Sciatica is a term used to describe the symptoms of leg pain, tingling, numbness, or weakness that travel down the low back via the sciatic nerve in the back of the leg. Sciatica (sometimes known as radiculopathy) is a description of symptoms, not a diagnosis.
Sciatica (pronounced sigh-at-ih-kah) is not a medical diagnosis in and of itself—it is a symptom of an underlying medical condition, such as a lumbar herniated disc, degenerative disc disease, or spinal stenosis.
A herniated disc, spinal stenosis, degenerative disc disease, and spondylolisthesis can all cause sciatica.
The term sciatica describes the symptoms of leg pain—and possibly tingling, numbness or weakness—that originate in the lower back and travel through the buttock and down the large sciatic nerve in the back of the leg.
Sciatica Nerve Pain
Sciatica is often characterized by one or a combination of the following symptoms:
Constant pain in only one side of the buttock or leg (rarely can occur in both legs)
Pain that is worse when sitting
Leg pain that is often described as burning, tingling or searing (vs. a dull ache)
Weakness, numbness or difficulty moving the leg or foot
A sharp pain that may make it difficult to stand up or to walk
Sciatic pain can vary from infrequent and irritating to constant and incapacitating. Specific sciatica symptoms can be different in location and severity, depending upon the condition causing the sciatica (such as a lumbar herniated disc ).
While symptoms can be painful and potentially debilitating, it is rare that permanent sciatic nerve damage (tissue damage) will result.
The Sciatic Nerve and Sciatica
Sciatica symptoms occur when the large sciatic nerve is irritated or compressed in the lumbar spine.
The sciatic nerve is the largest single nerve in the body and is composed of individual nerve roots that start by branching out from the spine in the lower back and combine to form the “sciatic nerve.”
The sciatic nerve starts in the lower back at lumbar segment 3 (L3).
At each level of the lower spine a nerve root exits from the inside of the spine, and these respective nerve roots then come together to form the large sciatic nerve.
The sciatic nerve runs from the lower back, through the buttock, and down the back of each leg
Portions of the sciatic nerve then branch out in each leg to innervate certain parts of the leg – the thigh, calf, foot, toes.
The specific sciatica symptoms – the leg pain, numbness, tingling, weakness, and possibly symptoms that radiate into the foot – largely depend on where the nerve is pinched.
For example, a lumbar segment 5 (L5) nerve impingement can cause weakness in extension of the big toe and potentially in the ankle.
When discussing sciatica it is important to understand the underlying medical cause of the sciatica symptoms, as effective treatment will focus on addressing the root cause of the pain.
6 most common causes of sciatica
There are 6 lower back problems that are the most common causes of sciatica:
Lumbar herniated disc
A herniated disc occurs when the soft inner core of the disc (nucleus pulposus) leaks out, or herniates, through the fibrous outer core (annulus) and irritates the contiguous nerve root.
A herniated disc is sometimes referred to as a slipped disc, ruptured disc, bulging disc, protruding disc, or a pinched nerve. Sciatica is the most common symptom of a lumbar herniated disc.
Degenerative disc disease
While disc degeneration is a natural process that occurs with aging, for some people one or more degenerated discs in the lower back can also irritate a nerve root and cause sciatica.
Degenerative disc disease is diagnosed when a weakened disc results in excessive micro-motion at that spinal level, and inflammatory proteins from inside the disc become exposed and irritate the nerve root(s) in the area.
This condition occurs when a small stress fracture allows one vertebral body to slip forward on another; for example, if the the L5 vertebra slips forward over the S1 vertebra.
With a combination of disc space collapse, the fracture, and the vertebral body slipping forward, the nerve can get pinched and cause sciatica.
Lumbar spinal stenosis
This condition commonly causes sciatica due to a narrowing of the spinal canal. Lumbar spinal stenosis is related to natural aging in the spine and is relatively common in adults over age 60.
The condition typically results from a combination of one or more of the following: enlarged facet joints, overgrowth of soft tissue, and a bulging disc placing pressure on the nerve roots, causing sciatica pain.
The sciatic nerve can get irritated as it runs under the piriformis muscle in the buttock. If the piriformis muscle irritates or pinches a nerve root that comprises the sciatic nerve, it can cause sciatica-type pain.
This is not a true radiculopathy (the clinical definition of sciatica), but the leg pain can feel the same as sciatica caused by a nerve irritation.
Interestingly, physical therapists in Los Angeles recently published a case report in the Journal of Orthopedic and Sports Physical Therapy on a 30 year old male with a 2-year history of piriformis syndrome.
A 3-month program that included 8 clinic visits with a daily home exercise program was prescribed.
The exercise program included the use of elastic resistance bands and resistance band loops which were very effective at reducing the symptoms of piriformis syndrome; they theorized that by strengthening the gluteus maximus, less stress is put on the piriformis, helping prevent any hip motion that may cause the piriformis to become strained and contract.
Irritation of the sacroiliac joint—located at the bottom of the spine—can also irritate the L5 nerve, which lies on top of the sacroiliac joint, causing sciatica-type pain.
The leg pain can feel the same as sciatica caused by a nerve irritation.
For some people, sciatica pain can be severe and debilitating. For others, the sciatica symptoms might be infrequent and irritating, but have the potential to get worse.
Low back pain may be present along with the leg pain, but typically the leg pain is markedly more severe than the low back pain. Patients often describe their sciatica symptoms as electrical shocks running down the leg, or searing or burning pain.
Common Sciatica Symptoms
Usually, sciatica only affects one side of the lower body and the pain often radiates from the lower back all the way through the back of the thigh and down through the leg.
Some combination of the following symptoms is most common:
Lower back pain, if experienced at all, is not as severe as leg pain
Constant pain in only one side of the buttock or leg, but rarely both the right and left sides
Pain that originates in the low back or buttock and continues along the path of the sciatic nerve – down the back of the thigh and into the lower leg and foot
Pain that feels better when patients lie down or are walking, but worsens when standing or sitting
Pain that is typically described as sharp or searing, rather than dull
Some experience a “pins-and-needles” sensation, numbness or weakness, or a prickling sensation down the leg
Weakness or numbness when moving the leg or foot
Severe or shooting pain in one leg that may make it difficult to stand up or walk
Depending on where the sciatic nerve is affected, the pain and other symptoms may also include foot pain or pain in the toes.
Sciatica Symptoms for Each Nerve Root
There are two nerve roots that exit the lumbar spine (L4 and L5) and three that exit the sacral segment (S1, S2 and S3).
All five nerves bundle together to form the sciatic nerve, and then branch out again within the leg to deliver motor and sensory functions to specific destinations in the leg and foot.
Sciatica symptoms vary based on where the compressed nerve root is located. For example:
L4 nerve root sciatica symptoms usually affect the thigh. Patients may feel weakness in straightening the leg, and may have a diminished knee-jerk reflex.
L5 nerve root sciatica symptoms may extend to the big toe and ankle (called foot drop). Patients may feel pain or numbness on top of the foot, particularly on the “web” of skin between the big toe and second toe.
S1 nerve root sciatica affects the outer part of the foot, which may radiate to the little toe or toes. Patients may experience weakness when raising the heel off the ground or trying to stand on tiptoes. The ankle-jerk reflex may also be reduced.
Since more than one nerve root may be compressed, patients may experience a combination of the above symptoms.
For severe or ongoing flare-ups of sciatic nerve pain, the condition may need to be treated so that it does not get worse over time.
For most, readily available nonsurgical remedies and regular exercise will go a long way to relieving their pain.
For others, when the pain is severe or does not get better on its own, a more structured treatment approach, and possibly surgery, may offer the best approach to finding pain relief and preventing or minimizing future pain and/or dysfunction.
For acute sciatic pain, heat and/or ice packs are readily available and can help alleviate the leg pain, especially in the initial phase. Usually ice or heat is applied for approximately 20 minutes, and repeated every two hours. Most people use ice first, but some people find more relief with heat. The two may be alternated. It is best to apply ice with a cloth or towel placed between the ice and skin to avoid an ice burn.
Over-the-counter or prescription medications are often effective in reducing or relieving sciatica pain. Non-steroidal anti-inflammatory drugs (such as ibuprofen, naproxen, or COX-2 inhibitors), or oral steroids can reduce the inflammation that is usually part of the cause of the pain. There are also alternative medications and supplements that appear to help some people.
If the pain is severe, an epidural steroid injection can be performed to reduce the inflammation. An epidural injection is different from oral medications because the steroid is injected directly into the painful area around the sciatic nerve to help decrease the inflammation that may be causing the pain.
While the effects tend to be temporary (providing pain relief for as little as one week up to a year), and it does not work for everyone, an epidural steroid injection can be effective in relieving acute sciatic pain. Importantly, it can provide sufficient relief to allow a patient to progress with a conditioning and exercise program.
Alternative Sciatica Treatment
In addition to standard medical treatments, several alternative treatments have also been shown to provide effective sciatica pain relief for many patients. Three of the more common forms of alternative care for sciatica include chiropractic manipulation, acupuncture, and massage therapy.
Spinal adjustments and manual manipulation performed by appropriately trained health professionals, such as chiropractors and osteopathic physicians, are focused on providing better spinal column alignment, which in turn should help to address a number of underlying conditions that can cause sciatic nerve pain.
Manual manipulation done to address the right indications by appropriately trained health professionals can create a better healing environment and should not be painful.
The practice is centered on the philosophy of achieving or maintaining well being through the open flow of energy via specific pathways in the body. Hair-thin needles (that are usually not felt) are inserted into the skin near the area of pain.
Acupuncture has been approved by the U.S. FDA as a treatment for back pain, and the National Institutes of Health has recognized acupuncture as effective in relieving back pain, including sciatica.
Certain forms of massage therapy have been shown to have a number of benefits for back pain, including increased blood circulation, muscle relaxation, and release of endorphins (the body’s natural pain relievers). Using a massage chair can be a good alternative for looking for convenience a savings.
TENS For Sciatica
TENS (transcutaneous electrical nerve stimulation) for sciatica is a very popular complementary therapy used in conjunction with many other forms of conservative treatment. TENS is the most common form of electrotherapy used to treat back and leg pain.
TENS treatment consists of steady or pulsing doses of electricity delivered directly to the affected area, via small electrodes which are adhered to the skin.
There are 2 different frequencies which are usually used, depending on the nature of the painful complaint: high frequency stimulation and low frequency stimulation.
TENS theoretically works by disrupting the neurological messages which signal pain. The charged currents provided by the treatment break up the nerve signals, which are also electrical in nature, before they can reach the brain.
Electrotherapy seems to provide very case-specific and individualized results. Two patients with the exact same clinical pain profile might experience completely different results from the same program of TENS treatment.
Many doctors speculate that this is due to the individual nature of each person’s nervous system and how they are wired to send and receive nerve messages.
Physical therapy exercises incorporating a combination of strengthening, stretching, and aerobic conditioning are a central component of almost any sciatica treatment plan.
When patients engage in a regular program of gentle exercises, they can recover more quickly from sciatica pain and are less likely to have future episodes of pain.
General Exercises for Sciatica
Sciatica exercises usually focus on three key areas: strengthening, stretching and aerobic conditioning.
Many exercises can help strengthen the spinal column and the supporting muscles, ligaments and tendons. Most of these back exercises focus not only on the lower back, but also the abdominal (stomach) muscles and gluteus (buttocks) and hip muscles.
Taken together, these strong core muscles can provide pain relief because they support the spine, keeping it in alignment and facilitating movements that extend or twist the spine with less chance of injury or damage.
Stretching is usually recommended to alleviate sciatic pain. Stretches for sciatica are designed to target muscles that cause pain when they are tight and inflexible.
Hamstring stretching is almost always an important part of a sciatica exercise program.
Low impact aerobic exercise
Some form of low impact cardiovascular exercise, such as walking, swimming or pool therapy is usually a component of recovery, as aerobic activity encourages the exchange of fluids and nutrients to help create a better healing environment.
Aerobic conditioning also has the unique benefit of releasing endorphins, the body’s natural pain killers, which helps reduce sciatic pain.
Typically, it is reasonable to consider surgery for sciatica in the following situations:
Severe leg pain that has persisted for 4 to 6 weeks or more
Pain relief that is not achieved after a concerted effort at non-surgical sciatica treatments, such as one or a combination of oral steroids, non-steroidal anti-inflammatory medication, manual manipulation, injections, and/or physical therapy
The condition is limiting the patient’s ability to participate in everyday activities
Urgent surgery is typically only necessary if the patient experiences progressive weakness in the legs, or sudden loss of bowel or bladder control, which may be caused by cauda equina syndrome.
Depending on the cause and the duration of the sciatica pain, one of two surgical procedures will typically be considered:
A microdiscectomy (or small open surgery)
A lumbar laminectomy (an open decompression)
Microdiscectomy for Sciatica
In cases where the sciatica pain is due to a lumbar disc herniation, a microdiscectomy or small open surgery with magnification may be considered. In this surgery, only the portion of the herniated disc that is pinching the nerve is removed – the rest of the disc is left intact.
This surgery is generally considered after 4 to 6 weeks if the severe pain is not relieved by non-surgical means. If the patient’s pain and disability is severe, surgery may be considered sooner than 4 to 6 weeks.
As a general rule, approximately 90% to 95% of patients will experience relief from their sciatica pain after this type of surgery.
Lumbar Laminectomy for Sciatica
In cases where the sciatica pain is due to lumbar spinal stenosis, a lumbar laminectomy may be recommended. In this surgery, the small portion of the bone and/or disc material that is pinching the nerve root is removed.
Laminectomy surgery may be offered as an option if the spinal stenosis causes the patient’s activity tolerance to fall to an unacceptable level. The patient’s general health may also be a consideration in whether or not to have surgery.
After a lumbar laminectomy (also called an open decompression), approximately 70% to 80% of patients typically experience relief from their sciatic nerve pain.
Surgery is the Patient’s Decision
In most cases, sciatica surgery is elective, meaning that it is the patient’s decision whether or not to have surgery. This is true for both microdiscectomy and laminectomy surgery.
The patient’s decision to have surgery is based primarily on the amount of pain and dysfunction the patient is experiencing, and the length of time that the pain persists. The patient’s overall health is a consideration as well.
Additional Sciatica Surgery Considerations
There are many personal considerations for the patient to take into account when deciding whether or not to have surgery.
Effectiveness of non-surgical treatments
Some patients may prefer to try as many different non-surgical sciatica treatments and remain with non-surgical care for as long as possible, and often they will figure out how to successfully manage their condition and keep painful symptoms at bay.
For example, a patient who has intermittent flare-ups of severe sciatica pain may find that a combination of initial rest and an epidural steroid injection followed by a gentle stretching and exercise program is effective in alleviating the pain as needed.
Need for immediate pain relief
Some patients may have a personal preference or a life situation that will benefit from the more immediate pain relief that is usually afforded by surgery. For example, a patient with small children may not have the time to pursue non-surgical remedies and may need immediate pain relief in order to be able to take care of the children and household duties.
The important point is that it is almost always the patient’s decision whether or not to have the surgery, and the surgeon’s role should be to help inform that patient of his or her options to help the patient make the best choice.
Sciatica is a painful condition and the road to recovery is different for everyone. Please share your experience with sciatica in the comment section below.
Thoughts, questions, tips? Feel free to comment below.