Diagnosis and Treatment of Sciatica

Sciatica is a condition where one experiences radiating pain in the legs. This pain is usually caused by inflammation or compression of the nerve roots in the lower back, specifically in the L4-S1 region, which form the sciatic nerve.

It can be quite uncomfortable and limit a person’s ability to carry out their daily tasks effectively.

The significance of conservative treatment options for sciatica is emphasized in recent clinical guidelines from Denmark, the US, and the UK.

As a result of these guidelines, a clinical update has been developed with the goal of offering a comprehensive overview of diagnosing sciatica and essential management principles. The update specifically caters to non-specialists, providing them with valuable insights.

The term “sciatica” is often used inconsistently due to its lack of a clear and universally accepted definition among clinicians and patients. As alternatives, medical professionals have suggested terms like radicular pain and lumbosacral radicular syndrome.

In this article, we consider sciatica and radicular pain to have the same meaning. The term radiculopathy is employed to describe the condition where a nerve root is affected, potentially leading to neurological symptoms like weakness or numbness.

Sciatica is characterized by a combination of aching and sharp leg pain that extends below the knee into the foot and toes. The pain can have a sudden or gradual onset and its intensity can vary.

It is frequently accompanied by concurrent low back pain. Disc herniations affecting specific nerve roots result in pain in different regions of the leg. Other symptoms include tingling, numbness, and muscle weakness in the affected leg.

What Is The Prevalence Of Sciatica?

The occurrence of sciatica varies among studies. In a UK primary care study, around 60% of patients experiencing back and leg pain were diagnosed with sciatica.

In a Danish primary care study, neurological examinations confirmed sciatica in 2% of patients attending chiropractic clinics and 11% of patients in general practices who were suffering from low back pain.

What Factors Contribute to the Development of Sciatica?

Compression of the nerve root and inflammation are the primary factors responsible for sciatica. The leading cause of sciatica is typically disc herniation caused by degenerative changes associated with aging, although trauma is infrequently involved.

Inflammation triggers the absorption of herniated disc material, often leading to improvement without surgical intervention. Additionally, sciatica can be caused by foraminal stenosis, soft tissue stenosis, or uncommon extraspinal conditions.

Smoking, obesity, and involvement in manual labor are modifiable factors that increase the risk of developing sciatica.

What Are the Methods Used to Diagnose Sciatica?

The primary method for diagnosing sciatica is a clinical evaluation that relies on the individual’s symptoms and findings from a physical examination.

Important factors to consider include leg pain that surpasses back pain, pain experienced below the knee, and accompanying symptoms like tingling, numbness, or muscle weakness. Although there isn’t a specific test for sciatica, positive findings during the examination can support the diagnosis.

It is crucial to exclude serious conditions such as cancer, trauma, or infection. Symptoms such as urinary retention or decreased anal sphincter tone are red flags that necessitate immediate referral for further evaluation.

How Does Imaging Contribute To The Diagnosis Of Sciatica?

Imaging is generally not recommended as a routine practice for non-specific low back pain, which includes sciatica, according to clinical guidelines. However, it may be appropriate to consider imaging if symptoms worsen or persist beyond 12 weeks, or if there are progressive neurological deficits.

Magnetic resonance imaging (MRI) is the preferred choice for imaging due to its higher safety profile compared to computed tomography (CT). On the other hand, radiography is usually not considered beneficial, and the interpretation of MRI findings may not have a significant impact on the course of treatment.

What Is The Outlook For Patients With Sciatica?

The outlook for most people with sciatica is typically positive, as they often experience symptom improvement through conservative treatment or surgical interventions. However, a minority may not fully recover, and some may continue to experience ongoing symptoms.

The presence of leg pain alongside low back pain is associated with heightened levels of pain, disability, and reduced quality of life. Factors such as the severity, duration of symptoms, and radiological findings do not consistently predict the success of conservative management in achieving recovery.

In a recent study, approximately 55% of patients reported improvement after one year of treatment, while longer durations of pain and patient beliefs about the condition’s long-term nature were associated with a less favorable prognosis.

What Are The Approaches To Managing Sciatica?

Managing sciatica involves addressing the distressing symptoms that can significantly impact daily life and productivity.

It is important to acknowledge the individual’s concerns and fears, while providing information about the typical course of sciatica and reassuring them that symptoms usually improve over time.

Treatment options should be discussed, taking into consideration the person’s preferences and priorities, in order to develop a personalized management plan that best suits their needs.

Non-Invasive Treatment Methods

The initial approach to treatment aims to address pain and preserve functional abilities as the compression and inflammation associated with sciatica subside.

Patients are encouraged to remain physically active and avoid prolonged bed rest to minimize the impact of the condition on their daily lives. It is important to educate individuals about monitoring and promptly reporting any changes in symptoms, such as an escalation of leg pain or the emergence of neurological deficits.

By actively managing symptoms and promoting a proactive approach, patients can optimize their recovery and minimize the impact of sciatica on their well-being.

Physical Activity and Manual Therapy

Engaging in exercise, which encompasses a variety of recommended exercises, can contribute to the reduction of leg pain intensity in the short term. It is possible to complement exercise with manual therapy, such as spinal mobilization.

However, acupuncture is not recommended for individuals with sciatica. Guidelines suggest avoiding traction and electrotherapies for individuals experiencing back pain, regardless of whether it is accompanied by sciatica or not.

Medication

The effectiveness of pain medications for sciatica is not well-established, and they can potentially cause negative effects. Non-steroidal anti-inflammatory drugs (NSAIDs) do not show significant improvement in pain and disability compared to placebo, while corticosteroids may offer temporary relief of symptoms.

However, both NSAIDs and corticosteroids carry an elevated risk of adverse events. There is limited or insufficient evidence to support the use of other medications such as paracetamol, benzodiazepines, opioids, antidepressants, anticonvulsants, and biological agents for sciatica, and their use is not recommended.

Spinal Injections

Guidelines on spinal injections differ in their recommendations. NICE guidelines recommend offering epidural injection of local anaesthetic and steroid in the lumbar nerve root area in people with acute, severe sciatica where they would otherwise be considered for surgery.

The Danish national clinical guidelines do not recommend their use as the beneficial effect was estimated to be very low and only short term based on limited evidence.

Surgery

Individuals who experience persistent chronic pain for a duration of more than 12 weeks, despite undergoing conservative treatment methods, may be considered for surgical intervention.

It is essential to confirm the presence of lumbar disc herniation at the specific nerve root level through the utilization of imaging techniques and clinical examination.

Open micro discectomy is the prevailing surgical procedure, although less invasive approaches like endoscopic surgery are also utilized. Discectomy rates have demonstrated variation, but on the whole, they have exhibited an upward trend across European countries.

According to literature, a systematic review of five randomized controlled trials found low-quality evidence indicating that early surgery within 6-12 weeks of radicular pain may provide faster relief compared to prolonged conservative care.

However, no significant differences in clinical outcomes were observed between surgery and conservative care at one- and two-year follow-ups.

In instances of significant or progressive neurological deficits, such as motor weakness or bladder dysfunction, surgery is advised.

Do you have more questions?Ā 

What causes sciatica?

Sciatica is most commonly caused by a herniated disc in the spine, bone spurs, or spinal stenosis, all of which can compress the sciatic nerve. Other causes include muscle spasms, pregnancy, or piriformis syndrome.

Can sciatica go away on its own?

Yes, in many cases, sciatica can improve on its own within a few weeks with rest, self-care measures, and conservative treatments. However, if the pain persists or worsens, itā€™s important to seek medical attention.

How is sciatica diagnosed?

Sciatica is diagnosed through a combination of medical history, physical examination, and imaging tests such as X-rays, MRI, or CT scans to identify the cause of nerve compression.

 

What are the most effective non-surgical treatments for sciatica?

Effective non-surgical treatments include physical therapy, medications (such as NSAIDs and muscle relaxants), epidural steroid injections, chiropractic care, acupuncture, and lifestyle modifications like weight management and exercise.

How does physical therapy help with sciatica?

Physical therapy helps by strengthening the muscles supporting the spine, improving flexibility, and encouraging proper posture, which can alleviate pressure on the sciatic nerve and reduce pain.

Are there specific exercises I should avoid if I have sciatica?

Avoid exercises that put excessive strain on your lower back, such as heavy lifting, high-impact activities, and bending or twisting movements. Always consult a physical therapist before starting any new exercise regimen.

Can medications completely relieve sciatica pain?

Medications can help manage the pain and inflammation associated with sciatica, but they may not completely eliminate the pain, especially if the underlying cause, like a herniated disc, is not addressed.

How long does it take for epidural steroid injections to work?

Epidural steroid injections typically begin to relieve pain within 1 to 3 days, with peak effects around one week. Relief can last anywhere from several days to a few months.

What are the risks of epidural steroid injections?

While generally safe, risks include infection, bleeding, nerve damage, and headaches. Discuss these risks with your doctor to determine if this treatment is right for you.

Can chiropractic care worsen sciatica?

When performed by a qualified chiropractor, spinal adjustments are generally safe and can relieve sciatica. However, inappropriate or overly aggressive manipulations could potentially worsen symptoms, so itā€™s important to work with a licensed professional.

Is acupuncture effective for treating sciatica?

Acupuncture can be an effective complementary treatment for sciatica, helping to reduce pain and improve function by stimulating the body’s natural pain-relieving mechanisms.

How do lifestyle modifications help with sciatica?

Lifestyle modifications, such as maintaining a healthy weight, quitting smoking, and practicing good posture, can reduce the strain on your spine and lower your risk of recurring sciatica.

Should I use heat or ice for sciatica pain?

Both heat and ice can be beneficial. Ice is typically used in the initial stages to reduce inflammation, while heat can help relax tight muscles and increase blood flow to the affected area after the acute phase.

Can sciatica be prevented?

While not all cases of sciatica can be prevented, maintaining a healthy lifestyle with regular exercise, proper lifting techniques, and good posture can reduce the risk of developing sciatica.

How do I know when itā€™s time to consider surgery for sciatica?

Surgery is typically considered when conservative treatments have failed to relieve symptoms after several months, or if you experience severe pain, significant weakness, loss of bowel or bladder control, or signs of cauda equina syndrome.

What is the success rate of conservative treatments for sciatica?

Conservative treatments are successful in managing sciatica symptoms in approximately 80-90% of cases. The success largely depends on the severity of the condition and adherence to treatment plans.

How often should I do physical therapy exercises?

Itā€™s generally recommended to perform physical therapy exercises daily or as advised by your physical therapist. Consistency is key to seeing improvements.

Will sciatica come back after treatment?

Sciatica can recur, especially if the underlying causes, such as poor posture or a sedentary lifestyle, are not addressed. Maintaining a healthy lifestyle and regular exercise can help prevent recurrence.

Can I continue to work with sciatica?

Many people with sciatica can continue working with modifications to their activities, such as avoiding heavy lifting or prolonged sitting. Discuss with your doctor or physical therapist for specific advice based on your condition.

Is bed rest recommended for sciatica?

Prolonged bed rest is not recommended for sciatica. While short periods of rest may help, staying active with gentle movements and walking is generally better for recovery.

Can sciatica cause permanent nerve damage?

In severe cases, untreated sciatica can lead to permanent nerve damage, resulting in chronic pain, muscle weakness, or loss of sensation in the affected leg.

 

How do I manage sciatica pain at night?

To manage sciatica pain at night, try sleeping on your side with a pillow between your knees, using a firm mattress, and avoiding positions that exacerbate the pain. Heat therapy before bed may also help.

Should I continue treatment even if my symptoms improve?

Yes, continuing treatment after symptoms improve is important to prevent recurrence. This includes maintaining an exercise routine, practicing good posture, and following any other advice from your healthcare provider.

What are the signs that my sciatica is improving?

Signs of improvement include reduced pain intensity, increased mobility, less frequent flare-ups, and a return to normal activities without discomfort.

Can sciatica cause knee pain?

Sciatica pain is usually radiated along the back or the side of the thigh and knee into the leg. Occasionally, patients may present with a confusing picture of knee problem, but maybe having sciatica. A thorough history and examination by the physician as well as diagnostic tests in the form of x-rays and MRI may be needed to confirm the diagnosis.

How to fix sciatica nerve pain?

Sciatica nerve pain can be relieved to various modalities. To start with, antiinflammatory medications like ibuprofen, naproxen or Tylenol may help. If pain is not relieved with the medications, physical therapy, chiropractor and acupuncture may also help. The patient may also take medications including gabapentin or pregabalin for pain relief.

The patient should take a short period of bed rest for a day or two. The patient should continue to do normal usual activities. If the pain is not relieved, he should see his doctor. Epidural injection or nerve root blocks may help in relieving the sciatica pain. Patients who are not having any relief with any of the above-mentioned treatment plans, may need an MRI for confirmation of diagnosis and possibly surgery to relieve their pain.

How do you diagnose sciatica?

Sciatica is a clinical diagnosis, which can be corroborated by imagings with or without nerve conduction/EMG studies. Typical patient will present with pain radiating down one leg along the back or the side of the thigh index. They may have been associated with tingling and numbness or back pain.

Occasionally, patients may have weakness in the toes or the ankle. Once the clinical diagnosis is made, confirmation can be done using x-rays and MRI. In patients who have a confusing picture due to underlying comorbidity or atypical presentation, nerve conduction study and electromyographic study can be done to further confirm or rule out sciatica.

Is heat or ice better for sciatica?

Heat is usually better in patients who have sciatica, though patients who are not relieved with heat should also try ice or occasionally rhythmic use of heat and ice, cyclic use of heat or ice may help better than one alone.

Does massage help sciatica?

Massage is one of the modalities of adjuvant therapy for sciatica can be helpful and can decrease pain by strengthening the muscles as well as stretching the nerves. Deep massage can also help decrease the muscle spasms that develop in patients with sciatica.

Where to put an ice pack for sciatica?

For sciatica, an ice pack or even a heating pad can be used by placing it into the lower back and the gluteal region. It helps decrease the inflammation of the nerve there and thereby decreasing the pain and associated symptoms.

Does the inversion table help sciatica?

Inversion table similar to traction helps sciatica by increasing the height of the disk and thereby allowing the disk to go back into space thereby decreasing the compression of the nerve root may help in decreasing the pain of sciatica. The issue of inversion table as well as traction is that this is effective until the patient uses them and once the patient is upright and moving, the effect of the inversion table or the traction may not be persistent.

Can the sciatica cause ankle pain?

Sciatica or lumbar radiculopathy causes pain radiating from the back or the hip into the lower extremities down the leg. The pain radiates along the back or the side of the thigh and leg and radiates down foot. An isolated ankle pain may not be caused by radiculopathy. If the pain is on outer or inner side of the ankle and is radiating down or coming from the top then it may be associated with sciatica or lumbar radiculopathy.

Does sciatica get worse before it gets better?

90% of patients with sciatica will eventually get better in a period of four to six weeks. During this time, the pain may worsen also or it may keep on improving. Patients who have severe pain with or without tingling or numbness usually will need medical attention to relieve their pain during this duration. The treatment may involve medications, physical therapy and cortisone shots. Patients who have sudden onset of neurological deficit or weakness or worsening of the neurological deficit may need surgery also.

Can stress cause sciatica?

Sciatica like any other neurologic pain can have relation with the mental status and cognitive functions of the person. Though stress may directly not be the causative factor for sciatica, it may have its effect on the severity as well as course of the disease process of sciatica. Patients with high stress levels may have difficulty coping with sciatica and may take longer time to get better.

What happens if sciatica left untreated?

Sciatica in most patients will get better by itself in a period of four to six weeks. The pain as well as tingling and numbness tend to improve over time, though it may have periods of worsening. Patients may need treatment in the form of medications or injections to relieve the pain, so as to spend this period of four to six weeks, till then the relief is evident.

Occasionally in about 10% of the patients, there will be no relief, worsening or recurrence of sciatica pain despite all treatment modalities over four to six weeks. These patients may need surgical management to relieve their pain due to the pressure over the nerve roots.

Can sciatica be a serious disorder?

Sciatica is usually self limiting in 90% of patients and only needs treatment in the form of medication and physical therapy and occasionally cortisone injection. In about 10% of patients, this may not be relieved by any modality and these patients may need to undergo surgical treatment.

Sciatica can also rarely lead to rapid neurological deficit presenting in the form of cauda equina syndrome, which can be potentially disabling. The neurological deficit caused due to cauda equina syndrome may be permanent especially if not treated early in the disease process. Such patients may not only have weakness in their legs, but may also lose control over their bowel and bladder, which may or may not recover over time.

What are the medication that can help sciatica?

Sciatica pain can be relieved by the help of anti-inflammatory medications like ibuprofen, naproxen. It can also be helped by Tylenol. Stronger pain medications like tramadol and narcotic medications may occasionally be needed for a short period of time.

Neuromodulator medications like gabapentin and pregabalin may also be helpful in decreasing the sciatica pain. Occasionally, medications like amitriptyline, duloxetine and carbamazepine may also be used in some patients to relieve their pain.

Is the back brace helpful for sciatica pain?

Back brace may be helpful in patients who have back pain with or without sciatica. Patients who have only radicular pain in their lower extremity may not be helped by the back brace. Use of back brace for a long period of time may be detrimental by causing atrophy of the back muscles.

Dr. Nakul Karkare

I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

You can see my full CV at my profile page.