Sciatica

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Definition/Description

Sciatica is a set of symptoms including pain, numbness, muscular weakness and tingling sensations that may be caused by compression or irritation of the lumbar nerve L4 and L5 and the sacral nerves S1,S2 and S3. The symptoms can be felt in the lower back, buttock, and/or various parts of the leg and foot.

Clinically Relevant Anatomy

The hip consists of the iliacum that is connected on the ventral side with the symphybis pubis. On the posterior side the iliacum is connected with the sacrum which is called the sacroiliacum. The nerves that cause sciatica are L4,L5,S1,S2,S3.

Epidemiology /Etiology

Sciatica is generally caused by compression of the nerve roots L4,L5,S1,S2 and S3. When sciatica is caused by the compression of a dorsal nerve root it is called a radiculopathy.

Other causes of sciatica:

• misalignment of the corpus vertebrae also called spondylolisthesis. This can be caused by a fall or trauma
•  spinal stenosis which is a condition where the spinal canal narrows and compresses the spinal cord. In 15% of the population the sciatic nerve runs through the periformis muscle. When the periformis muscle shortens or spasms, it can compress the sciatic nerve

Irritation of the sacroiliac joint can also irritate nerve L5 which lies on the sacroiliac joint. This is called sacroiliac joint dysfunction. Women who are pregnant frequently develop sciatica because there is a rapid increase in body mass, a shift of the center of gravity and a change of hormone secretion.

Rare causes of Sciatica:

• a spinal tumor can compress the sciatic nerve and cause sciatica
• a muscle strain in the lower back can cause some inflammation that can pressure the sciatic nerve

Characteristics/Clinical Presentation

Characteristics:

Pain that radiates from the lower (lumbar) spine to the buttock and down the back of the leg is the hallmark of sciatica. Discomfort may be felt almost anywhere along the nerve pathway, but it's especially likely to follow a path from the low back to the buttock and the back of the thigh and calf. Sciatica is characterized by constant pain, tingling, weakness and numbness affecting only one side of the leg and/or buttock. The pain gets worse when sitting and standing up. The pain can vary widely, from a mild ache to a sharp, burning sensation or excruciating discomfort. Sometimes it may feel like a jolt or electric shock. It may be worse when you cough or sneeze, and prolonged sitting can aggravate symptoms.

Clinical presentation:

Sciatica can be caused by the compression or irritation of nerve L4, L5, S1, S2 and S3. The sciatica symptoms depend on which nerve is compressed or irritated.

• L4:When the L4 nerve is compressed or irritated the patient feels pain, tingling and numbnessiIn the thigh. The patient also feels weak when straightening the leg and may have a diminished knee jerk reflex.
  
• L5:When the L5 nerve is compressed or irritated the pain, tingling and numbness may extend to the foot and big toes.
  
• S1:When the S1 nerve is compressed or irritated the patient feels pain, tingling and numbness on the outer part of the foot. The patient also experiences weakness when elevating the heel off the ground and standing on tiptoes. The ankle jerk reflex may be diminished.

Differential Diagnosis

Spondyloarthropathies, Spinal Claudication, Nerve Entrapment at the fibular head, Thalmic Cerebrovascular Accident, Multiple Sclerosis,Thoracic Spinal Fracture, Cauda Equina Syndrome.

Diagnostic Procedures

Sciatica is diagnosed by physical examination, neurological testing and patient history. The most applied diagnostic test is the straight leg raise test or Lasègue's sign. KEMP test can also be carried out. 

Outcome Measures

• Sciatica and Disc Herniation: Outcome Measures and Prognostic Factors[2]

Examination

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Medical Management

When treating Sciatica the use of ice or heat is often used. The heat or ice is placed on the affected area for 20 minutes every 2 hours.Medications are commonly prescribed for the treatment of Sciatica but evidence of clinical trials suggest that the use of analgesics to relieve pain isn’t proven.Research failed to prove significant difference between placebos, NSAIDs, analgesics, and muscle relaxants. There is also no proof in the use of opioids and compound drugs.In severe cases of Sciatica an epidural steroid injection is often used. This treatment consists of an injection of steroid in the affected area to reduce the inflammation and pain. The effect is temporary and can last from one week and up to a year. An epidural injection doesn’t work with everyone.

In severe cases of Sciatica elective surgery is proposed. This treatment focuses on the removal of the underlying cause by removing the hernia and eventually parts of the disc. When Sciatica is caused by lumbar spinal stenosis a lumbar laminectomy is recommended. In this surgery, the small portion of the bone and/or disc material that is pinching the nerve root is removed. In cases of a disc herniation a microdescectomy is recommended. With this surgery a small opening is created and with the use of magnification the portion of the herniated disc that is pinching the nerve is removed. One study has proven that there is significant difference in the first year but no significant difference after 4 and 10 years. 

Acupuncture has been proven to reduce pain in the back. 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 are inserted into the skin near the area of pain.  

Also neuromuscular techniques are often used. This consists of applying pressure with the knuckles, fingers or elbow on a certain trigger/pressure point for 10 and 30 seconds. Massage therapy has proven to be useful with the treatment of back pain. It increases the blood circulation, muscle relaxation and the release of endorphins.

Physical Therapy Management

The physical therapy exercises consist of strengthening, stretching and low impact aerobic conditioning. When a patient follows a physical therapy program the patient will not only recover more quickly but are also less likely to develop future episodes of sciatica. There are differences between the exercises due to the cause of sciatica. There are specific exercises for sciatica that is caused by herniated disc, spinal stenosis, degenarative disc disease, ithmic spondilolisthesis, piriformis syndrome, sacroiliac joint syndrome. In general, the strengthening exercises can help strengthen the spinal column and the supporting muscles, ligaments and tendons. These focus on the abdominal, lower back, gluteus and hip muscles. These core muscles support the spine keeping it in alignment and facilitating movements that extend or twist the spine with less chance of injury or damage. The stretching exercises focus on the muscles which are tight and inflexible which are frequently the hamstrings. The low impact aerobic exercises such as, walking and swimming, encourage the exchange of fluids and nutrients to help create a better healing environment. During aerobic exercise there is also an increase in secretion of endorphins which are the bodies natural painkillers. 

Herniated Disc Sciatica Management:

• extension exercises or press ups are often prescribed; for example, Upper Back Extension.  

Spinal Stenosis Sciatica Management:

• flexion exercises of the lower back are suggested. Flexing the lower spine increases the size of these passageways and allows the irritation or impingement to resolve. The stretching exercises of the back are forward flexion. For strengthening the abdominal muscles frequently used exercises are Hook-lying March and Curl-Ups. 

Degenerative Disc Disease Sciatica Management:

•  a dynamic lumbar stabilization program is recommended. This program tries to find the most comfortable position for the lumbar spine and pelvis and training the body to maintain this position during activities. In doing this correctly, one can improve the proprioception of the lumbar spine and reduce the excess motion at the spinal segments. This will in turn reduce the amount of irritation at these segments, relieving pain and protecting the area from further damage. Examples of these exercises are; Hook-lying March, Hook-lying March Combination and Bridging.  

Spondylolisthesis Sciatica Management:

• flexion based exercises and a stabilization program. The objective of this program is to teach the lumbar spine to remain stable in a flexed position. A few examples are: Hooked-lying; March; Curl-Ups and Pelvic Tilt.  

Piriformis Syndrome Sciatica Management:

• stretching of the piriformis muscle, hamstring muscles and hip extensor muscles may be used to decrease the pain of the patient and help to  regain his/her range of motion. 

Sacroiliac Joint Dysfunction Sciatica Management:

• the treatment consists of a range of motion exercises directed at the SI joint; this can often restore normal movement and alleviate the irritation of the sciatic nerve. The 3 most important exercises are: Single Knee to Chest Stretch; Press-Up andLumbar Rotation(non-weight bearing).

The use of spinal manipulation or chiropractic treatments try to create a better healing environment. Research suggests that spinal manipulation is affective for acute cases of sciatica but hasn’t proven useful with chronic cases.Chiropractic treatment is based on the hypothesis that vertebral decompression can be prevented by a flexion-distraction procedure. During this procedure, there is greater intervertebral space and less compression on the vertebral elements: for example, the patient lies on his/her stomach with a little flexion in the spine and due to downward flexion a distraction occurs. It has been proven that this treatment decreases the interdiscal pressure. 

Key Research

• Genevay S, Finckh A, Zufferey P, Viatte S, Balagué F, Gabay C. Adalimumab. In acute sciatica reduces the long-term need for surgery: a 3-year follow-up of a randomised double-blind placebo-controlled trial. 2011 Oct 13.(C)
• Ashworth J, Konstantinou K, Dunn KM. Prognostic Factors in Non-Surgically Treated Sciatica: A Systematic Review. 2011 Sep 25.(A1)
  
• Wassenaar M, van Rijn RM, van Tulder MW, Verhagen AP, van der Windt DA, Koes BW, de Boer MR, Ginai AZ, Ostelo RW. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. 2011 Sep 16.(A1)
  
• Van Rijn RM, Wassenaar M, Verhagen AP, Ostelo RW, Ginai AZ, de Boer MR, van Tulder MW, Koes BW. Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. 2011 Sep 14.(A1)
• Righesso O, Falavigna A, Avanzi O. Correlation between persistent neurological impairment and clinical outcome following microdiscectomy for treatment of lumbar disc herniation. 2011 Aug 10.(C)
• Erginousakis D, Filippiadis DK, Malagari A, Kostakos A, Brountzos E, Kelekis NL, Kelekis A. Comparative prospective randomized study comparing conservative treatment and percutaneous disc decompression for treatment of intervertebral disc herniation. 2011 Aug.(B)

Resources

• Loren Fishman, Carol Ardman. Sciatica Solutions: Diagnosis, Treatment, and Cure of Spinal and Piriformis Problems. W W Norton & Co Inc. 2007. (D)
• John Barrett, Douglas Noel Golding. The practical treatment of backache and sciatica.1984. (D)
• Larry P. Credit,Sharon G. Hartunian,Margaret J. Nowak .Relieving sciatica. Old Broadway.2000.p 30-34. (D)

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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• http://www.spinecentre.com.hk/thumbnail-list-layout-en/case-study-2-sciatica-and-disc-protrusion#2 - Sciatica and Disc Protrusion