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Sciatica; Common Causes, Symptoms, Diagnosis & Treatment

A person suffering from sciatic nerve pain (sciatica).

Sciatica is the term used to describe pain in the sciatic nerve distribution behind the leg with or without sensory deficits. Sciatica is characterized by radicular nerve pain (originating from the nerve root level), in 90% of the cases, it is caused by intervertebral disc herniations and nerve root irritation.

Sciatica due to disc herniations has significant consequences as it is an extremely common cause of visits to the ER and medical doctors. Its management varies drastically in different parts of the world, reflecting treatment availability, evidence-based practices, and access to medical resources.

Lumbar spine consists of the five bones (vertebra) in your lower back. Your lumbar vertebrae, known as L1 to L5, are the largest of your entire spine. This spine is located below your 12 chest (thoracic) vertebra and above the five fused bones that make up your triangular-shaped sacrum bone.
The sciatic nerve travels behind the leg and further branches into the peroneal nerves and any inflammation of the nerve can cause sciatica pain.

The nerve carries both sensory information and motor information. This nerve travels behind the leg and further branches into the peroneal and tibial nerves as it travels past the knee.

The anatomy of the sciatic nerve at the buttock is unique in a relatively superficial way and close to an important muscle called the Piriformis. The sciatic nerve can either sit above, underneath, or traverse through this muscle; in some instances, tightness in this muscle may be the reason for the sciatica pain.

We will further discuss the different conditions that can result in sciatica, common symptom presentation, and treatment options below.

What Is Sciatica?

Sciatica (also called sciatica pain) refers to inflammation of the sciatic nerve. Sciatica is a symptom and not a diagnosis. The symptom can present concurrently alongside other symptoms that indicate nerve irritation and is broadly referred to as “sciatica”.

The cause of this inflammation is multifactorial, and many different conditions and pathophysiology can result in the irritation of this important nerve.

Sciatic nerve is located behind the leg as a distribution of the nerve root.

In sciatica, patients experience pain that radiates from the lower back to the back of the thigh and even down the leg. Although a herniated lumbar disc is the most common cause of sciatica, other factors can also cause this pain.

Tightness in the Piriformis muscle, lumbar spine stenosis, osteophyte formations and lifestyle factors are all important considerations to better understand the presentation of the sciatica as it pertains to the patient, its unique presentation, and its impact on the patient’s lifestyle and movements.

How Sciatic Nerve Might Get Injured?

There are many different etiologies of how the sciatic nerve can become injured. Injuries such as a lumbar disc herniation, spinal stenosis, and canal narrowing can be more serious and central.

They can also be more peripheral due to muscular injuries such as a fall on the buttock or prolonged sitting behind a computer.

Lifestyle factors such as obesity, smoking, diabetes and lack of physical activity also increase the risk of developing sciatica and are associated with higher hospitalization rates.

Injuries place significant challenges on the body, both physically and mentally. Injuries are our body’s way of telling us to slow down and they can result in hindrance to our life and goals that we are trying to accomplish and can take a toll on our mental health.

Knowing risk factors and causes for these injuries can empower us to seek the appropriate care and help us heal quicker.

Sciatica has several causes. Piriformis Syndrome, pregnancy, and aging are some of them.

Here, we have provided a list of various conditions and injuries that can result in sciatica.

This list is not exhaustive; however it covers the most common conditions and is a powerful starting point for helping our patients understand their injuries and learn where they can start if they are suffering from one of these.

What Are the Causes of Sciatica?

The are several direct and indirect factors contributing to sciatica. Below is the list of factors that directly or indirectly cause pain in sciatic nerve.

Sciatica Direct Causes

  • Piriformis Syndrome

  • Lumbar Disc Herniation

  • Osteophytes

  • Sedentary Lifestyle

  • Spondylolisthesis

  • Muscle Spasms

  • Pregnancy

  • Spinal Stenosis

  • Smoking

  • Degenerative Disk Disease

  • Age-related Degeneration

Sciatica Indirect Causes

  • Nutritional Deficiencies (Vitamins D, B1, B6, B9, and B12)
  • Stress and Anxiety
  • Sleep Deprivation
  • Occupational Hazards
  • Poor-fitting Shoes

The direct causes of sciatica will be discussed in more detail.

Piriformis Syndrome

The Piriformis muscle is a small muscle in the glutes. The reason why this muscle is relevant is due to its proximity to the sciatic nerve. The sciatic nerve can lay over it, be underneath it or traverse through the muscle.

The piriformis syndrome is feeling numbness in the piriformis muscle near the sciatic nerve.

Tightness or pressure from the piriformis muscle can cause impingement to the sciatic nerve, resulting in Piriformis Syndrome. It can present as a dull deep ache in the buttock and can be accompanied by pain in the leg or even neurological symptoms such as weakness and numbness.

Piriformis syndrome occurs when your piriformis muscle compresses your sciatic nerve and results in inflammation. It can cause pain or numbness in your buttock and down the back of your leg and might happen on one side of your body or both.

This condition is easily treatable with conservative therapy such as chiropractic, massage, and physiotherapy with excellent results.

Herniated Disks

Lumbar disc herniation can cause pain in two ways:

1- Mechanical pressure from the bulging disc and chemical release of inflammatory factors. A herniated disc can mechanically push on the surrounding nerve root creating impingement.

2- The release of pro-inflammatory factors by the disc’s nucleus pulposus. This condition creates a localized inflammatory environment involving the nerve root exiting the spine and eventually forming the sciatic nerve.

Interesting facts about disc herniations observed through time are that:

  • Surgical intervention does not yield pain relief on a consistent basis.
  • The severity of the pain does not depend on the size of the disc herniation.
  • Pain can still be present despite a negative MRI result and a positive MRI result does not correlate with the presence of pain.
  • The presence of neurological symptoms does not correlate with the size of the disc herniation.
  • Conservative therapy is often effective.

Bone Spurs (Osteophytes)

Osteophyte formations are common with aging and are part of the degenerative changes that occur in the spine. It can result in the narrowing the foramina where the nerve roots exit and can create impingement on these structures resulting in nerve root irritation.

Bone spurs, or osteophytes, are smooth, bony growths, usually near joints. They develop over time in patients with arthritis or joint damage. The feet, hands, knees and spine often develop bone spurs.

Obesity and Diabetes

Certain lifestyle factors have been shown to contribute to an increased risk of developing sciatica and hospitalization as a result. Obesity is one of these factors and goes hand in hand with lack of physical activity and immobility.

One meta-analysis showed that being overweight increases the risk of sciatica by 12% and the risk of hospitalization by 16%. For obesity, this risk increases to 31% and 38%, respectively. Obesity and lack of physical activity are also associated with increased risk of diabetes. Therefore, this makes diabetes another risk factor for developing sciatica.

Spondylolisthesis

Spondylolisthesis is a spine disorder that occurs over time as one level of the vertebrae slips against its adjacent level.

Spondylolisthesis is a very common cause of sciatica and is caused when the vertebrae slips against its adjacent level.

This slip may cause inflammation and chemical irritation of the nerve root but also impose a mechanical force on the nerve root. These forces can create compression to the nerves and present sciatica.

Muscle Spasm

Muscle spasms are very common in low back pain and sciatica cases, especially if the diagnosis is lumbar disc herniation. Muscle spasms of the low back occur in the presence of pain and result in inflammation as a way of the body to protect the sensitive spine from excessive movement.

Hence, muscle spasms on their own do not cause sciatica but are a symptom that can present concurrently with sciatica as a result of the disc injury and lumbar spine instability.

Pregnancy

Pregnancy is associated with significant changes to the pelvic structure and ligament stability due to hormonal changes. These changes, in addition to postural imbalances and a tendency for the mom to lean back can create compressive forces on the spine and the nerve root causing sciatic pain in the legs.

The pregnancy and its specific conditions has direct effects on sciatic nerve and can cause inflammation and pain.

Sciatica during pregnancy responds favorably to conservative therapy such as chiropractic adjustment and gentle exercise therapy through physio and pilates.

In this scenario, movement and light stretching is recommended and has shown to help alleviate symptoms of sciatica and improve the quality of sleep.

Lumbar Spinal Stenosis

Lumbar Spinal Stenosis refers to the narrowing of the central canal where the spinal cord resides. Stenosis can be genetic or due to age as osteophyte formations can result in the narrowing of the canal diameter, but also the small outlets where the nerve roots exit can become compromised.

This narrowing can close down the space for the sciatic nerve roots resulting in impingement and compression of these structures. Irritation of the nerve root will present like sciatica with or without sensory loss down the affected leg.

Flexion-based exercises are effective in helping with sciatic nerve pain due to lumbar spinal stenosis. They can be prescribed by our physiotherapists or chiropractors during your first visit.

Smoking

Smoking is another lifestyle risk factor that has been shown to have associations with the development of sciatica. a 2016 study found that smoking is a risk factor for lumbar pain and sciatica.

Fortunately, there are still benefits to quitting. Smoking cessation drops this risk down to only 10% compared to those that never smoke. Additionally, a high level of leisure time and physical activity has a protective effect against lumbar radicular pain.

Degenerative Disk Disease

Degenerative Disk Disease (DDD) is a condition where the disks can lose their height and reduce the support they offer between the vertebral bodies. This condition is most often associated with age, however, there are also genetic components that may increase the prevalence of DDD in the younger population.

Degenerative Disk Disease or DDD is a common cause of sciatica and is occurred when disks lose their height.

Due to the thinning of the disc material, the vertebrae can sit closer together, creating added compressive forces to the spine as well as narrowing of the space for the nerve roots.

Compression of the nerve roots due to DDD can lead to sciatica through a similar mechanism as described above.

Although DDD is irreversible, slowing its progression is possible by making healthier lifestyle choices such as improved diet and increase in activity and mobility. Conservative therapy such as acupuncture, chiropractic and physiotherapy can do wonders for management of symptoms of DDD and may even result in elimination of the pain with the appropriate care.

Aging

Aging is a common risk factor for developing sciatica because aging is also associated with development of certain conditions such as DDD described above, osteophyte formation, and spinal stenosis.

Although the risks for sciatica slightly increase with age, there are healthy lifestyle habits that can be exercised to delay the effects of aging and to continue living a high quality pain free life. Don’t let age become an excuse for pain and know that you are in charge of your body and your mind. Age is just a number.

Symptoms of Sciatica

Sciatica is a symptom of its own and not a diagnosis; however, these signs DO NOT all need to occur at the same time to be sciatica.

Here are the most common signs of sciatic nerve pain:

  1. Presence of lower back pain – This is commonly present alongside sciatica.
  2. The sensation of buzzing or ants crawling on the legs
  3. Feeling of numbness and paralysis in the legs.
  4. Sharp electrical shooting pain into one leg or both legs.
  5. Dull, achy pain in the side of the leg or the calves.
  6. Weakness in one leg compared to the other side.
  7. Feeling of coldness in the toes.
  8. Tenderness along the buttock and top of glutes.
  9. Puffiness in the low back.
  10. Sensation of warmth in the low back alongside puffiness.

There are other symptoms that often present alongside sciatica suggesting involvement of a nerve root irritation. 

Sciatic Nerve Pain Diagnosis

With any injury or symptom presentation, seeking care quickly can greatly improve treatment outcomes.

As described earlier, sciatica is a symptom and not a diagnosis. The practitioner must perform a series of appropriate history and exams to understand the underlying cause of the sciatica.

This question may be answered from the exam; however it may also require further investigation, such as blood work, imaging, and nerve conduction testing in more complicated scenarios.

The diagnosis is critical in designing a successful treatment plan that can result in symptom alleviation quickly. In the first 6-8 weeks, conservative therapy is highly recommended and favorable, and imaging is not recommended.

However, imaging be ordered in later stages of chronic sciatica or unresponsive cases to further understand the pathophysiology and pain-generating structures.

X-ray

We use X-rays to examine the bony structures and some aspects of soft tissues. An X-ray can show us if there are bony and arthritic changes or narrowing of the canals and foramina where the nerve roots may be compressed.

X ray is one of the diagnosis methods for sciatic nerve pain.

MRI

MRI (Magnetic Resonance Imaging) is a more comprehensive type of imaging that allows us to visualize disc tissue and integrity in addition to nerve root health, inflammation and the existence of compression.

MRIs are expensive to perform and often have a long wait time. Studies have shown that a disc herniation or size of the disc is not correlated to the presence of pain or severity of pain.

CT Scan

CT (Computed Tomography) scan uses ionizing radiation, similar to X-Ray, however, it is multi dimensional and can create a 3D picture to reveal more in-depth information.

A CT scan can be used to look at disc spacing and disc health and may show nerve sheath inflammation if it is present.

Although these findings are rare, CT scan can also nicely visualize the presence of masses or tumors or blood clots that may be causing the sciatica, such as in the case of gluteal varicosities, thrombosis of iliac vein or aneurysms of inferior gluteal artery.

Electromyography (EMG)

EMG is a method used to test the health and conduction of the nerves of our body. EMG is used to assess if the nerve is transmitting neural signals from point A to point B; however it is more commonly used in more severe cases and is not a common method used, especially in the early stages of sciatica.

How Is Sciatica Treated?

There are different approaches to sciatica treatment in different parts of the world, depending on resource availability and the practice of evidence-based science.

Most common treatments available for sciatica include:

  • Physiotherapy (aka Physical Therapy)
  • Drugs
  • Surgical Intervention
  • Exercise Therapy
  • Chiropractic Adjustments
  • Nerve Root Blocks Injection
  • Massage Therapy
  • Epidural Corticosteroid Injections
  • Acupuncture

Regarding the different approaches to sciatica treatment, for instance, some countries are quicker to jump to surgical interventions. In contrast, others prefer to treat conservatively and see if they can have favorable results.

Through clinical experience and studying the research, we have observed that the best treatment outcomes are achieved through a multi-therapy and collaborative approach to care.

When multiple therapies are combined, patients have superior results and faster healing time, especially when all the practitioners are on the same page and support the patient’s healing at the last stages of sciatica.

Physical Therapy

Physical Therapy has always been shown to be effective for the treatment of musculoskeletal pain. In cases of acute pain, physiotherapy can have its limitations. Therefore, we recommend trying 2-3 therapies simultaneously such as acupuncture, chiropractic and physical therapy for the fastest and quickest recovery.

It is important to feel like you have a supportive team of healthcare practitioners that can guide you through the different stages of healing and know that you are not left to figure it all out on your own. 

Read More: Should You See a Chiropractor or Physiotherapist for Sciatica?

Medications

Non-steroidal anti-inflammatory drugs are the most commonly used for pain medication.

There are various medications and drugs available for sciatic nerve pain treatment.

Although these medications or even stronger pain meds such as Naproxen and T3 are effective for short-term symptomatic relief in those with acute and chronic pain, relying on this type of medication for long-term use is not recommended due to their long-term use adverse side effects.

Surgery

Although clinicians and patients often consider surgery during severe pain, the data is limited to understanding and comparing surgical intervention to conservative therapies fully .

Overall, surgical discectomy for prolapsed lumbar disc provided faster short-term relief than non-surgical management. However, long-term effects are thought to be similar and not significant between the surgical group and the conservative group. 

Exercise

Exercise therapy can be a very powerful tool and treatment option for sciatica but as mentioned above, it must be incorporated at the right time. For example, in cases of sudden acute pain, exercise therapy may not be possible to perform and patients may feel frustrated with their pain level and limitations it imposes.

Remember, healing is a step by step process. When you are seeking care, ask your practitioners how the treatment plan will change as you go through the different stages of healing. Initially, passive therapies such as acupuncture and massage or a combination of chiropractic may be most appropriate.

In later stages, physical therapy and different chiropractic alignment techniques may be the last step to get you feeling 100%. We are here to help with that and you are not alone to figure it all out.

Nerve Root Blocks

Nerve root blocks use numbing agents to specific nerve roots thought to be inflamed and contributing to the pain. Nerve root blocks are more specific and target a smaller area compared to epidural injections; however they have a higher chance of not being as effective if the affected nerve root is not identified correctly.

Massage Therapy

Massage Therapy is classically known as a more passive technique for sciatica treatment, and it’s said massage therapy is often the first choice for many when the pain is severe.

However, as the pain subsides and patients are making progress in their healing, it is recommended to transition therapies that focus on improving the alignment of the low back and pelvis as well as work on strengthening and building a strong core and pelvis to further progress healing and prevent the issue from returning quickly.

Steroid Injections

Epidural corticosteroid injections are injections to the epidural, targeting a larger area thought to be contributing to pain.

Steroid targets a larger area and is considered as effective treatment option for sciatica.

These injections were found that in the short-term, there was some small improvement in leg pain and disability with minimal side effects. Long-term follow ups were not investigated.

Steroid injections are man-made drugs very similar to cortisol, a hormone your body makes in your adrenal glands. “Steroid” is short for corticosteroid, which is different from the hormone-related steroid compounds that some athletes use. You may hear them called cortisone injections, cortisone shots, steroid shots, or corticosteroid injections.

In our opinion, when pain is severe and disabling, a steroid injection may be necessary to slightly reduce pain to allow the patient to transition from bed rest to being slightly more active.

However, this should not be the first option explored and conservative therapy should still be attempted if non-invasive therapies are preferred.

Acupuncture

Through studies including meta analysis and systematic reviews, acupuncture has demonstrated significant effectiveness and safety compared to over the counter pain medications. It is also associated with faster return to play and quicker healing time.

Never Ignore Your Sciatic Nerve Pain Symptoms

Sciatic nerve pain is a symptom of an underlying medical condition. The most common medical condition is associated with a lumbar disc herniation (90%). However, other diagnoses can present with sciatica as a symptom.

It is crucial to seek medical intervention when you start to notice symptoms of leg pain, low back pain, weakness and more in your legs or rest of your body. This may be your body telling you to slow down and take care of yourself.

When you notice these symptoms, make an appointment with a healthcare professional that can diagnose the issue is critical such as a chiropractor, medical doctor or physiotherapist.

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