lower back, buttocks, and legs. Chronic pain can significantly impact a person's quality of life, daily activities, and emotional well-being.
More concerning is that untreated sciatica can lead to long term nerve damage. Prolonged compression or irritation of the roots of the sciatic nerve can result in muscle weakness in the affected leg. Weakness can affect balance, stability, and overall mobility, leading to difficulties in walking, standing, or performing normal activities. If nerve damage is severe, sciatica may be accompanied by cauda equina syndrome—a medical emergency characterized by symptoms such as loss of bladder or bowel control, numbness in the genital area, and weakness in both legs. Cauda equina syndrome requires immediate medical attention and surgical intervention to prevent permanent nerve damage.
Acute sciatica treatments
Treatments for acute sciatica aim to alleviate pain and reduce inflammation caused by compression or irritation of the nerve roots in the lumbosacral spine that join to form the sciatic nerve. In general, strict bed rest is not recommended for sciatica but relative rest may be necessary to reduce pain. Medications such as non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can help manage pain and reduce inflammation. Other medications commonly recommended include acetaminophen, muscle relaxers, and neuropathic pain medications.
Applying heat to the affected area for 15-20 minutes several times a day may also help to reduce pain. Gentle stretching and low-impact exercises to improve flexibility and relieve pressure on the nerve can also help in the early days of sciatica treatment. In more severe cases, a healthcare professional may recommend epidural steroid injections to deliver anti-inflammatory medication directly to the affected area, but this treatment is usually only done after more conservative treatments have failed.
How is chronic sciatica treated?
Epidural steroid injections are one treatment that can provide relief to patients suffering from sciatica.
The treatment of chronic sciatica focuses on relieving pain, reducing inflammation, improving function, and enhancing the individual's overall quality of life. Since it can be complex and multifactorial, a combination of conservative treatments is often used to manage the condition effectively. Some of the common treatments include:
Physical therapy: Physical therapy is a cornerstone of treatment for chronic sciatica. It aims to stabilize the muscles that support the spine, improve flexibility of the lower extremities, and correct postural imbalances. Specific exercises and stretches can be tailored to the individual's needs to relieve pressure on the sciatic nerve roots and reduce pain.
Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can help reduce pain and inflammation associated with chronic sciatica. In some cases, muscle relaxants, neuropathic pain meds (nerve pain meds) or low-dose antidepressants may also be prescribed to alleviate nerve-related pain.
Epidural steroid injections: These injections deliver corticosteroids directly into the area surrounding the sciatic nerve to reduce inflammation and provide long-lasting pain relief.
Heat and cold therapy: Applying heat or cold to the affected area can help relax muscles and reduce inflammation, providing temporary relief from chronic sciatica pain.
Transcutaneous Electrical Nerve Stimulation (TENS): TENS involves the use of a device that delivers electrical impulses to the affected area, helping to block pain signals and provide pain relief.
Acupuncture: Some individuals find relief from chronic sciatica through acupuncture, a traditional Chinese medicine technique involving the insertion of thin needles into specific points of the body.
Mind-body techniques: Practices such as yoga, tai chi, or mindfulness meditation may help manage chronic sciatica by reducing stress and promoting relaxation.
Lifestyle modifications: Maintaining a healthy weight, engaging in regular low-impact exercises, and practicing good posture can help reduce pressure on the spine and alleviate chronic sciatic pain.
Assistive devices: The use of lumbar support cushions or ergonomic chairs may help reduce strain on the lower back and improve comfort during prolonged sitting.
Surgical intervention: In cases where conservative treatments have been ineffective or when there is evidence of severe nerve compression or structural issues, surgery may be considered. Surgical procedures, such as discectomy, laminectomy, or spinal fusion, aim to relieve pressure on the sciatic nerve roots and stabilize the spine.
It is important for individuals with chronic sciatica to work closely with their healthcare providers to develop a comprehensive treatment plan that addresses their specific needs and goals.
Outlook (Prognosis)
The prognosis for sciatica varies depending on the underlying cause and the severity of nerve compression. In many cases, the outlook for this condition is positive, and the majority of people experience improvement in their symptoms with appropriate management. However, the length of time for recovery can vary from a few weeks to several months, sometimes even longer.
Many minor cases of sciatica may resolve relatively quickly with conservative treatments such as rest, physical therapy, and medications. In these cases, the prognosis is generally excellent, and individuals can expect a full recovery.
In more severe cases of sciatica caused by conditions like herniated discs or spinal stenosis, the prognosis may be more variable. Some individuals may experience gradual improvement with conservative treatments, while others may require more extensive interventions such as epidural steroid injections or surgery to relieve nerve compression and alleviate symptoms. In such cases, the recovery process may take longer, and residual symptoms may persist even after treatment.
Overall, the prognosis is generally favorable, and most individuals experience significant relief from symptoms with appropriate care and management. However, the specific outcome can vary based on individual factors, and close collaboration with a healthcare professional is essential to ensure the best possible outcome and quality of life.
Surgery options for sciatica
Surgery for sciatica is typically considered when conservative treatments have not provided sufficient relief or when there is evidence of severe nerve compression or structural issues that require surgical intervention. The specific type of surgery performed for this condition depends on the underlying cause and the location of the nerve compression.
Some common types of surgery include microdiscectomy, laminectomy, spinal fusion, foraminotomy, and artificial disk replacement. The general goal of any of these surgeries in sciatica is to relieve compression and irritation of the affected nerve in order to reduce symptoms.
The choice of surgical approach depends on factors such as the patient's overall health, the severity and location of nerve compression, and the surgeon's expertise. Minimally invasive techniques are becoming increasingly common, offering smaller incisions, reduced tissue damage, and quicker recovery times compared to traditional open surgery.
How soon after treatment will I feel better?
The timing of improvement after treatment for sciatica is variable and usually depends on the particular cause of the condition and also the degree of the problem. Mild cases of sciatica can often resolve within days to weeks, but more severe cases can last many months or even years. Therefore, it is important to seek specialty care early in the course of sciatica in order to determine the best treatment plan. If the treatment plan is not helping the problem, it is important to adapt the plan to try and improve the patient's condition.
In patients that are not improving with exercise, medications, and relative rest, they may need to have more invasive treatments like injections or surgeries to treat their sciatica.
What are the possible complications or side effects of treatment?
All treatments for medical conditions like sciatica can have complications or side effects. Physical therapy is generally very low risk but can sometimes worsen the symptoms. Each medication prescribed for sciatica can have its own list of possible side effects, and these can usually be found on the insert within the medication package.
Epidural steroid injections for sciatica can cause a patient to have a red face for a few days, disrupted sleep for a few days, headache, worsening of pain, increased blood pressure, or increased blood sugar in diabetics. These injections also carry a very low risk of infection, nerve injury, paralysis, bleeding, or even death.
Surgeries are by definition invasive and carry more risk than the other treatments mentioned. Complications of surgery for sciatica include chronic pain, infection, bleeding, blood clots, and other less common issues. All possible complications should be discussed with the patient prior to surgical intervention.
When should I see my healthcare provider, or when should I seek care?
While mild, short-term sciatic pain can sometimes resolve on its own with rest and conservative measures, certain signs and symptoms warrant immediate medical attention. Here are some situations when you should seek healthcare for sciatica:
Severe pain: If you experience intense or excruciating pain in your lower back or legs, especially if it is affecting your ability to move or function, seek medical attention promptly.
Numbness or weakness: If you notice numbness, tingling, or weakness in your legs or feet, especially if it's on one side of your body, it could indicate nerve compression and requires evaluation by a healthcare professional.
Loss of bowel or bladder function or control: If you experience difficulty controlling your bowels or bladder, it could be a sign of cauda equina syndrome, a rare but serious condition requiring immediate medical attention.
Progressive symptoms: If your symptoms are worsening over time, rather than improving, it's important to get evaluated to identify any underlying causes.
History of trauma: If your symptoms are related to a recent injury, accident, or fall, seeking medical attention is important to rule out fractures or other serious spine injuries.
Recurring symptoms: If you have a history of sciatica and the symptoms are recurring or chronic, it's essential to consult a healthcare professional for proper management and to prevent potential complications.
Persistent symptoms: If your sciatica symptoms persist for more than a few weeks despite rest and home care, it's advisable to seek medical evaluation to determine the underlying cause and explore appropriate treatment options.
Impact on daily activities: If your sciatica pain is affecting your ability to perform daily activities, work, or sleep, medical evaluation can help identify strategies to manage the pain and improve your quality of life.
New or unexplained symptoms: If you experience new or unexplained symptoms along with sciatica, such as fever, unexplained weight loss, or loss of appetite, it's important to seek medical attention to rule out other potential medical conditions.
When in doubt, it's always better to err on the side of caution and consult a healthcare professional for a proper evaluation and diagnosis. A healthcare provider, more specifically a pain specialist, can assess your symptoms, perform a physical examination, order appropriate tests or imaging if necessary, and recommend an individualized treatment plan to manage your condition effectively. Early intervention can lead to better outcomes and prevent potential complications associated with sciatica.