The Complete Guide to Sciatica - Types, causes and treatments
If you have ever suffered from sciatica you will know how painful and disruptive it can be. Sciatica can stop you being able to do the most basic things such as walking, bending or sitting and severely interrupt your life.
In this blog we will look at:
- What is the sciatic nerve?
- What actually is sciatica?
- What are the types of sciatica?
- Who is at risk?
- What causes sciatica?
- What are the symptoms?
- How is sciatica diagnosed?
- What are the non surgical treatment options?
- What are the surgical options?
- Which health care professions do what?
- How long will it take to get better?
If you suffer from sciatica it’s vital that you understand what is the cause of your sciatica, the assessment and treatment options available to you and who you should see to regain your health.
WHAT IS THE SCIATIC NERVE?
The sciatic nerve is the name of the longest nerve in your body. It is actually made up of two nerve roots that exit from the lower lumbar spine and three nerve roots that exit from the sacrum.
It travels from your low back out through your buttocks and down your thigh to your knee, calf, foot and toes. Your brain connects with the muscles in the lower leg and feet via the sciatic nerve, controlling muscle activity and sensation in your leg. It is vital for the control of your movement, sensation and balance.
WHAT IS SCIATICA?
Sciatica is actually the term that we use to describe any pain or symptoms, such as tingling or numbness that travel down the path of the sciatic nerve. Just like the word “headache” it is not an actual diagnosis of your problems, just an accurate description of the location of your pain.
Sciatic pain can be anything from a mild ache in the to levels of pain of such severe intensity simple tasks such as walking, bending, sitting or even just standing up can be difficult and in some cases impossible.
What are the types of sciatica?
There are two types of sciatica:
In Neurogenic sciatica the pain is caused by compression of the sciatic nerve or smaller nerve roots that form it, symptoms can vary in severity due to the amount of pressure on the nerve. This can be caused by a variety of problems, from bulging discs to tight muscles.
The discs between the vertebra can bulge, herniate or sequestrate (burst) causing direct pressure on the nerves leaving the spine. Pressure directly onto the spinal cord from within the spine can also compromise the function of the sciatic nerve. Tight muscles through the buttocks and top of the legs can also irritate and put pressure on the sciatic nerve.
In most of these cases the leg pain is worse than the back pain and described as a sharp, burning, shooting pain. It is often associated with a feeling of numbness, pins and needles, hot and cold sensation and muscle weakness.
With neurogenic sciatica there are usually abnormal neurological exam findings such as a loss the normal reflexes, muscle weakness and sensory changes.
Referred Sciatica is pain due to a muscle and joint problem in the spine and pelvis, it can mimic sciatica and it is important to determine the cause of your pain. Referred pain is usually dull and achy but can also be sharp in nature. It does not usually cause a feeling of ‘pins and needles’, hot and cold sensation, numbness or muscle weakness.
In some cases the pain is worse in the back than it is in the leg and doesn’t usually have a shooting quality to it. Abnormal neurological findings, such as reflex changes, objective weakness and sensory changes, are unlikely to be present.
Who is at Risk for Sciatica?
It is estimated that over 40% of the population will experience sciatica at some time. The most common age for developing sciatica is between 40 to 50 years of age however it can affect any age group.
The major risk factors associated with sciatica are patients who have
- Pre-existing spinal degeneration
- Loss of normal spinal movement
- A Sedentary Lifestyle
- Employment involving in heavy work especially lifting
What Causes Sciatica?
1. Disc Bulge or Herniation
The intervertebral disc is constructed of outer rings of cartilage inside of which there is a soft centre called the nucleus pulposus.
When the disc bulges (prolapses) the nucleus polyposis has shifted with the disc however it remains contained within the outer cartilage rings. A bulging disc is very common in patients over 40 years of age.
When the disc herniates (sequestration) this soft material escapes out of the disc through tears that occur in the outer fibers of the cartilage called annular tears. The nerve roots are extremely sensitive and the subsequent sciatic pain is caused by irritation of the spinal nerve roots, inflammation caused by proteins contained in disc material or a combination of both. They are caused by pre-existing weakness in the annulus or a sudden increase in pressure through the disc, poor posture over time damaging the discs, a sudden unexpected load or a motor vehicle accident.
2. Degenerative Joint Disease
When there is degeneration (arthritis) in the spine and the intervertebral discs the spaces between the vertebra are narrowed. This can lead to nerve root irritation and sciatic pain in one or both legs. If the disc is damaged severely inflammatory proteins from inside the centre of the disc can irritate the nerve root causing sciatic pain.
3. Spinal Stenosis
The spinal canal is pathway the spinal cord passes through as it travels down inside the spine. In the case of spinal stenosis the canal has become narrowed and the restricted space inside the canal can put pressure on the spinal chord cause sciatica.
There are many different causes of spinal stenosis including spinal degeneration, damage to the spinal joints between the vertebra and cysts or tumors growing within the spinal canal.
4. Abnormal Spinal Movement
When the lumbar spine has a restricted or abnormal movement range there is often associated irritation of the joints between the vertebra, localised inflammation and muscle spasm and tightness. These changes can lead to irritation of the sciatic nerve and subsequent sciatica. These changes can be from poor posture past trauma to the spine and poor work and home environments placing stress on the spine.
5. Sacroiliac Joint Dysfunction
The sacroiliac (SI) joint is located between the sacrum (the large bone at the bottom of the spine) and the pelvis. The sciatic nerves run close to the SI joint as it exits the pelvis and damage or inflammatory condition affecting the joint can cuase irritation of the nerve and sciatica.
6. Piriformis Syndrome
The sciatic nerve runs below or through the piriformis muscle as it exits the spine. A tight or spasming piriformis muscle can irritate the nerve as it passes into the leg causing sciatic pain. Most patients with sciatica will have a tight piriformis muscle as the this muscle is plays a part in the stabilisation of the low back. When a patient is experiencing sciatica this muscle will tighten up as part of the natural protection mechanism of the body. It is rare however that the tight piriformis is the only cause of the sciatica.
A spondylolisthesis is where one vertebra slips forward over the vertebra below. There is usually an association with a loss of disc height and narrowing of the spaces where the spinal nerves exit. The most common site for a spondylolisthesis is the lower lumbar spine where the nerve roots that form the sciatic nerve exit from the spine. Pressure on the nerves at this level can cause radiating sciatic pain.
The most common causes of a spondylolisthesis are trauma to the spine, arthritis and degeneration, pathology (such as cancer or infection), and previous surgical procedures to the spine.
During a pregnancy the mother’s centre of gravity will move forward as the baby increases in size and weight. This causes an increase in the curve of the lower back and can lead to irritation of the spinal nerves in this area. In some cases this will lead to sciatic pain in one or both legs. The position of the baby can also lead to an irritation of the sciatic nerve and sciatica. Often spinal problems that were present before the pregnancy will worsen during this period.
9. Muscle Strain
Severe damage to the muscles surrounding the spine can cause irritation of the nerve roots as they exit the spine. When there is an injury to the spine one of the first mechanisms that your body will do to protect itself from further injury is to tighten the muscles surrounding the spine to try to prevent futher aggravation of the injury. It is rare for muscles to be the cause of sciaica in most cases the muscle tightness and spasm is secondary to the sciatica or spinal injury.
10. Tumors, Fractures, Infection
Damage to the structure of the spine from cancer, trauma or infections can cause pressure or impingement on the nerve roots in the lower back and subsequent sciatica. While this is a very uncommon cause of sciatica, it is vitally important that these potential causes are ruled out before any treatment is started.
11. Ankylosing Spondylitis
This is an uncommon type of arthritis that effects the spine and pelvis. The chronic inflammation that occurs in and around the spine with this disease can cause symptoms such as sciatica.
WHAT ARE THE SYMPTOMS OF SCIATICA
The symptoms of Sciatica are usually a combination of
- Sharp, shooting or searing pain in the leg
- Numbness or pins and needles in leg and foot
- Weakness when moving the leg or foot ,
- Electric shock sensation in back or legs
- Burning or prickling sensations
- Inability to bring the foot upwards (walk on heels)
- Weakness in lifting the big toe or ankle up
- Pain and/or numbness on top of the foot, particularly between the big toe and second toe.
- Pain and/or numbness to the lateral, or outside, of the foot;
- Difficulty raising the heels off the ground
These symptoms will vary depending on many different factors, including the cause and location of the symptoms. While these symptoms can be severe and debilitating, it is rare that the sciatic nerve is permanently damaged.
The location of sciatic pain is:
- back of the thigh
- back and outside of the calf,
- foot and toes.
The symptoms are usually only experienced in one leg but can occur in both.
With sciatica most patients will find that:
- Pain that is worse when sitting or standing
- Pain improves when lying down or walking
- It difficult to stand up or walk normally
- Pain is aggravated by sneezing or coughing
Cauda Equina Syndrome
Rarely people suffering sciatica can also experience a loss of bowel or bladder control or a progressive weakness or loss of sensation in their legs. These are symptoms of a possible cauda equina syndrome. This condition is very serious and anyone experiencing these symptoms should contact their doctor urgently. If the nerve is compressed and the pain and symptoms are severe, surgery may be warranted.
How Do You Find the cause of sciatica?
A thorough history and examination must be completed to determine the cause of your sciatica.
To diagnose what is actually causing your sciatica the first step is to get a complete history of your pain and symptoms. You will be asked about the location of your symptoms, what movements makes the pain worse, and what you find relieves the pain.
Often specific information at this stage starts to point to the location of the cause. Certain symptoms are unique depending on the underlying cause of the sciatica. For example, bending the body backward or walking more than a short distance will often aggravate sciatic symptoms when spinal stenosis is the cause. Bending the body forward may trigger symptoms if the cause is a lumbar herniated disc.
Once the history is completed a physical examination will be performed to help find any underlying causes of your sciatica. This will involve a thorough assessment of your posture, spinal range of motion, physical condition and balance. During this assessment what movements relieve or aggravate the sciatica is carefully monitored. In the physical exam, your doctor will observe your posture, spinal range of motion, muscle spasm and physical condition, noting any movement that causes you pain.
During this part of the examination your reflexes in your knees and ankles are tested. The strength of the muscles supplied by the sciatic nerve and ability to feel touch along the sciatic nerve is also assessed. These tests are very good indicators of the presence and location of specific nerve root irritation or injury.
During this examination the joints of the spine and pelvis, the muscles and nerves are put under a mild physical stress. During this assessment which tests relieve or aggravate the sciatic pain is carefully monitored. The results give valuable information about the cause of the sciatica.
What tests are performed depends on which specific disease, illness or injury are suspected to be causing the sciatica.
The most common tests include:
- Computer Tomography (CT scan)
- Magnetic Resonance Imaging (MRI)
- Blood tests
These tests help find the cause and also rule out any other pathologies as the cause of your symptoms so the most appropriate treatment can be given.
HOW DO YOU TREAT SCIATICA
Many people who experience sciatica get better within a few weeks or months using a functional approach to treatment without surgery.
Nonsurgical Treatment for Sciatica
If you suffer from sciatica its most likely started from a functional, mechanical problem in your spine. The initial aim of your treatment is to remove the irritation of the nerve, reduce inflammation in the area and improve the movement in your spine.
It is important to stop you aggravating the problem further by avoiding activities such as bending, lifting and prolonged sitting. In severe cases you will need painkillers and anti-inflammatory medication to help control the symptoms while the cause is removed. Initially stretching exercises are also an important part of your treatment.
The most important thing is that once your condition has stabilised your health care practitioner designs an individual treatment program and exercise regime to remove the underlying cause of your sciatica.
There is a broad range of treatment options available and sciatica generally responds best to a combination of the treatments below.
Spinal Manipulation and Mobilisation
Poor biomechanical function in the lower back is usually involved of the cause of sciatic pain. Spinal manipulation and mobilisation aims to restore normal balanced movement to the spine which will remove the irritation of the sciatic nerve and stop the sciatica. It is normally combined with specific flexibility and strengthening exercises to surrounding musculature to achieve the best long term improvement possible. Chiropractors are the experts at performing this treatment. It is also performed by osteopaths and some doctors and physiotherapists who have completed further training in this area.
Over-the-counter nonsteroidal anti-inflammatory drugs such as ibuprofen or stronger prescription medications are often used to reduce the inflammation that is associated with the irritation of the sciatic nerve. These drugs do not treat the cause however they can be effective at reducing or relieving sciatica pain. When combined with effective treatments to remove the cause such as spinal manipulation they can help provide fast effective treatment of sciatic pain. Muscle Relaxants or narcotic medications may also be prescribed for the short term (a few days and up to 2 weeks) to alleviate pain in severe cases.
Massage therapy aims to increase blood circulation, relax muscles and release of endorphins which are the body’s natural pain relievers. Massage therapists believe that reducing muscle tightness and will allow the restoration of normal movement of the spine and remove the irritation of the sciatic nerve.
A range of different exercises can used to help strengthening your core, improving the flexibility of your lower spine or stretching muscles through the area. Which exercises are recommended for will vary dependent on the cause of your sciatica and the severity of your condition.
TENs and Ultrasound
These are used to help reduce inflammation and pain due to sciatic nerve irritation. This is usually used in conjunction with exercises for flexibility and strength of the lower back.
For acute sciatic pain, heat and/or ice packs can help alleviate the leg pain, especially in the initial phase. Usually ice or heat is applied for approximately 20 minutes, and repeated every two hours. Most people use ice first, but some find more relief with heat. The two may be alternated. It is best to apply ice with a cloth or towel placed between the ice and skin to avoid an ice burn. Ask your health care practitioner
Epidural Steroid Injections
Epidural steroid injections are used to reduce the inflammation in the spine when the patients pain is severe. The injection goes directly into the inflamed area around the sciatic nerve. The effects tend to be temporary and do not address he underlying functional issues that created the problems. Importantly, it can provide sufficient relief to allow a patient to progress with a conditioning and exercise program.
Acupuncture and Dry Needling
These two techniques are very similar, hair-thin needles are placed into the skin at specific points. Acupuncture aims to restore well-being by altering energy flow in the body while dry needling aims to remove trigger points contained overactive muscles. Both of these techniques have shown good results in reducing sciatica pain however neither technique addresses the most common causes of sciatica such as disc damage and poor biomechanical damage.
Surgical Treatment for Sciatica
For the small number of people that when the pain is severe or does not get better with conservative treatment, a more structured treatment approach, and possibly surgery, may be the best option for finding pain relief and preventing or minimizing future pain and/or dysfunction.
Surgery should be a last resort and is sometimes necessary, especially if bowel and bladder control is affected. If your chiropractor has any doubts about the cause of your problems or whether they can help you they will refer you to your doctor or a spinal surgeon for another opinion.
Surgery for sciatica is considered when the patient has the following:
- Severe leg pain that has persisted for greater than six weeks
- Pain that is not relieved after all non surgical treatment such as chiropractic, drug treatment and injections
- Severe Limitations on the patient’s ability to participate in normal everyday activities
The most common types of surgery
In this surgery the part of the disc creating pressure on the nerve is removed while the rest of the disc is untouched. This is only applicable to the sciatic pain being caused by a disc herniation.
In this surgery, the small portion of the bone and/or disc material that is pinching the nerve root is removed. This allows for extra space within the vertebrae and the pressure on the nerve is reduced.
This type of surgery is performed for severe disc injuries. The vertebra above and below the injured disc are fused together to prevent movement. Short term this surgery can have a good result however the increased stress to the areas above and below the surgery can lead to long term problems at different levels.
The injured disc is replaced with an artificial disc usually made of metal. It is similar to a hip or knee replacement. This is relatively new surgery and its long term results are unknown at this stage.
Who treats sciatica?
Chiropractors aim to restore the normal spinal function to your spine, strengthen the surrounding muscles and balance the neurological control of the region. This is achieved by using highly specific spinal techniques and a specific rehabilitation exercise program
Clinically chiropractors generally find that most of their patients suffering from sciatica get relief after a period of chiropractic care, exercises, rest and avoiding any aggravating activities.
Your doctor may suggest Over-the-counter pain medications such as ibuprofen or codeine or stronger prescription drugs such as stronger narcotics for a short time. They can also use Nerve pain medications and Muscle relaxants to control symptoms. In severe cases Cortisone injections can be given into the area around the spinal nerves. Your doctor may recommend a chiropractor masseur or physiotherapist to help remove the underlying cause of the sciatica or refer you to a specialist for a further opinion.
Physiotherapy treatment for sciatica usually involves massage, dry needling, TENS machine, exercises or taping. Physiotherapists use similar exercise techniques to those used by chiropractors to improve spinal movement and strengthen spinal muscles.
Massage aims to increase blood circulation, relax muscles and release of endorphins which are the body’s natural pain relievers. Masseurs believe that reducing muscle tightness and will allow the restoration of normal movement of the spine and remove the irritation of the sciatic nerve.
How long will it take to get better?
The healing process takes time and varies from person to person, often depending on the severity of the condition and the history of the complaint. However, how active and compliant you are in your own treatment will influence your recovery time.
The recovery time can take days weeks or even months depending on the cause of your pain and will vary from perosn to person.
what to do if you have sciatica?
If you are experiencing sciatic pain it is important to achieve an accurate diagnosis prior to commencing any treatment. This is achieved through a thorough examination process that allows your chiropractor or other health professional to discover the cause of your sciatica and design the best treatment for you.
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