Making Sense of Sciatica
Who would think that one nerve could cause such severe pain? Pressure on the sciatic nerve can force even the most hardy person to seek treatment.
Sciatica. Just pronouncing it can be painful (sigh-AT-ik-ah). Sciatica gets its name from the longest and largest nerve in the body, the sciatic nerve. It is composed of five small nerves that join together in the pelvis, after they exit the lower spine. The sciatic nerve then branches into two trunks that travel down the entire length of each leg, dividing again into smaller nerves as they reach the knees and the lower legs. Sciatica is defined as pain anywhere along the course of the sciatic nerve.
Pain That Radiates
It can come on gradually or virtually overnight, the main symptom of sciatica is pain or discomfort that usually centers in the lower back and radiates down one leg. The pain can vary greatly in intensity and location. In some cases it is minimal and feels like a slight ache, a pins and needles feeling, or a slight numbness. In other cases, the pain can be extreme, making virtually any physical movement excruciatingly painful. And as noted, it can be felt anywhere along the length of the sciatic nerve from the lower back, hips, or buttocks, all the way down the length of the legs and into the feet and toes.
Though it can affect anyone at any age, sciatica tends to be more common in men over age 40. Depending on the cause and the success of the subsequent treatment, sciatica can last for days, weeks, months, or even years.
Causes Can Vary
Sciatica can result from a number of causes. Most commonly, it is caused by some part of the spine rubbing against or putting pressure on the sciatic nerve. Most often, this rubbing or pressure results when one of the discs (cushions) that sits between the vertebrae of the spine becomes inflamed, ruptures or herniates (protrudes). What might cause these disc problems?
- Injury to the disc itself or to the ligaments around it
- Arthritis in the lower back area
- Constant pressure on the spine and lower back due to pregnancy, excess weight, or certain repetitive physical activities
- Osteoporosis leading to fracture of the spine
- Slippage of vertebral bodies–known as spondylolisthesis
Although much less common, sciatica can also occasionally result when a blood clot, abscess, or some type of growth or tumor puts pressure on the sciatic nerve. As odd as it may seem, some men may be more susceptible to sciatica because they carry their wallets in their back pockets, at the exact spot where the sciatic nerve travels through the buttocks. When sitting, the weight of the wallet puts pressure on and, over time, can aggravate the sciatic nerve.
Treatment Is Conservative at First
In as many as 50% of all cases, sciatic pain will greatly diminish or disappear within a month with supportive treatments. Therefore, the initial treatment is generally conservative, including:
- Avoidance of all strenuous physical activity
- Application of ice packs for 10-15 minutes, sometimes alternating with heat every twenty minutes, two or three times a day (NOTE: Never apply ice directly to the skin)
- Adequate amounts of sleep
- Anti-inflammatory drugs and pain relievers, such as aspirin, acetaminophen (Tylenol and others), or ibuprofen (Motrin and others)
- Corticosteriods may occasionally be injected into the space around the spinal column for temporary reduction of inflammation and relief of particularly severe acute pain. There is little or no evidence that injections into the subdural space have any benefit in chronic pain
Looking for the Source of Pain
Many physicians recommend initial x-rays for persons over 50, with a history of cancer, or with persistent pain or pain worse at night. If pain is very severe or causes numbness, tingling, strange sensations, loss of sensation, difficulty in walking, or especially when there is associated difficulty with urination, bowel movements, or (in men) erection, your doctor or physical therapist may order tests to locate the source of the sciatica. Prompt CT scanning or magnetic resonance imaging (MRI) may be done. A type of x-ray of the spine called a myelogram may also be performed. This involves an injection of a dye into the spine.
Treatment will depend on what the tests find and on the duration and intensity of the pain. Positive findings may lead to emergency surgery; however sciatica, no matter how painful, is only rarely a surgical emergency. For most people there is no benefit in seeking the exact location of the source of pain. Waiting 2-4 weeks for pain improvement is the usual procedure.
- If the tests discover a growth, tumor, or blood clot, surgery to remove it or drugs to clear or shrink it are usually prescribed.
- If the tests discover a disc problem, surgery, physical therapy, chiropractic or osteopathic treatment, or injections to reduce the inflammation are all options, though there is little evidence that any of these produce better long-term outcomes than just waiting for the pain to go away on its own.
Exercise: Probably the Best Treatment
While many treatments, including spinal manipulation, have been shown to be helpful for treating acute sciatica, exercise has increasingly emerged as among the most important treatments for both acute and chronic sciatica. Strengthening of core muscles is probably helpful, as is exercise supervised by a physical therapist—especially when the therapist identifies in which directions the least pain is experienced.
Dealing With Disc Problems
Because of the risks associated with surgery, particularly around the spine, many people will first opt for physical therapy, chiropractic, and/or osteopathic treatment to try to ease the pressure the disc places on the sciatic nerve.
If therapy doesn't work, you may have corticosteroid injections to reduce the inflammation. Though generally less risky than surgery, the injections do entail some risk, including the risk (though relatively low) of nerve damage. These procedures have produced mixed degrees of success in people with unrelenting sciatica, and recent studies have questioned the effectiveness of corticosteroid injections. Electro-thermal surgery is an experimental procedure that offers an alternative to receiving injections, using electricity to heat and shrink the swollen tissue. Some patients choose less conventional, although increasingly more accepted, procedures such as acupuncture or biofeedback.
Surgery May Be Necessary
If none of these treatments adequately control your sciatica or you have any sensory changes, your doctor may suggest surgery. Surgery is usually a last resort though, and the desired results are not always obtained. The most common type of surgery for sciatica is a discectomy, whereby all or part of the disc that is pressing on the sciatic nerve is removed.
Since the advent of laser surgery, some patients and their surgeons now opt for laser discectomy, a somewhat less invasive procedure whereby a laser is used to remove the portion of the disc that is pressing on the sciatic nerve. Removing part of the vertebra that presses on the sciatic nerve is a procedure called laminotomy.
Though both types of surgery are relatively safe and can reduce or eliminate the sciatic pain, both are considered major surgery of the spinal area and only have moderate success rates. Surgery to this area always carries some degree of risk, including the risk of nerve damage.
Prevention: Taking Care of Your Back
As with most conditions, prevention is your best medicine. To avoid developing sciatica, take the following precautions:
- Keep physically fit, exercise, and strengthen your abdominal and back muscles.
- Try to maintain good posture, both when sitting and standing, and avoid sitting for extended periods of time.
- Avoid carrying your wallet in your back pocket, or keep its contents to a minimum.
- Never bend over to lift something. When lifting an object, keep your back straight, bend your knees, and extend your arms to grab the object. Keep it close to your body and raise it by straightening your legs.
"While it may or may not be connected to a problem with your sciatic nerve, anytime you have a loss of muscle control in the leg (or loss of bowel or bladder control), it is imperative to seek medical attention immediately." Shillue says.
The American Academy of Orthopaedic Surgeons
American Council on Exercise (ACE)
Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 2004 Dec 1;29(23):2593-602.
Last reviewed June 2008 by Rimas Lukas, MD
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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