Sciatica

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Sciatica
Left gluteal region, showing surface markings for arteries and sciatic nerve.
ICD-10	M54.3-M54.4
ICD-9	724.3
MeSH	D012585

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Synonyms and keywords: Neuralgia, sciatic; sciatic neuralgia; sciatica, bilateral

Overview

Sciatica is pain caused by general compression and/or irritation of one of five nerve roots that are branches of the sciatic nerve. The pain is felt in the lower back, buttock, and/or various parts of the leg and foot. In addition to pain, which is sometimes severe, there may be numbness, muscular weakness, and difficulty in moving or controlling the leg. Typically, the symptoms are only felt on one side of the body.

Although sciatica is a relatively common form of low back pain and leg pain, the true meaning of the term often is misunderstood. Sciatica is a set of symptoms rather than a diagnosis for what is irritating the root of the nerve, causing the pain. This point is important, because treatment for sciatica or sciatic symptoms often will be different, depending upon the underlying cause of the symptoms.

The first cited use of the word "sciatica" was registered in 1450.

Causes of sciatica

Sciatica is generally caused by the compression of a lumbar spine nerve root L4 or L5 or sacral nerve roots S1, S2 or S3, or far less commonly, by compression of the sciatic nerve itself. When sciatica is caused by compression of a lumbar nerve root it is considered a lumbar radiculopathy (or radiculitis when accompanied with an inflammatory response) from a spinal disc herniation (a herniated intervertebral disc in the spine), or from roughening, enlarging, and/or misaligning of the vertebrae (spondylolisthesis), or degenerated discs.

"Pseudo-sciatica", which causes symptoms similar to spinal nerve root compression, is caused by the compression of peripheral sections of the nerve, usually from soft tissue tension in the piriformis or related muscles (see piriformis syndrome and see below).

Spinal disc herniation

Main article: Spinal disc herniation

One cause of sciatica is a spinal disc herniation, pressing on one of the sciatic nerve roots. The spinal discs are composed of a spongiform cartilage with a liquid center. The discs separate the vertebrae, thereby allowing room for the nerve roots to properly exit through the spaces between the L4, L5, and sacral vertebrae. The discs cushion the spine from compressive forces, but are weak to pressure applied during rotational movements. That is why a person who bends to one side, at a bad angle, to pick up a piece of paper may more likely herniate a spinal disc than a person falling from a ladder and landing on his or her back. Herniation of a disc occurs when the liquid center of the disc bulges outwards, tearing the external ring of fibers, and compresses a nerve root against the lamina or pedicle of a vertebra, thus causing sciatica.

Spinal stenosis

Main article: Spinal stenosis

Other compressive spinal causes include Spinal Canal Stenosis, a condition wherein the spinal canal (the spaces through which the spinal cord runs) narrows and compresses the spinal cord. This narrowing can be caused by bone spurs, vertebral dislocation, inflammation, or herniated disc which decreases available space for the spinal cord, thus pinching nerves in the spinal cord that travel to the sciatic nerve and irritating them with friction.

Piriformis syndrome

Main article: Piriformis syndrome

The sciatic nerve runs through the piriformis muscle in the buttocks region beneath the gluteal muscles. When the muscle shortens or spasms due to trauma, it can compress or strangle the sciatic nerve beneath the muscle. This cause of sciatic symptoms is piriformis syndrome. This may be the major cause of sciatica when the nerve root is normal.

The risk of self-inflicted sciatica has increased in recent years with the fashion trend of lower-hanging trousers as well as lower-positioning of the pockets. For instance, sitting on a wallet for prolonged hours every day can cause self-inflicted sciatica. Symptoms of numbness and/or pain behind the knee cap are associated with this form of sciatica.

NonSurgical Treatment Options

Chiropractic
Doctors of Chiropractic medicine provide many conservative, non-invasive and drug-free therapies to reduce sciatic nerve symptoms.

Stronger Medication
If pain is severe, the doctor may prescribe a more potent NSAID. Chronic sciatica may require a muscle relaxant and/or anti-depressant medication. Certain anti-seizure and anti-depressant medications are effective in blocking pain messages sent to the brain. Some of these drugs may enhance the body's production of natural pain killers - endorphins.

Epidural Steroid Injection
This type of spinal injection places a steroid (corticosteroid) medication near spinal nerve roots. Steroids reduce inflammation and can help to ease back and leg pain. An epidural steroid injection may provide pain relief for several months or longer.

Structured Physical Therapy Program
Physical therapy and rehabilitation include passive treatments and therapeutic exercises customized to meet the patient's individual needs. Physical therapists work one-on-one with the patient to reduce pain, increase flexibility, and build strength.

Sacroiliac joint dysfunction

Another cause of sciatic symptoms is sacroiliac joint dysfunction. Unhealthy postural habits, such as excessive time sitting in chairs, and sleeping in the fetal position, along with insufficient stretching and exercise of the relevant myofascial areas, can lead to both the vertebral and soft tissue problems associated with sciatica .

Trigger points

Another source of sciatic symptoms is active trigger points of the lower back and the gluteus muscles. In this case, the referred pain is not consequent to compression of the sciatic nerve, though the pain distribution down the buttocks and leg is similar. Trigger points occur when muscles become ischemic (low blood flow) due to injury or chronic muscular contraction. The most commonly associated muscles with trigger points triggering sciatic symptoms are: the quadratus lumborum, the gluteus medius, the gluteus minimus, and the deep hip rotators.

Pregnancy

Sciatica may also be experienced in late pregnancy, primarily resulting from the uterus pressing on the sciatic nerve, and, secondarily, from the muscular tension and / or vertebral compression consequent to carrying the extra weight of the fetus, and the postural changes inherent to pregnancy.

Diagnosis and treatment

Because of the many conditions which can compress nerve roots and cause sciatica, treatment and symptoms often differ from patient to patient. Diagnostic tests can come in the form of a series of exams a physician will perform. Patients will be asked to adopt numerous positions and actions such as squatting, walking on toes, bending forward and backward, rotating the spine, sitting, lying on back, and raising one leg at a time. Increased pain will occur during some of these activities.

Treatment of the underlying cause of the compression is often the most effective course. When the cause is due to a prolapsed or lumbar disc herniation, research has shown that, with supportive treatment to help relieve pain, 90% of disc prolapse will recover with no specific intervention. Genetics appear to influence the risk of developing disc herniation.

Imaging methods such as MR neurography may help diagnosis and treatment of sciatica. MR neurography has been shown to diagnose 95% of severe sciatica patients, while as few as 15% of sciatica sufferers in the general population are diagnosed with disc-related problems. MR neurography is a modified MRI technique using MRI software to provide better pictures of the spinal nerves and the effect of compression on these nerves. MR neurography may help diagnose piriformis syndrome which is another cause of sciatica that does not involve disc herniation.

Most cases of sciatica can be effectively treated by one or a combination of the following:

Medication therapies

• Anti-inflammatory medications (i.e. NSAIDs or oral steroids)
• Pain medications (e.g. acetaminophen)
• Epidural steroid injections to deliver local anti-inflammatory agents (and possibly a pain medication) directly to the affected area

Invasive therapies

• Surgery
• Minimally invasive procedure

Minimally invasive procedures

Intradiscal Electrothermoplasty (IDET)

A needle is inserted into the affected disc, guided by x-ray. A wire is then threaded down through the needle and into the disc until it lies along the inner wall of the annulus. The wire is then heated which destroys the small nerve fibers that have grown into the cracks and have invaded the degenerating disc. The heat also partially melts the annulus, which triggers the body to generate new reinforcing proteins in the fibers of the annulus.

Radiofrequency Discal Nucleoplasty (Coblation Nucleoplasty)

A needle is inserted into the affected disc, although instead of a heating wire, a special RF probe (radio frequency) is used. This probe generates a highly focused plasma field with enough energy to break up the molecular bonds of the gel in the nucleus, essentially vaporizing some of the nucleus. The result is that 10-20% of the nucleus is removed which decompresses the disc and reduces the pressure both on the disc and the surrounding nerve roots. This technique may be more beneficial for sciatica type of pain than the IDET, since nucleoplasty can actually reduce the disc bulge, which is pressing on a nerve root. The high-energy plasma field is actually generated at relatively low temperatures, so danger to surrounding tissues is minimized.

Alternative therapies

The approach to treating Sciatica is to reduce the compressive forces causing the pressure upon the sciatic nerve. This can be accomplished through traction and realignment therapeutic procedures in the case where the sciatica is spinal-related.

• Acupuncture
• Chiropractic manipulation for the restoration of normal joint biomechanics and reduction of histochemical irritation to the involved nerves.
• Massage therapy to the involved lumbopelvic muscles.
• Structural Integration A systematic approach designed to reorganize major joints, and body segments (such as the lower back region and sacrum), while releasing the chronically held tension and torsion patterns. The goal is to achieve a rapid change in structural mechanics and correction of chronic musculoskeletal pain or dysfunction.

Related Chapters

• Back pain
• Piriformis syndrome
• Spinal disc herniation
• Laminectomy
• Hemilaminectomy

References

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