Wednesday, July 09, 2008
What You Need to Know About Sciatica
from a NYC Chiropractor
I have seen fantastic results using spinal decompression and core strengthing using the SpineForce. I wanted to provide additional information about Sciatica and other treatments that are being used to treat Sciatica.
The term sciatica describes the symptoms of leg pain and possibly tingling, numbness or weakness that travels from the low back through the buttock and down the large sciatic nerve in the back of the leg. The vast majority of people who experience sciatica get better with time (usually a few weeks or months) and find pain relief with non-surgical sciatica treatment. For others, however, sciatica can be severe and debilitating.
Common Causes of Sciatica:
lumbar herniated disc
degenerative disc disease
spondylolisthesisThe clinical diagnosis of sciatica is referred to as a "radiculopathy", which means simply that a disc has protruded from its normal position in the vertebral column and is putting pressure on the radicular nerve (nerve root) in the lower back, which forms part of the sciatic nerve.
An important thing to understand is that sciatica is a symptom of a problem — of something compressing or irritating the nerve roots that comprise the sciatic nerve — rather than a medical diagnosis or medical disorder in and of itself. This is an important distinction because it is the underlying diagnosis (vs. the symptoms of sciatica) that often needs to be treated in order to relieve sciatic nerve pain.
Sciatica occurs most frequently in people between 30 and 50 years of age. Often a particular event or injury does not cause sciatica, but rather it tends to develop as a result of general wear and tear on the structures of the lower spine.
For some people, the pain from sciatica can be severe and debilitating. For others, the pain might be infrequent and irritating, but has the potential to get worse.
While sciatica can be very painful, it is rare that permanent nerve damage (tissue damage) will result. Most sciatica pain syndromes result from inflammation and will get better within two weeks to a few months. Also, because the spinal cord is not present in the lower (lumbar) spine, a herniated disc in this area of the anatomy does not present a danger of paralysis.
Sciatica symptoms that may constitute a medical emergency include:
Progressive weakness in the leg
Bladder/bowel incontinence or dysfunction.
Patients with either of the above symptoms may have cauda equina syndrome and should seek immediate medical attention. In general, patients with complicating factors should contact their doctor if sciatica occurs, including people who: have been diagnosed with cancer; take steroid medication; abuse drugs; have unexplained, significant weight loss; or have HIV.
Sciatica medical definition: radiculopathy
To clarify medical terminology, the term sciatica (often misspelled as ciatica, cyatica or siatica) is often used very broadly to describe any form of pain that radiates into the leg. However, this is not technically correct. True sciatica occurs when the sciatic nerve is pinched or irritated and the pain along the sciatic nerve is caused by this nerve (radicular pain) and is called a radiculopathy. When the pain is referred to the leg from a joint problem (called referred pain), using the term sciatica is not technically correct. This type of referred pain (e.g. from arthritis or other joint problems) is quite common.
Symptoms of sciatica pain can vary greatly but usually decrease after a few weeks or months with non-surgical treatment.Sciatica nerve pain is caused by a combination of pressure and inflammation on the nerve root, and treatment is centered on relieving both of these factors. Typical sciatica treatment include:
Non-surgical sciatica treatments, which may include one or a combination of medical treatments and alternative (non-medical) treatments, and almost always includes some form of exercise and stretching. The goals of non-surgical sciatica treatment should include both relief of sciatica pain and prevention of future sciatica symptoms.
Sciatica surgery, such as microdiscectomy or lumbar laminectomy and discectomy, to remove the portion of the disc that is irritating the nerve root. This surgery is designed to help relieve both the pressure and inflammation and may be warranted if the sciatic nerve pain is severe and has not been relieved with appropriate manual or medical treatments.
Sciatica refers to a set of symptoms which are usually caused by a problem in the lower back called a radiculopathy—when a nerve root that connects to the sciatic nerve is compressed or irritated. Common low back problems and other spinal conditions that can cause sciatica include:
Lumbar herniated disc. A herniated disc occurs when the soft inner core of the disc (nucleus pulposus) extrudes or “herniates” through the fibrous outer core (annulus) of the disc, irritating the contiguous nerve root as it exits the spine.In general, it is thought that a sudden twisting motion or injury can lead to an eventual disc herniation and sciatica.However, most discs weaken due to repetitive stress and the final result is a herniation. A herniated disc is sometimes referred to as a slipped disk, ruptured disk, bulging disc, protruding disc, or a pinched nerve and sciatica is the most common symptom of a lumbar herniated disc.
See also Lumbar disc herniation
Treatment of sciatica requires a diagnosis of the underlying cause of the sciatica pain.Lumbar spinal stenosis. This condition commonly causes sciatica due to a narrowing of the spinal canal. Spinal stenosis is more common in adults over age 60, and typically results from a combination of one or more of the following: enlarged facet joints, overgrowth of soft tissue, and a bulging disc placing pressure on the nerve roots as they exit the spine and causing sciatica.
Degenerative disc disease. While disc degeneration is a natural process that occurs with aging, in some cases one or more degenerated discs can also irritate a nerve root and cause sciatica. Degenerative disc disease is diagnosed when a weakened disc results in excessive micro-motion at the corresponding vertebral level and inflammatory proteins from inside the disc become exposed and irritate the area (including the nerve roots).
See also Degenerative disc disease
Isthmic spondylolisthesis. This condition occurs when a small stress fracture allows one vertebral body to slip forward on another vertebral body (e.g. the L5 vertebra slips over the S1 vertebra). With a combination of disc space collapse, the fracture, and the vertebral body slipping forward, the L5 nerve can get pinched as it exits the spine and cause sciatica.
See also Isthmic spondylolisthesis
Piriformis syndrome. The sciatic nerve can also get irritated as it runs under the piriformis muscle in the rear. If the piriformis muscle irritates or pinches a nerve root that comprises the sciatic nerve, it can cause sciatica-type pain. This is not a true radiculopathy (the clinical diagnosis of sciatica), but the leg pain can feel the same as sciatica caused by a nerve irritation.
See also Piriformis syndrome—another irritation to the sciatic nerve
Sacroiliac joint dysfunction. Irritation of the sacroiliac joint at the bottom of the spine can also irritate the L5 nerve, which lies on top of it, and cause sciatica-type pain. This is not a true radiculopathy, but the leg pain can feel the same as sciatica caused by a nerve irritation.
See also Sacroiliac Joint Dysfunction
It is important to know the underlying clinical diagnosis of the cause of sciatica, as treatments will often differ depending on the cause. For example, specific sciatica exercises are different depending on pathology causing the sciatica symptoms.
For some people, sciatica pain can be severe and debilitating. For others, the sciatica symptoms might be infrequent and irritating, but have the potential to get worse. Usually, sciatica only affects one side of the lower body, and the pain often radiates from the lower back all the way through the back of the thigh and down through the leg. Depending on where the sciatic nerve is affected, the pain and other sciatica symptoms may also radiate to the foot or toes.
One or more of the following sciatica symptoms are typically experienced:
Pain in the rear or leg that is worse when sitting
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 pain that makes it difficult to stand up
With sciatica, low back pain may be present along with the leg pain, but usually the low back pain is less severe than the leg pain
Sciatica symptoms occur when the large sciatic nerve is irritated. The sciatic nerve is the largest single nerve in the body and is composed of individual nerve roots that start by branching out from the spine in the lower back and combine to form the “sciatic nerve”.
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The sciatic nerve starts in the lower back at lumbar segment 3 (L3).
The sciatic nerve roots run through the bony canal in the spine, and at each level in the lower back a pair of nerve roots exits from the spine and then comes together to form the large sciatic nerve that runs all the way down the back of each leg.
Portions of the sciatic nerve then branch out in each leg to innervate certain parts of the leg (e.g. the calf, the foot, the toes).
The nerve roots that originate in the lower back are named for the upper vertebral body that they run between (for example, the nerve that exits at L4-L5 in the spine is named L4). The nerve passing to the next level runs over a weak spot in the disc space, which is the reason discs tend to herniate (extrude) right under the sciatic nerve root and can cause sciatica.
The sciatica symptoms (e.g., low back pain, leg pain, numbness, tingling, weakness) are different depending on where the pressure on the nerve occurs. For example, a lumbar segment 5 (L5) nerve impingement can cause weakness in extension of the big toe and potentially in the ankle (foot drop) (See diagram of the sciatic nerve).
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What You Need to Know About Sciatica
Sciatica Treatment More On This Topic:
Myths About Sciatica Treatment Options
Sciatic nerve anatomy and sciatica symptoms
For most people, the good news is that sciatica usually will get better on its own, and the healing process usually only takes a few days or weeks. Overall, the vast majority of episodes of sciatica pain heal within a six to twelve week time span.
However, occasional flare-ups of sciatic nerve pain may be an indication of a condition that should be managed so that it does not get worse over time.
For most, readily available pain management techniques and regular exercise will go a long way to remedying the situation.
For others, when the pain is severe or does not get better on its own, a more structured pain management program (including specific physical therapy and exercise), and possibly surgery, may offer the best approach to finding pain relief and preventing or minimizing future flare-ups of sciatica.
Non-surgical sciatica treatment
During an episode of sciatica, there are a number of non-surgical treatment options available to help alleviate the sciatic pain and discomfort.
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For acute sciatica pain, heat and/or ice packs are most readily available and can help alleviate the leg pain, especially in the initial phase. Usually ice or heat is applied for approximately 20 minutes, and repeated every two hours. Most people use ice first, but some people find more relief with heat. The two may be alternated to help with sciatica pain relief.
See also Heat Therapy Cold Therapy
Sciatica Pain Medications
Over-the-counter or prescription medications may also be helpful in relieving sciatica. Non-steroidal anti-inflammatory drugs (such as ibuprofen, naproxen, or COX-2 inhibitors), or oral steroids can be helpful in reducing the inflammation which is usually a contributing factor in sciatica.
See also NSAIDs, Oral Steroids
Treatment of sciatica requires a diagnosis of the underlying cause of the sciatica pain.Epidural steroid injections for sciatica
If the sciatica pain is severe, an epidural steroid injection can be performed to reduce the inflammation. An epidural injection is different from oral medications because it injects steroids directly to the painful area around the sciatic nerve to help decrease the inflammation that may be causing the pain. While the effects tend to be temporary (providing pain relief for as little as one week up to a year), and it does not work for everyone, an epidural steroid injection can be effective in providing relief from an acute episode of sciatic pain. Importantly, it can provide sufficient relief to allow a patient to progress with a conditioning and exercise program.
See also Lumbar epidural steroid injections for low back pain and sciatica and Epidural Video
Alternative sciatica treatment
In addition to standard medical treatments, several alternative treatments have also been shown to provide effective sciatica pain relief for many patients. Three of the more common forms of alternative care for sciatica include acupuncture, massage therapy and chiropractic manipulation.
The practice is centered on the philosophy of achieving or maintaining well being through the open flow of energy via specific pathways in the body. Hair-thin needles (that are usually not felt) are inserted into the skin near the area of pain and left in place for a few minutes to over half an hour. Acupuncture has been approved by the U.S. FDA as a treatment for back pain, and the National Institutes of Health recognized acupuncture as effective in relieving back pain, including sciatica.
Certain forms of massage therapy have been shown to have a number of benefits for back pain, including increased blood circulation, muscle relaxation, and release of endorphins (the body’s natural pain relievers).
See also Massage Therapy for Lower Back Pain
Spinal adjustments and manual manipulation performed by appropriately trained health professionals (e.g. chiropractors, osteopathic physicians, physical therapists) are focused on providing better spinal column alignment, which in turn should help to address a number of underlying conditions that can cause sciatic nerve pain. Manual manipulation done to address the right indications by appropriately trained health professionals can create a better healing environment and should not be painful. In my Manhattan Spinal decompression practice I combine Medical massage, Spinal decompression and Core strengthing using the Spine Force and if patients are suffering I have a onsite MD that can provide pain management.
See also Chiropractic Treatments for Back Pain
Following initial pain relief, a program of physical therapy and exercise should usually be pursued in order to alleviate pain and prevent or minimize any ongoing sciatic pain.
Physical therapy and exercise
While is seems counter-intuitive, activity and exercise typically provides more sciatica pain relief than rest.When the sciatica pain is at its worst, patients may need to rest for a day or two, but resting for longer periods of time is usually not advisable. In fact, inactivity will usually make the sciatic pain worse. This is because regular movement and exercise is necessary to nourish the various structures in the low back and encourage the strength needed to support the low back.
Many sciatica exercises focus on strengthening the abdominal and back muscles in order to give more support for the back. Stretching exercises for sciatica target muscles that cause pain when they are tight and inflexible. When patients engage in a regular program of gentle strengthening and stretching exercises, they can recover more quickly from a flare up of sciatica and can help to prevent future episodes of pain.
Low impact aerobic exercise, such as walking or swimming (or pool therapy) is also usually a component of recovery, as aerobic activity encourages the exchange of fluids and nutrients to help create a better healing environment. Aerobic conditioning also has the added benefit of releasing endorphins, the body’s natural pain killers, which is a natural way to alleviate sciatic pain.
There are a number of types of non-surgical spine care professionals who specialize in treating sciatica symptoms, including chiropractors, physiatrists (physical medicine and rehabilitation specialists), pain medicine specialists, and physical therapists, all of whom have specialized training to provide pain relief and to help prevent future recurrences of sciatica. It is always advisable to have a qualified medical professional oversee any sciatica treatments
If the sciatica pain is severe and has not gotten better within six to twelve weeks, it is generally reasonable to consider spine surgery. Depending on the cause and the duration of the sciatica pain, one of two surgical procedures will typically be considered: a microdecompression (microdiscectomy) or an open decompression (lumbar laminectomy).
Microdiscectomy (microdecompression) for sciatica
In cases where the sciatica pain is due to a disc herniation, a microdiscectomy may be considered after four to six weeks if the pain is not relieved by non-surgical means. A microdiscectomy may be considered sooner than four to six weeks if the patient’s pain and disability is very severe. Urgent surgery is only necessary if the patient experiences progressive weakness in the legs, or sudden loss of bowel or bladder control.
A microdiscectomy is typically an elective procedure, and the patient’s decision to have surgery is based primarily on the amount of pain and dysfunction the patient is experiencing, and the length of time that the pain persists. Approximately 90% to 95% of patients will experience relief from their sciatica pain after this type of surgery.
See also Microdiscectomy
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Lumbar laminectomy (open decompression) for sciatica
Lumbar spinal stenosis often causes sciatica pain that waxes and wanes over many years. Surgery may be offered as an option if the patient’s activity tolerance falls to an unacceptable level. Again, surgery is elective and need only be considered for those patients who have not gotten relief from the sciatica after pursuing non-surgical treatments. The patient’s general health may also be a consideration.
After a lumbar laminectomy (open decompression), approximately 70% to 80% of patients typically experience relief from their sciatic nerve pain.
See also Laminectomy
To large extent, the patient’s individual situation will dictate his or her decision to have surgery or not.In 2005 the FDA approved a new surgery designed to relieve symptoms of lumbar spinal stenosis called the X Stop. This procedure involves placing an implant in the very back of the spine that prevents the patient from leaning backwards, a position that typically causes pain in patients with lumbar spinal stenosis.
It is important to note that the decision whether or not to pursue surgical or non-surgical remedies for sciatica is almost always the patient’s decision. There are many considerations for the patient to take into account when deciding whether or not to have surgery.
Some patients may prefer to try as many different non-surgical treatments and remain with non-surgical care for as long as possible, and often they will figure out how to successfully manage their condition and keep painful symptoms at bay. For example, a patient who has intermittent flare ups of severe sciatica pain may find that a combination of initial rest and an epidural steroid injection followed by a gentle stretching and exercise program is effective in alleviating the pain as needed.
Some patients may have a personal preference or a life situation that will benefit from the more immediate pain relief that is usually afforded by surgery. For example, a parent with small children may not have the time to pursue non-surgical remedies and may need immediate pain relief in order to be able to take care of the children and household duties.
The important point is that it is almost always the patient’s decision whether or not to have the surgery, and the surgeon’s role should be to help inform that patient of his or her options to help the patient make the best choice.