Sciatica

The sciatic nerve is the largest nerve that branches from the lower back through your hips, buttocks, and down each leg. Sciatica presents itself with pain along the pathway of the nerve, including the lower back, buttock, and the back of the thigh and calf. The symptoms include:

• Unilateral leg pain
• Pain in the lower back
• Radiating pain to foot or toes
• Numbness and burning in the distribution of the nerve
• Increased pain when keeping the leg straight
• Decreased range of motion of the hip joint

Sciatica symptoms occur when there is pathology anywhere along the course of the nerves. Sciatica develops in many ways; among them, the most common are the following:

• Herniated discs: This condition occurs when the soft center of a spinal disc pushes through a crack in the more rigid exterior casing of the spine.
• Degenerative disc disease: It is a natural aging process that acts as a precursor to disc herniation.
• Lumbar (lower back) spinal stenosis: It is the narrowing of the sciatic nerve.
• Isthmic spondylolisthesis: This condition results from the vertebra slipping forward on the sacral, pinching the nerve root as it leaves the spine.
• Piriformis syndrome: This occurs when the piriformis muscle (located in the gluteal region of the lower limbs) compresses the sciatic nerve, resulting in swelling and redness.
• Malignancy (cancer): Metastatic (spreading) bone or soft tissue cancer, sciatic nerve cancer, hemangioblastoma (a type of brain tumor).
• Infection: This can lead to abscess formation and inflammation of the disc.
• Vascular compression: Compression of the blood vessels can lead to the formation of a pseudoaneurysm (occurs when the walls of the blood vessels are injured).
• Bony compression: Overgrowth of bones in the sciatic nerve distribution can put pressure on it.
• Gynecological causes: Studies have shown that uterine fibroids and endometriosis (overgrowth of the inner lining of the uterus) can also cause sciatica.

Did you know?

Sciatica in COVID-19 patients is not uncommon. Studies have suggested that sciatic neuropathy can be seen in patients being treated for COVID-19 and that they need prolonged rehabilitation.

Sciatica may be caused due to reasons related to the disc or non-discogenic causes. However, your chances of getting sciatica increase with the following factors:

• Age: As you age, changes in your spine can lead to bony overgrowths and herniated discs, which are the most common causes of sciatica.
• Genetic predisposition: Studies suggest that lumbar disc disorders, characterized by disc herniation, have a significant genetic component that can lead to sciatica.
• Occupation: Particularly if associated with physical activity, especially flexion/torsion of the trunk, arms frequently raised above shoulder height, and driving motor vehicles.
• Incorrect walking posture: While walking, your shoulders should be back, down, and relaxed, as improper posture can compress your lumbar discs and cause sciatic nerve irritation.
• Jogging: It can predispose you to pain if you have a history of back or lumbar problems. Research shows that joggers have a lower risk for incidental sciatic pain but a higher risk for persistent symptoms.
• Smoking: Studies demonstrate that smoking is a modest risk factor for lumbar pain and clinically verified sciatica.
• Obesity: Studies show that being overweight and obese increases the risk of lumbar pain and sciatica in both men and women.
• Tall height: This risk factor is relevant for older age groups only. If you are tall, you may be at a higher risk of developing sciatica.
• Mental stress: Sciatica is linked to feelings of being overwhelmed or under pressure, and stress can exacerbate musculoskeletal conditions, including nerve pain.

Sciatic pain can mimic other types of nerve pain, making accurate diagnosis essential for effective treatment. Sciatica is primarily diagnosed through the following methods:

Medical History

A comprehensive medical history is necessary to assess:

• Localization and severity of pain
• Loss of strength
• Sensory disorders
• Duration and course of symptoms
• Influence of coughing, rest, or movement
• Impact on daily activities

Patients typically report radiating pain in the leg accompanied by sensory symptoms such as numbness, burning, or tingling. They may be asked to identify the pain distribution and whether it radiates below the knee.

Physical Examination

The physical examination largely relies on neurological testing. The most commonly used assessment is the straight leg raising test, also known as Lasègue’s sign. This sign is considered positive if the angle at which the leg can be raised before pain occurs is less than 45°.

Note: Patients with sciatica may also experience lower back pain, which is usually less severe than leg pain.

Imaging Tests

Imaging tests may be warranted if there are indications or "red flags" such as infections, cysts, tumors, or fractures, rather than disc herniation. These tests include:

• X-ray: Radiographs of the spine may reveal any bony overgrowth that could be compressing a nerve.
• CT Scan: A non-contrast computed tomography (CT) scan may be performed to evaluate fractures if plain radiographs are inconclusive. CT is also utilized to assess any soft tissue abnormalities.
• MRI: Magnetic resonance imaging (MRI) is indicated if pain persists for more than 6-8 weeks, to rule out any neurologic deficits or suspected mass effects.
• Electromyography (EMG): This minimally invasive diagnostic test evaluates the electrical signals between nerves and muscles, helping to determine the extent of nerve damage.

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Prevention is always the best course of action for any disorder. The best strategies for preventing sciatica include:

• Avoid prolonged rest: Too much rest can aggravate sciatica pain. Stay active as much as possible. Here are a few tips that can help you:
• Use the stairs instead of an elevator
• Get up and move every 30 minutes
• Switch to a standing desk with adjustable height
• Add simple stretches that you can do while sitting on your office chair
• Go for regular, short walks
• See a physical therapist and make exercise a part of your daily routine
• Exercise regularly: Beneficial exercises to prevent sciatica include walking, swimming, Pilates, and yoga. These activities strengthen the abdomen and back muscles that support the spine.
• Sleep in the correct posture: Lie flat on your back and bend your knees slightly while keeping your buttocks and heels flat against the bed. Practice stretching before sleeping and use a firm mattress to support your back.
• Burn that extra fat: Obesity is a critical risk factor in the development of sciatica. Losing weight can help relieve sciatica and prevent it in the long run.
• Be mindful of your posture: When sitting or standing, keep your back straight and shoulders back to relieve pressure on the back. Avoid sitting in the same position or habitual slouching while working at your desk for long periods.
• Lift weights with proper technique: A sudden lifting injury can herniate your disc, impinging or irritating a sciatic nerve root. Always lift objects properly by keeping your back straight and rising with your hips and legs.
• Say no to smoking: Smoking has detrimental effects on our bodies. Studies show that abstaining from smoking can reduce, but not eliminate, the excess risk of developing sciatica. Consider trying a range of smoking cessation products to eliminate this harmful habit.

While sciatica may not be a life-threatening condition, it can significantly impact the quality of life, affecting both the mind and body. Various treatment options for sciatica include:

Conservative Management

This involves explaining the cause of the symptoms and reassuring patients that symptoms usually diminish over time, even without specific measures. Advise them to stay active and continue daily activities with yoga or stretches to relieve pain.

Pharmacological Management

If pain is severe, certain medications are prescribed to provide relief. These include:

• Anticonvulsant Medications: Research supports the use of anticonvulsants that can relieve pain caused by damaged nerves, including:
  • Gabapentin
  • Pregabalin
• Tricyclic Antidepressants (TCAs): TCAs are the most studied antidepressants for the treatment of nerve-related pain. Amitriptyline is the most commonly used for managing sciatica.
• SNRIs: Serotonin and norepinephrine reuptake inhibitors (SNRIs) are antidepressants that help relieve symptoms of depression and are also used for anxiety disorders and nerve pain. The drugs used in sciatica include:
  • Duloxetine
  • Venlafaxine
• Opioid Analgesics: These are used for pain relief and include:
  • Oxycodone
  • Tramadol
  • Morphine sulfate (MST)
• Epidural Steroid Injections: These can temporarily relieve sciatica and assist patients in progressing with rehabilitation and exercise.

Surgery

Surgical intervention for sciatica focuses on removing herniated discs and, if necessary, part of the disc to eliminate the suspected cause of sciatica. Treatment aims to ease leg pain and associated symptoms, rather than reducing back pain.

Studies suggest that cauda equina syndrome (compression of a collection of nerve roots) is an absolute indication for immediate surgery. Elective surgery is the choice for unilateral sciatica. Surgical options include:

• Microdiscectomy: A minimally invasive surgical procedure performed on individuals with a herniated lumbar disc.
• Laminectomy: A surgery that creates space by removing bone spurs and tissues associated with arthritis of the spine.
• Epidurioscopy with Adhesiolysis: Epidural endoscopic adhesiolysis is a minimally invasive technique for accurately placing a drug injection (generally a local anesthetic) into the epidural space. Studies demonstrate that this technique alleviates pain and reduces sensory nerve dysfunction in patients suffering from sciatica.

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Management of sciatica requires proper care and maintaining the correct posture. Some home remedies that can prove beneficial in alleviating the pain include:

• Use hot and cold packs: Applying ice packs lessens the pain, numbs the area, and decreases inflammation. This is suggested in acute cases when sciatica flares up. A handy tip while using an ice pack is to alternate it with a heat pack once the acute pain subsides.
• Support your back: Wear a lumbar or hip brace for short durations, as it can help stabilize and support the lumbar tissues. Lumbar braces limit excessive spinal movement and can help relieve pain from nerve root endings.
• Take time for stretching: The pain from sciatica generally benefits from a stretching routine that targets the hips and hamstrings, relieving overused or inflamed muscles.
• Apply topical pain-relieving creams: Topical gels, creams, or patches that contain painkillers or numbing agents can provide fast and effective pain relief. These medications penetrate your tissues and act locally. Some of the drugs include:
• Methyl salicylate
• Menthol

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Sciatica results from pressure on the sciatic nerve, and potential complications of unresolved sciatic nerve compression include:

• Increased pain in the nerve distribution over time
• Weakness in the affected leg
• Burning or prickling sensation in the affected leg
• Decreased or loss of bowel or bladder function
• Permanent nerve damage

Complementary or alternative therapies are quite helpful in managing pain related to sciatica. However, always consult your doctor before starting anything new. Some of the beneficial treatments include:

• Physiotherapy: An essential component of conservative treatment, physiotherapy aims to promote physical and psychological health for the patient, mainly due to disc problems. Physical therapy generally includes mild stretching, pain relief modalities, conditioning exercises, and an ergonomic program.
• Acupuncture: Acupuncture is a form of alternative medicine in which thin needles are inserted into the body at specific points to provide pain relief. Studies suggest that acupuncture therapy is an effective non-drug therapy for sciatica, allowing physicians to facilitate individualized treatment decisions regarding its management.
• Chiropractic therapy: This form of alternative medicine is used to diagnose, treat, and prevent mechanical disorders, especially of the spine. A chiropractor is a trained professional who treats physical problems by manipulating the bones in a person’s back, which may help relieve sciatica pain.

Sciatica is a common condition that is a significant cause of work absenteeism and a major financial burden to industry and health service providers. Remember, time heals everything, and you can learn to manage pain with time. Some important considerations for managing sciatica include:

• Do not sit or stand in the same position for more than 20 minutes.
• Avoid exercises that stretch your hamstrings (muscles at the back of the thighs from hips to the knee).
• Always warm up before lifting heavy weights.
• Avoid rowing machines in the gym as they can strain the lower back.
• Do not stress your back by bending over too often.
• Stay away from complete bed rest.
• Make sure your office chair is comfortable.
• Avoid twisting motions of your spine.
• Try not to lift heavy objects.
• Avoid long car trips.
• Learn to manage stress efficiently.