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Sciatica
Are you suffering from spine pain and
want more information on available treatments that can help
relieve spinal conditions like sciatica?
Contact the professionals at United Spine & Joint to
determine what option is best for you, what your insurance
will cover and any additional surgery costs.
What is Sciatica?
The term
sciatica describes the
symptoms of leg pain and possibly tingling, numbness or
weakness that originates in the low back and travels through
the buttock and down the
large sciatic nerve in the
back of the leg.
The vast majority of people who experience sciatica get
better with time (usually a few weeks or months) and find
pain relief with non-surgical sciatica treatment. For
others, however, sciatic nerve pain can be severe and
debilitating.
Sciatica is often characterized by the following symptoms:
- Pain on one side of the buttock or in one 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
sharp pain that may make it
difficult to stand up or to walk
The clinical diagnosis of
sciatica is referred to as
a "radiculopathy", which simply means that a disc has
protruded from its normal position in the vertebral column
and is putting pressure on the radicular nerve (nerve root)
in the lower back, which forms part of the sciatic nerve.
Note that
sciatica is not a medical
diagnosis, but rather a symptom of an underlying problem in
the lower back (such as a
herniated disc or
spinal stenosis that is
compressing or irritating the nerve roots). This is an
important distinction because it is the underlying diagnosis
(vs. the symptoms of sciatica) that often needs to be
treated in order to relieve sciatic nerve pain.
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 the sciatic pain over time tends to develop as a
result of general
wear and tear on the
structures of the lower spine.
Sciatica Symptoms
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.
While
sciatica can be very
painful, it is rare that permanent sciatic nerve damage
(tissue damage) will result. Most sciatica symptoms 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.
While relatively rare, two
sciatica-related symptoms
that warrant prompt medical attention and possibly emergency
surgery, include: progressive weakness in the leg, and
either bladder or bowel incontinence or dysfunction.
Patients with either of these symptoms may have cauda equina
syndrome and should seek immediate medical attention.
Sciatica Medical Definition: Radiculopathy
To clarify medical terminology, the term
sciatica (often misspelled
as ciatica, cyatica or siatica) is often used very broadly
to describe any form of pain that radiates into the leg;
however, this is not technically correct. True sciatica
occurs when the
sciatic nerve is pinched or irritated
and the pain along the sciatic nerve is caused by this nerve
(radicular pain) and is called a radiculopathy. When the
pain is referred to the leg from a
joint problem (called referred pain),
using the term
sciatica is not technically
correct. This type of referred pain (e.g. from
arthritis or other joint
problems) is quite common.
Sciatica
Treatment
Sciatica nerve pain is caused by a combination of pressure
and inflammation on the nerve root, and treatment is
centered on relieving both of these factors. Typical
sciatica treatment include:
A. Non-surgical sciatica treatments, which may include one
or a combination of medical treatments and alternative
(non-medical) treatments, and almost always includes some
form of back exercises and stretching. The goals of
non-surgical sciatica treatment, such as
sciatica exercises, should
include both relief of sciatica pain and prevention of
future sciatica pain.
B.
Sciatica surgery, such as
microdiscectomy or
lumbar laminectomy and
discectomy, to remove the portion of the disc that is
irritating the nerve root. This surgery is designed to help
relieve both the pressure and inflammation and may be
warranted if the sciatic nerve pain is severe and has not
been relieved with appropriate manual or medical treatments.
Causes of Sciatica
Sciatica refers to a set of
symptoms that are usually caused by a problem in the lower
back called a radiculopathy - when a nerve root that
connects to the sciatic nerve is compressed or irritated.
The six most common problems that can cause sciatica and
sciatica-type symptoms include:
Lumbar herniated disc.
A herniated disc occurs when the soft inner core of the disc
(nucleus pulposus) leaks out, or “herniates”, through the
fibrous outer core (annulus) of the disc and irritates 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 over time 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, and
sciatica is the most common
symptom of a
lumbar herniated disc.
Lumbar spinal stenosis.
This condition commonly causes
sciatica due to a narrowing
of the spinal canal.
Spinal stenosis is
relatively common in adults over age 60. Lumbar spinal
stenosis is related to natural aging in the spine, 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 and causing sciatica pain.
Degenerative disc disease.
While
disc degeneration is a
natural process that occurs with aging, for some people one
or more degenerated discs in the lower back 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 spinal level, and
inflammatory proteins from inside the disc become exposed
and irritate the area (including the nerve roots).
Isthmic spondylolisthesis.
This condition occurs when a small stress fracture allows
one vertebral body to slip forward on another vertebral body
(e.g. the L5 vertebra slips over the S1 vertebra). With 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 and cause
sciatica.
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 nerve
root that comprises the sciatic nerve, it can cause
sciatica-type pain. This is not a true radiculopathy (the
clinical definition of
sciatica), but the leg pain
can feel the same as sciatica caused by a nerve irritation.
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 the sacroiliac joint, and can
cause
sciatica-type pain. This is
not a true radiculopathy, but the leg pain can feel the same
as sciatica caused by a nerve irritation.
Some less common causes of
sciatica include the
following:
- Pregnancy. The changes that the body goes
through during pregnancy, including weight gain, a shift on
one's
center of gravity, and hormonal changes, can cause sciatica
during pregnancy.
- Scar tissue. If scar tissue is affecting the
nerve root, it can cause sciatica.
- Muscle strain. In some cases, inflammation
related to a muscle strain can put pressure on a nerve root
and
cause
sciatica.
-
Spinal tumor. In rare
cases, a spinal tumor can impinge on a nerve root in the
lower back and cause sciatica
symptoms.
- Infection. While rare, an infection that occurs
in the low back can affect the nerve root and cause
sciatica.
It is important to know the underlying clinical diagnosis of
the cause of
sciatica, as treatments
will often differ depending on the cause. For example,
specific sciatica exercises, which are almost always a part
of a sciatica treatment program, will be different depending
on underlying cause of the
sciatica symptoms.
Symptoms of Sciatica
For some people, sciatica pain can be severe and
debilitating. For others, the sciatica symptoms might be
infrequent and irritating, but have 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
and other sciatica symptoms may also radiate,
prompting foot pain or pain in the toes.
There is a wide range of possible
sciatica symptoms. One or more of the following sciatica
symptoms are typical:
- Pain in the buttock 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, and for some makes it difficult to walk
With sciatica,
low back pain may be present along with the leg pain,
but usually the low back pain is less severe than the leg
pain.
Sciatica symptoms occur when the large sciatic nerve is
irritated. The sciatic nerve is the largest single nerve in
the body and is composed of individual nerve roots that
start by branching out from the spine in the lower back and
combine to form the “sciatic nerve”.
The
sciatic nerve starts in the lower 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 the L4-L5 segment in the
lower spine is named L4). The nerve passing to the next
level runs over a weak spot in the disc space, and the discs
tend to herniate (leak out) at this weak spot right under
the sciatic nerve root and can cause
sciatica.
The sciatica symptoms (e.g., leg pain, numbness, tingling,
weakness, possibly foot pain) 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).
Non-Surgical Sciatica Treatment
During an episode of
sciatica, there are a number of non-surgical treatment
options available to help alleviate the sciatic pain and
discomfort.
Heat/ice
For
acute sciatica pain, heat and/or ice packs are most
readily available and 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 people
find more relief with heat. The two may be alternated to
help with sciatica pain relief.
Sciatica Pain Medications
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
which is usually a contributing factor in
sciatica.
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.
Alternative Sciatica Treatment
In addition to standard medical treatments, several
alternative treatments have also been shown to provide
effective
sciatica pain relief for many patients. Three of the
more common forms of alternative care for sciatica
include acupuncture, massage therapy and chiropractic
manipulation.
Acupuncture
The practice is centered on the philosophy of
achieving or maintaining well being through the open
flow of energy via specific pathways in the body.
Hair-thin needles (that are usually not felt) are
inserted into the skin near the area of pain and
left in place for a few minutes to over half an
hour. Acupuncture has been approved by the U.S. FDA
as a treatment for back pain, and the National
Institutes of Health recognized acupuncture as
effective in
relieving back pain, including sciatica.
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).
Manual manipulation
Spinal adjustments and manual manipulation performed
by appropriately trained health professionals (e.g.
chiropractors, osteopathic physicians, physical
therapists) 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. Manual manipulation done to
address the right indications by appropriately
trained health professionals can create a better
healing environment and should not be painful.
Following initial pain relief, a program of
sciatica physical therapy and exercise should
usually be pursued in order to alleviate pain and
prevent or minimize any ongoing sciatic pain.
There are a number of types of non-surgical spine
care professionals who specialize in treating
sciatica symptoms, including chiropractors,
physiatrists (physical medicine and rehabilitation
specialists), pain medicine specialists, and
physical therapists, all of whom have specialized
training to provide pain relief and to help prevent
future recurrences of sciatica. It is always
advisable to have a qualified medical professional
oversee any type of sciatica treatment.
Surgical Treatment for Sciatica
If the sciatica pain is
severe and has not gotten better within six to
twelve weeks, it is generally reasonable to consider
spine surgery. Depending on the cause and the
duration of the sciatica pain, one of two surgical
procedures will typically be considered:
Microdiscectomy (microdecompression)
for sciatica
In
cases where the sciatica pain is due to a
disc herniation, a
microdiscectomy may be considered after four to six
weeks if the pain is not relieved by non-surgical
means. A
microdiscectomy may
be considered sooner than four to six weeks if the
patient’s pain and disability is very severe. Urgent
surgery is only necessary if the patient experiences
progressive weakness in the legs, or sudden loss of
bowel or bladder control.
A microdiscectomy is
typically an elective procedure, and the patient’s
decision to have surgery is based primarily on the
amount of pain and dysfunction the patient is
experiencing, and the length of time that the pain
persists. Approximately 90% to 95% of patients will
experience relief from their
sciatica pain after
this type of surgery.
Lumbar laminectomy
(open decompression) for sciatica
Spinal stenosis in
the lumbar spine often causes sciatica pain that
waxes and wanes over many years. Stenosis surgery
may be offered as an option if the patient’s
activity tolerance falls to an unacceptable level.
Again, stenosis 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.
In 2005 the FDA
approved a new surgery designed to relieve symptoms
of lumbar stenosis called the X Stop. This procedure
involves placing an implant in the very back of the
spine that prevents the patient from leaning
backwards, a position that typically causes pain in
patients with
lumbar spinal stenosis.
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.
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Some patients may
prefer to try as many different non-surgical
treatments and remain with non-surgical care for
as long as possible, and often they will figure
out how to successfully manage their condition
and keep painful symptoms at bay. For example, a
patient who has intermittent flare ups of severe
sciatica pain
may find that a combination of initial rest and
an
epidural steroid injection
followed by a gentle stretching and exercise
program is effective in alleviating the pain as
needed.
-
Some patients may
have a personal preference or a life situation
that will benefit from the more immediate pain
relief that is usually afforded by surgery. For
example, a parent with small children may not
have the time to pursue non-surgical remedies
and may need immediate pain relief in order to
be able to take care of the children and
household duties.
The important point is
that it is almost always the patient’s decision
whether or not to have the surgery, and it is our
goal at United Spine & joint to help inform our
patients of his or her options in order to make the
best choice.
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