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  • Writer's pictureDaniel Selin

Sciatica

Sciatic pain, Sciatica, intervertebral hernia, disc herniation, spinal stenosis, spondylolisthesis, vertebral displacement, radiating pain, leg pain, back pain

Sciatica refers to radiating pain along the path of the sciatic nerve, from the lower back or pelvic region to one or both legs. Sciatica is typically caused by a disc herniation, which irritates or compresses the nerve root in the spine. Sciatica causes intense nerve pain that is more pronounced in the lower limb than in the back, even though the cause is often related to the spine. A common misconception is that all back pain is sciatica or that all leg pains radiating to the lower limb are caused by the sciatic nerve and therefore Sciatica.


Sciatica is often associated with neurodynamic and/or neurological findings, such as impaired nerve mobility or increased sensitivity to stretching, weakness in specific muscles, or changes in reflexes and sensation.


Disc-related Sciatica often worsens during prolonged sitting or when bending or twisting the lumbar spine. Coughing, straining or sneezing can also feel difficult and increase Sciatic pain.

 

Anatomy

The sciatic nerve forms when multiple roots of the sacral plexus come together to create a unified nerve. The sciatic nerve originates from the nerve roots L4-S3 in the lumbar and sacral regions, from where it travels downward towards the leg. In the buttock area, it passes deep within the muscles, traversing between or, in some cases, even through the muscles.

In the above image, variations in the relationship between the sciatic nerve and the piriformis muscle are illustrated as an example.


Below the pelvis, the nerve runs in the back of the thigh between the hamstring muscles. Around the midpoint of the thigh, the nerve divides into two parts. One part winds around the to the front of the shin, further branching into two branches. The other part continues down the middle of the calf, eventually branching again around the area of the heel. Overall, the sciatic nerve innervates the muscles of the back of the thigh and all the muscles located below the knee.

In the above image, the course of the sciatic nerve from the pelvic region down to the leg is illustrated.


The Sciatic nerve is the largest and longest nerve in our body, with a diameter of up to 2 cm at its thickest point. It contains both motor and sensory fibers, meaning it is responsible for both muscle function and sensation in the lower limb. The sciatic nerve provides sensory input to the outer part of the leg and the foot, and it innervates the area below the knee and the muscles of the back of the thigh.

 

Etiology

Any condition that structurally, inflammatorily or compressively irritates the sciatic nerve may cause Sciatica.


A sciatic nerve injury can also result in Sciatic nerve symptoms, such as pain, muscle weakness, and numbness. A nerve injury is usually a consequence of an injury to the nerve rather than a compression or irritation of the nerve.


The causes of sciatic pain can be broadly divided into two groups: spine-related and non-spine-related reasons.


Spine-related causes of sciatic pain include:

  1. Lumbar disc herniation or protrusion

  2. Spinal canal stenosis

  3. Spondylolisthesis

  4. Spinal or paraspinal tumor, abscess, or hemorrhage


Non-spine-related causes of sciatic pain include:

  1. Piriformis syndrome

  2. Compression of the nerve root due to changes durin pregnancy

  3. Pelvic tumors

  4. Nerve injury

  5. Iatrogenic causes


Of these, the most common cause is a disc herniation in the lumbar spine, which compresses the nerve root and also irritates it chemically through inflammation.

 

The pathological process of Sciatica in a disc herniation:

Compression of a nerve root or nerve trunk, typically causes dysesthesia, a decrease or alteration in sensation in the skin area innervated by that nerve. However, the characteristic symptom of Sciatica caused by a disc herniation is a radiating pain to the lower limbs. Why does this happen?


The answer seems to lie in the inner mass of the disc, the nucleus pulposus, which, when herniated, irritates the nerve root not only mechanically but also chemically. The nucleus pulposus appears to irritate the nerve root and the dorsal root ganglia through inflammatory factors.


In the epidural space, the nucleus pulposus seems to be able to alter the nerve conduction velocity, even without direct mechanical compression on the nerve root. This chemical irritation also seems to accelerate the degeneration of nerve fibers and possibly alter the function and structure of the nerve root.


The interaction between mechanical compression and the inflammatory process is complex, but the chemical factors released during disc damage appear to be crucial. Therefore, reducing or eliminating mechanical compression usually does not immediately alleviate symptoms; addressing inflammation is also necessary. It's important to note that effective treatment of inflammation alone may be sufficient to reduce pain symptoms, even if the compression on the nerve remains.

 

Symptoms

Sciatic pain is typically felt in the lower limb and its location and intensity vary based on the irritation to the nerve in the back.


Sciatica often involves neurological symptoms such as:

  1. Sensory disturbances in the dermatomal area innervated by the irritated or damaged nerve root. These may include sensations like warmth or coldness on the skins surface, tingling or burning pain or a feeling of numbness in the lower limbs.

  2. Muscle weakness related to nerve damage may occur.

  3. Reflex disturbances are also possible.


Sciatic pain, area of numbness or sensory disturbances, as well as swelling in the lower limb, often vary depending on which nerve is irritated or damaged.

  • L4 nerve root: Compression or irritation of the L4 nerve root often manifests as pain, tingling, and numbness in the thigh area. This may also involve a reduction in power in the Quadriceps muscle and changes in the patellar reflex.

  • L5 nerve root: Compression or irritation of the L5 nerve root is typically felt as pain, tingling, and numbness in the leg or the area around the big toe. Flexion of the ankle or extension of the big toe may be weakened and walking on heels may become challenging without the foot giving in.

  • S1 nerve root: Compression or irritation of the S1 nerve root typically feels like pain, tingling, and numbness on the outer edge of the foot. Rising on ones toes becomes difficult as the calf muscles weakens, and the Achilles reflex may no longer respond.

 

Evaluation

Evaluating for possible Sciatica involves a thorough medical history, clinical examination, and possible imaging studies. Sciatic pain typically includes pain radiating below the knee, exacerbated by specific back movements or prolonged sitting. While pain may be felt in the lower back, it is often less bothersome than the pain experienced in the leg.


There may be sensory loss or alterations in the lower limb, with weakened muscles and a sensation of numbness.


In a clinical examination, the characteristics and sensitivity to stretching of the Sciatic nerve are assessed. Skin sensation is evaluated and reflex functions are compared to the non affected side. Testing for key muscle strength aims to identify changes in muscle strength in muscles known to be innervated by only one nerve root.


This detailed examination and thorough medical history usually results in knowledge about which nerve roots that are involved in creating the problem and also the underlying causes.


Imaging studies (MRI) can then confirm the findings, but these aren't always necessary if the clinical findings are strong and fitting with the symptoms.

 

Treatment

The primary approach to treating Sciatica is conservative. Treatment combines both pharmacological and non-pharmacological pain management methods along with physiotherapy. The majority of Sciatic pain and potential disc herniations improve over time without surgery.


The goal of conservative treatment is to alleviate pain and promote functional and work capacity. This is achieved through guidance, education, a precise and progressive exercise program and manual therapy. Pain and possible anti-inflammatory medication should be considered to optimize treatment outcomes. Engaging in strenuous activities against severe pain often complicates recovery and can, in the worst case, lead to chronic pain. Learn more about pain and pain mechanisms here.


Pharmacological treatment commonly involves a combination of pain and anti-inflammatory medications. Cold therapy, repeated several times a day, can also address inflammation. For more severe pain, the use of opioids or medications that raise the pain threshold may be considered.


Surgical intervention should be considered if desired results are not achieved with conservative treatment within a few months or if symptoms worsen. Emergency surgery may be necessary if a patient develops cauda equina syndrome, characterized by anesthesia in the saddle area (sensory changes in the genital area), intense pain, and paralysis symptoms in the lower limb. However, these cases are rare, and typically conservative treatment is continued for 3-6 months before potentially considering surgical interventions.

 

Physiotherapy

Physical therapy begins with a thorough assessment of current impairments and background factors, leading to the creation of an individualized rehabilitation program. Based on the evaluation, a treatment plan is tailored to individual findings with the goal of alleviating pain and improving functionality.


The content of physiotherapy is always designed individually, often encompassing a combination of the following methods:

  1. Manual Therapy: Soft tissue treatments and joint mobilizations to reduce muscle tension, promote fluid and blood circulation, and enhance fascial function.

  2. Movement and Posture Therapies: Aimed at promoting the sliding ability of nerve structures and reducing increased pressure on the nerve or nerve root.

  3. Activating Exercises: Intended to improve fluid circulation and maintain muscle function.

  4. Pain Management Techniques: May include heat or cold therapy, manual therapy, acupuncture or self-directed exercises.

  5. Biomechanical Assessment and Treatment: Identifying and addressing biomechanical challenges to reduce peak loads and enable decreased stress on already irritated tissues.


The combination of manual therapy, home exercise programs, and time has been shown to produce good results in the treatment of Sciatica.


Below are a few physiotherapy methods and their primary goals in treating sciatic pain:

  • Progressive Exercise and Load Modification:

  • Control overall load.

  • Reduce compression and stretching loads on irritated nerve tissues.

  • Increase fluid and blood circulation in irritated tissue areas.

  • Alleviate pain.

  • Improve the sliding properties of the irritated nerve through mobilizing exercises.


  • Manual Therapy Aims to:

  • Alleviate pain and activate descending pain pathways.

  • Reduce friction and pinching loads on the irritated nerve.

  • Reduce muscle tension.

  • Enhance muscle and joint performance.

  • Decrease cortisol secretion in tissues.

  • Increase or improve circulation in treated tissues.

  • Improve mobility.

  • Reduce pain interference.

Learn more about the effectiveness of manual therapy and the methods used here.


  • Guidance and Counseling Aims to:

  • Provide sufficient information about the nature of the condition, its underlying factors and the rehabilitation.

  • Ease patient concerns and enhance self-efficacy.

  • Offer information about the condition's healing process and treatment prognosis, motivating self-directed rehabilitation.

  • Address factors influencing treatment prognosis and timeline.

  • Decrease patient uncertainty and potential worries, making living with pain more manageable.

 

Self care

If you suspect you are suffering from sciatic pain, I strongly recommend reaching out to a healthcare professional to assess your situation. However, you can safely manage potentially irritated sciatic nerves with the following guidelines. If you notice that any of the activities below worsen your pain, it's best to avoid them.


  1. Avoid Provocative Activities: Identify activities that exacerbate your symptoms and try to avoid them. Typical aggravating factors include prolonged sitting, excessive physical exertion, heavy lifting or extended periods of immobility.

  2. Change Positions Regularly: Avoid sitting or standing in the same position for too long. Change your posture regularly to prevent excessive pressure or tension on the sciatic nerve.

  3. Proper Lifting Techniques: When lifting objects, kneel down and use your leg muscles instead of your back. If possible, refrain from lifting heavy objects.

  4. Activate Core Muscles: Engage in exercises that promote core stability and muscle function. A well-activated core provides better support for your spine and may help alleviate sciatic pain.

  5. Muscle Relaxation: Pain often triggers increased muscle tension as a protective mechanism. Practice relaxation exercises regularly for your lower back, buttocks and legs.

  6. Gentle Stretching: Perform gentle, back-and-forth stretching exercises for your lower back and hamstrings. Be attentive and if these cause pain or exacerbate your symptoms, skip them. Muscle stretching can sometimes worsen pain from an irritated nerve.

  7. Low-Impact Exercise: Incorporate low-impact exercises into your routine. Walking, swimming, water aerobics or light bodyweight exercises are good options.

  8. Rest: Ensure that you get adequate rest and sleep. Sufficient sleep promotes recovery and tissue healing.

  9. Stress Reduction: Consider stress-reducing techniques such as deep breathing, meditation or yoga. Stress management can positively impact overall well-being and often alleviate Sciatic symptoms.

Remember, it's crucial to consult with a healthcare professional for an accurate diagnosis and discuss suitable self-care strategies based on your individual situation. If symptoms persist or worsen, seek medical attention from a doctor or physiotherapist.

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