Sciatica, Symptoms, Causes and Treatment strategies
Sciatica
Sciatica is a type of back pain that affects the sciatic nerve. The sciatic nerve is a large nerve that exits from the spine in the area of the low back, travels down to the buttock and continues down along the back of the thighs into the feet. It is an important nerve that branches in several places in the legs and provides nerve innervation to the legs and feet. A disc in the spine can herniate and compress the sciatic nerve causing symptoms of sciatica.
SymptomsPatients with sciatica usually experience the familiar electric jolt like sensation propagating along the back of the thighs sometimes all the way to the feet. The sensation of pins and needles or ants crawling under the skin of the legs is also frequently described by patients experiencing sciatica. The intensity of the pain varies among the patients. Some individuals experience excruciating debilitating pain that causes them to become bedridden for a couple of days, while others have only mild pain in their back and legs. While the sciatic pain usually starts in the low back and continues down the leg along the path of the sciatic nerve, the pain is usually more intense in the legs than in the back. Sciatica generally affects only one leg at a time. It is rare to see the involvement of both legs at the same time. If this is the case, it is important to seek medical evaluation to rule out other causes for these symptoms.
Most patients complain of more significant pain when they sit down. Standing for extended periods of time is also very painful and most people prefer to lay down or slowly walk around to ease their pain. Numbness and weakness in the leg are also frequently associated with sciatica. If the sciatic nerve becomes compressed in the buttock by a muscle called piriformis, it is called piriformis syndrome. The main differentiating symptoms between sciatica and the piriformis syndrome is that painful sensation caused by piriformis syndrome propagates down the leg along the back of the thighs and only up to the knees and not past the knees. The quality of the pain is also different. Pain radiating down the legs due to the Piriformis Syndrome generally feels like a dull, achy sensation unlike the electric-like, burning sensation caused by a pinched nerve in the spine causing sciatica.
CausesThere are many reasons why someone may develop sciatica. The risk factors are similar to developing any back pain. The excessive weight which creates too much pressure on the spine, sedentary occupation with lack of movement or carrying heavy objects are some of the most important causes. Aging is an independent factor that compounds any of the above risk factors because most people become more sedentary as they get older, gain weight and become less flexible. Sciatica is however not exclusive of young healthy individuals. Many individuals in the 30s present to their health care provider’s office with symptoms of sciatica after sustaining injury from doing exercises at the gym. This is usually related to lifting heavy weights, not stretching before and after exercising, as well as not getting enough rest to allow body fully recover and regenerate. To prevent flare-ups of sciatica it is, therefore, crucial to maintaining healthy weight and stay mobile.
Treatment GuidelinesWhile sciatica can be rarely caused by a bone spur or a tumor, in most cases of sudden onset of sciatica, it is related to a disc herniation. The treatment for sciatica is therefore essentially the same as for disc herniation since both share the same underlying cause. Treatment guidelines for disc herniation can be found here.
Summary
SymptomsElectric jolt like sensation in the back & back of the leg
“Pins and needles” sensation
Numbness and weakness in the leg
Burning sensation
Affects usually only one leg
More pain with sitting or standing
Pain is better when laying down or walking slowly
CausesExcessive weight
Sedentary occupation & lack of movement
Carrying heavy objects
Advanced age
Lifting heavy weights
Disc Herniation: Understanding Symptoms, Causes, and Treatments
Disc Herniation
Disc herniation is a result of a disc protruding out of the spine. The disks in the spine are important structures for providing space and cushioning between the individual bones (vertebras) in the spine. The disk is a round soft cushion which has a soft jelly-like consistency in the center and tougher outer part providing for the structural integrity. When too much pressure is generated on the disc, the tough outer part can break and small tear develops. The inner soft part can protrude outside of the disc and irritate or push against the nearby nerves causing pain and other symptoms. Herniated disc doesn’t always cause pain, and there are some individuals who only find out about disc herniation accidentally when imaging of their torso is done for other purposes. Studies indicate that 41% of disk protrusions and up 71% of more severe disk extrusions eventually resolve spontaneously.
SymptomsThe symptoms related to disc herniation can vary not only in intensity but also in presentation. The major differentiating factor is whether the herniated disc touches the spinal nerve or not. If the disc is not touching the nearby spinal nerve, the affected individual may only experience low-grade back pain which is worse with certain movements. If, however, the disc is touching a spinal nerve and causing impingement of the nerve, the pain is typically more intense. There will be also other associated symptoms based on the level of the spine where the herniation occurred. In most cases of disc herniation in the lower back, when the herniated disc is impinging on the spinal nerve, the pain will be mostly felt in the buttock and in the legs rather than in the low back. Radiating pain may, in some cases, reach all the way down into the foot. This is usually described as sciatic pain.
The symptoms of electric shooting pain radiating down the leg usually resolve fairly soon with or without any treatment, however, the numbness may be present for several months. In severe cases of herniation, the numbness can become permanent, and it may never completely resolve. Many individuals also develop weakness in the leg supplied by the affected nerve and may have difficulties maintaining a steady gate. It is important for the individual developing this type of back pain, to contact their provider immediately if they notice new changes in their bowel movement or urination. A condition called Cauda Equina can result from impingement of the nerves controlling bowel movement and emptying the urinary bladder. The affected individual may develop difficulty emptying their bladder and present with loss of sensation in the area of the buttock that would be in contact with a horse saddle- hence called saddle anesthesia. This is a serious complication of disc herniation that requires a surgical intervention to prevent permanent nerve damage.
CausesWhile the exact cause of disc herniation is usually hard to elicit, it is generally associated with more advanced age and activities involving heavy lifting and or twisting movements. As we age, the tough outer layer of the disc becomes more fragile as it undergoes degeneration. The disc also loses some of the inner soft cushioning jelly-like substance. This makes the disc more fragile and prone to rupture when it is exposed to sudden twisting movement or excessive load. Young individuals engaged in strenuous jobs or sports activities that require heavy lifting, especially when combined with twisting movements, are at great risk for disk herniation due to the instability that this combination of pressure and twisting movement creates in the spine. Additionally, having tight muscles that attach to the individual vertebras above and below the disc, can also predispose the individual to disc herniation by keeping the disc under constant pressure. In such cases, a small innocent movement such as picking up a pen from the floor can be the final hit for rupturing the disc and causing herniation.
Treatment guidelinesPain due to acute disc herniation can be very debilitating. Unless there are, however, any so-called red flags, which your provider will rule out during his physical exam, there is no need for any invasive procedures to treat acute disc herniation. Most patients will feel significantly better in 4-6 weeks, and they will fully recover in 3-4 months. Conservative treatment is therefore recommended as first-line therapy. There are a number of treatment options and all of them help to some extent in the recovery process. Their selection depends on availability and personal preference. Making certain changes to your daily routine can also speed up the recovery process. You can read more about optimizing your recovery process here. During the acute onset of symptoms, bed rest can be helpful for one to two days. Being inactive and staying in bed longer than two days has been associated with worse outcomes. Motion is the lotion, therefore early referral to physical therapy to learn appropriate mobilization and stretching exercises is very important for successful rehabilitation. Pain medication such as Motrin or Naproxen can help ease some of the pain, but if this is not sufficient, talk to your provider about using additional pain medication for short period of time. After initial 24-48 hrs from the onset, hot baths or heating pads applied for no more than 20 minutes can also help loosen up the muscle spasm and relieve some pain. This should be followed by gentle stretching. Avoid sitting for extended periods of time and walk slowly avoiding any sudden movements. If heated pool or larger Jacuzzi tub is available, stretching for 15- 20 minutes in the warm water and doing gentle ranges of motion can also be very helpful.
