Sciatica

Last updated
Sciatica
Other namesSciatic neuritis, sciatic neuralgia, lumbar radiculopathy, radicular leg pain
Sciatic nerve2.jpg
Anterior view showing the sciatic nerve going down the right leg
Pronunciation
Specialty Orthopedics, neurology
Symptoms Pain going down the leg from the lower back, weakness or numbness of the affected leg [1]
Complications Loss of bowel or bladder control [2]
Usual onset40s–50s [2] [3]
Duration90% of the time less than 6 weeks [2]
Causes Spinal disc herniation, spondylolisthesis, spinal stenosis, piriformis syndrome, pelvic tumor [3] [4]
Diagnostic method Straight-leg-raising test [3]
Differential diagnosis Shingles, diseases of the hip [3]
Treatment Pain medications, surgery, [2] physical rehabilitation
Frequency2–40% of people at some time [4]

Sciatica is pain going down the leg from the lower back. [1] This pain may go down the back, outside, or front of the leg. [3] Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. [5] The pain is often described as shooting. [1] Typically, symptoms are only on one side of the body. [3] Certain causes, however, may result in pain on both sides. [3] Lower back pain is sometimes present. [3] Weakness or numbness may occur in various parts of the affected leg and foot. [3]

Contents

About 90% of sciatica is due to a spinal disc herniation pressing on one of the lumbar or sacral nerve roots. [4] Spondylolisthesis, spinal stenosis, piriformis syndrome, pelvic tumors, and pregnancy are other possible causes of sciatica. [3] The straight-leg-raising test is often helpful in diagnosis. [3] The test is positive if, when the leg is raised while a person is lying on their back, pain shoots below the knee. [3] In most cases medical imaging is not needed. [2] However, imaging may be obtained if bowel or bladder function is affected, there is significant loss of feeling or weakness, symptoms are long standing, or there is a concern for tumor or infection. [2] Conditions that may present similarly are diseases of the hip and infections such as early shingles (prior to rash formation). [3]

Initial treatment typically involves pain medications. [2] However, evidence for pain medication and muscle relaxants is lacking. [6] It is generally recommended that people continue with normal activity to the best of their abilities. [3] Often all that is required for sciatica resolution is time; in about 90% of people symptoms resolve in less than six weeks. [2] If the pain is severe and lasts for more than six weeks, surgery may be an option. [2] While surgery often speeds pain improvement, its long term benefits are unclear. [3] Surgery may be required if complications occur, such as loss of normal bowel or bladder function. [2] Many treatments, including corticosteroids, gabapentin, pregabalin, acupuncture, heat or ice, and spinal manipulation, have limited or poor evidence for their use. [3] [7] [8]

Depending on how it is defined, less than 1% to 40% of people have sciatica at some point in time. [4] [9] Sciatica is most common between the ages of 40 and 59, and men are more frequently affected than women. [2] [3] The condition has been known since ancient times. [3] The first known use of the word sciatica dates from 1451. [10]

Definition

Sciatica often results in pain radiating down the leg Sciatica.jpg
Sciatica often results in pain radiating down the leg

The term "sciatica" usually describes a symptom—pain along the sciatic nerve pathway—rather than a specific condition, illness, or disease. [4] Some use it to mean any pain starting in the lower back and going down the leg. [4] The pain is characteristically described as shooting or shock-like, quickly traveling along the course of the affected nerves. [11] Others use the term as a diagnosis (i.e. an indication of cause and effect) for nerve dysfunction caused by compression of one or more lumbar or sacral nerve roots from a spinal disc herniation. [4] Pain typically occurs in the distribution of a dermatome and goes below the knee to the foot. [4] [6] It may be associated with neurological dysfunction, such as weakness and numbness. [4]

Causes

Risk factors

Modifiable risk factors for sciatica include smoking, obesity, occupation, [9] and physical sports where back muscles and heavy weights are involved. Non-modifiable risk factors include increasing age, being male, and having a personal history of low back pain. [9]

Spinal disc herniation

Spinal disc herniation pressing on one of the lumbar or sacral nerve roots is the most frequent cause of sciatica, being present in about 90% of cases. [4] This is particularly true in those under age 50. [12] Disc herniation most often occurs during heavy lifting. [13] Pain typically increases when bending forward or sitting, and reduces when lying down or walking. [12]

Spinal stenosis

Other compressive spinal causes include lumbar spinal stenosis, a condition in which the spinal canal, the space the spinal cord runs through, narrows and compresses the spinal cord, cauda equina, or sciatic nerve roots. [14] This narrowing can be caused by bone spurs, spondylolisthesis, inflammation, or a herniated disc, which decreases available space for the spinal cord, thus pinching and irritating nerves from the spinal cord that become the sciatic nerve. [14] This is the most frequent cause after age 50. [12] Sciatic pain due to spinal stenosis is most commonly brought on by standing, walking, or sitting for extended periods of time, and reduces when bending forward. [12] [14] However, pain can arise with any position or activity in severe cases. [14] The pain is most commonly relieved by rest. [14]

Piriformis syndrome

Piriformis syndrome is a condition that, depending on the analysis, varies from a "very rare" cause to contributing up to 8% of low back or buttock pain. [15] In 17% of people, the sciatic nerve runs through the piriformis muscle rather than beneath it. [14] When the piriformis shortens or spasms due to trauma or overuse, it is posited that this causes compression of the sciatic nerve. [15] Piriformis syndrome has colloquially been referred to as "wallet sciatica" since a wallet carried in a rear hip pocket compresses the buttock muscles and sciatic nerve when the bearer sits down. Piriformis syndrome may be suspected as a cause of sciatica when the spinal nerve roots contributing to the sciatic nerve are normal and no herniation of a spinal disc is apparent. [16] [17]

Endometriosis

Sciatic endometriosis, also called catamenial or cyclical sciatica, is a sciatica whose cause is endometriosis. Its incidence is unknown. Diagnosis is usually made by an MRI or CT-myelography. [18]

Pregnancy

Sciatica may also occur during pregnancy, especially during later stages, as a result of the weight of the fetus pressing on the sciatic nerve during sitting or during leg spasms. [14] While most cases do not directly harm the woman or the fetus, indirect harm may come from the numbing effect on the legs, which can cause loss of balance and falls. There is no standard treatment for pregnancy-induced sciatica. [19]

Other

Pain that does not improve when lying down suggests a nonmechanical cause, such as cancer, inflammation, or infection. [12] Sciatica can be caused by tumors impinging on the spinal cord or the nerve roots. [4] Severe back pain extending to the hips and feet, loss of bladder or bowel control, or muscle weakness may result from spinal tumors or cauda equina syndrome. [14] Trauma to the spine, such as from a car accident or hard fall onto the heel or buttocks, may also lead to sciatica. [14] A relationship has been proposed with a latent Cutibacterium acnes infection in the intervertebral discs, but the role it plays is not yet clear. [20] [21]

Pathophysiology

Left: Illustration of herniated spinal disc, superior view. Right: MRI showing herniated L5-S1 disc (red arrow tip), sagittal view. 728 Herniated Disk.jpg
Left: Illustration of herniated spinal disc, superior view. Right: MRI showing herniated L5-S1 disc (red arrow tip), sagittal view.

The sciatic nerve comprises nerve roots L4, L5, S1, S2, and S3 in the spine. [22] These nerve roots merge in the pelvic cavity to form the sacral plexus and the sciatic nerve branches from that. Sciatica symptoms can occur when there is pathology anywhere along the course of these nerves. [23]

Intraspinal sciatica

Intraspinal, or discogenic sciatica refers to sciatica whose pathology involves the spine. In 90% of sciatica cases, this can occur as a result of a spinal disc bulge or herniation. [13] [24] Sciatica is generally caused by the compression of lumbar nerves L4 or L5 or sacral nerve S1. [25] Less commonly, sacral nerves S2 or S3 may cause sciatica. [25]

Intervertebral spinal discs consist of an outer anulus fibrosus and an inner nucleus pulposus. [13] The anulus fibrosus forms a rigid ring around the nucleus pulposus early in human development, and the gelatinous contents of the nucleus pulposus are thus contained within the disc. [13] Discs separate the spinal vertebrae, thereby increasing spinal stability and allowing nerve roots to properly exit through the spaces between the vertebrae from the spinal cord. [26] As an individual ages, the anulus fibrosus weakens and becomes less rigid, making it at greater risk for tear. [13] When there is a tear in the anulus fibrosus, the nucleus pulposus may extrude through the tear and press against spinal nerves within the spinal cord, cauda equina, or exiting nerve roots, causing inflammation, numbness, or excruciating pain. [27] Inflammation of spinal tissue can then spread to adjacent facet joints and cause facet syndrome, which is characterized by lower back pain and referred pain in the posterior thigh. [13]

Other causes of sciatica secondary to spinal nerve entrapment include the roughening, enlarging, or misalignment ( spondylolisthesis ) of vertebrae, or disc degeneration that reduces the diameter of the lateral foramen through which nerve roots exit the spine. [13] When sciatica is caused by compression of a dorsal nerve root, it is considered a lumbar radiculopathy or radiculitis when accompanied by an inflammatory response. [14]

Extraspinal sciatica

The sciatic nerve is highly mobile during hip and leg movements. [28] [29] Any pathology which restricts normal movement of the sciatic nerve can put abnormal pressure, strain, or tension on the nerve in certain positions or during normal movements. For example, the presence of scar tissue around a nerve can cause traction neuropathy. [30]

A well known muscular cause of extraspinal sciatica is piriformis syndrome. The piriformis muscle is directly adjacent to the course of the sciatic nerve as it traverses through the intrapelvic space. Pathologies of the piriformis muscle such as injury (e.g. swelling and scarring), inflammation (release of cytokines affecting the local cellular environment), or space occupying lesions (e.g. tumor, cyst, hypertrophy) can affect the sciatic nerve. [31] Anatomic variations in nerve branching can also predispose the sciatic nerve to further compression by the piriformis muscle, such as if the sciatic nerve pierces the piriformis muscle. [32]

The sciatic nerve can also be entrapped outside of the pelvic space and this is called deep gluteal syndrome. [33] Surgical research has identified new causes of entrapment such as fibrovascular scar bands, vascular abnormalities, heterotropic ossification, gluteal muscles, hamstring muscles, and the gemelli-obturator internus complex. [34] In almost half of the endoscopic surgery cases, fibrovascular scar bands were found to be the cause of entrapment, impeding the movement of the sciatic nerve. [35] [36]

Diagnosis

Straight leg test sometimes used to help diagnose a lumbar herniated disc Straight-leg-test.gif
Straight leg test sometimes used to help diagnose a lumbar herniated disc

Sciatica is typically diagnosed by physical examination, and the history of the symptoms. [4]

Physical tests

Generally, if a person reports the typical radiating pain in one leg, as well as one or more neurological indications of nerve root tension or neurological deficit, sciatica can be diagnosed. [37]

The most frequently used diagnostic test is the straight leg raise to produce Lasègue's sign, which is considered positive if pain in the distribution of the sciatic nerve is reproduced with passive flexion of the straight leg between 30 and 70 degrees. [38] While this test is positive in about 90% of people with sciatica, approximately 75% of people with a positive test do not have sciatica. [4] Straight leg raising of the leg unaffected by sciatica may produce sciatica in the leg on the affected side; this is known as the Fajersztajn sign. [14] The presence of the Fajersztajn sign is a more specific finding for a herniated disc than Lasègue's sign. [14] Maneuvers that increase intraspinal pressure, such as coughing, flexion of the neck, and bilateral compression of the jugular veins, may transiently worsen sciatica pain. [14]

Medical imaging

Imaging modalities such as computerised tomography or magnetic resonance imaging can help with the diagnosis of lumbar disc herniation. [39] The utility of MR neurography in the diagnosis of piriformis syndrome is controversial. [15]

Discography could be considered to determine a specific disc's role in an individual's pain. [13] Discography involves the insertion of a needle into a disc to determine the pressure of disc space. [13] Radiocontrast is then injected into the disc space to assess for visual changes that may indicate an anatomic abnormality of the disc. [13] The reproduction of an individual's pain during discography is also diagnostic. [13]

Differential diagnosis

Cancer should be suspected if there is previous history of it, unexplained weight loss, or unremitting pain. [12] Spinal epidural abscess is more common among those who have diabetes mellitus or immunodeficiency, or who have had spinal surgery, injection or catheter; it typically causes fever, leukocytosis and increased erythrocyte sedimentation rate. [12] If cancer or spinal epidural abscess is suspected, urgent magnetic resonance imaging is recommended for confirmation. [12] Proximal diabetic neuropathy typically affects middle aged and older people with well-controlled type-2 diabetes mellitus; onset is sudden, causing pain, usually in multiple dermatomes, quickly followed by weakness. Diagnosis typically involves electromyography and lumbar puncture. [12] Shingles is more common among the elderly and immunocompromised; typically, pain is followed by the appearance of a rash with small blisters along a single dermatome. [12] [40] Acute Lyme radiculopathy may follow a history of outdoor activities during warmer months in likely tick habitats in the previous 1–12 weeks. [41] In the U.S., Lyme is most common in New England and Mid-Atlantic states and parts of Wisconsin and Minnesota, but it is expanding to other areas. [42] [43] The first manifestation is usually an expanding rash possibly accompanied by flu-like symptoms. [44] Lyme can also cause a milder, chronic radiculopathy an average of 8 months after the acute illness. [12]

Management

Sciatica can be managed with a number of different treatments [45] with the goal of restoring a person's normal functional status and quality of life. [13] When the cause of sciatica is lumbar disc herniation (90% of cases), [4] most cases resolve spontaneously over weeks to months. [46] Initially treatment in the first 6–8 weeks should be conservative. [4] More than 75% of sciatica cases are managed without surgery. [13] In persons that smoke who also have sciatica, smoking cessation should be strongly considered, in order to promote healing. [13] Treatment of the underlying cause of nerve compression is needed in cases of epidural abscess, epidural tumors, and cauda equina syndrome. [13]

Physical activity

Physical activity is often recommended for the conservative management of sciatica for persons who are physically able. [3] However, the difference in outcomes between physical activity compared to bed rest have not been fully elucidated. [3] [47] The evidence for physical therapy in sciatica is unclear though such programs appear safe. [3] Physical therapy is commonly used. [3] Nerve mobilization techniques for sciatic nerve is supported by tentative evidence. [48]

Medication

There is no one medication regimen used to treat sciatica. [45] Evidence supporting the use of opioids and muscle relaxants is poor. [49] Low-quality evidence indicates that NSAIDs do not appear to improve immediate pain, and all NSAIDs appear to be nearly equivalent in their ability to relieve sciatica. [49] [50] [51] Nevertheless, NSAIDs are commonly recommended as a first-line treatment for sciatica. [45] In those with sciatica due to piriformis syndrome, botulinum toxin injections may improve pain and function. [52] While there is little evidence supporting the use of epidural or systemic steroids, [53] [54] systemic steroids may be offered to individuals with confirmed disc herniation if there is a contraindication to NSAID use. [45] Low-quality evidence supports the use of gabapentin for acute pain relief in those with chronic sciatica. [49] Anticonvulsants and biologics have not been shown to improve acute or chronic sciatica. [45] Antidepressants have demonstrated some efficacy in treating chronic sciatica, and may be offered to individuals who are not amenable to NSAIDs or who have failed NSAID therapy. [45]

Surgery

If sciatica is caused by a herniated disc, the disc's partial or complete removal, known as a discectomy, has tentative evidence of benefit in the short term. [55] If the cause is spondylolisthesis or spinal stenosis, surgery appears to provide pain relief for up to two years. [55]

Alternative medicine

Low to moderate-quality evidence suggests that spinal manipulation is an effective treatment for acute sciatica. [3] [56] For chronic sciatica, the evidence supporting spinal manipulation as treatment is poor. [56] Spinal manipulation has been found generally safe for the treatment of disc-related pain; however, case reports have found an association with cauda equina syndrome, [57] and it is contraindicated when there are progressive neurological deficits. [58]

Prognosis

About 39% to 50% of people with sciatica still have symptoms after one to four years. [59] In one study, around 20% were unable to work at their one-year followup, and 10% had had surgery for the condition. [59]

Epidemiology

Depending on how it is defined, less than 1% to 40% of people have sciatica at some point in time. [9] [4] Sciatica is most common between the ages of 40 and 59, and men are more frequently affected than women. [2] [3]

See also

Related Research Articles

<span class="mw-page-title-main">Lumbar disc disease</span> Medical condition

Lumbar disc disease is the drying out of the spongy interior matrix of an intervertebral disc in the spine. Many physicians and patients use the term lumbar disc disease to encompass several different causes of back pain or sciatica. In this article, the term is used to describe a lumbar herniated disc. It is thought that lumbar disc disease causes about one-third of all back pain.

<span class="mw-page-title-main">Back pain</span> Area of body discomfort

Back pain is pain felt in the back. It may be classified as neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia based on the segment affected. The lumbar area is the most common area affected. An episode of back pain may be acute, subacute or chronic depending on the duration. The pain may be characterized as a dull ache, shooting or piercing pain or a burning sensation. Discomfort can radiate to the arms and hands as well as the legs or feet, and may include numbness or weakness in the legs and arms.

<span class="mw-page-title-main">Sciatic nerve</span> Large nerve in humans and other animals

The sciatic nerve, also called the ischiadic nerve, is a large nerve in humans and other vertebrate animals which is the largest branch of the sacral plexus and runs alongside the hip joint and down the lower limb. It is the longest and widest single nerve in the human body, going from the top of the leg to the foot on the posterior aspect. The sciatic nerve has no cutaneous branches for the thigh. This nerve provides the connection to the nervous system for the skin of the lateral leg and the whole foot, the muscles of the back of the thigh, and those of the leg and foot. It is derived from spinal nerves L4 to S3. It contains fibers from both the anterior and posterior divisions of the lumbosacral plexus.

<span class="mw-page-title-main">Lumbar</span> Abdominal segment of the torso

In tetrapod anatomy, lumbar is an adjective that means of or pertaining to the abdominal segment of the torso, between the diaphragm and the sacrum.

<span class="mw-page-title-main">Discectomy</span> Surgical removal of an intervertebral disc

A discectomy is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an intervertebral disc, which causes pain, weakness or numbness by stressing the spinal cord or radiating nerves. The traditional open discectomy, or Love's technique, was published by Ross and Love in 1971. Advances have produced visualization improvements to traditional discectomy procedures, or endoscopic discectomy. In conjunction with the traditional discectomy or microdiscectomy, a laminotomy is often involved to permit access to the intervertebral disc. Laminotomy means a significant amount of typically normal bone is removed from the vertebra, allowing the surgeon to better see and access the area of disc herniation.

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<span class="mw-page-title-main">Piriformis muscle</span> One of six small hip muscles in the lateral rotator group

The piriformis muscle is a flat, pyramidally-shaped muscle in the gluteal region of the lower limbs. It is one of the six muscles in the lateral rotator group.

<span class="mw-page-title-main">Piriformis syndrome</span> Medical condition

Piriformis syndrome is a condition which is believed to result from nerve compression at the sciatic nerve by the piriformis muscle. It is a specific case of deep gluteal syndrome. The largest and most bulky nerve in the human body is the sciatic nerve. Starting at its origin it is 2 cm wide and 0.5 cm thick. The sciatic nerve forms the roots of L4-S3 segments of the lumbosacral plexus. The nerve will pass inferiorly to the piriformis muscle, in the direction of the lower limb where it divides into common tibial and fibular nerves. Symptoms may include pain and numbness in the buttocks and down the leg. Often symptoms are worsened with sitting or running.

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<span class="mw-page-title-main">Cauda equina syndrome</span> Nerve damage at the end of the spinal cord

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<span class="mw-page-title-main">Traction (orthopedics)</span> Process for straightening broken bones

Traction is a set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system. There are two types of traction: skin traction and skeletal traction. They are used in orthopedic medicine.

Failed back syndrome or post-laminectomy syndrome is a condition characterized by chronic pain following back surgeries. Many factors can contribute to the onset or development of FBS, including residual or recurrent spinal disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness, spinal muscular deconditioning and even Cutibacterium acnes infection. An individual may be predisposed to the development of FBS due to systemic disorders such as diabetes, autoimmune disease and peripheral blood vessels (vascular) disease.

A nerve root is the initial segment of a nerve leaving the central nervous system. Nerve roots can be classified as:

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the intervertebral disc between two spinal vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.

<span class="mw-page-title-main">Radiculopathy</span> Medical condition

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly. Radiculopathy can result in pain, weakness, altered sensation (paresthesia) or difficulty controlling specific muscles. Pinched nerves arise when surrounding bone or tissue, such as cartilage, muscles or tendons, put pressure on the nerve and disrupt its function.

<span class="mw-page-title-main">Spinal disease</span> Diseases involving the vertebral column

Spinal disease refers to a condition impairing the backbone. These include various diseases of the back or spine ("dorso-"), such as kyphosis. Dorsalgia refers to back pain. Some other spinal diseases include spinal muscular atrophy, ankylosing spondylitis, lumbar spinal stenosis, spina bifida, spinal tumors, osteoporosis and cauda equina syndrome.

<span class="mw-page-title-main">Nerve compression syndrome</span> Human disease

Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by chronic, direct pressure on a peripheral nerve. It is known colloquially as a trapped nerve, though this may also refer to nerve root compression. Its symptoms include pain, tingling, numbness and muscle weakness. The symptoms affect just one particular part of the body, depending on which nerve is affected. The diagnosis is largely clinical and can be confirmed with diagnostic nerve blocks. Occasionally imaging and electrophysiology studies aid in the diagnosis. Timely diagnosis is important as untreated chronic nerve compression may cause permanent damage. A surgical nerve decompression can relieve pressure on the nerve but cannot always reverse the physiological changes that occurred before treatment. Nerve injury by a single episode of physical trauma is in one sense an acute compression neuropathy but is not usually included under this heading, as chronic compression takes a unique pathophysiological course.

<span class="mw-page-title-main">Spinal stenosis</span> Disease of the bony spine that results in narrowing of the spinal canal

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.

<span class="mw-page-title-main">Deep gluteal syndrome</span> Medical condition

Deep gluteal syndrome describes the non-discogenic extrapelvic entrapment of the sciatic nerve in the deep gluteal space. It is an extension of non-discogenic sciatic nerve entrapment beyond the traditional model of piriformis syndrome. Symptoms are pain or dysthesias the buttocks, hip, and posterior thigh with or without radiating leg pain. Patients often report pain when sitting. The two most common causes are piriformis syndrome and fibrovascular bands, but many other causes exist. Diagnosis is usually done through physical examination, magnetic resonance imaging, magnetic resonance neurography, and diagnostic nerve blocks. Surgical treatment is an endoscopic sciatic nerve decompression.

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