Sciatica: The Word Sends Shivers Down My Back
I can remember, about 10 years ago, when a nagging pain occurred in my left hip. Especially at night, before I fell asleep, the discomfort would increase. A hip replacement would probably be needed soon, I rationalized.
Then, one evening after a particularly boresome 4 hour drive, I walked into the house, bent over to pick up a very light trash can, and bang!!! Lightening hit me in my lower back, that quickly spread across my entire back like fire. I had a top of my body, and a bottom of my body; but nothing was holding my body together. It had melted in a torrid flood of hot lava. Quickly, the realization that I was in excruciating pain hit. I couldn’t sit, I couldn’t lay down. I could only stand. And, cry! I must have cried for hours, while my poor caring husband paced the floor begging me to allow him to call 911. But I could not do that, they would make me lie down, and that would be impossible.
Finally, the pain subsided slightly and I fell into an exhausted rest. For the next several days, even minimal work was impossible; i.e. putting on my nylons. A cough or a sneeze had me screaming. Weeks later, when I could finally walk, I went to see my doctor.
Her first question was; “why didn’t I see her sooner”? She could have given me something for the acute pain of sciatica. Sciatica! Unbelievable! I had always thought of sciatica as an inconvenience only; which a little aspirin, and a whole lot of distraction would help. Apparently, I had all of the signs, but not enough common sense to act on any of them.
Hopefully, this article will prevent much of the agony I endured. If it helps only one soul, I will feel justified that it was written.
What you need to know about sciatica
The first thing necessary to understanding Sciatica is not how to spell this often misspelled word, but a little knowledge of anatomy.
• The spine or backbones is comprised of 26 bones. The last seven bones are called the lumbar spine (5 bones) and sacrum-coccyx (the tail bone).
• Shock absorbers or disks are in between each backbone, acting as both cushion and stabilizer. The outer disk becomes inelastic and stiff as one ages. At times, as the outer core becomes weaker due to its lack of flexibility, the inner core may protrude through to the outer core, or may herniate completely, protruding outside of the core. When the inner core protrudes backwards, it presses against the spinal canal.
• Spinal cord and nerves: The spinal cord is a bundle of nerves which runs through a tube or canal from the base of your brain, almost to the end of your spine. Thirty-one nerves ‘shoot-off’ from the spinal cord in between the vertebrae or back bone, providing muscle movement and sensation to the rest of your body.
• Muscles and ligaments – Muscles and ligaments also run the length of the spine, providing strength and power to the rest of your body, as well as support and stability to the spine itself.
The sciatica nerve originates from 5 different nerve roots in your lower back. It is the largest nerve in your body, measuring almost the size of a pencil in diameter. It extends through your buttocks, and down the back of your legs, to your toes. It is the longest nerve in your body. Its function is to innervate the muscles in your buttocks, legs, feet and toes. It also provides sensation to the same areas.
True sciatica is caused when the nerve is pinched or irritated at the point of origin. This pain usually radiates down the leg, and is called lumbar radiculopathy. It’s common for people who have this type of leg pain to always refer to the pain as sciatica pain. However, this is not true. Frequently, the pain is referred from a joint pain, usually hip, caused from osteoarthritis. The cause dictates treatment guidelines, so your doctor will spend time determining the origin of the pain you might be feeling.
Causes of a pinched sciatica nerve are the following:
• lumbar herniated disc: This is the most common cause, and usually resolves itself in 2-8 weeks. As the spinal cord does not go to the end of the backbone, the person is in no danger of paralysis via the herniated disc. If the disc herniates completely, a chemical called hyaluronic acid is also secreted, which exponentially increases the inflammation and subsequent pain.
• lumbar spinal stenosis: The spinal canal which houses your spinal cord is narrowed. If this occurs in your lower back, lumbar sciatica may result.
• Piriformis Sydrome: The pyriformis muscle attaches at the lower back bone and attaches to both bones in the upper thigh. It lays over the sciatic nerve, and when it becomes tightened, or spasms, may irritate the sciatica nerve. This syndrome may occur in a fall, prolonged sitting, or car accident. Runners also have a higher tendency to incur this disorder.
• spondylolisthesis: This disease is caused by degenerative disc disease, and occurs when one vertebrae slips over another one, and in the process, pinches or irritates the nerve
Other non-orthopedic causes of injury to the sciatica nerve include the following:
• Diabetes: Diabetes harms several nerves, including the sciatica
• Tumors/Cancer: Can put pressure on the sciatica nerve, causing pain. Symptoms of complete loss of feeling in the legs/feet or pelvic region, or incontinence of bowel or bladder should contact 911 immediately.
• Obesity: If someone is overweight, and sits for long periods, the sciatica nerve which runs through the buttocks, may become irritated
• Trauma: Gunshot wounds, accidents, pelvic fractures may cause increased pressure and inflammation
• Internal bleeding: Again, pressure and inflammation may both increase as a result of internal bleeding.
However, sometimes no cause for the sciatica disorder can be found.
Symptoms
Orthopedic reasons remain the number one reason for sciatic pain. Therefore, the symptoms identified are mainly for one’s which occur due to bone or joint disease, such as osteoarthritis.
• Sensation changes
o Of the back of the calf or the sole of the foot
o Numbness, decreased sensation
o Tingling, burning sensation
o Pain, may be severe (pain on one side of the buttocks/hip may be constant, which may be worse when sitting or laying down, based on pressure points; electric/shooting pains down one side of the leg are common, burning type of pain can be intolerable, usually pain in leg is much more severe than lower back pain)
• Weakness of the knee or foot
o Difficulty walking
o Inability to move the foot (in severe cases)
o Inability to bend the knee (in severe cases)
• Emergency symptoms include complete loss of feeling in pelvic region, or loss of sensation greater than 5 minutes of foot/leg.
• Sudden loss of bowel or bladder functions always indicates an emergency situation. Contact 911.
Diagnosis:
Signs and tests If pain is acute, the physician will always first rule out acute medical causes such as tumors, internal bleeding, infection, or other chronic diseases such as diabetes. After acute medical emergencies have been resolved, the physician will continue their examination to look for other neurological causes.
• Physical examination:
Reflexes: weak or absent ankle-jerk reflex
Foot may bend inward or downward with extreme difficulty
Reproduction of sciatica pain when leg lifted straight off exam table.
Weakness of knee bending
• EMG (a recording of electrical activity in muscles). Needles are strategically placed along the nerve passage, and the electrical conduction is recorded.
• Radiological exams: X-Rays, MRI’s, CAT Scans, etc. may all be included as a part of the examination process
Treatment
The pain from the sciatica nerve is caused by pressure and inflammation, so the goals of any treatment are to work, simultaneously, on both causes of pain. The severity of the pain one may feel is due to the large size and length of the nerve.
There are two main categories of treatment for sciatica:
Non-Surgical
• Anti-inflammatories: Aspirin or the NSAIDS such as Motrin or Naproxen are the first line anti-inflammatories. To provide more relief, and possibly to avoid the associated GI discomfort, the Cox-2 Inhibitors such as Celebrex may be used. Steroids, such as cortisones are also used in very severe cases. However, the latest research on steroids indicates that the effectiveness may last for only 2 weeks. In deed, rebound or even worse pain may occur 3-6 months after receiving the back injection.
• Heat/cold packs: Using either a heat or cold pack is sometimes based on patient preference. Heat will relax the muscles, which if tightened and pressing against the sciatica nerve, will relieve pain. Cold will constrict the muscles, which may help to support weakened muscles, thereby relieving pain.
• Antispasmodics: Irritated nerves may cause muscle cramping, which may be sustained and very painful.
• Other Medications: Lumbar radiculopathy (or pain that radiates along the sciatica nerve) may be helped with anticonvulsants or antidepressants. These medications seem to work on the nerve transmitters themselves, regulating the transmitters that are increasing the pain. Narcotics such as opioids can also be used; however, due to their significant consequences, are used as a last recourse, and always in conjunction with other modifiers of pain.
• Exercise: Specific physical exercises can be used to strengthen the core abdominal muscles for increased supports, and increase the flexibility of the hamstring/gluteal (buttocks muscles). Flexibility is increased through stretching exercises.
• Diet: Weight loss, if obese, is definitely helpful in decreasing the pressure on the sciatica nerve. Additionally, an ‘anti-inflammatory’ diet is also advised; e.g. foods high in omega-3’s, such as fish, and low in saturated fats.
• Acupuncture/Chiropractor: Both may be helpful in reducing pressure and releasing energy to promote healing. Before one ‘pooh-poohs’ acupuncture, be aware that the National Institute of Health, as early as 1998, stated it was effective with certain types of low back pain. Additionally, in 1994 the Agency for Healthcare Research and Quality, formerly the Agency for Health Care Policy and Research proclaimed the increase in mobility which Chiropractors can provide, is effective in reducing low back pain.
• Good body mechanics: Not only does this include proper posture when sitting or standing, but using good lifting techniques. Additionally, a good mattress helps to maintain alignment while sleeping. High heels are never encouraged.
• Smoking: Smoking seems to always be a culprit, no matter what the disease, and so it goes with low back pain/sciatica. Cigarette smoking has been shown to increase the degenerative changes which occur in osteoarthritis and degenerative disc. Both of these diseases contribute to sciatica.
Surgical Interventions:
• microdiscectomy or
• lumbar laminectomy and
• discectomy,
All of the above surgical interventions remove a part of the disc irritating the sciatica nerve. If the pain in your lower leg was your only symptom, there is a 90% chance of complete recovery with surgery. Surgery to take pressure off the nerve is generally reserved for cases of severe pain, progressive nerve damage, and failure to respond to conservative care.
http://www.medpagetoday.com/PrimaryCare/BackPain/dh/5226
American Academy of Neurology
http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=91&topcategory=Spine
American Academy of Orthopedic Surgeons
http://www.mayoclinic.com/health/sciatica/DS00516
Mayo Clinic
http://www.nlm.nih.gov/medlineplus/ency/article/000686.htm
Medline Plus Medical Encyclopedia
http://www.niams.nih.gov/hi/topics/spinalstenosis/spinal_sten.htm
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
http://www.ninds.nih.gov/disorders/piriformis_syndrome/piriformis_syndrome.htm
National Institute of Neurological Disorders & Stroke. NIH. HHS
http://www.spine-health.com/topics/cd/d_sciatica/sc01.html
Spine-health.com
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