By Joseph Williams, M.D.
Board Certified Orthopedic Surgeon
Orthopedic Center of Illinois
Sciatica is a term that is commonly used to describe the pain an individual has radiating down an extremity. Patients will come to the office with complaints of severe pain down one leg or, less commonly, down both legs. The term is often overused and not all cases of self-diagnosed “sciatica” are actually correct.
Sciatic nerve anatomy.
The sciatic nerve is the largest nerve in the lower body. It is made up of multiple nerve roots that originate in the low back, the lumbar spine and sacral spine. These nerve roots join together within the pelvis and form the sciatic nerve. This nerve then travels down the back of the leg innervating the muscles and providing sensation to the leg.
Sciatica is typically the term used to describe pain that one experiences in a leg, however, there is usually numbness or tingling and possibly weakness occurring as well. As stated previously, the sciatic nerve provides innervation to multiple muscles in the leg and also sensation to specific locations of the leg. Thus, if there is enough dysfunction within the sciatic nerve, the person could very well experience more than just pain.
A bulging disc pressed on the sciatic nerve.
The most common cause of sciatica pain is compression of one of the nerve roots that makes up the sciatic nerve. This compression is usually in the form of a disc herniation in the lower lumbar spine, typically, at the L4 – L5 disc or the L5 – S1 disc. These herniations protrude into the spinal canal and compress the nerve roots before they exit the spine and travel into the pelvis. This compression of the nerve root will then initiate an inflammatory reaction. The nerve will swell, and the patient will experience immediate pain. As the inflammation grows, the pain will become more intense. Thus, the source of the pain is usually in a nerve root before it actually combines to help form the actual sciatic nerve.
Another group of people will experience sciatica pain not as a result of an acute disc herniation, but rather a chronic condition called disc degeneration. These people are often older, and the pain may develop more slowly. The degenerative condition will cause collapse and bulging of the disc and ultimately result in a gradual narrowing of the spinal canal. The specific location of this narrowing is within the lateral recess, or the periphery of the canal. As this narrowing becomes more severe, the nerve root or roots will become compressed within the canal. Again, the inflammatory cascade is initiated, causing the nerve to swell and pain to occur.
There are a variety of ways to treat sciatica, and the treatment depends on the cause. A thorough physical exam needs to be performed in order to help determine the diagnosis. Typically, the treatment is initiated with a regimen of oral medications. These medications can include non-steroidal medication, muscle relaxers and pain medications. In some cases, an oral dose of steroids is provided. In addition to medication, activity modifications are commonly required. The patient will receive instructions to refrain from any strenuous activities, including work related-activities and some hobbies.
If symptoms are poorly controlled with limited activity and/or medication, symptoms are worsening, or a physical exam warrants next steps, an MRI of the lumbar spine will be required. The timing of this MRI is somewhat controversial, because a significant number of sciatica cases will actually resolve with these simple treatments and time. Those patients who experience symptoms and who do not respond to medication and rest may require further diagnostic workup. An MRI is always needed in the face of progressive weakness.
Typically, every effort should be given to first pursue the least invasive options. However, once a successful MRI has been obtained, another set of treatment options becomes available, including epidural steroid injections and possible surgical interventions. The epidural steroid injection is often times the first line of treatment for patients who do not get resolution with medications and activity modifications. Epidural steroid injections are common and place steroid solution at the nerve root responsible for the pain symptoms. They are performed in a operating room with the use of X-Ray. The actual technique can often be performed in a matter of minutes, and they are low risk compared to other treatment options. Up to three injections can be performed in a twelve month period. Injections are a great option for those patients that do not wish to pursue a surgical option or individuals with medical problems that preclude a surgical procedure.
The last option for a patient with sciatic pain would be surgical intervention, and can be accomplished with minimally invasive techniques. The mainstay of surgical treatment for both disc herniation and/or a degenerative bone spur will involve a laminotomy. A laminotomy is a surgical procedure that involves removal of a small portion of the bone. It is a safe procedure, and the most common procedure performed on the spine. There are minimally invasive techniques that can be utilized that can decrease the pain associated with the procedure and offer quicker recoveries.
A patient with a disc herniation will undergo a laminotomy and removal of the disc herniation. Again, this surgery is done as an outpatient procedure—meaning the patient will not need to stay in the hospital. Typically, patients do not receive any formal physical therapy after the procedure. However, they are commonly restricted in their activities for a total of six weeks postoperatively. These restrictions can include limitations as to the amount of weight they can pick up and avoidance of strenuous activities including repetitive bending, lifting and twisting. These restrictions are required to avoid another disc herniation from occurring. Surgical results are often very successful and predictable. Often times, patients will have some tingling in the extremity that improves with time, and usually experience almost complete relief of the pain in the extremity. Symptoms can fully resolve with time as the nerve heals.
Sciatic nerve pain is a very common and debilitating condition. However, with proper diagnostic workup, successful treatment is possible. Typically, treatment starts with nonsurgical options. However, if this approach is unsuccessful, epidural steroid injections and possibly surgery are often utilized to resolve symptoms and return the patient to a pain free lifestyle. If you are experiencing the symptoms explained in this article, please do not hesitate to call our office and schedule a consultation. Our physicians want you to live pain free and can help you get the relief you need.
This article was published in the April-June 2015 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.