Sciatica refers to pain or discomfort associated with the sciatic nerve. This nerve runs from the lower part of the spinal cord down the back and side of the leg to the foot. Injury to or pressure on the sciatic nerve can cause the characteristic pain of sciatica: a sharp or burning pain or even numbness that radiates from the lower back or hip, possibly following the path of the sciatic nerve to the foot.
Description
The sciatic nerve is the largest and longest nerve in the body. About the thickness of a person's thumb, it spans from the lower back to the foot. The nerve originates in the lower part of the spinal cord, the so-called lumbar region. As the sciatic nerve branches off from the spinal cord, it passes between the bony vertebrae (the component bones of the spine) and runs through the pelvic girdle, or hip bones, and the buttock area. The nerve passes through the hip joint and continues down the back and side of the leg to the foot.
Sciatica is a fairly common disorder, approximately 40% of the population experiences it at some point in their lives. However, only about 1% have coexisting sensory or motor deficits. Sciatic pain has several root causes and treatment may hinge upon the underlying problem.
Of the identifiable causes of sciatic pain, lumbosacral radiculopathy and back strain are the most frequently suspected. The term lumbosacral refers to the lower part of the spine, and radiculopathy describes a problem with the spinal nerve roots that pass between the vertebrae and give rise to the sciatic nerve. This area between the vertebrae is cushioned with a disk of shock-absorbing tissue. If this disk shifts or is damaged through injury or disease, the spinal nerve root may be compressed by the shifted tissue or the vertebrae.
This compression of the nerve roots sends a pain signal to the brain. Although the actual injury is to the nerve roots, the pain may be perceived as coming from any point along the sciatic nerve.
The sciatic nerve can be compressed in other ways. Back strain may cause muscle spasms in the lower back, placing pressure on the sciatic nerve. In rare cases, infection, cancer, bone inflammation, or other diseases may cause the pressure. More likely, but often overlooked, is the piriformis syndrome. As the sciatic nerve passes through the hip joint, it shares the space with several muscles. One of these muscles, the piriformis muscle, is closely associated with the sciatic nerve. In some people, the nerve actually runs through the muscle. If this muscle is injured or has a spasm, it places pressure on the sciatic nerve—in effect, compressing it.
In many sciatica cases, the specific cause is never identified. About half of affected individuals recover from an episode within a month. Some cases can linger a few weeks longer and may require aggressive treatment. In other cases, the pain may return or potentially become chronic.
Causes & symptoms
Persons with sciatica may experience some lower back pain, but the most common symptom is pain that radiates through one buttock and down the back of the adjoining leg. The most identified cause of the pain is compression or pressure on the sciatic nerve. The extent of the pain varies among individuals. Some people describe pain that centers in the area of the hip, and others perceive discomfort all the way to the foot. The quality of the pain also varies; it may be described as tingling, burning, prickly, aching, or stabbing.
Onset of sciatica can be sudden, but it can also develop gradually. The pain may be intermittent or continuous. Certain activities, such as bending, coughing, sneezing, or sitting, may make the pain worse.
Chronic pain may arise from more than just compression on the nerve. According to some pain researchers, physical damage to a nerve is only half of the equation. A recent theory proposes that some nerve injuries result in a release of neurotransmitters and immune system chemicals that enhance and sustain a pain message. Even after the injury has healed or the damage has been repaired, the pain continues. Control of this abnormal type of pain is difficult.
Diagnosis
Before treating sciatic pain, as much information as possible must be collected. The individual is asked to recount the location and nature of the pain, how long it has continued, and any accidents or unusual activities prior to its onset. This information provides clues that may
point to back strain or injury to a specific location. Back pain from disk disease, piriformis syndrome, and back strain must be differentiated from more serious conditions such as cancer or infection. Lumbar stenosis, an overgrowth of the covering layers of the vertebrae that narrows the spinal canal, must also be considered. The possibility that a difference in leg lengths is causing the pain should be evaluated; the problem can be easily be treated with a foot orthotic or built-up shoe.
Often, a straight-leg-raising test is done, in which the person lies face upward and the healthcare provider raises the affected leg to various heights. This test pinpoints the location of the pain and may reveal whether it is caused by a disk problem. Other tests, such as having the individual rotate the hip joint, assess the condition of the hip muscles. Any pain caused by these movements may provide information about involvement of the piriformis muscle, and piriformis weakness is tested with additional leg-strength maneuvers.
Further tests may be done depending on the results of the physical examination and initial pain treatment. Such tests might include magnetic resonance imaging (MRI) and computed tomography (CT) scans. Other tests examine the conduction of electricity through nerve tissues, and include studies of the electrical activity generated as muscles contract (electromyography), nerve conduction velocity, and evoked potential testing. A more invasive test involves injecting a contrast substance into the space between the vertebrae and making x-ray images of the spinal cord (myelography), but this procedure is usually done only if surgery is being considered as an option. All of these tests can reveal problems with the vertebrae, the disk, or the nerve itself.
Treatment
Massage is a recommended form of therapy, especially if the sciatic pain arises from muscle spasm. Symptoms may also be relieved by icing the painful area as soon as the pain occurs. Ice should be left on the area for 30–60 minutes several times a day. After two or three days, a hot water bottle or heating pad can replace the ice. Chiropractic or osteopathy may offer possible solutions for relieving pressure on the sciatic nerve and alleviating the accompanying pain. Biofeedback may also be useful as a pain control method. Bodywork, such as the Alexander technique, can assist an individual in improving posture and preventing further episodes of sciatic pain.
Acupuncture is another alternative approach that appears to offer relief to many persons with sciatica, as indicated by several clinical trials in the United States and Europe. The World Health Organization (WHO) lists sciatica as one of 40 conditions for which acupuncture is recognized as an appropriate complementary treatment.
Practitioners of Ayurvedic medicine regard sciatica as a disorder resulting from an imbalance in vata, one of three doshas or energies in the human body. The traditional Ayurvedic treatment for vata disorders is vasti, or administration of an oil-based enema to cleanse the colon. An Ayurvedic herbal preparation that is used to treat sciatica is made from the leaves of Nyctanthes arbor tristis, which is also known as Parijat or "sad tree." A recent study of an alcohol-based extract of this plant indicates that it is effective as a tranquilizer and local anesthetic, which supports its traditional Ayurvedic use.
Western herbalists typically treat sciatica with valerian root to relax the muscle spasms that often accompany sciatica, and with white willow bark for pain relief.
Homeopathic remedies for sciatica include Ruta graveolens, Colocynth (for sciatic pain that is worse in cold or damp weather), or Magnesium phosphoric (for lightning-like pains that are soothed by heat and made worse by coughing).
Allopathic treatment
Initial treatment for sciatica focuses on pain relief. For acute or very painful flare-ups, bed rest is advised for up to a week in conjunction with medication for the pain. Pain medication includes acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, or muscle relaxants. If the pain is unremitting, opioids may be prescribed for short-term use, or a local anesthetic will be injected directly into the lower back. Massage and heat application may be suggested as adjuncts.
If the pain is chronic, different pain relief medications are used to avoid long-term dosing of NSAIDs, muscle relaxants, and opioids. Antidepressant drugs, which have been shown to be effective in treating pain, may be prescribed alongside short-term use of muscle relaxants or NSAIDs. Local anesthetic injections or epidural steroids are used in selected cases.
As the pain allows, physical therapy is introduced into the treatment regime. Stretching exercises that focus on the lower back, buttock, and hamstring muscles are suggested. The exercises also include finding comfortable, pain-reducing positions. Corsets and braces may be useful in some cases, but evidence for their general effectiveness is lacking. However, they may be helpful to prevent exacerbations related to certain activities.
With less pain and the success of early therapy, the individual is encouraged to follow a long-term program to maintain a healthy back and prevent re-injury. A physical therapist may suggest exercises and regular activity, such as waterexercise or walking. Patients are instructed in proper body mechanics to minimize symptoms during light lifting or other activities.
If the pain is chronic and conservative treatment fails, surgery to repair a herniated disk or to cut out part or all of the piriformis muscle may be suggested, particularly if there is evidence of nerve or nerve-root damage.
A new minimally invasive surgical treatment for sciatica was introduced in 2002. It is known as microscopically assisted percutaneous nucleotomy, or MAPN. MAPN allows the surgeon to repair a herniated disk with less damage to surrounding tissues; it shortens the patient's recovery time and relieves the pain of sciatica as effectively as more invasive surgical procedures.
Expected results
Most cases of sciatica are treatable with pain medication and physical therapy. After four to six weeks of treatment, an individual should be able to resume normal activities.
Prevention
Some sources of sciatica are not preventable, such as disk degeneration, back strain due to pregnancy, or accidental falls. Other sources of back strain, such as poor posture, overexertion, being overweight, or wearing high heels, can be corrected or avoided. Cigarette smoking may also predispose people to pain, and should be discontinued with the onset of pain.
General suggestions for avoiding sciatica or preventing a repeat episode include sleeping on a firm mattress; using chairs with firm back support; and sitting with both feet flat on the floor. Habitually crossing the legs while sitting can place excess pressure on the sciatic nerve. Sitting for long periods of time can also place pressure on the sciatic nerves, so it is recommended to take short breaks and move around during the work day, during long trips, or in other situations that require sitting for extended periods of time. If lifting is required, the back should be kept straight and the legs should provide the lift. Regular exercise, such as swimming and walking, can strengthen back muscles and improve posture. Exercise can also help maintain a healthy weight and lessen the likelihood of back strain.
BOOKS
Maigne, Robert. "Sciatica." In Diagnosis and Treatment of Pain of Vertebral Origin: A Manual Medicine Approach. Baltimore: Williams & Wilkins, 1996.
Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Sciatica." New York: Simon & Schuster, 2002.
Rydevik, Björn, Mitsuo Hasue, and Peter Wehling. Etiology of Sciatic Pain and Mechanisms of Nerve Root Compression, vol. 1: The Lumbar Spine, 2d ed., edited by Sam W. Wiesel, et al. Philadelphia: W.B. Saunders Company, 1996.
PERIODICALS
Chiodo, A., and A. J. Haig. "Lumbosacral Radiculopathies: Conservative Approaches to Management." Physical Medicine and Rehabilitation Clinics of North America 13 (August 2002): 609-621.
Douglas, Sara. "Sciatic Pain and Piriformis Syndrome." The Nurse Practitioner 22 (May 1997): 166.
Greiner-Perth, R., H. Bohm, and H. El Saghir. "Microscopically Assisted Percutaneous Nucleotomy, An Alternative Minimally Invasive Procedure for the Operative Treatment of Lumbar Disc Herniation: Preliminary Results." Neurosurgical Review 25 (August 2002): 225-227.
Parziale, John R., Thomas H. Hudgins, and Loren M. Fishman. "The Piriformis Syndrome." The American Journal of Orthopedics (December 1996): 819.
Saxena, R. S., B. Gupta, and S. Lata. "Tranquilizing, Antihistaminic and Purgative Activity of Nyctanthes arbor tristis Leaf Extract." Journal of Ethnopharmacology 81 (August 2002): 321-325.
Wheeler, Anthony H. "Diagnosis and Management of Low Back Pain and Sciatica." American Family Physician (October 1995): 1333.
ORGANIZATIONS
American Academy of Medical Acupuncture (AAMA). 4929 Wilshire Blvd., Suite 428, Los Angeles, CA 90010. (323) 937-5514. <www.medicalacupuncture.org>.
American Academy of Orthopaedic Surgeons (AAOS). 6300 North River Road, Rosemont, IL 60018. (847) 823-7186 or (800) 346-AAOS. <www.aaos.org>.
American Physical Therapy Association (APTA). 1111 North Fairfax Street, Alexandria, VA 22314. (703) 684-APTA or (800) 999-2782. <www.apta.org>.
National Center for Homeopathy. 801 North Fairfax Street, Alexandria, VA 22314. (703) 548-7790. <www.homeopathic.org>.
National Institute of Ayurvedic Medicine. 584 Milltown Road, Brewster, NY 10509. (845) 278-8700. <www.niam.com>.
