Sciatica Pain, Symptoms, Causes, Diagnosis and Treatment

The term “sciatica” has been used since the days of Hippocrates and while our sciatica treatments have evolved since that time—we no longer routinely prescribe boiled milk or laxatives—the symptoms have remained largely the same. Sciatica is a symptom, typically used to describe pain radiating from the back or buttocks to the lower leg.
sciatica pain in a man's upper thighSciatica's hallmark symptom is low back or buttock pain that travels downward into the thigh and in some cases, past the knee. Photo Source: iStock.com.The sciatic nerve is the largest and longest nerve in the human body and begins with contributions from the lower lumbar and upper sacral nerve roots. It runs from the spine, through the pelvis, down the thigh, and to the back of the knee where it branches into the tibial and peroneal nerves. The tibial and peroneal nerves continue their journey to the foot, giving off motor and sensory branches along the way.

While irritation of the sciatic nerve itself can cause sciatica, over three-quarters of people suffering from sciatica have symptoms due spinal abnormalities that impact the nerves upstream of the sciatic nerve. The remainder of this article will describe the symptoms, causes, diagnosis and treatment of sciatica.

Sciatica Symptoms

The hallmark sciatica symptom is sharp, achy pain radiating from the lower back or buttocks into the thigh and, in some cases, past the knee. The exact distribution of the pain varies depending on the location of the abnormality causing the pain. Sciatica pain can also travel down the front or side of the thigh, and sometimes stops short of passing past the knee into the leg or foot. The pain tends to occur in one leg and is usually more severe than the back pain that is also commonly present.

Muscle weakness and altered sensation (tingling, numbness, or burning) in the painful leg may also be present. If the cause of sciatica pain is due to a lumbar disc herniation, maneuvers that increase pressure within the intervertebral discs, known as Valsalva maneuvers, will typically lead to worsening of sciatica symptoms. Examples of Valsalva maneuvers include attempting to forcefully exhale against a closed nose and mouth—as one might do when trying to clear their ears—coughing, sneezing, or straining during defecation.

Causes of Sciatica

Sciatica can be caused by both spinal and non-spinal pathology.

  • Examples of sciatica caused by pathology of the spine include: lumbar herniated discs, spinal stenosis, and spondylolisthesis.
  • Examples of sciatica caused by conditions not related to the spine include: pregnancy and childbirth, endometriosis, piriformis syndrome, herpes zoster (shingles), diabetic neuropathy, trauma (hip fracture, hip dislocation or hematoma compressing the sciatic nerve), or an aneurysm within a pelvic artery. While rare, tumors to the spine, pelvis, or leg causing sciatica can occur.

sciatic nerve distribution; low back through one legAnatomical illustration shows the sciatica nerve and its nerve distribution through one leg. Photo Source: 123RF.com.

Making the Sciatica Diagnosis

Determining the cause of sciatica allows for a more accurate prognosis and treatment to be tailored to the underlying cause. History and physical exam can diagnose most cases of sciatica and imaging in the form of x-rays and MRI can help confirm the suspected diagnosis.

The role of electromyography tests (EMG) and nerve conduction velocity tests (NCV) are not well defined and are not routinely used in the diagnosis of sciatica. An EMG or NCV may be ordered in the rare cases where a patient has persistent sciatica despite a normal spine MRI.

Your doctor will be interested in how long the pain has been present, any particular event or trauma that started the pain, activities or positions that make the pain better or worse, and any treatments you might have tried and whether they were helpful. The path your pain takes as it travels down your leg and whether you have any weakness or areas where you feel numb, tingling, or burning can help localize the cause of your sciatica.

Your medical and surgical history is also important particularly if you have already had surgery on your spine or hip, have a history of diabetes or cancer, or take medications that might make it more difficult for your body to fight infection such as steroids. Make sure to mention to your doctor any “red flag symptoms” that might indicate a more serious problem such as cancer (unexplained weight loss, fever), infection (fever, IV drug abuse), or cauda equine syndrome (new urinary retention, bowel or bladder incontinence, genital numbness, or severe, progressive lower extremity weakness).

Disc herniations are the most common cause of sciatica. They typically occur in people under the age of 55 years. Pain usually occurs in one leg and tends to be aggravated by Valsalva maneuvers and sitting for an extended period of time. Physical exam findings consistent with the diagnosis of disc herniation include decreased range of motion of the lumbar spine, decreased sensation or strength in the lower extremity, diminished patellar or Achilles reflexes, and a positive straight leg raise test (increase in leg pain when you are lying on your back and your affected leg is straightened and raised off the table) or crossed leg raise test (increase in leg pain when the straight leg raise test is performed on the unaffected leg).

Sciatica Treatment

People suffering from recent onset sciatica have an overall good prognosis regardless of what treatment they receive. Over half of people will have resolution of their symptoms without surgery within two to three months. Nearly 90% will experience improvement of their symptoms at two weeks.

Nonsurgical treatments focus on symptom relief rather than altering the natural course of the disease.

  • The mainstay of treatment includes nonsteroidal anti-inflammatories, alternating heat and ice, and staying active.
  • Formal physical therapy, especially therapy that focuses on exercises that alleviate pain and centralize it away from the leg towards the back can be considered once the severe, acute phase is passed.
  • Oral or epidural steroid injections can be considered in more recalcitrant or severe cases.
  • Opioid pain medication and extensive bed rest should be avoided.

The only setting in which decompression surgery is indicated without an extensive trial of multimodal nonoperative treatment is in cases where the sciatica is caused by infection, cancer, or cauda equina syndrome.

Updated on: 01/09/20
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