Sciatica

Sciatica (or sciatic neuritis)[1] is a set of symptoms including pain that may be caused by
general compression and/or irritation of one of five spinal nerve roots that give rise to each
sciatic nerve, or by compression or irritation of the left or right or both sciatic nerves. The
pain is felt in the lower back, buttock, and/or various parts of the leg and foot. In addition to
pain, which is sometimes severe, there may be numbness, muscular weakness, pins and
needles or tingling and difficulty in moving or controlling the leg. Typically, the symptoms
are only felt on one side of the body.

Although sciatica is a relatively common form of low back pain and leg pain, the true
meaning of the term is often misunderstood. Sciatica is a set of symptoms rather than a
diagnosis for what is irritating the root of the nerve, causing the pain. This point is important,
because treatment for sciatica or sciatic symptoms will often be different, depending upon the
underlying cause of the symptoms.

The first known use of the word sciatica dates to 1451.[2]

Cause

Sciatica is generally caused by the compression of lumbar nerves L4 or L5 or sacral nerves

S1, S2 or S3, or by compression of the sciatic nerve itself. When sciatica is caused by
compression of a dorsal nerve root (radix) it is considered a lumbar radiculopathy (or
radiculitis when accompanied with an inflammatory response) from a spinal disk bulge or
spinal disc herniation (a herniated intervertebral disc in the spine), or from roughening,
enlarging, and/or misaligning of the vertebrae (spondylolisthesis), or degenerated discs. The
intervertebral discs consist of an annulus fibrosus which forms a ring surrounding the inner
nucleus pulposus. When there is a tear in the annulus fibrosis, the nucleus pulposus (pulp)
may protrude through and push against spinal nerves within the spinal cord or those exiting,
causing numbness or excruciating pain. Sciatica due to compression of a nerve root is one of
the most common forms of radiculopathy.

Pseudosciatica or non-discogenic sciatica, which causes symptoms similar to spinal nerve

root compression, is most often referred pain from damage to facet joints in the lower back
and is felt as pain in the lower back and posterior upper legs. Pseudosciatic pain can also be
caused by compression of peripheral sections of the nerve, usually from soft tissue tension in
the piriformis or related muscles (see piriformis syndrome and see below).

Spinal disc herniation

One of the possible causes of sciatica is a spinal disc herniation pressing on one of the sciatic
nerve roots. The spinal discs are composed of a tough spongiform ring of cartilage (annulus
fibrosus) with a more malleable center (nucleus pulposis). The discs separate the vertebrae,
thereby allowing room for the nerve roots to properly exit through the spaces between the L4,
L5, and sacral vertebrae. The discs cushion the spine from compressive forces, but are weak
to pressure applied during rotational movements. That is why a person who bends to one side,
at a bad angle to pick something up, may more likely herniate a spinal disc than a person
jumping from a ladder and landing on his or her feet.
Herniation of a disc occurs when the liquid center of the disc bulges outwards, tearing the
external ring of fibers, extrudes into the spinal canal, and compresses a nerve root against the
lamina or pedicle of a vertebra, thus causing sciatica. This extruded liquid from the nucleus
pulposus may cause inflammation and swelling of surrounding tissue which may cause
further compression of the nerve root in the confined space in the spinal canal.

Sciatica caused by pressure from a disc herniation and swelling of surrounding tissue can
spontaneously subside if the tear in the disc heals and pulposis extrusion and inflammation
cease.

Sciatica can be caused by tumours impinging on the spinal cord or the nerve roots. Severe
back pain extending to the hips and feet, loss of bladder or bowel control, or muscle
weakness, may result from spinal tumours. Trauma to the spine, such as from a car accident,
may also lead to sciatica.

Spinal stenosis

Other compressive spinal causes include lumbar spinal stenosis, a condition in which the
spinal canal (the spaces through which the spinal cord runs) narrows and compresses the
spinal cord, cauda equina, and/or sciatic nerve roots. This narrowing can be caused by bone
spurs, spondylolisthesis, inflammation, or herniated disc which decreases available space for
the spinal cord, thus pinching and irritating nerves from the spinal cord that travel to the
sciatic nerves.

Piriformis syndrome

In 15% of the population, the sciatic nerve runs through the piriformis muscle rather than
beneath it. When the muscle shortens or spasms due to trauma or overuse, it can compress or
strangle the sciatic nerve beneath the muscle. Conditions of this type are generally referred to
as entrapment neuropathies; in the particular case of sciatica and the piriformis muscle, this
condition is known as piriformis syndrome. It has colloquially been referred to as "wallet
sciatica" since a wallet carried in a rear hip pocket will compress the muscles of the buttocks
and sciatic nerve when the bearer sits down. Piriformis syndrome may be a cause of sciatica
when the nerve root is normal. [3] [4]

Trigger points

Another source of sciatic symptoms is active trigger points of the lower back and the gluteus
muscles.[citation needed] In this case, the referred pain is not a result of compression of the sciatic
nerve, though the pain distribution down the buttocks and leg is similar. Trigger points occur
when muscles become ischemic (having low blood flow) due to injury or chronic muscular
contraction. The most commonly associated muscles with trigger points that affect the sciatic
symptoms are: the quadratus lumborum, the gluteus medius, the gluteus minimus, and the
deep hip rotators.[citation needed]
[5]
Habits

The risk of self-inflicted sciatica has increased in recent years with, for instance, sitting on a
wallet [6] or standing for prolonged periods of time every day which can cause self-inflicted
sciatica. Symptoms of numbness and/or pain behind the knee cap are associated with this
form of sciatica. Work-related sciatica may be caused by the use of tool belts which hang
around the hips and cause significant misalignment of the sacral vertebrae over long time
periods.

Diagnosis

Because of the many conditions that can compress nerve roots and cause sciatica, treatment
and symptoms often differ from patient to patient. Some common indicators of sciatica are
numbness in the feet or legs, strange sensations, impaired reflexes, and weakness.[7]
Diagnostic tests can come in the form of a series of examinations by a physician. Patients will
be asked to adopt numerous positions and actions, such as squatting, walking on toes,
bending forward and backward, rotating the spine, sitting, lying on the back and raising one
leg at a time. Increased pain will occur during some of these activities.

If no improvement in symptoms has occurred in six weeks or red flags are present, imaging is
appropriate. Imaging may include either CT or MRI.[8] Imaging methods such as MR
neurography may help in diagnosis and treatment of sciatica. MR neurography has been
shown to diagnose 95% of severe sciatica patients, while as few as 15% of sciatica sufferers
in the general population are diagnosed with disc-related problems.[9] MR neurography is a
modified MRI technique using MRI software to provide better pictures of the spinal nerves
and the effect of compression on these nerves. MR neurography may help diagnose piriformis
syndrome which is another cause of sciatica that does not involve disc herniation.[citation needed]

Treatment

When the cause of sciatica is due to a prolapsed or lumbar disc herniation 90% of disc
prolapses will be resolved with no intervention. Treatment of the underlying cause of the
compression is needed in cases of epidural abscess, epidural tumors, and cauda equina
syndrome.

Cases of sciatica are treated with different measures. Evidence of the effectiveness of these
measures is limited, however.[8] Some of these measures are:

 Anti-inflammatory medications (e.g., NSAIDs or oral steroids. However, NSAIDs are no more
effective than placebos for acute sciatica)[10]
 Amitryptyline: developed as an antidepressant but has been shown to be effective in
treating neuropathic pain, including sciatica. Recommended in the UK by the National
Institute of Clinical Excellence[11]
 Paracetamol (acetaminophen): limited evidence of effectiveness
 Narcotics: often used if pain is severe
 Chiropractic spinal manipulation [12]
 Physical therapy / Stretching exercises
 Epidural steroid injections provide no long-term improvements in outcomes but do provide
some short-term benefits
 Non-surgical spinal decompression
 Massage therapy[citation needed])
 Weight loss reduces pressure on Spinal nerve roots
 Surgery

Surgery speeds the resolution of pain. Two years after surgery, however, surgical and non-
surgical management have about the same results; so a patient's preference can be a valid
reason to choose one or the other.[8]

Prevention

Exercise like swimming strengthen the muscles that support the back without putting any
strain on it or subjecting it to a sudden jolt, and can prevent and reduce the symptoms of
sciatica. Yoga or pilates can help improve the flexibility and the strength of the back muscles.
[13]

Bad posture can aggravate sciatica. Taking measures to improve it can alleviate pain and
swelling:

Standing

Stand upright with a straight back and front-facing head. Weight should be balanced evenly
on both feet and legs kept straight.

Sitting

Sit upright with a support, such as a cushion or rolled-up towel in the small of the back.
Knees and hips should be level and feet should be flat on the floor, with the aid of a footstool
if necessary.

Driving

As with sitting, the back should be properly supported. Correctly position wing mirrors to
prevent having to twist the back. Foot controls should be squarely in front of the feet. If
driving long distances, regular breaks should be taken to stretch legs.

Sleeping

Sleep on a medium-firm mattress (not too firm). The mattress should be firm enough to
support the body while supporting the weight of the shoulders and buttocks, keeping the
spine straight. Support the head with a pillow, but make sure the neck is not forced up at a

Lifting and handling

To prevent injury-caused sciatica, the correct method for lifting and handling objects should
be followed.[13]