Although sciatica is often confused with lower back pain, it’s not quite the same thing. With sciatica, as pain tracks down the sciatic nerve — the largest nerve in the body — it radiates to your buttock and hip, and travels down the back of your leg, sometimes all the way to your foot. Fortunately, proper treatment and good self-management can help stop sciatica in its path.
What is sciatica? The spinal cord is divided into four main sections from top to bottom: the cervical, thoracic, lumbar and sacral regions. Spinal nerves are named for the part of the spine where they originate. In sciatica, the fifth lumbar nerve (L5) and first sacral nerve (S1) are most often involved.
“The sciatic nerve arises primarily from the L5 and S1 nerve roots,” says Dr. Joseph Feinberg, Physiatrist-in-Chief Emeritus at the Hospital for Special Surgery in New York City. When these nerve roots are irritated, sciatica can result.
Although other pain patterns are confused with it, Feinberg says, for true sciatica, “You need to have pain that radiates more into the calf or the outer aspect of the leg, or into the foot or toes.”
What causes sciatica? Causes of sciatica include herniated discs, bone spurs and cysts in a facet joint of the back. “They can all actually irritate or compress a nerve in the spine area, or as the nerves are leaving the spine,” Feinberg says.
Lumbar spinal stenosis, in which the spinal canal of the lower back becomes narrow, can also lead to sciatica. Spondylolisthesis, a condition in which a lower back bone slips forward, is another cause.
Improper spine mechanics play a significant role in sciatica, Feinberg says. Spine mechanics are related to posture and how you lift objects, stand or sit.
Who gets sciatica? Sciatica can strike almost anybody. People in their 30s to 50s are most likely to have sciatica, but so can seniors and teens. Pregnant women may experience sciatica-like pain.
“We see the whole gamut,” says Dr. Madhu K. Singh, an assistant professor at Rush University in Chicago, and a physical medicine and rehabilitation physician specializing in interventional spine care with Midwest Orthopaedics at Rush. “I will see young athletes and older athletes,” she says. “I see people in their 60s and 70s who have been biking or running their whole lives and have this issue. I’ll see kids who play sports with this issue. I see people who aren’t athletes. I see people who are overweight and people who are thin.”
Sciatica can happen for no particular reason, Singh says. “Some people say, ‘I woke up in the morning with pain, all of a sudden.’ Sometimes people will say, ‘I was lifting something heavy and felt a pop in my back.’ It can happen without warning. It can happen when you’ve clearly done something to trigger your back. There’s just no way to know.”
What does sciatica pain feel like? Patients describing sciatica symptoms typically complain of shooting pain that runs down the back of their thigh. “It can be both, but it’s usually just one leg,” Singh says. Patients sometimes compare the nerve pain to that of a toothache. “Sometimes they’ll say it’s a sharp, stabbing pain,” she says. “Occasionally, people will say their leg feels numb.”
Sciatica pain can feel like tingling or burning down the leg. The leg may also feel weak, making it difficult to stand. Sitting becomes uncomfortable from pain in the affected buttock or leg.
How do I know that it’s sciatica? “There are times sciatica can be tricky to differentiate,” Singh says. “So it’s always nice to be able to follow the doctor’s advice. But for the most part, patients will come in to me and say, ‘I think I’ve got sciatica.’ And a lot of times they’re right.”
When should you see a doctor? “If symptoms persist past a couple of weeks or if it’s really unbearable to the point where you’re unable to do your activities of daily living, those are really your first couple of clues that you need to see a physician,” Singh advises.
A medical workup for sciatica can include the following:
— A medical history and physical exam are important for diagnosis. “There are provocative maneuvers you can do that will create a little extra tension on those nerves,” Feinberg says. “You can try to reproduce the sciatica symptoms.” For example, having a patient do a straight-leg raise could elicit the radiating pain of sciatica.
— A neurological exam consists of motor, sensation and reflex testing. “If you see neurologic deficits that correspond to a nerve, usually the L5 or S1 nerve, or both, then that would also more strongly support the diagnosis of sciatica,” Feinberg says.
— Imaging tests are sometimes used to further inform a sciatica diagnosis. Your doctor may order a spinal X-ray, CT scan or MRI.
— Electromyography, or EMG testing, measures electrical activity of the nerves and how muscles respond to nerve stimulation.
How is sciatica treated? With most common causes of nerve irritation, Feinberg says, sciatica pain can be managed with physical therapy and exercises to help patients strengthen the abdominal muscles to better support the spine. Pilates classes may help some patients with sciatica.
Biomechanical modifications, similar to ergonomics, are tailored to the individual patients. “It’s the way someone bends down and picks things up,” Feinberg says. “It’s the way they sit at their desk. Is their seat height proper? There are safe ways to do things for the spine.”
Cumulative events lead to disc herniation, Feinberg notes: “So you want to address them in the work environment, the sports environment and during your normal recreational activities.” Occupational therapists and exercise physiologists can offer guidance in these areas.
What are sciatica exercises and stretches? Physical therapy makes a significant difference for many people with sciatica, Singh says. Doing exercises at home doesn’t replace PT, she emphasizes, but is an additional strategy.
“In terms of at-home exercises, core-strengthening is really the hallmark of what we want to do to keep your back healthy,” Singh says. “Yoga is an excellent exercise in the long term, but sometimes it’s not very helpful in acute sciatic problems,” she adds. “I notice that people who do yoga pretty consistently tend to have less pain.”
Some people with sciatica independently choose the McKenzie Method, developed several decades ago by a New Zealand physical therapist. It involves patient education and individualized, extension-based exercises to address certain types of lower back pain.
Although people sometimes respond well to the McKenzie Method, Singh says, “It’s not an end-all and be-all.” In her practice, she says, clinicians tell patients it’s great if the method helps, but if it exacerbates their pain, then it’s not right for them.
What works for sciatica pain relief? For acute bouts of sciatica involving muscle spasms in the back area, at-home approaches may include applying ice or heat to relieve the spasms, Feinberg says. Over-the-counter medications like acetaminophen (Tylenol) or nonsteroidal anti-inflammatory medications such as Advil or Motrin can help, too.
If sciatica persists, it’s best to seek medical help. “I tell patients that we stratify our treatment based on least to more aggressive treatment,” Singh says. “So, we start off with the most common things: physical therapy, acupuncture, massage, a chiropractor.”
If these measures fail to ease sciatica, medications can be the next step. “Sometimes we’ll do medication in conjunction with those conservative options, as well,” Singh says. Prescription anti-inflammatory drugs are helpful. Seizure medicines like gabapentin are sometimes used to treat sciatica pain.
“We try to stay away from narcotics as best as we can, as often as we can,” Singh says. “But occasionally, they are indicated for a very short and limited period.”
Epidural injections are an option when conservative treatments and medication aren’t enough to manage sciatica.
“Once all those things have failed, then we’ll usually send the patient to see a surgeon,” Singh says. “But there are exceptions to that. When a patient has weakness in the leg or if the pain is so extreme they’re unable to function, then sometimes we’ll skip those things and send them straight to a surgeon.”
What’s the connection between stress and sciatica? Stress can bring on sciatica episodes, Feinberg says. Finding proactive ways to limit stress can help stave off sciatica.
Stressful situations play a role in provoking and amplifying pain in general, Feinberg says: “Usually it’s some type of emotional situation with family, work or maybe something else going on.”
How can I prevent sciatica? Following a healthy lifestyle can keep your back healthy and help you avoid sciatica. Maintaining a healthy body weight — as challenging as that can be — is important, Singh says, especially as you age. Keeping active and moving also matter. “Even if it’s walking every day — that’s great exercise.”
Incorporating daily yoga, alternating sitting and standing at work, doing core-strengthening exercises and abstaining from smoking can all help promote long-term back health, Singh says.
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