All You Need to Know About Sciatica
By: Dr. Abe Kopolovich, DPT, MBA
Sciatica pain is caused by irritation, inflammation, pinching, or compression of a nerve in the lower back. The most common cause is a herniated or slipped disk that causes pressure on the nerve root. Most people with sciatica get better with physical therapy and self-care treatments.
True sciatica is an injury or irritation to the sciatic nerve, which starts in your buttock/gluteal area.
What is sciatica?
Sciatica is nerve pain from an injury or irritation to the sciatic nerve, which originates in your buttock/gluteal area. The sciatic nerve is the longest and thickest (almost finger-width) nerve in the body. It’s made up of five nerve roots: two from the lower back region called the lumbar spine and three from the final section of the spine called the sacrum. The five nerve roots come together to form a right and left sciatic nerve. On each side of your body, one sciatic nerve runs through your hips, buttocks, and down a leg, ending just below the knee. The sciatic nerve then branches into other nerves, which continue down your leg and into your foot and toes.
True injury to the sciatic nerve “sciatica” is rare, but the term “sciatica” is commonly used to describe any pain that originates in the lower back and radiates down the leg. What this pain shares in common are an injury to a nerve — an irritation, inflammation, pinching, or compression of a nerve in your lower back.
If you have “sciatica,” you experience mild to severe pain anywhere along the path of the sciatic nerve – that is, anywhere from the lower back, through the hips, buttocks, and/or down your legs. It can also cause muscle weakness in your leg and foot, numbness in your leg, and an unpleasant tingling pins-and-needles sensation in your leg, foot, and toes.
What does sciatica pain feel like?
People describe sciatica pain in different ways, depending on its cause. Some people describe the pain as sharp, shooting, or jolts of pain. Others describe this pain as “burning,” “electric” or “stabbing.”
The pain may be constant or may come and go. Also, the pain is usually more severe in your leg compared to your lower back. The pain may feel worse if you sit or stand for long periods, when you stand up and when you twist your upper body. A forced and sudden body movement, like a cough or sneeze, can also make the pain worse.
Can sciatica occur down both legs?
Sciatica usually affects only one leg at a time. However, sciatica can occur in both legs. It’s simply a matter of where the nerve is being pinched along the spinal column.
Does sciatica occur suddenly or does it take time to develop?
Sciatica can come on suddenly or gradually. It depends on the cause. A disk herniation can cause sudden pain. Arthritis in the spine develops slowly over time.
How common is sciatica?
Sciatica is a very common complaint. About 40% of people in the U.S. experience sciatica sometime during their life. Back pain is the third most common reason people visit their healthcare provider.
What are the risk factors for sciatica?
You are at greater risk of sciatica if you:
- Have an injury/previous injury: An injury to your lower back or spine puts you at greater risk for sciatica.
- Live life: With normal aging comes a natural wearing down of bone tissue and disks in your spine. Normal aging can put your nerves at risk of being injured or pinched by the changes and shifts in bone, disks, and ligaments.
- Are overweight: Your spine is like a vertical crane. Your muscles are the counterweights. The weight you carry in the front of your body is what your spine (crane) has to lift. The more weight you have, the more your back muscles (counterweights) have to work. This can lead to back strains, pains, and other back issues.
- Lack a strong core: Your “core” is the muscles of your back and abdomen. The stronger your core, the more support you’ll have for your lower back. Unlike your chest area, where your rib cage provides support, the only support for your lower back is your muscles.
- Have an active, physical job: Jobs that require heavy lifting may increase your risk of low back problems and use of your back, or jobs with prolonged sitting may increase your risk of low back problems.
- Lack of proper posture in the weight room: Even if you are physically fit and active, you can still be prone to sciatica if you don’t follow proper body form during weight lifting or other strength training exercises.
- Have diabetes: Diabetes increases your chance of nerve damage, which increases your chance of sciatica.
- Have osteoarthritis: Osteoarthritis can cause damage to your spine and put nerves at risk of injury.
- Lead an inactive lifestyle: Sitting for a long period and not exercising and keeping your muscles moving, flexible, and toned can increase your risk of sciatica.
- Smoke: The nicotine in tobacco can damage spinal tissue, weaken bones, and speed the wearing down of vertebral disks.
Is the weight of pregnancy the reason why so many pregnant women get sciatica?
It’s true that sciatica is common in pregnancy but increased weight is not the main reason why pregnant women get sciatica. A better explanation is that certain hormones of pregnancy cause a loosening of their ligaments. Ligaments hold the vertebrae together, protect the disks and keep the spine stable. Loosened ligaments can cause the spine to become unstable and might cause disks to slip, which leads to nerves being pinched and the development of sciatica. The baby’s weight and position can also add pressure to the nerve.
The good news is there are ways to ease sciatic pain during pregnancy, and the pain goes away after birth. Physical therapy and massage therapy, warm showers, heat, medications, and other measures can help. If you are pregnant, be sure to follow good posture techniques during pregnancy to also ease your pain.
SYMPTOMS AND CAUSES
What causes sciatica?
Sciatica can be caused by several different medical conditions including:
- A herniated or slipped disk that causes pressure on a nerve root. This is the most common cause of sciatica. About 1% to 5% of all people in the U.S. will have a slipped disk at one point in their lives. Disks are the cushioning pads between each vertebrae of the spine. Pressure from vertebrae can cause the gel-like center of a disk to bulge (herniate) through a weakness in its outer wall. When a herniated disk happens to a vertebrae in your lower back, it can press on the sciatic nerve.
- Degenerative disk disease is the natural wear down of the disks between vertebrae of the spine. The wearing down of the disks shortens their height and leads to the nerve passageways becoming narrower (spinal stenosis). Spinal stenosis can pinch the sciatic nerve roots as they leave the spine.
- Spinal stenosis is the abnormal narrowing of the spinal canal. This narrowing reduces the available space for the spinal cord and nerves.
- Spondylolisthesis is a slippage of one vertebra so that it is out of line with the one above it, narrowing the opening through which the nerve exits. The extended spinal bone can pinch the sciatic nerve.
- Osteoarthritis. Bone spurs (jagged edges of bone) can form in aging spines and compress lower back nerves.
- Trauma injury to the lumbar spine or sciatic nerve.
- Tumors in the lumbar spinal canal that compress the sciatic nerve.
- Piriformis syndrome is a condition that develops when the piriformis muscle, a small muscle that lies deep in the buttocks, becomes tight or spasms. This can put pressure on and irritate the sciatic nerve. Piriformis syndrome is an uncommon neuromuscular disorder.
- Cauda equina syndrome is a rare but serious condition that affects the bundle of nerves at the end of the spinal cord called the cauda equina. This syndrome causes pain down the leg, numbness around the anus, and loss of bowel and bladder control.
What are the symptoms of sciatica?
The symptoms of sciatica include:
- Moderate to severe pain in the lower back, buttock, and down your leg.
- Numbness or weakness in your lower back, buttock, leg, or feet.
- Pain that worsens with movement; loss of movement.
- “Pins and needles” feeling in your legs, toes, or feet.
- Loss of bowel and bladder control (due to cauda equina).
DIAGNOSIS AND TESTS
The straight leg raise test helps spot your point of pain. This test helps identify a disk problem.
How is sciatica diagnosed?
First, your healthcare provider will review your medical history. Next, they’ll ask about your symptoms.
During your physical exam, you will be asked to walk so your healthcare provider can see how your spine carries your weight. You may be asked to walk on your toes and heels to check the strength of your calf muscles. Your provider may also do a straight leg raise test. For this test, you’ll lie on your back with your legs straight. Your provider will slowly raise each leg and note the point at which your pain begins. This test helps pinpoint the affected nerves and determines if there is a problem with one of your disks. You will also be asked to do other stretches and motions to pinpoint pain and check muscle flexibility and strength.
Depending on what your healthcare provider discovers during your physical exam, imaging and other tests might be done. These may include:
- Spinal X-rays to look for spinal fractures, disk problems, infections, tumors, and bone spurs.
- Magnetic resonance imaging (MRI) or computed tomography (CT) scans to see detailed images of bone and soft tissues of the back. An MRI can show pressure on a nerve, disk herniation, and any arthritic condition that might be pressing on a nerve. MRIs are usually ordered to confirm the diagnosis of sciatica.
- Nerve conduction velocity studies/electromyography to examine how well electrical
- Myelogram to determine if a vertebrae or disk is causing the pain.
MANAGEMENT AND TREATMENT
How is sciatica treated?
Self-care treatments include:
- Physical Therapy: First, use ice packs to reduce pain and swelling. Apply ice packs or bags of frozen vegetables wrapped in a towel to the affected area. Apply for 20 minutes, several times a day. Switch to a hot pack or a heating pad after the first several days. Apply for 20 minutes at a time. If you’re still in pain, switch between hot and cold packs – whichever best relieves your discomfort.
- Taking over-the-counter medicines: Take medicines to reduce pain, inflammation, and swelling. The many common over-the-counter medicines in this category, called non-steroidal anti-inflammatory drugs (NSAIDs), include aspirin, ibuprofen (Advil®, Motrin®) and naproxen (Naprosyn®, Aleve®). Be watchful if you choose to take aspirin. Aspirin can cause ulcers and bleeding in some people. If you’re unable to take NSAIDS, acetaminophen (Tylenol®) may be taken instead.
- Performing gentle stretches: Learn proper stretches from an instructor with experience with low back pain. Work up to other general strengthening, core muscle strengthening, and aerobic exercises.
How long should I try self-care treatments for my sciatica before seeing my healthcare professional?
Every person with sciatic pain is different. The type of pain can be different, the intensity of pain is different and the cause of the pain can be different. In some patients, more aggressive treatment may be tried first. However, generally speaking, if a six-week trial of conservative, self-care treatments – like ice, heat, stretching, over-the-counter medicines – has not provided relief, it’s time to return to a healthcare professional and try other treatment options.
- Prescription medications: Your healthcare provider may prescribe muscle relaxants, such as cyclobenzaprine (Amrix®, Flexeril®), to relieve the discomfort associated with muscle spasms. Other medications with pain-relieving action that may be tried include tricyclic antidepressants and anti-seizure medications. Depending on your level of pain, prescription pain medicines might be used early in your treatment plan.
- Physical therapy: The goal of physical therapy is to find exercise movements that decrease sciatica by reducing pressure on the nerve. An exercise program should include stretching exercises to improve muscle flexibility and aerobic exercises (such as walking, swimming, water aerobics). Your healthcare provider can refer you to a physical therapist who’ll work with you to customize your stretching and aerobic exercise program and recommend other exercises to strengthen the muscles of your back, abdomen, and legs.
- Spinal injections: An injection of a corticosteroid, an anti-inflammatory medicine, into the lower back might help reduce the pain and swelling around the affected nerve roots. Injections provide short-time (typically up to three months) pain relief and are given under local anesthesia as an outpatient treatment. You may feel some pressure and burning or stinging sensation as the injection is being given. Ask your healthcare provider about how many injections you might be able to receive and the risks of injections.
- Alternative therapies: Alternative therapies are increasingly popular and are used to treat and manage all kinds of pain. Alternative methods to improve sciatic pain include spine manipulation by a licensed chiropractor, yoga, or acupuncture. Massage might help muscle spasms that often occur along with sciatica. Biofeedback is an option to help manage pain and relieve stress.
When is surgery considered?
Spinal surgery is usually not recommended unless you have not improved with other treatment methods such as stretching and medication, your pain is worsening, you have severe weakness in the muscles in your lower extremities or you have lost bladder or bowel control.
How soon surgery would be considered depends on the cause of your sciatica. Surgery is typically considered within a year of ongoing symptoms. Pain that is severe and unrelenting and is preventing you from standing or working and you’ve been admitted to a hospital would require more aggressive treatment and a shorter timeline to surgery. Loss of bladder or bowel control could require emergency surgery if determined to be cauda equine syndrome.
The goal of spinal surgery for sciatic pain is to remove the pressure on the nerves that are being pinched and to make sure the spine is stable.
Surgical options to relieve sciatica include:
- Microdiscectomy: This is a minimally invasive procedure used to remove fragments of a herniated disk that are pressing on a nerve.
- Laminectomy: In this procedure, the lamina (part of the vertebral bone; the roof of the spinal canal) that is causing pressure on the sciatic nerve is removed.
How long does it take to perform spine surgery and what’s the typical recovery time?
Discectomy and laminectomy generally take one to two hours to perform. Recovery time depends on your situation; your surgeon will tell you when you can get back to full activities. Generally, the time needed to recover is six weeks to three months.
What are the risks of spinal surgery?
Though these procedures are considered very safe and effective, all surgeries have risks. Spinal surgery risks include:
- Blood clots.
- Nerve damage.
- Spinal fluid leak.
- Loss of bladder or bowel control.
What complications are associated with sciatica?
Most people recover fully from sciatica. However, chronic (ongoing and lasting) pain can be a complication of sciatica. If the pinched nerve is seriously injured, chronic muscle weakness, such as a “drop foot,” might occur, when numbness in the foot makes normal walking impossible. Sciatica can potentially cause permanent nerve damage, resulting in a loss of feeling in the affected legs. Call your provider right away if you lose feeling in your legs or feet, or have any concerns during your recovery time.
Can sciatica be prevented?
Some sources of sciatica may not be preventable, such as degenerative disk disease, sciatica due to pregnancy, or accidental falls. Although it might not be possible to prevent all cases of sciatica, taking the following steps can help protect your back and reduce your risk:
- Maintain good posture: Following good posture techniques while you’re sitting, standing, lifting objects and sleeping helps relieve pressure on your lower back. Pain can be an early warning sign that you are not properly aligned. If you start to feel sore or stiff, adjust your posture.
- Don’t smoke: Nicotine reduces the blood supply to bones. It weakens the spine and the vertebral disks, which puts more stress on the spine and discs and causes back and spine problems.
- Maintain a healthy weight: Extra weight and a poor diet are associated with inflammation and pain throughout your body. To lose weight or learn healthier eating habits, look into the Mediterranean diet. The closer you are to your ideal body weight the less strain you put on your spine.
- Exercise regularly: Exercise includes stretching to keep your joints flexible and exercises to strengthen your core – the muscles of your lower back and abdomen. These muscles work to support your spine. Also, do not sit for long periods.
- Choose physical activities least likely to hurt your back: Consider low-impact activities such as swimming, walking, yoga, or tai chi.
- Keep yourself safe from falls: Wear shoes that fit and keep stairs and walkways free of clutter to reduce your chance of a fall. Make sure rooms are well-lighted and there are grab bars in bathrooms and rails on stairways.
OUTLOOK / PROGNOSIS
What can I expect if I have been diagnosed with sciatica?
The good news about sciatic pain is that it usually goes away on its own with time and some self-care treatments. Most people (80% to 90%) with sciatica get better without surgery, and about half of these recover from an episode fully within six weeks.
Be sure to contact your healthcare provider if your sciatica pain is not improving and you have concerns that you aren’t recovering as quickly as hoped.
When should I contact my healthcare provider?
Get immediate medical attention if you experience:
- Severe leg pain lasting more than a few hours that is unbearable.
- Numbness or muscle weakness in the same leg.
- Bowel or bladder control loss. This could be due to a condition called cauda equina syndrome, which affects bundles of nerves at the end of the spinal cord.
- Sudden and severe pain from a traffic accident or some other trauma.
Even if your visit doesn’t turn out to be an emergency, it’s best to get it checked out.
Is the sciatic nerve the only source of “sciatica” pain?
No, the sciatic nerve is not the only source of what is generally called “sciatica” or sciatica pain. Sometimes the source of pain is higher up in the lumbar spine and causes pain in front of the thigh or the hip area. This pain is still called sciatica.
How can I tell if the pain in my hip is a hip issue or sciatica?
Hip problems, such as arthritis in the hip, usually cause groin pain, pain when you put weight on your leg, or when the leg is moved around.
If your pain starts in the back and moves or radiates towards the hip or down the leg and you have numbness, tingling, or weakness in the leg, sciatica is the most likely cause.
Is radiculopathy the same as sciatica?
Radiculopathy is a broader term that describes the symptoms caused by a pinched nerve in the spinal column. Sciatica is a specific type, and the most common type, of radiculopathy.
Should I rest if I have sciatica?
Some rest and change in your activities and activity level may be needed. However, too much rest, bed rest, and physical inactivity can make your pain worse and slow the healing process. It’s important to maintain as much activity as possible to keep muscles flexible and strong.
Before beginning your exercise program, see your healthcare provider or spine specialist first to get a proper diagnosis. This healthcare professional will refer you to the proper physical therapist or other trained exercise or body mechanics specialist to devise an exercise and muscle strengthening program that’s best for you.