Sciatica

Picture of a herniated lumbar disc.

Sciatica (pronounced sigh-AT-ih-ka) is low back pain combined with a pain radiating through the buttock and down one leg. The leg pain often goes past the knee and may go to the foot. Weakness in the leg muscles and limping can be a sign of sciatica.

• The sciatic nerves are the largest nerves in the body and are about the size of a little finger. They are formed by two lumbar nerve roots and two sacral nerve roots joining in the lowest part of the spine. These nerve roots come out of the spinal column low in the back and then pass behind the hip joint, down the buttock, and down the back of the leg to the ankle and foot.
• Sciatica is different from other forms of low back pain because while the pain most often begins in the back, it usually travels down one lower extremity.
• The pain is usually a shooting pain, like electricity. The nerve pain can also burn like fire or tingle much like the feeling when one's leg "goes to sleep." The pain can range from slightly annoying to unbearable. Some people have pain in one part of the leg and numbness in another part of the same leg.

Sciatica is caused by irritation of the sciatic nerve. Usually, there is no specific injury that is related to the onset of sciatica. Occasionally, the pain will suddenly begin after lifting something heavy or moving quickly. The following are causes of sciatica:

• Herniated disc: Herniated disc (sometimes called a slipped disc) is the most common cause of sciatica. When a disc herniates near the spinal nerve roots that form the sciatic nerve, it can cause pressure on the nerve, or irritation, which results in the symptoms of sciatica.
  • Discs are the cushions between the bones in the back. They act like "shock absorbers" when we move, bend, and lift. They are the size and shape of checkers.
  • There is a tough ring around the outside of each disc and a thick jellylike center inside (called a nucleus pulposus). If the outer edge of the disc ruptures, the center can push through and put pressure on the sciatic nerve, leading to the pain of sciatica (referred to as a herniated nucleus pulposus).
• Lumbar spinal stenosis: Lumbar spinal stenosis, a narrowing of the canal that contains the spinal cord, can cause sciatica. With age, the bone can overgrow and put pressure on the sciatic nerve. Many people with spinal stenosis have sciatica on both sides of the back.
• Spondylolisthesis: Spondylolisthesis, a condition in which one backbone has slipped forward or backward over another backbone, can result in pressure on the sciatic nerve.
• Pinched nerve: A pinched or stretched sciatic nerve can also cause sciatica.
• Piriformis syndrome: Piriformis syndrome can cause the sciatic nerve to become trapped deep in the buttock by the piriformis muscle. The symptoms of piriformis syndrome are the same as those of sciatica. Sciatica can also be caused by the nerves being pinched by osteoarthritis and fractures due to osteoporosis.
• Age-related causes: Sciatica can also be caused by other effects of aging, such as osteoarthritis and fractures due to osteoporosis.
• Pregnancy: Many women experience sciatica during pregnancy.
• Habits: Symptoms of sciatica can be caused by carrying large wallets or other hard objects such as golf balls in the back pocket of pants or sitting on a hard surface for an extended period of time.
• Underlying disease: Rarely, sciatica is a symptom of a far more serious disease, such as a tumor, blood clot, or an abscess (boil).

• Age: Age-related changes in the spine, such as arthritis and degenerating discs, are a risk factor for sciatica.
• Obesity: Excess weight, especially in the abdomen, increases the stress on the spine.
• Lifestyle: Prolonged sitting and a sedentary lifestyle are risk factors for sciatica and other back problems.

The most common symptom from sciatica is pain. Most people describe a deep, severe pain that starts low on one side of the back and then shoots down the buttock and the back of the thigh with certain movements. The medical term for nerve pain caused by a pinched nerve in the spine is radiculopathy. Sciatica can also cause knee pain, hip pain, and foot pain. Often there is muscle spasm in the low back or leg, as well.

• Sciatica pain is usually worse with both prolonged sitting and standing. Frequently, the pain is made worse by standing from a low sitting position, such as standing up after sitting on a toilet seat.
• In most people, sciatic pain is made worse by sneezing, coughing, laughing, or a hard bowel movement. Bending backward can also make the pain worse.
• People may also notice a weakness in their leg or foot, along with the pain. The weakness may become so bad they can't move their foot.

Call a doctor if any of the following conditions occur:

• Pain is not improving after several days or seems to be getting worse.
• Patient is younger than 20 years of age or older than 55 years of age and is having sciatica for the first time
• Patient has cancer or a history of cancer.
• Patient has lost a large amount of weight recently or has unexplained chills and fever with back pain.
• Patient is HIV positive or uses IV drugs.
• Patient has trouble bending forward after more than a week or two.
• Patient notices weakness is getting more pronounced over time.

Go to the emergency room if any of the following occur along with sciatica.

• Pain is unbearable, despite trying first aid methods.
• Pain follows a violent injury, such as a fall from a ladder or an automobile crash.
• Pain is in the back of the chest.
• Patient is unable to move or feel his or her legs or feet.
• Patient loses control of his or her bowels or bladder or has numbness in his or her genitals. These may be symptoms of cauda equina syndrome (a serious nervous system condition caused by damage to the nerves at the end of the spinal canal).
• Patient has a high temperature (over 101 F).

Sciatica is a clinical diagnosis. In other words, the health care professional will be able to make the diagnosis based on the patient's medical history, a physical examination, and description of his or her symptoms. If the patient has had sciatica for only a brief time and has no sign of any other diseases, no lab studies or X-ray films may be needed.

• If the pain has not improved after several weeks, CT (computerized tomography) or MRI (magnetic resonance imaging) scans of the spine may be ordered.
• If the patient has a history of cancer, HIV infection, IV drug use, or has been taking steroids over a period a time, the doctor may want to evaluate plain X-ray films of the back or a bone scan.
• Occasionally, laboratory studies may be helpful. A CBC (complete blood count) may suggest infection, anemia due to certain cancers, or other unusual causes of sciatica. Elevated sedimentation rate may suggest inflammation somewhere in the body. Urinalysis can suggest a kidney stone if there is blood in the urine, or infection, if there are bacteria and pus in the urine.

Pain from sciatica often limits one's activities. Here are some home treatments for sciatica:

• Do not bend, lift, or sit in a soft, low chair; the pain will get worse.
• Unless someone is allergic or should not take them for other reasons (if someone takes a blood thinner such as Coumadin, for example), over-the-counter pain medicines such as acetaminophen (Tylenol), aspirin (Bufferin or Bayer Aspirin), or ibuprofen (Advil, Motrin IB) will probably help ease the pain.
• Try a cold pack to see if it helps the pain. If a cold pack is not available, use a large bag of frozen vegetables; it makes a good first aid cold pack. Or have someone massage the sore areas in a triangular pattern with an ice cube. The person should move the ice cube if the skin gets too cold (this may melt several ice cubes).
  • After the cold massages, try alternating with heat from an electric heating pad to see if it helps the pain. (Do not sleep with a heating pad on the back. It could cause a bad burn.)
  • If an electric heating pad is not available, put a hand towel under hot water, wring it out, and place it on the back. Some physical therapy experts believe that moist heat penetrates more deeply and gives better relief of pain. (Do not use wet packs with an electric heating pad because electrical shock may result.)
• The affected individual may feel better lying on his or her back on a firm surface with a pillow under his or her knees. Another option is lying on one's side with a pillow between the knees to keep the back straight. Also, one might find that a recliner chair is helpful.
• Take it easy, but do not simply lie in bed because this has been shown to actually worsen the condition. Do activities one is able to tolerate, and do not expect to feel better overnight.

The mainstay of treatment for sciatica is activity modification and pain medication. After diagnosing sciatica, the doctor will almost certainly prescribe or give medication for the pain.

• Prescription-strength NSAIDs (nonsteroidal anti-inflammatory drugs) such as meloxicam (Mobic) and diclofenac (Voltaren) are frequently prescribed.
• Acetaminophen (Tylenol) and muscle relaxants such as cyclobenzaprine (Flexeril) and tizanidine (Zanaflex) are also frequently prescribed.
• If the pain is severe and not relieved by these measures, stronger medication such as a narcotic (Codeine, Vicodin, morphine) may be prescribed for relief. Narcotic medications are best used for short periods of time.

If, despite doing everything one is instructed to do, the pain continues and the CT or MRI shows a problem with the disc or bone, back surgery may be recommended. Back surgery is generally performed for patients who have tried all other methods of treatment first.

There are exceptions to this, such as people with ongoing nerve damage or cauda equina syndrome.

• Physical therapy is often prescribed for sciatica.
• Someone may receive special instructions from a doctor on dealing with back pain. Some will recommend using heat, others cold. One may also get information with pictures of back exercises and stretches one is expected to start when the pain improves. (These patient education articles come from different sources and may have conflicting information.)
• Current research articles recommend staying active, within limits imposed by one's pain. Try to stay at work if possible. If the pain forces someone to rest, do so, but avoid staying in bed just because of the back pain.
• If there is no improvement after a week or 10 days, talk with a doctor about alternative therapies. Millions of people get some relief by visiting physical therapists, osteopaths, and chiropractors. Others find that relaxation techniques and acupuncture work for them.
• Epidural injections, which are injections of a steroid (commonly known as cortisone or prednisone) into the spine, are sometimes performed for persistent sciatica.
• Studies have shown that exercise therapy is helpful to treat back pain that persists for more than a few weeks. Good exercises for sciatica include walking, yoga, Pilates, and other specialized exercise programs.
• Studies have investigated the utility of spinal manipulation (chiropractic treatment), acupuncture, and lumbar traction in treating back pain and sciatica, and the results vary. So it is not clear if these treatments are helpful.
• Recent studies in Europe and Scotland show that injection of botulinum toxin (Botox) gives relief to many people suffering from long-term sciatica. There are, thus far, not enough cases or completed studies to make this more than an experimental procedure.

• Follow the simple home care measures described above for pain relief. Use pain medicines, both over the counter and those prescribed by a doctor.
• Avoid reinjuring oneself. If hurting too much, back off on that activity and rest. Go slowly, if necessary, but try to keep active.
• Using a cane or a crutch for support will be helpful until the pain is under control.

• Proper lifting techniques in keeping the back straight while bending the knees to pick up items often help avoid mechanical back problems.
• Keep flexibility and muscle tone by performing stretching exercises. These help keep the muscles in the back healthy and strong. Maintaining one's weight within the recommended limits for one's height will go a long way to maintaining a healthy back as well.
• Walking and yoga have been shown in studies to help back pain.

While sciatica can be very painful, most of the time, the pain associated with sciatica goes away in days to weeks. Chronic pain may affect a small number of people, leading to some disability. Sciatica tends to reoccur frequently, sometimes without warning.

As one's back is recovering, avoid twisting the back while bending at the same time because this move may aggravate one's healing back and may slow recovery.