Sciatica

Sciatica is a term used to describe nerve pain caused by irritation of the sciatic nerve. The sciatic nerve is a big thick nerve which consists of fibers that come out of the spinal cord in the lower back and tail bone. It is the largest nerve in the body, which can be as thick as your thumb in some parts. The sciatic nerve’s job is to supply sensation and muscle control to the lower leg and feet. When it gets compressed the nerve gets irritated and inflamed leading to pain and even muscle weakness in advanced cases.

The pain in sciatica is typically felt from the lower back to behind the thigh and spreading down below the knee. It’s commonly seen in one leg, but can happen in both.

What causes sciatica?

Most often a lumbar disc herniation which directly presses on the sciatic nerve will cause it, but really anything that irritates or causes that nerve to swell will cause the pain. In essence, it’s not a disease, but the symptom of a disease.

Some other causes of sciatica could be:

• Irritation of the nerve by an adjacent bone
• Tumors
• Internal bleeding
• Infections in or around the lumbar spine
• Trauma
• Pregnancy (due to excess stress on the lower back)

People who suffer from degenerative arthritis of the lumbar spine, lumbar disc disease, or even slipped discs are at risk of developing sciatica. Obesity and a sedentary lifestyle contribute to the problem and make it more likely to develop as well.

How is it Diagnosed?

First off, the issue needs to be examined by a physician. A good general physician, neurologist / neurosurgeon or orthopedic spine surgeon can do the examination. The doctor will examine your back, the curvature of the spine and the sensation in your lower legs and feet. They will also want to test the muscles of your legs and check your reflexes. A good neurological exam is the absolute first step.

After that, there are a number of imaging and functional tests to see if the nerve is compressed or not. In general, X-rays of the lower back are the first investigation, but your doctor may want to go straight for a CT (a better imaging modality). An MRI of the lumbar spine without contrast has become the standard test to check for the nerve compression. If your doctor can’t match up your actual symptoms with the images, the doctor will rely more heavily on his or her examination. Imagining is notoriously fickle. Sometimes what looks like a nerve compression is not really what’s causing the problem, and at other times, the imaging may not show the compression well and it gets missed.

An ‘ENMG’ (electroneuromyography) is a functional test which tries to see if electrical impulses are travelling through the nerve correctly. Sometimes, the cases are so extreme that the diagnosis is obvious and the doctor won’t want to put you through the test. Occasionally though, when the symptoms and imaging can’t clinch the diagnosis, this test will help tip the balance.

Treatment Options

Many people will tell you that continuous bed rest is the best option. But sciatica can’t be treated through bed rest alone. Research shows that bed rest really does nothing to help the issue in the long term and only reduces the acute pain for a while. Let’s divide the more involved treatment options into conservative (non-surgical) and surgical.

The conservative methods of treating sciatica are:

1. Physical therapy, which is designed to strengthen the core muscles and soft supportive muscles and connective tissue of the spine
2. Pain medications and muscle relaxants, which relieve the spasm of the muscles connected to the nerve.
3. Steroid injections into the space between the spine and the cord to reduce the swelling.

Any one of these or a combination will be needed to handle the issue. Most cases resolve if the treatment is adhered to. On the other hand, if these things don’t end up working, surgery is the next step.

You always want to try all the possible non-surgical treatments before going for surgery. The vast majority of back pain patients will not need surgical treatments if the medical ones are followed correctly.

The most common disease process that will lead to surgery for low back pain is disc herniation. Another issue called spinal stenosis (where the spinal canal gets very narrow) is high up on the list of indications for surgery.

In general, surgery gives better short term and possibly quicker relief in the right circumstances. Many approaches and minimally invasive procedures for surgery are available. However, over time, nonsurgical treatments are generally as effective.

You’ve always got to keep in mind that surgery does not always improve the outcome. In fact, in certain cases, surgery can even make things worse. So the surgeon is going to be very picky about taking you into the operation theater, or at least should be.