Sciatica

What is Sciatica?

Sciatica is a set of symptoms including pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of the leg and foot. In addition to pain, which is sometimes severe, there may be numbness, muscular weakness, pins and needles or tingling and difficulty in moving or controlling the leg. Typically, the symptoms are only felt on one side of the body.

Although sciatica is a relatively common form of low back pain and leg pain, the true meaning of the term is often misunderstood. Sciatica is a set of symptoms rather than a diagnosis for what is irritating the root of the nerve, causing the pain. This point is important, because treatment for sciatica or sciatic symptoms will often be different, depending upon the underlying cause of the symptoms.

 

Causes of Sciatica

Sciatica is generally caused by the compression of lumbar nerves L4 or L5 or sacral nerves S1, S2 or S3, or far less commonly, by compression of the sciatic nerve itself. When sciatica is caused by compression of a dorsal nerve root it is considered a lumbar radiculopathy (or radiculitis when accompanied with an inflammatory response) from a spinal disc herniation (a herniated intervertebral disc in the spine), or from roughening, enlarging, and/or misaligning of the vertebrae (spondylolisthesis), or degenerated discs. Sciatica due to compression of a nerve root is one of the most common forms of radiculopathy.

“Pseudo-sciatica,” which causes symptoms similar to spinal nerve root compression, is caused by the compression of peripheral sections of the nerve, usually from soft tissue tension in the piriformis or related muscles (see piriformis syndrome and see below).

 

Spinal Disc Herniation 

One cause of sciatica is a spinal disc herniation, pressing on one of the sciatic nerve roots. The spinal discs are composed of a tough spongiform ring of cartilage (annulus fibrosis) with a more malleable center (nucleus pulposis). The discs separate the vertebrae, thereby allowing room for the nerve roots to properly exit through the spaces between the L4, L5, and sacral vertebrae. The discs cushion the spine from compressive forces, but are weak to pressure applied during rotational movements.

That is why a person who bends to one side, at a bad angle to pick something up, may more likely herniate a spinal disc than a person falling from a ladder and landing on his or her back.

Herniation of a disc occurs when the liquid center of the disc bulges outwards, tearing the external ring of fibers, extrudes into the spinal canal, and compresses a nerve root against the lamina or pedicle of a vertebra, thus causing sciatica. This extruded liquid from the nucleus pulposis may cause inflammation and swelling of surrounding tissue which may cause further compression of the nerve root in the confined space in the spinal canal.

Sciatica caused by pressure from a disc herniation and swelling of surrounding tissue can spontaneously subside if the tear in the disc heals and pulposis extrusion and inflammation cease.

Sciatica can be caused by tumors impinging on the spinal cord or the nerve roots. Severe back pain extending to the hips and feet, loss of bladder or bowel control, or muscle weakness, may result from spinal tumors. Trauma to the spine, such as from a car accident, may also lead to sciatica.

 

Spinal Stenosis

Other compressive spinal causes include spinal stenosis, a condition wherein the spinal canal (the spaces through which the spinal cord runs) narrows and compresses the spinal cord, cauda equina, and/or sciatic nerve roots. This narrowing can be caused by bone spurs, vertebral dislocation, inflammation, or herniated disc which decreases available space for the spinal cord, thus pinching nerves from the spinal cord that travel to the sciatic nerve and irritating them with friction.

 

Piriformis Syndrome

In 15% of the population, the sciatic nerve runs through the piriformis muscle rather than beneath it. When the muscle shortens or spasms due to trauma, it can compress or strangle the sciatic nerve beneath the muscle. This cause of sciatic symptoms is piriformis syndrome. This may be the major cause of sciatica when the nerve root is normal.

Another source of sciatic symptoms is active trigger points of the lower back and the gluteus muscles.  In this case, the referred pain is not consequent to compression of the sciatic nerve, though the pain distribution down the buttocks and leg is similar. Trigger points occur when muscles become ischemic (having low blood flow) due to injury or chronic muscular contraction. The most commonly associated muscles with trigger points triggering sciatic symptoms are: the quadratus lumborum, the gluteus medius, the gluteus minimus, and the deep hip rotators.

 

Diagnosis and Treatment

Because of the many conditions which can compress nerve roots and cause sciatica, treatment and symptoms often differ from patient to patient. Diagnostic tests can come in the form of a series of exams a physician will perform. Patients will be asked to adopt numerous positions and actions such as squatting, walking on toes, bending forward and backward, rotating the spine, sitting, lying on back, and raising one leg at a time. Increased pain will occur during some of these activities.

Treatment of the underlying cause of the compression is often the most effective course. When the cause is due to a prolapsed or lumbar disc herniation, research has shown that, with supportive treatment to help relieve pain, 90% of disc prolapse will recover with no specific intervention. Genetics appear to influence the risk of developing disc herniation.

Imaging methods such as Magnetic Resonance Imaging (MRI) may help diagnosis and treatment of sciatica. MRI has been shown to diagnose 95% of severe sciatica patients; while as few as 15% of sciatica sufferers in the general population are diagnosed with disc-related problems.

For most people, sciatica responds well to self-care measures. You’ll heal more quickly if you continue with your usual activities, but avoid what may have triggered the pain in the first place. Although resting for a day or so may provide some relief, prolonged bed rest isn’t a good idea. In the long run, inactivity will make your signs and symptoms worse.

In addition to resuming usual activities, try the following measures:

• Cold packs. Initially, using cold packs may be able to reduce inflammation and relieve discomfort. Wrap an ice pack or a package of frozen peas in a clean towel and apply to the painful areas for 15 to 20 minutes at least several times a day.

 

•  Hot packs. After 48 hours, apply heat to the areas that hurt. Use warm packs, a heat lamp or a heating pad on the lowest setting. If you continue to have pain, try alternating warm and cold packs.

 

• Stretching. Stretching exercises for your low back can help you feel better and may help relieve nerve root compression. Avoid jerking, bouncing or twisting during the stretch and try to hold the stretch at least 30 seconds.

 

• Over-the-counter medications. Pain relievers (analgesics) fall into two categories — those that reduce pain and inflammation and those that only treat pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, and acetaminophen (Tylenol, others) can both be helpful for sciatica.

 

Although they can provide real relief, both types of medication have a “ceiling effect” — that is, there’s a limit to how much pain they can control. If you have moderate to severe pain, exceeding the recommended dosage won’t provide additional benefits. What’s more, NSAIDs can cause side effects such as nausea, stomach bleeding or ulcers, and acetaminophen can cause liver problems if taken in excess.

If you use these medications, talk to your doctor so that you can be monitored for problems. In addition, periodically re-evaluate whether you still need them. Exercise, stretching, massage and other nondrug treatments can often provide the same benefits without side effects.

Most cases of sciatica can be treated by one or more of the following:

• Non-surgical spinal decompression.  Spinal Decompression is a non-invasive, non-surgical technology where a patient is placed onto an instrument which belts them in and separates their lower body from their upper body. This allows for pressure to be relieved on certain joints and structures in the lumbar region of the spine. Spinal Decompression is the result of traction when negative pressure is created within the disc during traction.

 

To achieve Spinal Decompression, this type of traction needs to be applied in long axis of extension. In other words, the spinal segments need to be gently pulled part, systematically and continuously. When this technique is applied, negative pressure is created within the disc allowing for the disc material that has moved away from the central part of the disc, and crowding a nerve, to be “sucked back in” and drawn back inside the disc, which takes the pressure off the nerve. Subsequently this results in reduced back pain and leg pain, as well as promotes true healing of the disc. So, for lack of a better term, this type of traction is also referred to as “Spinal Decompression” – although it’s the “traction” that causes the spine to decompress.

• Physical therapy. If you have a herniated disk, physical therapy can play a vital role in your recovery. Once acute pain improves, your doctor or a physical therapist can design a rehabilitation program to help prevent recurrent injuries.

 

Rehabilitation typically includes exercises to help correct your posture, strengthen the muscles supporting your back and improve your flexibility. Your doctor will have you start physical therapy, exercise or both as early as possible. It’s the cornerstone of your treatment program and should become part of your permanent routine at home.

• Prescription drugs. In some cases, your doctor may prescribe an anti-inflammatory medication along with a muscle relaxant. Narcotics also may be prescribed for short-term pain relief. Tricyclic antidepressants and anticonvulsant drugs also can help ease chronic pain. They may help by blocking pain messages to the brain or by enhancing the production of endorphins, your body’s natural painkillers.

 

• Epidural steroid injections. In some cases, your doctor may inject a corticosteroid medication into the affected area. Corticosteroids mimic the effects of the hormones cortisone and hydrocortisone, which are made by the outer layer (cortex) of your adrenal glands. When prescribed in doses that exceed your natural levels, corticosteroids suppress inflammation around the irritated nerve, thereby helping to relieve pain.

 

Their usefulness in treating sciatica remains a matter of debate. Some research has found that corticosteroids can provide short-term symptom relief, but that these medications aren’t a long-term solution. In addition, corticosteroids can have side effects, so the number of injections you can receive is limited — usually no more than three in one year.

• Surgery. This is usually reserved for times when the compressed nerve causes significant weakness, bowel or bladder incontinence, or you have pain that gets progressively worse or doesn’t improve with other therapies.

 

Surgical options include lumbar laminectomy and microdiskectomy. In lumbar laminectomy with diskectomy, surgeons remove a portion of a herniated disk that’s pressing on a nerve. Ideally, most of the disk is left intact to preserve as much of the normal anatomy as possible. Sometimes a surgeon will perform this operation through a small incision while looking through a microscope (microdiskectomy).

Success rates of standard diskectomy and microdiskectomy are about equal, but you may have less pain and recover more quickly with microdiskectomy. Discuss which option might be best for you with your doctor, and carefully weigh the potential benefits of surgery against the risks.

• Exercise regularly. This is the most important thing you can do for your overall health   as well as for your back. Pay special attention to your core muscles — the muscles in your abdomen and lower back that are essential for proper posture and alignment. For cardiovascular benefits, try using a stationary bike, treadmill, elliptical trainer or cross-country ski machine. Cycling outdoors also is beneficial, but be certain your seat and handlebars are adjusted properly.

 

• Maintain proper posture when you sit. A good chair should comfortably support your hips, and the seat shouldn’t press on the back of your thighs or knees. If the chair doesn’t support the natural curve in your lower spine, place a rolled towel or pillow behind your back.

 

When working at a computer, adjust your chair so that your feet are flat on the floor and your arms rest on your desk or the chair’s arms, with your elbows bent at a right angle. Take frequent breaks, even if it’s just to walk around your office.

When you drive, adjust your seat to keep your knees and hips level, and move the seat forward to avoid overreaching for the pedals.

• Use good body mechanics. Being conscious of how you stand, lift heavy objects and even how you sleep can go a long way toward keeping your back healthy. That’s because poor posture stresses your back, leading to fatigue and stress on joints and nerves. If you stand for long periods, rest one foot on a stool or small box from time to time. While you stand, hold reading material at eye level instead of bending forward. Before you lift something heavy, decide where you’ll place it and how you’ll get there. Bend at your knees, not your back, so that your legs do the lifting. Carry objects close to your body at about waist level. If possible, set the object down on a surface between shoulder and knee height to avoid lifting objects over your head or bending over too far. Don’t twist at your waist. Instead, turn by pivoting your feet.

 

Be careful moving heavy things when you’re tired — fatigue can cause you to move more awkwardly. Heavy loads pose the greatest risk, so know your limitations. Don’t attempt to lift something you feel is beyond your ability. For the best sleep posture, choose a mattress that feels comfortable to you. Use pillows for support, but don’t use one that forces your neck up at a severe angle.

• Regular exercise. It may seem counterintuitive to exercise when you’re in pain, but regular exercise is one of the best ways to combat chronic discomfort. Exercise prompts your body to release endorphins — chemicals that prevent pain signals from reaching your brain.

 

Early in the course of sciatica, water exercise or other low-impact exercise such as a stationary bicycle will help you stay active without worsening your symptoms. Later, as you improve and the pain lessens, combining aerobic activity with strength training and core stability exercises that improve the strength of your back muscles can help limit the effects of age-related degenerative changes in your back.

If you’re new to exercise, start out slowly and progress to at least 30 minutes most days. To prevent injury, consider learning proper weightlifting techniques from a certified personal trainer, fitness specialist or physical therapist.

Complementary and alternative medicine (CAM) refers to medical and health care systems, practices, and products that aren’t currently part of conventional medicine — the care you receive in your primary care doctor’s office. Many of these therapies are being studied intensely, and some have proved to help alleviate back pain.

• Acupuncture. This therapy is based on the idea that your health depends on a vital energy called qi — pronounced “chee” — that flows along pathways in your body. It’s believed that when qi is blocked, disease and pain result and that inserting fine needles into specific points along the pathways unblocks energy flow and restores balance.

During an acupuncture treatment, you’ll have hair-thin needles inserted into your skin. In most cases, you won’t feel the needles — in fact, many people find the treatments extremely relaxing.

Research into acupuncture’s safety and efficacy has been inconsistent. Some studies have suggested that acupuncture can help back pain, while others have found no benefit. If you decide you’d like to try acupuncture, choose a licensed practitioner to ensure that he or she has had extensive training.

• Chiropractic. Chiropractic treatment is based on the philosophy that restricted movement in the spine may lead to reduced function and pain. Spinal adjustment (manipulation) is one form of therapy chiropractors use to treat restricted spinal mobility. The goal is to restore spinal movement and, as a result, improve function and decrease pain.

 

Chiropractors manipulate the spine from different positions using varying degrees of force. Manipulation doesn’t need to be forceful to be effective. Chiropractors may also use massage and stretching to relax muscles that are shortened or in spasm.

Some studies done on spinal manipulation have found it to be as effective and safe as standard treatments, especially for initial pain relief, though the optimal number of treatments is unknown.

• Massage. It’s difficult to conduct objective clinical trials in massage due to variances in practitioners and in massage types. However, studies that have been conducted suggest that massage may ease low back pain symptoms.

In Closing, if you or someone you know is suffering from poor health let them know that there may be hidden health problems that chiropractic can help.

To schedule a free consultation to see if chiropractic can help you, call our office today at 510-796-7000

Yours in excellent health,
Gary Wong, DC

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