Sciatica (Lumbar Radiculopathy)

Sciatica is the layman’s term for lumbar radiculopathy. It means affection or involvement of the sciatic nerve. It means the sciatic nerve is irritated or inflamed, which leads to pain along one or more components of the sciatic nerve depending on the level and number of nerve roots involved. It presents with pain radiating down the one or sometimes both lower extremities along with tingling or numbness and rarely weakness or involvement of bowel or bladder imbalance.

Once the sciatic nerve is irritated and inflamed, the treatment essentially involves a short period of rest along with antiinflammatory medications and may be steroids. Physical therapy can also help in decreasing the inflammation. Occasionally when none of these things worked, corticosteroid injection or even surgery may be needed to decrease the inflammation and treat sciatica.

Sciatica is caused by irritation and inflammation of the nerve root. This nerve root can be inflamed due to compression possibly due to disk herniation or a synovial cyst or an osteophyte. The injury is essentially a chemical injury due to decreased blood supply to the nerve root leading to inflammation.

Sciatica pain can be relieved by short-term rest, physical therapy, antiinflammatory medications and steroid medications. If these things do not work then epidural or a nerve root block using corticosteroid injection or maybe surgery is needed to get total relief from the pain.

Sciatic nerve is formed by the fusion of multiple nerve roots in the lower back. These nerve roots come out at different levels and immediately after coming out merged to make a big nerve, which is called the sciatic nerve. This sciatic nerve travels along the back of the hip and the thigh up to the knee where it is divided into two main nerves, the common peroneal nerve and the tibial nerve. The sciatic nerve essentially supplies the muscles below the knee and controls the movement of the foot and toes.

In most of the patients, sciatica usually last less than four to six weeks and can be treated without invasive means. Patients usually get relives with short-term rest, antiinflammatory medications, corticosteroid medications and even possibly injections. Patients whose sciatica has not resolved in four to six weeks or those patients who have worsening pain or neurological deficits in the form of involvement of bowel or bladder or balance may need surgical intervention.

Patients with sciatica may have difficulty sleeping, especially lying supine. They can put pillows under the knee to bend the knee and the hip and therefore, relax the sciatic nerve. Sleeping by the side with the knee and hip bent can also help.

Sciatica pain is usually treated with the short-term rest, antiinflammatory medications in the form of Aleve or Advil, corticosteroid medications like Medrol Dosepak and physical therapy or chiropractic care. Patients who do not get relief may also need cortisone injection in the form of epidural or selective nerve root block.

Patients who do not get relief with all the above-mentioned treatments may need surgical intervention. Patients who also have worsening pain or neurological deficit in the form of weakness or involvement of bowel or bladder imbalance may also need surgical treatment as an emergency to stop the progression and optimized recovery.

Chiropractic treatment and manipulation causing stretch of the muscles and nerves can help relieve sciatica pain. This can be adjunct to physical therapy by stretching and strengthening the core muscles as well as the muscles of the hip and knee joints.

It is difficult to say that the sciatica can be cured permanently because it can happen at multiple levels and can have recurrence at the same level and on either side. Sciatica is essentially treated symptomatically initially, but may need surgical treatment to remove the compression on the nerve root. Even after the surgery, there are chances of recurrence at the same level as well as on the other side or at other levels, which may or may not be related to the initial sciatica.

Though wear and tear of the disk is contributory to the cause of disk prolapse or disk herniation as well as osteophytes and synovial cyst, it is difficult to predict a flare up of sciatica in any patients. Patients who have had an episode of sciatica in the past are at higher risk of having it again.

Sciatica causes shock-like pain along the back of the hip, thigh and legs into the sole or along the outer part of the thigh and leg into the top of the foot. It can also feel like a sharp sensation along the front of the thigh or the knee or the inner part of the leg. The pattern of pain depends on the nerve root involved. This pain can also be associated with tingling and numbness in the same area. Rarely, this pain can be associated with the weakness of the leg or foot and involvement of bowel or bladder control.

Sciatica pain usually takes four to six weeks to resolve with or without the help of medications and physical therapy or chiropractic care. Occasionally, the pain may not get better even despite all treatments. The patient may need epidural injection or selective nerve root block for resolution of the pain.

Rarely, the patient may have recurrence of pain once the effect of the steroid injection weans away. Such patients may be amenable for surgical treatment in the form of microdiscectomy or tubular discectomy to remove the herniated disk and thereby remove the pressure over the nerve root.

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.

Walking does not cause deterioration of sciatica, though excessive walking may cause pain and patients may need to rest. Despite that, walking is a good exercise, which helps in mobilization of the muscles, stretching and strengthening of the muscles as well as increasing the vascularity and thereby helping in long-term resolution of the back pain and sciatica.

Obviously, the low back pain and sciatica may sometimes be difficult for patients who have low back pain and sciatica to sleep. Such patients may have to try different postures. A foam mattress may help in good sleep. Also using a thick pillow under the knee or sleeping by the side in a curled up position can help in relieving the pain of sciatica as well as low back pain and allowing sleep.

The sciatic nerve is formed along the side of the lower back by the confluence of multiple nerve roots. It runs into the pelvis and then along the back of the hip joint along the back of the thigh and the knee. At the level of the knee, the sciatic nerve divides into two median nerves called the common peroneal nerve and the tibial nerve.

Sciatic pain can radiate along the back or the outer aspect of the hip and can sometimes be confused with a hip pain and itself. Thorough history and examination by the physician as well as radiological examination in the form of x-rays and MRI may be needed to differentiate the two pains.

Patients with sciatica may have difficulty sitting. Such patients should sit such that their knees are bent 90 degrees while they are resting on the floor. They should sit on a soft comfortable seat with the lumbar back support to support their back. These patients may need to bend forward a little bit to relieve the pressure over the nerve root.

Sciatic nerve is on either side of the lower back. It is from the base of the lower back on both sides and runs through the pelvis along the back of the hip joint and thigh on both sides.

Sciatic nerve presents with pain along the outer aspect of the back of the thigh, knee, leg and foot. Pain in the sole of the foot or on the dorsum of the foot involving either the outer toes or the inner toes may be related to sciatica on examination by the physician along with radiological examination may help find the cause of the pain.

Though the sciatic nerve runs along the back of the hip and can present with pain along the back of the hip and over the outer aspect of the hip, it is highly unlikely for it to cause groin pain. The groin pain can usually be caused by hip joint problems or issues like inguinal hernia. Occasionally compression of higher nerve roots, which suffered a femoral nerve can present with groin 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.

Pregnancy causes a lot of limitations with regards to treatment of sciatica. These patients cannot take medications especially in the first and the second trimester. If patients are out of the risk period, they can take medications like Tylenol if their OB/GYN doctor allows.

The patients may have to rest more often. Physical therapy may help in decreasing the pain. If the pain is not relieved, other treatment modalities can be discussed including epidural injection. All such treatment should be done in consultation with the OB/GYN doctor of the patient.

When sciatica is improving, the pain that radiates from the back into the leg decreases in intensity as well as frequency. The tingling and numbness will also improve. The patient will have more relief and longer durations of pain free period. This is a good sign and indicates a path towards complete resolution of 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.

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.

Sciatica can be worsened due to activity, prolonged standing, lifting, pushing and pulling things. It can also be worsened due to arching the back or leaning backwards. Though short term of bed rest may help relieve pain, longer duration of bed rest causes deconditioning of the back and atrophy of the back muscles, which can lead to worsening of sciatica and back pain and poorer results.

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.

Occasionally, sciatica may be associated with the trigger points in the muscles on the side of the back or even into the hip area. Deep massage of these trigger points can help decrease the pain and relieve the spasm. The deep massage is usually done by another person with the use of the elbow or palm or the thumb. Knuckle of the fingers can also be used. There are many mechanical devices that are available in the market, which can also be used for deep massage.

Sciatic nerve carries the nerve fibers from the lower back to the muscles of the leg and foot. It also carries sensations from the foot to the spinal cord and to the brain. The sciatic nerve is essential for the movement of the foot and toes, which help in normal gait and walking.

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.

There are multiple reasons for calf pain, one of the dreaded one is blood clots and should always be checked for sciatica. Especially the involvement of S1 nerve root can also cause pain along the calf. This pain is usually felt around the back of the thigh as well as the calf into the foot. If it is caused by sciatica, it may be associated with tingling and numbness and occasionally weakness.

Sciatic nerve is a very important and one of the thickest nerves of the body. It is important for supplying motor function to the muscles of the leg and foot as well as taking sensations from the foot to the brain. Their critical function cannot be replaced by any other nerve or muscle.

Thereby, it is important that the sciatic nerve is functional and present. Very rarely, patients may have tumor involving the sciatic nerve, which may have to be excised and may lead to sacrifice of the sciatic nerve; unless otherwise, the sciatic nerve is never removed due to its critical function.

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.

Sciatica can be a self-containing disease process, which can improve over a period of four to six weeks. The body takes care of the inflammation of the nerve root and also the disk herniation in most patients. 90% of the patient will get better in four to six weeks. Medications, epidural or nerve root block injections may help during this recovery period.

It is difficult to predict, which patient will get better and which will not. Therefore, a nonoperative treatment is planned for all the patients except those who develop neurological deficit or have severe worsening pain. Patients who do not get better by four to six weeks may need surgical intervention to improve their pain.

Sciatica can be treated by multiple types of doctors including primary care doctor, pain physician, sports physician, spine surgeons and orthopedic surgeons among others. The methodology to treat sciatica nonoperatively is essentially the same among all field. Operative treatment for sciatica can be done by an orthopedic surgeon or a spine surgeon or neurosurgeon.

Acupuncture, as among all other modalities including physical therapy, massage and acupressure can also help in decreasing the pain of sciatica. Done in well-trained hands, acupuncture can give good results in many patients. Patients who do not get relief with acupuncture should try other modalities as well as medications. They can also try epidural or nerve block injection for pain relief.

Exercises are important and beneficial in patients with sciatica.  These patients should also do stretching of the nerve.  Exercises in the form of cord strengthening exercises, hip exercises are important not only in relieving pain, but also keeping the mobility and activity as well as the tone of the muscles in good shape.

Sciatica is not permanent, though it can be a recurrent. Patients who have had one episode of sciatica are at a higher risk of getting recurrence over the period of months and years. If the patient gets relieved with recurrent episodes of sciatica in shorter duration of time then it can be still treated nonoperatively.

Patient who have recurrent or prolonged episodes of sciatica, not relieved medications and physical therapy or patients who have neurological deficit or worsening pain, may need surgical treatment.

Lumbago is another term that is used for low back pain. Such low back pain is essentially for a longer period, about more than 3 months or more. Most of the time, lumbago is due to mechanical causes especially involving weakness or atrophy of the paraspinal muscles. The treatment for lumbago essentially involves core strengthening exercises that are to strengthen the muscles of the core of the back, which include the muscles in the back, also the muscles in the front that are abdominals and the obliques.

Occasionally, low back pain may be associated with radicular pain down the leg with or without tingling or numbness. Such patients are said to have lumbago with sciatica. The treatment plan is essentially a mix of the treatment for low back pain and radiculopathy, which includes strengthening of the muscles along with stretching, medications, possible need for steroid injections and occasionally surgery.

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.

Occasionally, sciatica can present with pain in the back muscles only or the muscles of the hip. Such pain causes soreness or pain in one or both hips on the back or the outer aspect. Such pain can be confused with the pelvic pain. True pelvic pain will usually be on the front of the belly or on the side of the belly. These pains can also be confused with a hip pathology. A thorough history as well as examination with or without further imaging may be helpful to rule out pelvic cause, sciatica.

Sciatica or lumbar radiculopathy involving the L2, L3 and L4 nerve roots present as pain along the front of the thigh. The pain caused by pinching of the L2 and L3 nerve roots are present with pain along the upper and the middle thigh and may be associated with tingling and numbness. Pain due to the pinching of the L4 nerve root causes pain along the front of the lower thigh as well as over the knee and may have radiation into the inner leg.

Sciatica is caused due to nerve root irritation or compression. It usually happens on one side of the spine, but occasionally if the problem is on both sides or if the problem is in the midline then a patient can present with radiating pain, tingling, numbness with or without weakness on both sides also. Rarely, patients who have severe compression of the spinal nerve roots in the canal can present with cauda equina syndrome, which is an emergency and they present with involvement of both lower extremities or both legs.

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.

The muscles on the back of the thigh are prone to spasms in patients who have sciatica. These muscles get tensed up while activity or may be at rest also. To relieve these spasms, stretching of the muscle regularly as well as performing exercises for the back is of crucial importance. Patients may also need a prescription of muscle relaxant if the muscle spasms are causing discomfort especially difficulty during sleep.

Sciatica is caused due to irritation of the nerve root on either side of the lower back. This irritation is commonly caused due to disk herniation or osteophyte formation. Since most of the causes are due to degenerative spine disease, the degeneration of spine does have some genetic component, so indirectly sciatica can have a genetic or hereditary component, but there are many more factors associated with sciatica which are not genetic-related and it may be difficult to define how much genetics can play a role in sciatica.

TENS pads for sciatica nerve pain are usually placed on the lower back on the side of the pain.. They can also be put over the muscles of which is having spasm or in pain.

In severe form of sciatica presenting with an emergency condition called cauda equina syndrome, in which there is severe compression with almost loss of all function of the nerve root, the patient may present with weakness of either or both lower extremities with or without involvement of bowel and bladder. Most of such patients will have loss of rectal tone leading to incontinence and loss of control of falls.

Swelling in the foot is most likely not related to sciatica because sciatica is caused due to neurogenic pain. They should try to find out and exhaust all other reasons for foot swelling, which may or may not be related to blood pressure, heart condition, liver condition, kidney condition and others. Occasionally, patients may develop neurogenic edema of the extremity due to involvement of the autonomic nervous system leading to compression of the nerve root.

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.

Yoga leads to good exercise of all muscles of the body. The yoga also causes good muscle stretching and strengthening of the core muscles of the back. Some form of yoga are focus on back exercises only, though it may be difficult to do yoga in the earlier phase of sciatica, but trying to stretch the muscles of the back as well as legs as well as strengthening helps in relieving the pain of sciatica as well as rehabilitating the back to improve.

Sciatica nerve innervates all the muscles of the leg below the knee joint as well as carries sensations from the skin of the leg and foot. It also supplies all the muscles of the foot and is crucial in ambulating.

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.

Sciatica is a pain that radiates from the back into the thigh, leg and maybe into the foot also. This pain can be associated with tingling and numbness in the area of its pain. It can cause tingling or numbness along the outer or the back of the thigh, outer or the back of the legs and the top or the bottom of the foot. It can also cause tingling or numbness in the front of the thigh or the inner leg depending on the nerve root, which is pinched and causing the sciatica.

Radiculopathy or sciatica of S1 nerve root may be associated with pain along the bottom of the foot and may mimic heel pain. If there is no pain on pressing the heel then it may be associated with sciatica. If there is pain on pressing the heel then it is unlikely to be sciatica and maybe due to many other causes.

Physical therapy is one of the modalities used to treat sciatica. It can help relieve sciatica as well as optimize the muscles of the back and legs, so that the patient can stay active while being during the phase of sciatica.

Sciatica can get worse in the night, as the muscles relax while lying down, which causes the load to be more on the bones and the disk of the back. Convalescing sciatica pain may worsen while standing and walking also due to the dynamic change causing compression of the disk and leading to further protrusion. The patients who have instability and sciatica pain due to instability can also have worsening of pain due to the worsening of instability while standing and walking.

Car accidents can cause sciatica pain due to irritation of the nerve or radiculitis. This may be caused due to injury to the nerve root or more commonly due to disk herniation that causes pressure on the nerve root and ischemia and chemical injury leading to radiculitis.

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.

Sciatica pain or radiculopathy can be associated with decreased motor innervation to the muscles leading to weakness. This will also lead to muscle atrophy over the long run.

The upper extremity equivalent of sciatica is called cervical radiculopathy. The process is similar to sciatica. The nerve root in the neck or the cervical spine is inflamed and irritated most commonly due to disk herniation in the neck. This leads to radicular pain along the arm and the forearm and to the hand depending on the nerve root, which is compressed or irritated.

True form of sciatica, due to compression of one nerve root may have isolated components of pain in the lower extremity.  These patients may not have any back pain or back complaints.

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.

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.

If the sciatica pain is under control or mild then doing workout which should include stretching as well as strengthening muscles especially of the back may be helpful in decreasing the pain and recovering from sciatica.

Sciatica damage to L5 nerve root and S1 nerve root maybe associated with ankle weakness and occasionally foot drop. Such patients usually have a severe form of nerve damage. Treatment could include management of the radiculopathy, medications, physical therapy with or without surgery. Surgery may be more often needed in such patients especially if the neurological deficit is still evolving, so as to decrease or elevate the further neurological deficit as well as to optimize the recovery.