Sciatica: A Real Pain in the Rear

Sciatica is the inflammation or irritation of the sciatic nerve – a very large nerve that is formed from the lower part of the spinal cord. It exits the lower part of the spinal cord, travels behind the hip joint and passes down the back of the thigh and down the leg. Most commonly, this inflammation of the sciatic nerve is caused by a herniated or ruptured disc–the cushion located between the vertebrae of the spinal column. When this happens, the disc pushes out into the area of the sciatic nerve and compresses the nerve root. Other causes are rarer and can include bony irregularities from arthritis, and very rarely, tumors or abscesses in the spine.

When you have sciatica, pain radiates along the course of the sciatic nerve, typically down the buttocks to the back of the upper leg and below the knee, usually to the foot or ankle. Low back pain may or may not occur. The pain is typically described as burning, cramping or stabbing and may get worse with coughing, sneezing or squatting. It also may be associated with numbness or tingling. The pain often comes on suddenly and typically occurs in patients between ages 30 and 50.

If you think you have sciatica, you should see your doctor to confirm the diagnosis. Your doctor will complete a thorough history and physical exam and test several specific functions of the nerve. He or she will test the strength and sensation of the leg, evaluate your reflexes and try to reproduce your pain by lifting your leg straight off of the exam table. With this history and physical, he or she will ensure that the most likely cause of your pain is sciatica and rule out some more dangerous problems.

Most commonly, your doctor will recommend brief treatment with acetaminophen (Tylenol) or NSAIDs (Advil, Aleve). Muscle relaxers are often used but can lead to drowsiness and are often not tolerated by patients. For some patients with severe pain, a short course of powerful steroids is recommended. After the pain subsides, physical therapy may be recommended. Chiropractic therapy has been examined in large research trials and has been found to be as effective as traditional medical therapy. Bed rest is not particularly helpful and is not recommended beyond the first day or so of symptoms. Rather, you should attempt to return to your usual activities as soon as possible.

If these therapies are ineffective after several weeks, your doctor will probably recommend either referral to a specialist in neurology or physiatry or an MRI. An MRI should be ordered sooner if you have any true weakness or sensory loss, if your symptoms get worse instead of better or if your doctor suspects a more serious illness. (An interesting note is that bulging discs are seen on MRI in more than 50 percent of patients without symptoms.) At this point, you may benefit from epidural steroid injections or surgery. Epidural steroid injections deliver anti-inflammatory steroids into the back directly to the inflamed area around the nerves. Fortunately, only 10 to 15 percent of patients with sciatica ultimately require surgery, which expands the area around the nerve in the compressed area, either by removing the ruptured disc or opening the bone around the nerve.

Most people with sciatica recover within three weeks to three months. Unfortunately, many if not most patients will experience a return of symptoms at some point in their lifetimes.

Some cases of sciatica are more serious and could lead to permanent nerve damage if not treated immediately. This is called cauda equine syndrome and involves difficulty with bowel or bladder function, loss of sensation around the genitals or progressive weakness in the legs. If you experience these symptoms, go to the emergency room immediately.