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Sciatica

Sciatica is characterized by pain that extends down the course of the sciatic nerve .


Presentation

Sciatica presents with a range of symptoms which are often characteristic enough to make a diagnosis. Symptoms are mainly neurological and related to the musculoskeletal system.

Musculoskeletal symptoms

Symptoms begin with mild to moderate pain in the lower back and buttocks which radiates down the leg. There is numbness and a pins and needles sensation (paraesthesia) in the affected limb. Symptoms can be in just one limb or rarely, in both. The pain is sometimes so severe that the affected individual is in extreme discomfort and debilitated.

Neurological symptoms

Sciatica is always due to nerve involvement. The sciatic nerve may be directly involved as in the case of intervertebral disc herniation or protrusion or due to a tumor. Or the nerve may become indirectly involved due to a spasm or excessive contraction of the piriformis muscle, as in the piriformis syndrome [5]. It may also arise due to indirect nerve involvement in pregnancy.

Complications 

  • Irreversible nerve damage leading to persistent pain
  • Chronic sciatica
  • Partial or complete loss of sensation in the involved limb
  • Immobility
  • Incompletely healing lower limb injuries

Risk factors

Some people are more at risk for developing sciatica. Common risk factors include:

  • Extremely tall people
  • Pregnant females
  • Improper exercising
  • Lower spinal lesions
  • Tumors in the lumbar or sacral region
  • Degenerative bone or muscle diseases
  • Old age
  • Athletes
  • Sedentary lifestyle
Skin Lesion
  • At the first visit to our hospital, there were no skin lesions. A magnetic resonance imaging showed spinal canal stenosis between the 4th and 5th lumbar spine. Thus, we diagnosed the patient with sciatica induced by spinal canal stenosis.[ncbi.nlm.nih.gov]
Back Pain
  • Find out more Exercise to relieve back pain Back pain can be annoying for anyone, especially if you have to deal with it even in the middle of a busy workday. For most working adults, back pain is a constant complaint.[back-pain.co.uk]
  • -35.87, -18.46)] and back pain [WMD -20.80 (95 % CI -25.15, -16.44)].[ncbi.nlm.nih.gov]
  • Call your provider right away if you have: Unexplained fever with back pain Back pain after a severe blow or fall Redness or swelling on the back or spine Pain traveling down your legs below the knee Weakness or numbness in your buttocks, thigh, leg,[nlm.nih.gov]
Low Back Pain
  • BACKGROUND: Previous trials of yoga therapy for nonspecific low back pain (nsLBP) (without sciatica) showed beneficial effects . OBJECTIVE: To test effects of yoga therapy on pain and disability associated with lumbar disc extrusions and bulges.[ncbi.nlm.nih.gov]
  • Linton , Low back pain , Nature Reviews Disease Primers , 10.1038/s41572-018-0052-1 , 4 , 1 , (2018) .[doi.org]
  • Violante, Stefano Mattioli and Roberta Bonfiglioli, Low-back pain, Occupational Neurology, 10.1016/B978-0-444-62627-1.00020-2, (397-410), (2015).[doi.org]
  • About Sciatica Many people have low back pain that keeps on coming back. Often, an exact cause cannot be determined and the pain goes away on its own after a few days or a couple of weeks.[web.archive.org]
  • back pain and sciatica Low back pain: guidelines for its management (www.backpaineurope.org)—Recently issued guidelines for the management of low back pain and sciatica from the European Commission Research Directorate General A patient's perspective[ncbi.nlm.nih.gov]
Leg Pain
  • The primary outcome was the leg-pain intensity score on a 10-point scale (with 0 indicating no pain and 10 the worst possible pain) at week 8; the leg-pain intensity score was also evaluated at week 52, a secondary time point for the primary outcome.[ncbi.nlm.nih.gov]
  • Outcome measures were recovery and leg pain severity. Recovery was registered on a 7-point Likert scale. Complete/near complete recovery was considered a satisfactory outcome. Leg pain severity was measured on a 0- to 100-mm visual analog scale.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To identify potential prognostic factors for persistent leg-pain at 12 months among patients hospitalized with acute severe sciatica.[ncbi.nlm.nih.gov]
  • The primary outcome was leg pain scores. Meta-analysis was performed using random-effect model. Four RCTs and one CCT involving 184 patients were included in the meta-analysis.[ncbi.nlm.nih.gov]
  • CONCLUSION: There is low-quality evidence (GRADE) that exercise provides small, superior effects compared with advice to stay active on leg pain in the short term for patients experiencing sciatica.[ncbi.nlm.nih.gov]
Buttock Pain
  • Patients typically have sciatica, buttocks pain, and worse pain with sitting. They usually have normal neurological examination results and negative straight leg raising test results.[ncbi.nlm.nih.gov]
  • All patients had unilateral sciatic distribution pain that consisted of buttock pain, usually radiating down the posterior thigh into the leg. In 6 patients, the pain first appeared shortly after trauma or strenuous exercise.[dx.doi.org]
  • The sciatic nerve runs very close to this muscle and tension in the muscle can cause compression of the sciatic nerve resulting in buttock pain which radiates and down the leg.[sportsinjuryclinic.net]
Hip Pain
  • Lower back pain Pain in the buttocks or leg that is worse when sitting Hip pain Burning or tingling down the leg Weakness, numbness, or difficulty moving the leg or foot A shooting pain that makes it difficult to stand up Renuva Can Help Sciatica.[renuvacenters.com]
  • Common symptoms of sciatica include: Lower back pain Pain in the rear or leg that is worse when sitting Hip pain Burning or tingling down the leg Weakness, numbness, or difficulty moving the leg or foot A constant pain on one side of the rear A shooting[webmd.com]
  • For those of you who aren’t near a trained MELT instructor, I’d recommend that you follow the Pelvis or Hip Pain Self-Treatment Plan in the MELT Method book.[meltmethod.com]
  • The result is lumbar pain , buttock pain , hip pain , and leg pain . Sometimes the pain radiates around the hip or buttock to feel like hip pain .[medicinenet.com]
  • Other symptoms include, but are not limited to: Lower back pain Pain in the rear or leg that intensifies when standing or sitting Hip pain Weakness, numbness or difficulty moving the leg or foot A constant pain on one side of the rear Sensations that[spinecare.luminhealth.com]
Dyspareunia
  • METHODS: We report a case of a 41-year-old woman with a history of severe dysmenorrhea, dyspareunia, and chronic pelvic pain with concomitant monolateral right sciatica because of deep infiltrating pelvic endometriosis involving the sciatic nerve and[ncbi.nlm.nih.gov]
Sciatica
  • See Sciatic Nerve and Sciatica Sciatica Symptoms for Each Nerve Root Sciatica symptoms typically occur when L4, L5, and/or S1 nerve roots are affected. 8 Sciatica symptoms arising from each of these nerve roots are discussed below 9-10 : Sciatica from[spine-health.com]
  • […] pain with right sciatica Lumbago w sciatica Lumbago with left sided sciatica Lumbago with right sided sciatica Lumbago with sciatica R lumbago w sciatica Right lumbago w sciatica Right sided sciatica Sciatica, bilat sides Sciatica, bilateral sides Sciatica[icd9data.com]
  • For the purposes of this review, first time incidence sciatica was defined as either of the following: 1) no prior history of sciatica or 2) transition from a pain-free state to sciatica.[ncbi.nlm.nih.gov]
Peripheral Neuropathy
  • Gabapentin has also demonstrated proven efficacy for the treatment of diabetic peripheral neuropathy and trigeminal neuralgia, although these represent off-label uses of the drug.[ncbi.nlm.nih.gov]
  • Sciatica causes Sciatica, a form of nerve dysfunction (peripheral neuropathy), occurs when there is compression on, or damage to, the sciatic nerve. This nerve innervates the muscles behind the knee and lower leg.[laserspineinstitute.com]
  • Maravilla KRBowen BC Imaging of the peripheral nervous system: evaluation of peripheral neuropathy and plexopathy. AJNR Am J Neuroradiol 1998;191011- 1023 PubMed Google Scholar 2.[dx.doi.org]
  • Focal Peripheral Neuropathies. In: Anon. West Vancouver : JBJ Publishing ; 2010. p. 443 – 8. 15. Wilbourn, AJ. Thoracic outlet syndrome is overdiagnosed. Muscle Nerve. 1999 ; 22 ( 1 ): 130 – 6. 16. Benzon, HT, Katz, JA, Benzon, HA, Iqbal, MS.[doi.org]
Stroke
  • LaValle in his book, "The Cox-2 Connection," you may wish to avoid certain strokes, such as the overhead crawl, breaststroke and butterfly stroke, which can place strain on your back.[livestrong.com]
  • Sciatica (Mayo Foundation for Medical Education and Research) Also in Spanish Tarlov Cysts (National Institute of Neurological Disorders and Stroke)[medlineplus.gov]
  • National Institute of Neurological Disorders and Stroke: "Piriformis Syndrome." American Academy of Orthopaedic Surgeons: "Spinal Injections." Chou, R. Annals of Internal Medicine, October 2007; vol 147: pp 492-504.[webmd.com]
  • Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse 1 AMS Circle Bethesda, MD 20892-3675 Phone: 301-495-4484 Toll-Free: 1-877-226-4267 Fax: 301-718-6366 TTY: 301-565-2966 National Institute of Neurological Disorders and Stroke[drugs.com]
  • , pelvic and gluteal abscesses. [1] [3] Vascular problems: due to increased blood volume in the spine during the late stages of pregnancy, the fixed space inside the spinal cord may narrow and cause compression on the nerves. [1] Central mechanisms: stroke[physio-pedia.com]
Insomnia
  • Sciatic nerve compression may result in the loss of feeling (sensory loss), paralysis of a single limb or group of muscles (monoplegia), and insomnia.[spineuniverse.com]
  • Evidence from the 2012 systematic review 10 and the largest subsequent trial 12 shows that adverse events, such as insomnia and nervousness, were more common in the corticosteroid group compared with the placebo group (table 1 ).[bmj.com]
Neglect
  • Other sources of similar pain patterns are generally neglected. Despite absence of obligatory neurological signs in radicular syndromes, a number of patients are subjected to extensive, but redundant screenings.[ncbi.nlm.nih.gov]

Workup

Diagnosis is based on a complete history and physical examination.

A complete work up may include:

Checking for Lasegue's sign: In this test, the involved leg is passively flexed between 30 to 70 degrees and if the pain appears or aggravates, it is taken to be positive for sciatica.

Computerized Tomography Scan (CT): A CT scan be be conducted to check for possible causes of sciatica like spinal disc herniation or lumbar canal stenosis [7].

Magnetic Resonance Imaging (MRI): An MRI may be conducted for a more through scan for spinal lesions or tumors.

Treatment

Treatment for sciatica is prolonged bed rest, physiotherapy and pain relieving medications [8], if needed. The pain subsides on its own if the underlying cause is detected and treated.

Prognosis

Sciatic pain occurs in response to obvious trauma, or due to internal wear and tear. It may arise due to jerky movements or posture change which may somehow irritate the sciatic nerve [6].
Whatever the cause may be, the pain is often sudden in onset and increases gradually but may subside after some time.

Sciatica, though not necessarily continuous for life, does have a tendency to reoccur, often without any warning or predisposing factor. The pain lasts around for a few days to a few weeks and then subsides. Proper bed rest, medication and physiotherapy may speed up the process of alleviating the pain.

Etiology

Sciatica is caused by any disease or pressure or trauma that results in compression of the nerve roots from L4 to S3. The symptoms of sciatica can be presented with the following conditions [2]:

  1. Spinal Disc Herniation: The intervertebral discs are composed of an inner soft portion called nucleus pulposus surrounded by an outer thicker and stronger ring called annulus fibrosus. The integrity of the outer fibrous ring keeps the central portion in place. If there is a tear, especially on the posterio-lateral aspect of the ring, the inner nucleus pulposus may herniate outwards. This herniation may put pressure on the nerve roots, or cause an inflammatory response which may damage the nerve roots. Either way, due to spinal disc herniation, sciatica may arise.
  2. Spinal Disc Protrusion or Slip Disc: This condition is somewhat similar to the spinal disc herniation. The difference is that the annular ring, in this case, is intact. The nucleus pulposus does not squeeze out so there is no herniation. Instead, due to increased pressure on the lumbar and sacral vertebras, and thus the intervertebral discs, the disc itself slightly slips out. This causes a protrusion, commonly in the posterior aspect, called a disc slip. This protrusion of the intervertebral disc puts pressure on the surrounding nerve roots which then causes sciatica.
  3. Degenerative Disc Disease: This condition is a result of either aging or due to trauma which causes unresolved inflammation in the lumbar area leading to damage to the intervertebral discs. As a result of the inflammatory process, or sometimes direct trauma, the weakened disc is prone to cause nerve damage, sometimes leading to sciatica.
  4. Lumbar Spinal StenosisIt is a condition in which factors like slipped disc, inflammation, tumors, bony spurs, etc cause the spinal canal to narrow down. This narrowing or stenosis of the lumbar spinal canal causes damage to the cauda equina and/or the nerve roots, leading to sciatica.
  5. Piriformis Syndrome: In about 15% of people, the sciatic nerve travels through or underneath the piriformis muscle. So a contraction or spasm in the muscle may put excessive pressure on the nerve causing sciatic pain to arise.
  6. PregnancyIn some pregnancies, the weight of the fetus may cause pressure on the sciatic nerve leading to sciatica.
  7. Other: Tumors may increase the pressure of the vertebral canal or directly impinge upon the sciatic nerve roots causing sciatica. Injury or trauma to the spine may also result in lifelong pain in the lower back, buttocks and legs.

Epidemiology

None of the studies conducted have been specific for sciatica, but rather have been based on the diseases that may cause sciatica, such as lumbar disc herniation, etc. So the exact occurrence of sciatica is unknown.

Race: Sciatica has no known predilection to race or cast.

Ag: It is more common in older people due to age-related wear and tear of the spinal discs leading to herniation, and weakening of the vertebral canal leading to lumbar canal stenosis [1].

Sex: There are no definite studies declaring a predisposition in either sex, however, some studies suggest a higher prevalence in males.

Sex distribution
Age distribution

Pathophysiology

As mentioned earlier, the sciatic nerve arises from 5 nerve roots, beginning from lumbar 4th to sacral 3rd. Sometimes, nerve fibres from L3 may also be involved. The lumbo-sacral plexus forms in the substance of the psoas muscle and the sciatic nerve, which arises when these nerve roots unite, passes beneath the piriformis muscle, through the greater sciatic foramen into the leg [3].

Damage to the nerve roots, due to any number of causes like those mentioned in the previous segment, leads to pain in the regions the nerve traverses. These regions include the lower back, buttocks, thighs, legs and feet.

Sometimes, the whole lower limb may be involved, sometimes just the proximal part or the distal portion of the limb, depending upon the nerve root involved. Sciatica does not necessarily arise on both lower limbs. It is often present in just one limb, unless there is a significant spinal injury involved [4].

Prevention

By avoiding the common risk factors such as improper exercising, sudden, twisting movements that may damage the nerve and a sedentary life style, sciatica can be prevented.

Also taking a healthy diet, so as to prevent bone diseases and muscle weakening, may decrease the chances of developing sciatica [10].

Summary

Sciatica, or sciatic neuritis, is a common condition that affects the whole or part of the sciatic nerve. Damage or compression to any one of the nerve roots causes characteristic and often progressive symptoms to appear. 

The sciatic nerve is the largest and thickest nerve of the body. It is formed from L4 to S3 segments of the sacral plexus, which emerge out from the lower spinal cord and merge together in front of the piriformis muscle. The nerve then passes through the greater sciatic foramen and leaves the pelvis, entering the back of the leg. While moving downwards, the sciatic nerve divides into its two branches:

Common fibular nerve: Which courses in and supplies the anterior and lateral compartments of the leg. It also innervates the dorsum of the foot.

Tibial nerve: Which travels in the posterior compartment of the leg, supplying both the muscles and the skin. It also gives sensory innervation to the sole of the foot.

If any one of the five nerve roots is compressed, either when it emerges out of the cord or during the path where it unites with the others, it causes sciatica.

The symptoms include sudden, mild to severe pain in the lower back, moving downwards in the buttocks, back of the leg and sometimes as far as to the foot. The pain may or may not be accompanied with numbness and paraesthesia.

Patient Information

Definition

Sciatica is referred to pain in the lower back which radiates to the buttocks and one or both the legs. It is accompanied by numbness, tingling and a pins and needles sensation in the affected limb.

Cause

It is due to irritation, damage or compression of the sciatic nerve, which supplies the lower limb muscles and skin. It arises most commonly due to spinal disc herniation or protrusion (slipped disc).

Signs and Symptoms 

Numbness, tingling and pain in the lower limbs are the presenting symptoms. The pain may be localised to just the back, or involving the entire leg; from the hip to the foot. The severity of the pain is also varying. It may be mild to extremely severe that it immobilises the patient.

Treatment

It includes prolonged bed rest and physiotherapy. The underlying cause should be identified and treated [9].

Prevention

With the right lifestyle and diet, and avoidance of the risk factors may prevent the occurrence of sciatica.

References

Article

  1. Anderssen GBJ. Epidemiologic features of chronic low back pain. Lancet. 1999;354:581-5
  2. Nachemson Al, Waddell G, Norland AL. Nachemson AL, Jonsson E (eds.). Epidemiology of Neck and Low Back Pain, in. Neck and Back Pain: The scientific evidence of causes, diagnoses, and treatment. Philadelphia: Lippincott Williams & Wilkins; 2000:165-187.
  3. Mooney V. Presidential address. International Society for the Study of the Lumbar Spine. Dallas, 1986. Where is the pain coming from?. Spine (Phila Pa 1976). Oct 1987;12(8):754-9.
  4. Wheeler AH, Murrey DB. Chronic lumbar spine and radicular pain: pathophysiology and treatment. Curr Pain Headache. 2001;Rep 6:97-105.
  5. Mooney V. Presidential address. International Society for the Study of the Lumbar Spine. Dallas, 1986. Where is the pain coming from?. Spine (Phila Pa 1976). Oct 1987;12(8):754-9.
  6. Haldeman S. North American Spine Society: failure of the pathology model to predict back pain. Spine (Phila Pa 1976). Jul 1990;15(7):718-24.
  7. National Center for Health Statistics (1976):. Surgical operations in short stay hospitals by diagnosis, United States. 1973. Series 13, No.24.
  8. van Tulder MW, Scholten RJ, Koes BW, Deyo RA. Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine (Phila Pa 1976). Oct 1 2000;25(19):2501-13
  9. Breivik H, Hesla PE, Molnar I, et al. Treatment of chronic low back pain and sciatica. Comparison of caudal epidural injections of bupivacaine and methylprednisolone with bupivacaine followed by saline. In: Bonica JJ, Albe-Fessard D, eds. Advances in pain research and therapy. Vol 1. New York: Raven Press; 1976:927-32.
  10. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976). Mar 1983;8(2):131-40. 

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Last updated: 2017-08-09 18:09