Sciatica

What is Sciatica?

The longest nerve in your body, the sciatic nerve runs from your pelvis through your hip area and buttocks and down each leg. It divides into the tibial and peroneal nerves at the level of your knees. The sciatic nerve controls many of the muscles in your lower legs and provides feeling to your thighs, legs and feet.

The term sciatica refers to pain that radiates along the path of this nerve — from your back into your buttock and leg. The discomfort can range from mild to incapacitating, and may be accompanied by tingling, numbness or muscle weakness. Rather than a disorder in and of itself sciatica is a symptom of another problem, such as a herniated disk, that puts pressure on the nerve.

Sciatic pain usually goes away on its own in six weeks or so. In the meantime, hot and cold packs, over-the-counter pain relievers, and exercise or physical therapy can help ease discomfort and speed recovery. Surgery to relieve pressure on the nerve may be an option when symptoms don't respond to conservative treatment and pain is chronic or disabling

What are the signs and symptoms of Sciatica?

Pain that radiates from your lower (lumbar) spine to your buttock and down the back of your leg is the hallmark of sciatica. You may feel the discomfort almost anywhere along the nerve pathway, but it's especially likely to follow one of these routes:

• From your lower back to your knee
• From the mid buttock to the outside of your calf, the top of your foot and into the space between your last two toes
• From the inside of your calf to your inner ankle and sole

The pain can vary widely, from a mild ache to a sharp, burning sensation or excruciating discomfort. Sometimes it may feel like a jolt or electric shock. Sciatic pain often starts gradually and intensifies over time. It's likely to be worse when you sit, cough or sneeze. Usually only one lower extremity is affected.

In addition to pain, you may also experience:

• Numbness or muscle weakness along the nerve pathway in your leg or foot. In some cases, you may have pain in one part of your leg and numbness in another.
• Tingling or a pins-and-needles feeling. This occurs most commonly in your toes or part of your foot.
• A loss of bladder or bowel control. This is a sign of cauda equina syndrome, a rare but serious condition that requires emergency care. If you experience either of these symptoms, seek medical help immediately.

What are the causes of Sciatica?

Sciatica usually results from compression of a nerve root in your lower (lumbar) spine — a condition called a radiculopathy. By far the most common cause of this compression is a herniated disk in your lower back. Disks are pads of cartilage that separate the bones (vertebrae) in your spine. Each disk consists of a ring of tough fibrous tissue (annulus fibrosis) surrounding a jelly-like centre (nucleus pulposus). Healthy disks keep your spine flexible and act as shock absorbers to cushion the vertebrae when you move.

But as you grow older, the disks may start to deteriorate, becoming drier, flatter and more brittle. Eventually, the tough, fibrous outer covering of the disk may develop tiny tears, causing the jelly-like substance in the disk's centre to seep out (herniation or rupture). The herniated disk then often presses on a nerve root, causing pain — which can be excruciating — in your back, leg or both. If the damaged disk is in the middle or lower part of your back, you also may experience numbness, tingling or weakness in your buttock, leg or foot.

Other conditions that may put pressure on the sciatic nerve include:

Lumbar spinal stenosis. Your spinal cord is a bundle of nerves that extends the length of your spine. It's housed inside a channel (spinal canal) within the vertebrae. Thirty-one pairs of nerves branch off from the spinal cord, providing communication between your brain and the rest of your body. In spinal stenosis, one or more areas in the spinal canal narrow, putting pressure on the spinal cord or on the roots of these branching nerves. When the narrowing occurs in the lower spine, the lumbar and sacral nerve roots may be affected.

Spondylolisthesis. This condition, often the result of degenerative disk disease, occurs when one vertebra slips slightly forward over another vertebra. The displaced bone may pinch the sciatic nerve where it leaves the spine.

Piriformis syndrome. Running directly above the sciatic nerve, the piriformis muscle starts at your lower spine and connects to each thighbone (femur). Piriformis syndrome occurs when the muscle becomes tight or goes into spasms, putting pressure on the sciatic nerve. Active women — runners and serious walkers, for example — are especially likely to develop the condition. Prolonged sitting, car accidents and falls also may contribute to piriformis syndrome.

Spinal tumors. A tumour is a mass of abnormal cells. In the spine, these growths may occur inside the spinal cord, within the membranes (menninges) that cover the spinal, or in the space between the spinal cord and the vertebrae — the most common site. As it grows, a tumour compresses the cord itself or the nerve roots. This can cause severe back pain that may extend to your hips, legs or feet; muscle weakness and a loss of sensation — especially in your legs; difficulty walking; and sometimes loss of bladder or bowel function.

Trauma. A car accident, fall or blow to the spine can injure the lumbar or sacral nerve roots.

Sciatic nerve tumour or injury. Although uncommon, the sciatic nerve itself may be affected by a tumour or injury, leading to sciatic pain.

Other causes. In some cases, your doctor may not be able to find a cause for your sciatica. A number of problems can affect the bones, joints and muscles, all of which could potentially result in sciatic pain.

Diagnosis

Treatment.

For most people, sciatica responds well to self-care measures. You'll heal more quickly if you continue with your usual activities but avoid what may have triggered the pain in the first place. Although resting for a day or so may provide some relief, prolonged bed rest isn't a good idea. In the long run, inactivity will make your symptoms worse.

Here are conservative measures that you can take or that your doctor may suggest:

• Cold packs. Initially, your doctor may suggest using cold packs to reduce inflammation and relieve discomfort. Wrap an ice pack or a package of frozen peas in a clean towel and apply to the painful areas for 15 to 20 minutes at least four times a day.
• Hot packs. After 48 hours, apply heat to the areas that hurt. Use warm packs, a heat lamp or a heating pad on the lowest setting. If you continue to have pain, try alternating warm and cold packs.
• Stretching. Initially, passive stretching exercises can help you feel better and may relieve compression, but avoid jerking, bouncing or twisting.
• Over-the-counter medications. Pain relievers (analgesics) fall into two categories — those that reduce pain and inflammation and those that only treat pain. Non steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen which help alleviate both discomfort and inflammation, are the most helpful for sciatica. Although they can provide real relief, NSAIDs have a "ceiling effect" — that is, there's a limit to how much pain they can control. If you have moderate to severe pain, exceeding the recommended dosage won't provide additional benefits. What's more, NSAIDS can cause side effects such as nausea, stomach bleeding or ulcers. If you take these medications, talk to your doctor so that you can be monitored for problems. In addition, periodically re-evaluate whether you still need NSAIDs. Exercise, stretching, massage and other non drug treatments can often provide the same benefits without side effects.
• Prescription drugs. In some cases, your doctor may prescribe an anti-inflammatory medication along with a muscle relaxant. Tricyclic antidepressants, such as nortriptyline or amitriptyline and anticonvulsant drugs, such as gabapentin, also may be prescribed for chronic pain. They may help by blocking pain messages to the brain or by enhancing the production of endorphins, your body's natural painkillers.
• Physical therapy. If you have a herniated disk, physical therapy can play a vital role in your recovery. Once acute pain improves, your doctor or a physical therapist can design a rehabilitation program to help prevent recurrent injuries. Rehabilitation typically includes exercises to help correct your posture, strengthen the muscles supporting your back and improve your flexibility. Your doctor will have you start physical therapy, exercise or both as early as possible. It's the cornerstone of your treatment program and should become part of your permanent routine at home.
• Regular exercise. It may seem counterintuitive to exercise when you're in pain, but the fact is that regular exercise is one of the best ways to combat chronic discomfort. Exercise prompts your body to release endorphins — chemicals that prevent pain signals from reaching your brain. Endorphins also help alleviate anxiety and depression, conditions that can make your pain more difficult to control. What's more, combining aerobics with strength training and exercises that maintain or improve flexibility can help prevent age-related degenerative changes in your back. If you're new to exercise, start out slowly and progress to at least 30 minutes most days. To prevent injury, consider learning proper weight lifting techniques from a certified personal trainer, fitness specialist or physical therapist.

Alternative therapy

Complementary and alternative medicine (CAM) refers to medical and health care systems, practices and products that aren't currently part of conventional medicine — the care you receive in your primary care doctor's office. Many of these therapies are being studied intensely and some have proven to help alleviate back pain.

• Acupuncture. Originating in China more than 2,500 years ago, this medical system is based on the idea that that health and life depend on a vital energy called qi — pronounced "chee" and sometimes written chi — that is believed to flow along 14 pathways in your body. When qi is blocked, disease and pain result. Inserting very fine needles into specific points along the meridians is designed to unblock energy flow and restores your body's healthy balance. During an acupuncture treatment, you're likely to have from one to 20 or more hair-thin needles inserted into your skin. Most needles are inserted superficially, although some may go deeper, depending on where they're placed and the problem being treated. In most cases, you won't feel the needles — in fact, many people find the treatments extremely relaxing. The needles may remain in place from a few minutes to half an hour or longer.
• Magnetic therapy. The application of static high strength rare earth magnets at the point of pain over a period of time. Available in many forms such as magnetic straps/ wraps, pillows, jewellery, mattress covers and water.
• Acupressure. This therapy is based on the same principles as acupuncture, but rather than using needles, the practitioner massages or presses specific points along the meridians to effect healing. Although the results may be more subtle than with acupuncture, acupressure may be a good choice if you'd rather avoid needles.
• Chiropractic. Chiropractic treatment is based on the philosophy that restricted movement in the spine may lead to reduced function and pain. Spinal adjustment (manipulation) is one form of therapy chiropractors use to treat restricted spinal mobility. The goal is to restore spinal movement and, as a result, improve function and decrease pain.
• Hypnosis. People have been using hypnosis to promote healing since ancient times. In the past 50 years, however, it's experienced a resurgence among physicians, psychologists and mental health professionals. Hypnosis produces an induced state of deep relaxation in which your mind stays narrowly focused and open to suggestion. During hypnosis, you can receive suggestions designed to decrease your perception of pain and increase your ability to cope with it. It also can help you stop habits such as smoking. No one knows exactly how hypnosis works, but experts believe it alters your brain wave patterns in much the same way as other relaxation techniques.

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