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Sciatica  

What you need to know about sciatica

Understanding sciatica
Low back pain and/or leg pain that usually travels down the large sciatic nerve, from the lower back down the back of each leg, is generally referred to as sciatica and is fairly common. This pain can be caused when a nerve root in the lower spine that helps form the sciatic nerve is pinched or irritated.

Sciatica is usually caused by pressure on the sciatic nerve from a herniated disc (also referred to as a ruptured disc, pinched nerve, slipped disk, etc.) in the lumbar spine.

Sciatica occurs most frequently in people between 30 and 50 years of age. Often a particular event or injury does not cause sciatica, but rather it may develop as a result of general wear and tear on the structures of the lower spine. The vast majority of people who experience sciatica get better with time (usually a few weeks or months) and find pain relief and correction with non-surgical treatments.

Understanding sciatica pain
For some people, the pain from sciatica can be severe and debilitating. For others, the pain might be infrequent and irritating, but has the potential to get worse. Usually, sciatica only affects one side of the lower body, and the pain often radiates from the lower back all the way through the back of the thigh and down through the leg. Depending on where the sciatic nerve is affected, the pain may also radiate to the foot or toes.

One or more of the following sensations may occur as a result of sciatica:

  • Pain in the rear or leg that is worse when sitting
  • Burning or tingling down the leg
  • Weakness, numbness or difficulty moving the leg or foot
  • A constant pain on one side of the rear
  • A shooting pain that makes it difficult to stand up
  • Low back pain may be present along with the leg pain, but usually the low back pain is less severe than the leg pain

While sciatica can be very painful, it is rare that permanent nerve damage (tissue damage) will result. Most sciatica pain syndromes result from inflammation and will get better within two weeks to a few months. Also, because the spinal cord is not present in the lower (lumbar) spine, a herniated disc in this area of the anatomy does not present a danger of paralysis.

Symptoms that may constitute a medical emergency include progressive weakness in the leg or bladder/bowel incontinence. Patients with these symptoms may have cauda equina syndrome and should seek immediate medical attention.

Any condition that causes irritation or impingement on the sciatic nerve can cause the pain associated with sciatica. The most common cause is a lumbar herniated disc. Other common causes of sciatica include lumbar spinal stenosis, degenerative disc disease, or spondylolisthesis, sacro-iliac joint dsfunction and piriformis syndrome.

Sciatica symptoms and causes

Back problems and the sciatic nerve
The sciatic nerve is the largest nerve in the body and is composed of individual nerve roots that combine to form the “sciatic nerve”. It starts in the low back at lumbar segment 3 (L3). The sciatic nerve roots run through the bony canal in the spine, and at each level in the lower back a pair of nerve roots exits from the spine and then comes together to form the large sciatic nerve that runs all the way down the back of each leg. Portions of the sciatic nerve then branch out in each leg to innervate certain parts of the leg (e.g. the calf, the foot, the toes).

The nerve roots that originate in the lower back are named for the upper vertebral body that they run between (for example, the nerve that exits at L4-L5 in the spine is named L4). The nerve passing to the next level runs over a weak spot in the disc space, which is the reason discs tend to herniate (extrude) right under the sciatic nerve root and can cause sciatica.

The sciatica symptoms (e.g., low back pain, leg pain, numbness, tingling, weakness) are different depending on where the pressure on the nerve occurs. For example, a lumbar segment 5 (L5) nerve impingement can cause weakness in extension of the big toe and potentially in the ankle (foot drop)

Practical point:
Treatment of sciatica requires a diagnosis of the underlying cause of the sciatica pain.

Back problems that cause sciatica pain
Common low back problems and other spinal conditions that can cause sciatica - pain along the sciatic nerve - include:

  • Lumbar herniated disc. A herniated disc occurs when the soft inner core of the disc (nucleus pulposus) extrudes through the fibrous outer core (annulus) of the disc and the bulge places pressure on the contiguous nerve root as it exits the spine. In general, it is thought that a sudden twisting motion or injury can lead to an eventual disc herniation and sciatica. However, most discs weaken due to repetitive stress and the final result is a herniation. A herniated disc is sometimes referred to as a slipped disk, ruptured disk, bulging disc, protruding disc, or a pinched nerve.
    * See also Lumbar disc herniation
  • Lumbar spinal stenosis. This condition commonly causes sciatica due to a narrowing of the spinal canal. It is more common in adults over age 60, and typically results from a combination of one or more of the following: enlarged facet joints, overgrowth of soft tissue and a bulging disc placing pressure on the nerve roots as they exit the spine.
    * See also Lumbar spinal stenosis
  • Degenerative disc disease. While disc degeneration is a natural process that occurs with aging, in some cases one or more degenerated discs can also irritate a nerve root and cause sciatica. Degenerative disc disease is diagnosed when a weakened disc results in excessive micro-motion at the corresponding vertebral level and inflammatory proteins from inside the disc become exposed and irritate the area (including the nerve roots). The term “degenerative disc disease” is an unfortunate one as it is a process, not a disease.
    * See also Degenerative disc disease
  • Spondylolisthesis. This condition is not that uncommon in adults (approximately 5% to 7% of adults are thought to have it), but it only rarely causes back pain or sciatica pain. Spondylolisthesis occurs when a small stress fracture (most often at the fifth segment) allows the L5 vertebral body to slip forward on the S1 vertebral body. Caused by a combination of disc space collapse, the fracture, and the vertebral body slipping forward, the L5 nerve can get pinched as it exits the spine.
    * See also spondylolisthesis
  • Piriformis syndrome. The sciatic nerve can also get irritated as it runs under the piriformis muscle in the rear. If the piriformis muscle irritates or pinches a root that comprises the sciatic nerve, it can cause sciatica-type pain. This is not a true radiculopathy, but the pain can feel the same as sciatica caused by a nerve irritation.
    * See also Piriformis syndrome—another irritation to the sciatic nerve
  • Sacroiliac joint dysfunction. Irritation of the sacroiliac joint at the bottom of the spine can also irritate the L5 nerve, which lies on top of it, and cause sciatica-type pain. This is not a true radiculopathy, but the pain can feel the same as sciatica caused by a nerve irritation.
    * See also What is sacroiliac joint dysfunction?

Sciatica treatments

The good news for patients is that sciatica usually will get better over time, and the healing process usually only takes a few days or weeks. Overall, the vast majority of episodes of sciatica pain heal within a six to twelve week time span. However, occasional flare-ups of sciatic nerve pain may be an indication of a condition that should be managed so that it does not get worse over time. For most, chiropractic and regular exercise will go a long way to remedying the situation.

Sciatica medical treatments
During an episode of sciatica, there are a number of conservative care (meaning non-surgical) options available to help alleviate the sciatic pain and discomfort.

Manual manipulation
Chiropractic spinal adjustments and manual manipulation are focused on providing better spinal column alignment, which in turn should help to address a number of underlying conditions that can cause sciatic nerve pain. Chiropractic manipulation addresses the cause of the sciatic pain and can provide lasting relief.

Heat/ice for sciatica
For acute sciatica pain, heat and/or ice packs are most readily available and can help alleviate the pain, especially in the acute phase. Usually ice or heat is applied for approximately 20 minutes, and repeated every two hours. Most people use ice first, but some people find more relief with heat. The two may be alternated to help with sciatica pain relief.

Massage therapy
Certain forms of massage therapy have been shown to have a number of benefits for back pain, including increased blood circulation, muscle relaxation, and release of endorphins (the body’s natural pain relievers).

Spinal Decompression or Lumbar Traction
Traction on the lumbar spine can help reduce pressure over the nerve root. It does not work for everyone but for those that get relief it can be an effective way to treat sciatica.

Medications for sciatica
Over-the-counter or prescription medications may also be helpful in relieving sciatica. Non-steroidal anti-inflammatory drugs (such as ibuprofen, naproxen, or COX-2 inhibitors), or oral steroids can be helpful in reducing the inflammation and pain associated with sciatica. Please talk to your medical doctor regarding treatment with drugs and their associated side effects

Epidural steroid injections for sciatica

If the sciatica pain is severe, an epidural steroid injection can be performed to reduce the inflammation. An epidural injection is different from oral medications because it injects steroids directly to the painful area around the sciatic nerve to help decrease the inflammation that may be causing the pain. While the effects tend to be temporary (providing pain relief for as little as one week up to a year), and it does not work for everyone, an epidural steroid injection can be effective in providing relief from an acute episode of sciatic pain. Importantly, it can provide sufficient relief to allow a patient to progress with a conditioning and exercise program.

Physical therapy and exercise
When the sciatica pain is at its worst, patients may need to rest for a day or two, but resting for longer periods of time is usually not advisable. In fact, inactivity will usually make the sciatic pain worse. This is because regular movement and exercise is necessary to nourish the various structures in the low back and encourage the strength needed to support the low back.

Many sciatica exercises focus on strengthening the abdominal and back muscles in order to give more support for the back. Stretching exercises for sciatica target muscles that cause pain when they are tight and inflexible. When patients engage in a regular program of gentle strengthening and stretching exercises, they can recover more quickly from a flare up of sciatica and can help to prevent future episodes of pain.  

Low impact aerobic exercise, such as walking or swimming (or pool therapy) is also usually a component of recovery, as aerobic activity encourages the exchange of fluids and nutrients to help create a better healing environment. Aerobic conditioning also has the added benefit of releasing endorphins, the body’s natural pain killers, which is a natural way to alleviate sciatic pain.

Lumbar laminectomy (open decompression) for sciatica
Lumbar spinal stenosis often causes sciatica pain that waxes and wanes over many years. Surgery may be offered as an option if the patient’s activity tolerance falls to an unacceptable level. Again, surgery is elective and need only be considered for those patients who have not gotten relief from the sciatica after pursuing non-surgical treatments.  The patient’s general health may also be a consideration.

After a lumbar laminectomy (open decompression), approximately 70% to 80% of patients typically experience relief from their sciatic nerve pain.

It is important to note that the decision whether or not to pursue surgical or non-surgical remedies for sciatica is almost always the patient’s decision.  There are many considerations for the patient to take into account when deciding whether or not to have surgery.

At Holmes Spine & Sport Chiropractic we provide a number of conservative treatments to treat your sciatic pain. We also work with your family physician or orthopedic surgeon to assist in getting you any medications you may need.