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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 ďherniatesĒ, 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
           - 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 ďsciatic nerveĒ.

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.

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.

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 bodyís 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 patientís 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 patientís 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 patientís 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 patientís 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 patientís decision. There are many considerations for the patient to take into account when deciding whether or not to have surgery.

  • 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 patientís 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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