Sciatica

Sciatica is also called lower extremity (L5/S1) radiculitis or radiculopathy and is a condition characterized by weakness or sensory changes along the sciatic nerve pathway.

The sensory changes are often described as “pins and needles” and can extend down the buttock, leg, and foot.

Symptoms of serious concern include severe nerve impingement, bladder incontinence, bowel incontinence, lower extremity weakness, and profound loss of sensation.

Pathology

The sciatic nerve can be affected by many different conditions and disease states. Many of these conditions ultimately lead the nerve to become pinched or stretched. Some of the most commonly seen conditions that produce sciatica are:

Herniated or bulging disc: This is the most common cause of sciatica.
Spinal stenosis: This is a disorder due to narrowing of the spinal canal that causes nerve or spinal cord impingement.
Piriformis syndrome: The piriformis is a large muscle that is part of the pelvis. When this muscle becomes inflamed or overused, this muscle can trap the sciatic nerve deep in the buttock causing sciatica.
Facet hypertrophy: The facet joints allow for movement, especially backwards extension. When the facet joints become arthritic they can become knobby and large. They also can develop cysts. The larger joints can irritate exiting nerve roots causing sciatica.
Other causes: Less commonly, sciatica can be due to tumors, pelvic infections, and other causes.

Diagnosis

Diagnosis of sciatica is most often done clinically by a medical physician. The physician performs a physical examination demonstrating tenderness over certain areas of the spine as well as assessing the various limitations in movement of the lower extremity.

The physician may also order radiological imaging such as X-ray, CT scan, MRI, or bone scan depending on his clinical suspicion. Currently MRIs are the standard of care to visualize chronic back pain and are especially useful before any procedures are undertaken. If a history of cancer, IV drug use, HIV infection, or recent steroid use is known then the physician will most likely order additional studies before deciding on sciatica therapy.

Sciatica Treatment

Pharmacotherapy: NSAIDs (ibuprofen-like drugs), acetaminophen, membrane-stabilizing drugs, muscle relaxants, and other analgesics are often used in the management of pain associated with sciatica.
Epidural steroid injections (ESI)
Transcutaneous electrical stimulation (TENs): This pain relief technique is a passive process with no known side effects. TENS decreases the perception of pain and may be used to control acute and chronic pain. There are several patches placed on your skin in the area that is affected and mild electrical current generates stimuli. This stimuli confuses the spinal cord and brain pain processing centers. Painful signals are replaced by tingling electrical signals in this sciatica treatment. This provides relaxation of the muscle, improves mobility, and can relieve pain.
Spinal cord stimulation (SCS): An implanted electrical device can decrease the perception of pain by confusing the spinal cord and brain pain processing centers. Initially a trial is done to see if this device will help you long-term. In the initial trial, your pain physician places a small electrical lead through a needle in the epidural space. Painful signals are replaced by tingling electrical signals. If you have success in your trial, you may decide to have a permanent SCS device implanted.
Deep tissue massage: Focal rubbing of tender areas may help relieve muscle spasms or contractions and improve the discomfort associated with it. Massage as a sciatica therapy can also help you relax, decreasing stress and tension.
Acupuncture: Small needles are inserted into the skin. These needles cause your body to release hormones called endorphins, which are your body’s natural pain relievers. Acupuncture can also help you relax, decreasing stress, tension, and muscular spasm.
Physical therapy: Physical therapy helps improve symptoms of sciatica by increasing flexibility, range of motion, posture, and improving muscle strength.
Nutrition and exercise: Exercise improves the pain of sciatica by increasing flexibility and range of motion. Another benefit is the release of hormones called endorphins, which are your body’s natural pain relievers. Nutrition and healthy eating may be powerful treatments to combat nutritional deficits.
Disc decompression: A needle is inserted through the skin into the affected disc. Disc material is suctioned out of the bulging disc and pressure is relieved within the disc.
Trigger point injections (TPIs): These can be an effective treatment for muscle spasms. The procedure involves injecting a local anesthetic and steroid into a trigger Point. Performing a piriformis injection can be considered a type of TPI.
Biofeedback: This is a treatment that teaches a patient to become aware of processes that are normally thought to be involuntary inside of the body (such as blood pressure, temperature, and heart rate control). This method enables you to gain some conscious control of these processes, which can influence and improve your level of pain. A better awareness of one’s body teaches one to effectively relax, and this can help to relieve pain.