Sciatica - Ask Dr. P - The Pain Doc

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 tinglig 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.

What Causes Low Back Pain?

by Pain Doc | May 29, 2020 | Low Back Pain

Low back pain continues to be a problem for many people. If not you, then most likely several people you know: neighbors, co-workers, friends and relatives. That’s what the statistics tell us.

Since it is so prevalent throughout the world, “what causes low back pain?” is a question millions of people want answered. Is it normal and expected as we age? Is it genetic? Will you need to get surgery? As you can expect, the answer is different for different people. First of all, the pain is not identical from person to person. Some people get low back pain on the right side; some get it on the left side. Some get low back pain into the hip.

In this post, I will do my best to help you understand what causes low back pain and at the end of the article provide you a tool to pinpoint what is causing your particular low pain.

The Lumbar Spine and Its Significance

Your low back or lumbar spine engineering-wise is your body’s lynch-pin– along with your pelvis, it connects your upper body to your lower body and is tasked with balancing and moving your torso. If you injure your low back it can put you out of commission: any attempt at moving places a load on your low back and makes pain worse. In extreme cases it is even painful to take in a deep breath! Acute low back pain can instantly stop a 250 pound football player in his tracks; that’s the power it has.

While most cases of low back pain self-resolve over a few days, about 20% of them become chronic, or recurring. For some, it strikes every couple of months; for others, it’s enough to impede their daily activities and quality of life. In fact, low back pain is said to be the number one reason for lost work days (disability) in industrialized nations, and therefore lost productivity.

The reason why low back pain is so prevalent is a societal phenomenon, made possible by evolution. You see, humans are the only bi-pedal animal on the planet. Dancing bears and meerkats don’t count because although they can walk a few steps their pelvic design is still quadri-pedal (walking on four limbs). When nature selected homo sapiens to be bi-pedal, it freed up his arms to carry things–heavy things. Carrying and lifting things and bending the low back places a tremendous load on the lumbar spine, and like any machine, the components bearing the most stress will be the first to break down.

Secondly, the invention of the chair and desk. When our ancient ancestors roamed the plains and forests 30,000 years ago there weren’t any chairs around to sit in for hours, placing pressure on the low back and weakening the postural muscles of the spine. Today, many jobs require sitting at a desk in front of a computer, doing just that. Also, food these days is abundant and much less nutritious causing humans to gain excess weight, placing constant stress on the low back throughout the day.

Causes of Low Back Pain

The vast majority of low back pain cases are mechanical in nature; meaning caused by a breakdown of some physical component of the lumbar spine. These components are the muscles, fascia (muscle sheath), ligaments and tendons; vertebrae, vertebral joints, and discs (which are technically ligaments). If the dysfunction causes compression of nerve roots, then nerve pain is involved, which usually means shooting / radiating pain and/ or numbness down the buttock to lower extremity; sometimes as far down to the sole of the foot.

Here are the main categories of mechanical low back pain:

Congenital Malformations

Sometimes there are abnormalities in the development of the spinal column which interfere with proper movement and balance placing excess stress on soft tissues and sometimes nerves, generating pain or constant stiffness and aches, and loss of range of motion/flexibility. Examples include fused vertebrae (two adjacent vertebrae fused together instead of forming a joint); scoliosis; spina bifida, pars defect, hyperkyphosis (hunchback); and hyperlordosis (swayback).

Injuries

Low back pain is often due to injuries to tissues: sprains to ligaments; ruptured intervertebral discs from a herniated or prolapsed nucleus pulposus (jelly-like shock absorbing substance in all discs); strains (tears, small and large) to muscles and tendons; muscle spasms, and fractures. These can be traumatic from a specific incident such as a sports injury, or can be cumulative over time, often years, from performing a certain movement repeatedly or sitting/slouching causing gradual degenerative disc disease. With acute tissue injury, the inflammatory response is initiated, which is responsible for the pain generation.

Degenerative Changes

Joints wear out over time. Most doctors will tell patients their condition is from “normal” wear and tear. But that’s not accurate. For some people, joints deteriorate at an abnormally fast rate, mainly due to lifestyle factors under their control. I’ve seen X-rays of 60 year-olds look much better than 30 year-olds, on many occasions.

Factors that promote lumbar spine degeneration include:

Being overweight
Genetic predisposition
Sedentary lifestyle/ lack of physical activity
Sitting frequently (airline pilot, police officer, truckers, data entry)
Heavy labor job
Contact sports, especially football
Occupation or recreation that involve hard landings (basketball, gymnastics, parachuting, etc.)
Previous injuries/accidents such as falls and car accidents
Poor diet (your body needs proper nutrients to heal tissues)
Smoking (smoking reduces oxygen to cells and may trigger inflammation)

Doctors use three terms to describe spinal degeneration:

Spondylosis when referring to the vertebrae as a whole;
Degenerative joint disease or DJD if referring to the vertebral joints: facet joints and intervertebral joints; and
Degenerative disc disease or DDD if referring to the intervertebral discs

In all cases, the joint surfaces of the vertebrae lose their smooth borders and form jagged bone spurs called osteophytes. You can have a lot of osteophytes in your spine and not feel pain at all. In fact, if you are over age 40 you probably have them yourself. But if the osteophytes get big enough to narrow the openings where nerves pass through, called foramen, problems start. This narrowing of the foramen is called spinal stenosis and can occur with the intervertebral foramen (IVFs), the small holes formed by adjacent vertebrae which nerve roots pass through; and also the central canal where the spinal cord and cauda equina reside. This can lead to shooting pain down one or both legs; numbness and tingling in the legs, and leg muscle weakness, atrophy and loss of sensation.

Since osteophytes do not resorb (shrink) and only get bigger with time the only option is spinal decompression surgery which involves shaving off the osteophytes to make more room for the nerves.

And there is another problem: when spinal discs degenerate, they lose height (this is part of the reason why most people get shorter as they age). A healthy L5-S1 disc can be in excess of 1 cm thick while a degenerated one can be just 2-3 mm thick. When this happens, the posterior and anterior longitudinal ligaments that run down the front and back of your vertebral column slacken, or buckle, at those levels. Like osteophytes, buckled ligaments can cause stenosis, compressing or irritating nerves and causing the same neurological symptoms.

When the degenerative changes involve deterioration of cartilage, you have bone on bone contact. The cartilage in your spine is located in the encapsulated facet joints, located behind the vertebral bodies. This triggers inflammation, which leads to osteoarthritis. It’s the same process as osteoarthritis of the knees and hips, occurring in the spine.

Like knee osteoarthritis, people with spinal OA will feel burning pain in their lumbar spine especially when standing, and stiffness which is worse upon waking in the morning. Osteoarthritis is a chronic, degenerative disease that is best managed by lifestyle modification (anti-inflammatory diet, exercises, stress reduction). Those with severe cases sometimes elect to use prescription anti-inflammatory medication.

Non-Mechanical Causes of Low Back Pain

Less than 1% of low back pain cases are due to other factors, most of which are “red flag” cases that require immediate medical attention. These include pelvic tumors, kidney stones, metastatic cancer (usually from prostate cancer), infection, and endometriosis. A brain tumor is capable of causing sciatica-like symptoms if it affects the sensory neurons that go to the leg. While rare, if you have low back pain that does not improve with physical therapy or rest, it is a good idea to see your doctor and get some tests done to rule out these conditions.

Summary and Main Take Aways

If you have low back pain, chances are very good it will go away with rest. Apply ice for the first 1 to 2 days. If severe, you can try taking over the counter anti-inflammatory medications (NSAIDs) such as Motrin or Ibuprofen to knock down some of the pain. And if you are lucky to have a cryotherapy center near you, you can do a couple of visits to shorten the healing time.

If the pain lasts more than 4 days, then it usually means something is perpetuating it: perhaps you are not resting it properly; are re-aggravating it; or have some kind of contributing factor such as a rotated vertebra or disc protrusion. These issues can be dealt with by visiting a good physical therapist or chiropractor. You can even do some home exercises and home therapy for low back pain on your own and still get great results.

While most cases of low back pain go away, it doesn’t mean that it will stay away for the rest of your life: 20% of people who get low back pain will experience it again in the future; either from a new injury/event or a flare-up of a pre-existing injury. And remember, some cases become chronic (pain decreases, but the improvement plateaus and remains, with some days worse than others). Your prognosis will depend on what is causing your low back pain (see below for a self-diagnosis tool) and other factors related to your medical history and daily activities.

When dealing with low back pain, besides focusing on reducing the pain think of what things caused it and eliminate those causes as best you can. It may mean:

Getting a stand up desk (standing puts less stress on your low back than sitting)
Losing some weight
Eating a healthier diet
Stopping smoking
Exercising more often
Reducing emotional stress in your life
Improving the ergonomics of your work station
Learning how to lift properly
Getting your back adjusted by a chiropractor periodically to improve joint movement and joint health

And lastly, remember that low back pain should noticeably and progressively improve each day after initial onset. If you notice that pain does not get better with rest, express your concern to your doctor: demand an X-ray, MRI and/or a blood test. Red flag cases like cancer are often misdiagnosed by doctors (dismissed) as general back pain due to spasms because doctors know that the medical literature estimates red flag cases to be 1% or less of all low back pain cases. Remember to be persistent; it is your life you are dealing with.

Below is a low back pain algorithm I created to help you diagnose your particular low back pain so that you can take appropriate action. Use the top one if your low back pain onset was sudden; use the bottom one if the onset was gradual. This is only a guide; always check with you doctor who can examine you, to get an accurate diagnosis.

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.