Sciatica

Definition
Sciatica is leg pain that follows the path of the sciatic nerve, the largest nerve in the body. (The sciatic nerve begins in the low back and runs through the buttocks into the thigh and lower leg.) Sciatica can cause mild to severe pain through the buttocks, thigh and back of the leg. This pain may be accompanied by numbness, tingling and weakness in the leg. Sciatica may be associated with back pain or may occur alone.

Causes/associated factors
Sciatica results from compression or inflammation of the sciatic nerve. The most frequent cause is a herniated intervertebral disk (when a cushion between your vertebrae -- the bony sections that make up your spine -- "slips" or bulges out of place and presses on the nerve). Less often, sciatica may be caused by:
back strain due to injury
a tumor in your spine
narrowing of the spinal canal
an abdominal mass (abnormal growth of tissue in the abdomen)
an infection
Sometimes, the cause of sciatica remains a mystery.

Risk factors for sciatica include:

repetitive back motion (such as lifting, bending and twisting)
repetitive or prolonged vibration (such as driving a vehicle or using a jack hammer)
sedentary lifestyle
smoking (which leads to spinal degeneration)
obesity
psychosocial factors (such as anxiety, depression or high stress)

Signs/symptoms
Sciatica can appear suddenly or develop slowly. Unlike other types of lower back conditions, sciatica is usually present on only one side. Besides lower back discomfort, the condition may also cause a sharp, shooting pain (sometimes described as a burning sensation) that follows the path of the sciatic nerve from the buttocks through the thigh and the lower leg. The pain may even extend all the way down to the foot. You may also notice tingling, numbness or weakness in the affected leg or foot.

Diagnosis
The doctor will review your medical history and do a physical exam. You may need other tests if your sciatica started after an injury or if you:
are over 50
have severe or persistent symptoms
have symptoms of infection or other illness
have a history of cancer
have pain that worsens while lying down or severe nighttime pain
Diagnostic tests may include:

blood tests
spinal X-ray
magnetic resonance imaging (MRI, an imaging technique based on computer analysis of the body's response to a magnetic field), which can help your doctor see the internal structures of the spine, including the soft tissues of the lumbar disks and nerves
computed tomography (CT scan -- a computer-generated, cross-sectional picture of internal body parts), which can also help your doctor see the internal structures of the spine
myelography (injection of a special X-ray dye into a layer of the spinal cord covering), which is sometimes used in combination with a CT scan to clarify the extent and location of a disk herniation
electromyography (a technique used to measure a muscle's electrical activity), which can help determine nerve or muscle damage
bone scan (injection of a special dye that can be detected in the bone by a camera that scans the body), which can identify abnormal bone structure or functioning

Treatment
Although recovery from the most common types of sciatica often takes longer than recovery from simple back pain, most people improve within four to 12 weeks with conservative treatment. Depending on your symptoms, medical history and the cause of the sciatica, your doctor may offer the following treatment suggestions:
Modify your activities. Your doctor may recommend up to two days of bedrest. However, do not try bedrest without consulting your doctor. An early return to normal activities, such as walking, is encouraged so you do not become stiff or deconditioned. Avoid high-risk activities, such as lifting and bending.

Take pain medications as recommended by your doctor. He or she may nonsteroidal anti-inflammatory medications (NSAIDs) to help ease pain.

Apply heat or ice to the painful area.

Do physical therapy or a home exercise program. Changes in work, recreational or exercise activities may also be helpful.

Lose weight.

If you smoke, quit.
If the pain does not improve or worsens, other treatment options may be recommended. Acute pain usually resolves by 12 weeks. Pain that persists longer than 12 weeks is considered chronic pain.

Medications
Other medications may be used alone or in combination with NSAIDs.

Muscle relaxants: Muscle relaxants are effective for treating acute back pain, but their benefit for treating chronic back pain has not been proved. They have not been found to be more effective then NSAIDs, and they have more serious side effects, such as dependency, drowsiness and dizziness. They are usually prescribed only for a short time.

Steroid medications: Oral steroids can reduce inflammation and relieve pain, but they are not the first course of treatment for most acute back pain. NSAIDs are often avoided or minimized when oral steroids are used.

Benefits of medications: Most over-the-counter (OTC) medications have fewer side effects than prescription medications, cost less, and are effective and safe to use for most people.

Risks of medications: Ask your doctor about possible side effects, such as drowsiness, stomach irritation, bleeding, nausea, rash or dizziness. If you develop any side effects, stop taking the medication and call your doctor for medical advice. Side effects may be more frequent or severe in people over age 60. Always discuss any medication use during pregnancy or while breastfeeding with your doctor.
Multidisciplinary treatment programs
Intensive treatment programs that involve many disciplines, such as a doctor, physical therapist, psychologist, social worker and occupational therapist, working together have been found to be helpful for people with chronic back pain. Programs that offer some sort of treatment every day seem to be most effective.

Benefits of multidisciplinary treatment programs: This type of program seems to be most helpful for people who have chronic back pain.

Risks of multidisciplinary treatment programs: Results may not be as good if the person doesn't participate every day.
Behavior therapy
Behavior therapy is based on the theory that how you feel about your pain can make it better or worse. Weekly sessions with a trained therapist can help you learn skills such as stress-management and relaxation techniques. There are many different techniques, and behavior therapy seems to be most effective for people with chronic pain.

Benefits of behavior therapy: Behavior therapy seems to be most helpful for people who have chronic pain.

Risks of behavior therapy: Results may depend on the your commitment to your therapy, as well as the therapist's skill.
Acupuncture
One of the major clinical uses for acupuncture is pain control. It's performed by placing thin needles into the skin at specific points in the body according to principles of Chinese medicine.

Benefits of acupuncture: It's thought to stimulate the release of natural chemicals that block pain sensations in the brain and spinal cord. Several studies on the management of chronic back pain have shown acupuncture may be helpful. No studies have been done to evaluate acupuncture for acute back pain.

Risks of acupuncture: For most health professionals, the biggest concern is that people may delay seeking necessary medical attention by relying solely on acupuncture treatments. Possible complications include tissue injury and infection.
If you're considering acupuncture, ask the practitioner if he or she uses sterile, disposable needles, according to U.S. Food and Drug Administration (FDA) directives. This is a must! Also ask about the practitioner's qualifications.

Epidural steroid injections
A specialist, such as anesthesiologist or radiologist, uses fluoroscopy (a live X-ray) to guide a needle into the lower back to the epidural space (space surrounding the spinal cord). A steroid solution is injected that helps reduce the swelling and inflammation to try to relieve pain. Epidurals are more appropriate for people with chronic back pain.

Benefits of epidural injections: The injection may numb the nerve roots and reduce inflammation, but exactly how it works is unknown. Practitioners consider this treatment to be relatively safe. Treatment may reduce or relieve pain.

Risks of epidural injections: The injections are expensive. Headache is the most common complication. Serious, but rare, complications include infection, meningitis and neurologic problems.
Surgery
Surgery is usually reserved for those with a spinal injury, serious spinal disease or significant nerve involvement. An initial surgery may increase the likelihood for future surgeries. In turn, repeat surgeries have the potential for higher complication rates. If surgery is recommended, you may want to seek a second opinion before the operation.


Complications
Sciatica may recur, and about 10 percent of people may develop chronic pain. For effective relief, a team of health care providers may need to coordinate care.

Pregnancy-specific information
As your baby grows, your center of gravity will change and your body may be thrown off balance. You will probably change the way you walk, stand and sit, which may contribute to back problems, including sciatica. As the uterus enlarges, it can affect the sciatic nerve, causing pain. This pain may resolve as your baby's position changes, or it may persist until delivery. Practice good body mechanics, and discuss any back or leg pain with your obstetrician.

Senior-specific information
The degenerative effects of aging on the back, combined with injuries that may occur over time, increase the risk of sciatica in older adults.

Prevention
To reduce your chances of developing or having a recurrence of sciatica:
Concentrate on good posture and proper body mechanics. Avoid frequent bending and twisting at the waist, and try not to lift heavy objects. If you must lift something heavy, use your legs, keep your back straight, and hold the item as close to your body as possible.

Avoid sitting or standing for long periods of time.

Adjust your workstation to a comfortable height, and sit in a chair with good back support. If you must sit for long periods of time, rest your feet on a stool. Take frequent breaks and walk around periodically.

Sleep on a firm mattress. Place a pillow between your knees when lying on your side, and place a pillow under your knees when lying on your back.

Maintain a healthy weight, and exercise regularly.

If you smoke, quit.

Wear comfortable, low-heeled shoes.

Avoid constipation or straining during bowel movements.

Avoid stress as much as possible.