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Sciatica, also known as lower extremity (L5/S1) radiculitis or radiculopathy, sciatica is a condition that causes weakness or sensory changes along the sciatic nerve pathway. Suffers report a “pins and needles” sensation that can extend from the buttock to the leg and foot. Other serious symptoms include bladder and bowel incontinence, weakness of the lower extremities, loss of sensation and severe nerve impingement. Sciatica that results in loss of bladder or bowel function is a true medical emergency and is referred to as “Cauda Equina Syndrome.”
The Sciatic nerve — the longest and largest nerve in the human body — runs through the lower spinal column behind the hip joints, exits on the back of the thigh and extends down the foot. It controls and innervates a majority of the muscle groups in the lower extremity and also provides sensation to the foot, leg and thigh. Pain that radiates along the path of this nerve is known as “sciatica.”
Many different conditions and diseases can affect the sciatic nerve, causing it to become pinched or stretched. The most common conditions that cause sciatica are:
- Herniated or Bulging Disc – This is the most common cause of sciatica. Between each vertebra (spinal bones), there are discs that cushion the impact of the spinal column. The discs are soft, so they are prone to herniation and can irritate nearby nerves either through contact or by leaking caustic spinal substances on to the nerve. Disk disease accounts for close to 10% of all low back pain complaints and is one of the most common causes of chronic back pain.
- Spinal Stenosis – is caused when the spinal canal narrows, causing spinal cord or nerve impingement. This disease presents with persistent pain in the lower back and extremities. Many sufferers experience sciatica on both sides (bilateral) which can result in decreased physical activity, decreased sensation and difficulty walking.
- Piriformis syndrome – Located in the pelvis, the piriformis is a larger muscle that when enflamed or overused can irritate or trap the sciatic nerve causing sciatica.
- Facet Hypertrophy – Facet joints are crucial in allowing backwards extension movement. These joints can cause sciatica when they become arthritic or grow cysts. When arthritic, the large knobby size of the joint irritates exiting nerve roots.
- Tumors, pelvic infections and more can cause sciatica as well.
Diagnoses of sciatica can be achieved clinically by a medical professional who will test for tenderness in areas of the spine and by assessing movement limitations in the lower extremity.
Radiological imaging such as a CT Scan, MRI, x-ray or bone scan can also confirm sciatica. MRI is the most consistently utilized to visualize chronic back pain and can be crucial before any procedures are undergone. Additional studies may be ordered by the physician if the patient has a history of IV drug use, HIV infection, cancer or recent steroid use.
- Drugs similar to Ibuprofen (NSAID’s), membrane stabilizing drugs, Acetaminophen, muscle relaxants and other analgesics can be used to manage sciatica pain.
- Epidural Steroid Injections (ESI) – This procedure requires an injection directly into the area , or epidural space, where the irritated nerve is located. The injection is made up of two parts: The first is a long-lasting steroid that reduces inflammation. The second part of the injection is a local anesthetic (lidocaine, bupivacaine) that works to interrupt the pain-spasm cycles and nocicepter transmission (Boswell 2007). As the medicine remains in the body, it works towards other levels of the spine in order to relieve inflammation and irritation. It is a short procedure, usually taking less than fifteen minutes. Typically, Epidural injections are incredibly successful due to rapid symptom relief that allows the recipient to become active again. A 2005 study of two hundred and twenty eight unilateral sciatica patients revealed a 75% pain improvement report after three lumbar ESIs at intervals of 3 weeks (Arden 2005).
- Lysis of Adhesions – This procedure, also called the “Racz Procedure” has been found to be successful in removing scar tissue from the epidural space when more conservative measures have failed. A 2005 study reported, “a spinal adhesiolysis with targeted delivery of local anesthetic and steroid is an effective treatment in a significant number of patients with chronic low back and lower extremity pain without major adverse effects.”
- Infusions Techniques – This procedure consists of a small catheter that is inserted into the epidural space or next to affected nerves through a needle and remains while local anesthetic and other medicines are administered through the catheter for extended time periods. Blocking the nerves continuously can lead to dramatic and lengthy pain relief.
- Transcutaneous Electrical Stimulation (TENs) – This procedure is accomplished by applying mild electrical current to the affected areas through several patches placed directly on the skin. It is a passive process without side-effects. The electronic stimuli confuses the spinal cord and processing centers in the brain, thereby decreasing the perception of pain. By replacing pain signals with tingling electrical signals, acute and chronic pain can be relieved allowing for relaxation of the muscle and improved mobility.
- Spinal Cord Stimulation (SCS) – Consists of an implanted electrical device implanted in the epidural space. As with the TENs procedure, the signals of pain are replaced by the electronic tingling of the device allowing relaxation and improved mobility. While these devices are usually temporary at first, if they’re successful in the patient, they can be permanently implanted.
- Deep Tissue Massage – Massage consists of focal rubbing of tender areas in order to relieve muscle spasms and contractions. The stress, tension-release and relaxation improves discomfort.
- Acupuncture – Consisting of small needles placed strategically into the skin, acupuncture causes your body to release endorphins, which are a natural pain reliever. The practice of acupuncture can be similar to massage in the relieving of tension and stress.
- Physical Therapy – Physical therapy aids in strength, felxibility and range of motion, which can relieve symptoms of sciatica.
- Nutrition and Exercise – Eating well and participating in exercise releases endorphins, increases flexibility, strength and range of motion. Nutrition may go a long way in combating nutritional defects that may be contributing to pain.
- Intrathecal Pump Implants – Implanted pain pumps can lead to considerably less pain and even long-term control. Cancer patients suffering from nociceptive pain showed a 66.7% reduction in pain (Becker 2000).
- Disc Decompression – A needle is inserted into affected, bulging discs. Disc material is removed through the needle and pressure is alleviated.
- Trigger Point Injections (TPIs) – A form of Piriformis Injection, this procedure can relieve muscle spasms by injecting a local anesthetic and a steroid into a “Trigger Point.”
- Botox – Frequently used to treat neck pain, Botulinum toxin Type A (BtA) is a widely accepted treatment. . In 2005 “Botulinum toxin Type A (BtA) became the first line therapy for the treatment for cervical dystonia.” Multiple rounds of injections have been found to work better than a single shot (Costa 2005). Patients with whiplash injuries reported reductions in pain and increased range of motion after botox treatment (Juan 2004).
- Biofeedback – is a form of treatment that educates patients about body processes that are often thought of as involuntary (such as blood pressure, body temperature and heart rate control). Gaining control of such processes can allow patients to relax and relieve pain.
- Sciatica – PainDoctor.com
- Rheumatology (Oxford). 2005 Nov;44(11):1399-406. Epub 2005 Jul 19 Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, Michel M, Rogers P, Cooper C; WEST Study Group. Rheumatology (Oxford). 2005 Nov;44(11):1399-406. Epub 2005 Jul 19 PMID: 16030082
- Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Boswell et. All. Pain Physician 2007; 10:7-111