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Understanding Sciatica: Causes, Treatment Options, and Prognosis

by Pain Doc | May 10, 2024 | Chronic Pain, Sciatica

Introduction:

Sciatica is an often debilitating condition that typically appears after age 60 in those affected, characterized by dysthesias: abnormal sensations that can include shooting pain, numbness and tingling radiating (traveling) along the path of the sciatic nerve, the largest diameter nerve in the body, which runs from the lower back, between the deep hip rotator muscles, and down the back of each leg. This condition can significantly impair one’s quality of life, affecting mobility, work, and daily activities. In this post, I’ll delve into the main details of sciatica, exploring its causes, pathology, treatment options ranging from conservative approaches to surgical interventions, and the prognosis associated with each.

Understanding the Pathology of Sciatica:

Sciatica typically arises from compression or irritation of the sciatic nerve roots, also called the cauda equina, most commonly at the lumbar spine level. The sciatic nerve is composed of nerve roots originating from the lumbar and sacral spine (L4-S3). When these nerve roots are compressed or inflamed, they can give rise to the characteristic symptoms of sciatica, including pain, numbness, tingling, and weakness along the nerve’s distribution. The sciatic nerve is comprised of both motor and sensory fibers, but since the sensory fibers are larger in diameter they are more susceptible to mechanical pressure; hence, irritation of the nerves results in mostly sensory dysfunction and less of motor function (leg muscle strength and coordination).

Common Causes of Sciatica

Herniated Disc: One of the leading causes of sciatica is a herniated disc, also known as a slipped or ruptured disc. Intervertebral discs act as cushions between the vertebrae of the spine, providing support and flexibility. When a disc herniates, its inner gel-like material protrudes through the tough outer layer, exerting pressure on nearby nerve roots, including those of the sciatic nerve.
Spinal Stenosis: Spinal stenosis refers to the narrowing of the spinal canal: the passageway formed from the stacking of the spinal vertebrae, which are solid in the front and have a ringed rear portion that when stacked form the canal in which the spinal cord resides. Narrowing can occur due to age-related degenerative changes, such as the formation of bone spurs and thickening of ligaments. The bone spurs and buckled ligaments encroach the canal, narrowing it. This narrowing can compress the spinal cord and nerve roots, or cause them to rub against them during movements especially back extension, leading to sciatic symptoms.
Piriformis Syndrome: The piriformis muscle, located in the buttocks region, plays a crucial role in hip rotation. In some individuals, the sciatic nerve may pass through or under the piriformis muscle, making it susceptible to compression or irritation. This condition, known as piriformis syndrome, can mimic the symptoms of sciatica. The muscles scissor the nerve if they get spasmed, which can produce sciatica symptoms.
Spondylolisthesis: Spondylolisthesis occurs when a vertebra slips out of alignment anteriorly, often due to degenerative changes or trauma (fractured pars). This misalignment offsets the foramen at that level, usually at L4’L5 effectively scissoring the nerve roots and producing sciatica symptoms.
Degenerative Disc Disease: With age, the intervertebral discs undergo wear and tear, leading to degenerative changes such as disc dehydration, loss of disc height, and the formation of bone spurs. These changes can contribute to nerve root compression and the development of sciatica.

Treatment Options for Sciatica:

The management of sciatica aims to alleviate pain, reduce inflammation, improve mobility, and address the underlying cause of the condition. Treatment options may vary depending on the severity of symptoms, the underlying pathology, and individual patient factors.

Conservative Management: Conservative approaches are often the first line of treatment for sciatica and may include:

Pain Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and analgesics can help alleviate pain and reduce inflammation.
Physical Therapy: Targeted exercises, stretches, and manual techniques can improve spinal flexibility, strengthen supporting muscles, and alleviate pressure on the sciatic nerve.
Heat and Cold Therapy: Applying heat or cold packs to the affected area can help reduce pain and inflammation.
Epidural Steroid Injections: Corticosteroids injected into the epidural space can provide temporary relief by reducing inflammation around the affected nerve roots.

Surgical Intervention: If conservative measures fail to provide adequate relief or if there is evidence of progressive neurological deficit, surgical intervention may be considered. Surgical options for sciatica include:

Discectomy: In cases of herniated discs causing nerve compression, a discectomy may be performed to remove the protruding disc material and relieve pressure on the affected nerve roots.
Laminectomy: This procedure involves removing a portion of the vertebral bone (lamina) to alleviate pressure on the spinal cord and nerve roots, particularly in cases of spinal stenosis.
Spinal Fusion: Spinal fusion surgery may be recommended to stabilize the spine and prevent further slippage of vertebrae in cases of spondylolisthesis or severe degenerative disc disease.

Alternative Therapies: Some individuals may find relief from sciatica symptoms through alternative therapies, although evidence supporting their efficacy may vary. These may include:

Acupuncture: The insertion of fine needles into specific points on the body may help reduce pain and improve nerve function.
Chiropractic Care: Spinal manipulation techniques performed by trained chiropractors may help alleviate pressure on the sciatic nerve and improve spinal alignment. Combining chiropractic with a stretching and exercise routine is even better.
Mechanical Traction: Some chiropractic and physical therapy clinics have special tables that can stretch the spine using an electric motor. This may increase space between the vertebrae, retract buckled ligaments and provide temporary relief.
Yoga and Pilates: These forms of exercise focus on strengthening core muscles, improving flexibility, and promoting relaxation, which can be beneficial for individuals with sciatica.
Low Level Laser (LLLT): Lasering the area of the sciatic nerve may alleviate symptoms. LLLT, also known as cold laser (non-thermal) helps by providing deep penetrating light to the nerve tissue. Photons from laser light enter the sciatic nerve and can modulate pain producing biochemical pathways.

Prognosis:

The prognosis for sciatica depends on various factors, including the underlying cause, the severity of symptoms, and the effectiveness of treatment. In many cases, sciatica resolves with conservative measures within a few weeks to months. However, some individuals may experience chronic or recurrent symptoms that require ongoing management. Over time, the neurons in the irritated nerve roots lose some of their ability to conduct sensory signals, and the symptoms tend to be less acute.

Surgical intervention can provide significant relief for those with severe or persistent symptoms, but it also carries risks and requires careful consideration of potential benefits versus potential complications. With advances in surgical techniques and rehabilitation protocols, the outcomes of surgical treatment for sciatica have improved, with many patients experiencing long-term symptom relief and improved function.

Ultimately, the prognosis for sciatica is influenced by factors such as the individual’s overall health, adherence to treatment recommendations, and the presence of any underlying medical conditions. Early intervention, comprehensive management strategies, and a multidisciplinary approach involving healthcare providers from various specialties can optimize outcomes and improve the quality of life for individuals affected by sciatica.

Conclusion:

Sciatica is a complex condition with diverse causes, ranging from herniated discs to spinal stenosis and piriformis syndrome. Understanding the underlying pathology is crucial for guiding appropriate treatment interventions, which may include conservative measures, surgical intervention, and alternative therapies. With timely and comprehensive management, the prognosis for sciatica can be favorable, enabling individuals to regain function and resume their daily activities with minimal pain and discomfort.

Spinal Stenosis – What it Is, and What to Do

by Pain Doc | Sep 14, 2013 | Leg Pain, Sciatica

Spinal Stenosis

Recently, Carrie Ann Inaba, one of the judges of the show Dancing With the Stars publicly announced that she has been suffering for quite some time from cervical spinal stenosis– a condition in which the canal that encases the spinal cord in the neck narrows and obstructs nerve tissue. She explained how her condition impacts her life, limiting her from doing the things she loves to do. To Carrie Ann’s dismay, she no longer dances with a partner for fear of getting whiplash and paralysis. That’s quite unfortunate for someone whose entire career revolved around dancing.

Although spinal stenosis is a generalized term for narrowing of the spinal canal by any cause, the most common type, which will be discussed here, is the type caused by osteophytes— growth of bony projections that narrow the openings where nerves pass through. Advanced osteophytic activity is also referred to as spondylosis. When it is severe enough to narrow the spinal canal (foramen) it then creates the condition known as spinal stenosis. For your information, other forms of spinal stenosis are those caused by herniated discs, spondylolisthesis, tumors or any mass that encroaches into the spinal canal.

In her article, Carrie Ann mentioned that spinal stenosis is a form of arthritis and that she is anxious to find a cure for it. Unfortunately spinal stenosis is not one of those conditions that can resolve on its own with rest, exercise and time and other non- invasive measures. And since the inflammation from spinal stenosis is secondary to irritation of nerves, it is technically not a type of arthritis. That is why anti-inflammatory medications have minimal effect on the pain associated with spinal stenosis, which is typically deep, sharp and radiating in nature.

Spinal stenosis occurs when vertebrae, the bones that comprise the spinal column gradually morph in a way that constricts the spinal foramen (canal), or space where the spinal cord resides. When there is less space for the spinal cord to move, it is subject to more abrasion with spinal movement; i.e. bending and turning your neck. The cord (actually, meninges or covering of the cord) rubs against sharp edges of the bony projections into the foramen with movement causing inflammation and injury to the nerve tissue, sometimes causing sclerosis (hardening). In advanced cases, especially cases of lumbar spinal stenosis (due to the more significant weight burden) the narrowing gets so advanced that there is constant pressure on the nerve roots. At this point, it is an emergency situation as renal function and sensation to the legs are affected.

Signs of advanced spinal stenosis include paresthesias, sharp pain with movement, weakness in the extremities, and muscle atrophy in legs and/or arms. Symptoms can be permanent if not treated early.

And what is the treatment for spinal stenosis? First of all, doctors will usually order MRI and x-ray to determine extent of narrowing. If it is caught early, physical therapy and lifestyle modification is recommended. The goal is to slow down or stop the progression of the narrowing.

Surgery is the only option for advanced cases. Since spinal stenosis involves physical structures compressing nerve tissue, there are surgical procedures that can enlarge the spinal canal by scraping off the encroaching bone material and buy the patient more time. Since bone is comprised of live cells, the movement of bony projections (called osteophytes) into the spinal canal is still likely after surgery and many who have had such spinal decompression surgeries develop the same problem several years later.

It’s not quite evident why some people suffer from spinal stenos more than others. But those who have a history of physical trauma to the spine like car accidents, sports injuries and falls are at a higher risk. The theory is that the injury event disrupts the normal alignment of the spinal segments resulting in accelerated wear and tear over time; much like how a loose screw in a machine accelerates mechanical failure. Some orthopedists hypothesize that the appearance of bony projections is the body’s attempt to fuse and stabilize adjacent vertebrae so they can no longer move separately; thus reducing the probability of injury. However, the nerves that share the space with the vertebrae get damaged in the process. If this theory holds true, then it is an inherent design flaw of the body’s self-healing mechanisms.

Also, heavy smoking and obesity, and general poor health can increase your chances of developing spinal stenosis.

I’m sure more than one doctor broke the news to Ms. Inaba that there basically is no “cure” for spinal stenosis once it is in its advanced stages, which appears to be her case based on her own description of her symptoms. It is a mechanical condition that mandates mechanical intervention. No amount of drugs will cure spinal stenosis from advanced osteophyte formatioin. Her only option at this point is spinal decompression surgery to widen the spinal canal and hope that the nerve tissue did not sustain permanent damage.

The best strategy for dealing with spinal stenosis is prevention. If you sustained injury to your spine from a car accident (even a low impact one that did not require medical treatment), a sports injury (including repetitious trauma like that related to gymnastics and football) or slip and fall, realize that “the seed” for spinal stenosis may have been planted in you already. If your injury event was over five years ago, get an x-ray to identify any levels where osteophytes are present; these are the sentinels of potential areas of spinal stenosis as they identify areas of biomechanical weakness. If there are some, the first course of action is to not worsen things. Avoid or reduce activities that regularly place trauma to your spine. Engage in specific exercises that strengthen the neck and lower back to offer more stability. Stretch often (yoga is a great choice) and take care of the insides of your body as well with proper diet, nutrition, hydration and adequate rest.

Lastly, the Cervical and Lumbar Posture Pump is a home rehabilitation device that tractions and separates vertebrae to hydrate the discs and increase nutrient absorption which can slow down the progression of spinal stenosis if done diligently on a regular basis. I have personally used them in my practice, and patients reported positive results.

Sciatica – Ever Had a Pain in the Butt?

by Pain Doc | Aug 25, 2010 | Leg Pain, Sciatica

(Updated 3/29/2021)

No, I don’t mean a really bad boss or acquaintance. I mean literally.

Buttock pain, medically called gluteal pain is a deep pain usually affecting one buttock. The sensation is often described as an electrical-like shock shooting from the bottom area of the buttock down to the back of the same side leg. Numbness and tingling is also often present. When not shooting, it feels like a bruise and is quite bothersome. Sciatica can make prolonged standing difficult, and even light walking. Sitting is very uncomfortable. Walking upstairs can make it hurt even more. Slouching over tends to ameliorate the pain.

The pain is usually described to be in the cheek part (lower) of the buttock a couple of inches to the side and downwards, from the sacrum– the triangular bone at the base of your lower back that is connected to your pelvic bones on either side. In some people, the pain continues down the back of the thigh to the calf, and sometimes the bottom of the foot.

In many cases, the patient cannot explain what caused the pain. This type of problem usually is reported to have a gradual onset, getting progressively worse.

Sciatica, or pain down the sciatic nerve is usually the diagnosis. The sciatic nerve is the largest nerve in the body. It forms from nerve roots that branch from the sides of the lower lumbar spine and sacrum.

However, the term “sciatica” describes a symptom and does not provide much clinical information. Sciatica can be caused by a herniated disc that presses on a nerve root that partially forms the sciatic nerve; spinal stenosis, which is narrowing of the lumbar spinal canal to the point where the cauda equina, the long nerve roots that form at the terminus of the spinal cord, experiences irritation/compression; it can be caused by a pelvic tumor that encroaches upon the sciatic nerve (or in very rare cases, the part of the brain that controls the affected leg), and it can be caused by a condition called piriformis syndrome.

piriformis syndrome compression

Piriformis – Muscles of the Lower Extremity Anatomy Visual Atlas, page 8 (Photo credit: robswatski)[/caption]

The piriformis muscle is one of the small muscles that connect your hip bone (femur head) to the side of the sacrum and is used to externally rotate the leg (turn outwards). The sciatic nerve passes between the piriformis muscle and adjacent muscles before it descends down the leg. If the piriformis muscle is in spasm, it can squeeze the sciatic nerve causing deep gluteal pain; the piriformis muscle itself can generate pain if it is inflamed.

Piriformis muscle spasm can be caused by a hard fall on your seat that puts the muscle in spasm. It can also develop when the pelvis is uneven; i.e. one hip is higher than the other when standing. This can cause uneven pull on the gluteal muscles, causing the hip rotators to spasm.

SELF-TREATMENT FOR SCIATICA

If the pain persists for over a month or is unrelenting, see your doctor so that a herniated disc, spinal stenosis and tumor can be ruled out (you may get an MRI). Once that is ruled out, you can do a couple of things to make the pain go away:

1. Check the level of your iliac crests while standing in front of a mirror. Place your fingertips flat on top of your hip bones; see if one is higher than the other. Sometimes if the unevenness is large, you can see the high side and low side simply by looking in the mirror, and focusing on your belt or skirt/pant top — it will not be parallel to the ground, one side will be higher. If this is the case, try inserting a heel lift in the shoe on the side of the “lower” pelvic bone. This will help even out the pelvis and remove strain to the gluteal muscles. You can purchase an “over the counter” heel lift at most drugstores like Walgreens or CVS. Check out this YouTube video that explains it:

Optionally, you can buy a pair of gel inserts for shoes, and use only one in the shoe on the side of the low iliac crest. Make sure to wear the lifts for at least two weeks to see if they help. Decreased pain or frequency of pain indicates that they are working.

2. Slowly and gently stretch the painful piriformis muscle by lying on your back, raising the leg on the affected side and bending the knee. Grab with both hands behind the knee and pull gently at a 45 degree angle relative to your body; you should feel a stretch in your gluteal muscle. Hold the position for 30 seconds; repeat three times. Watch this Sciatica YouTube video for a demonstration:

3. Apply infrared heat with an IR heat lamp and red light therapy. IR heat penetrates deeper, which is necessary to reach the nerve which is several inches deep, beneath layers of gluteal fat and muscle.

Follow up with a Red Light therapy wrap. Red light invigorates cells and gives them a boost of energy.

red light therapy LED wrap

In summary, sciatica can be caused by several things. Your prognosis is good if it is due to a bulging disc or piriformis syndrome, which can be managed by exercises, stretches and the therapeutic modalities I listed here.

If your sciatica is due to degenerative disc disease, spondylosis (bone spurring) and subsequent central spinal canal stenosis, unfortunately you are likely to have chronic, intermittent sciatica. Some people with this presentation have found success with spinal decompression surgery involving removal of the posterior structures of one or several vertebrae (laminectomy), but it is a very risky procedure and can often cause new, low back pain problems.