From ama-assn.org
Imagine a sharp, shooting pain that starts in your lower back and travels like an electric shock down your leg, making it difficult to stand, sit or even walk. This is the reality of sciatica, which is a condition that affects millions of people and can turn even the simplest daily tasks into a painful struggle. But sciatica doesn’t have to be a life sentence of pain. There are ways to manage the symptoms and regain control.
The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.
In this instalment, Kevin Taliaferro, MD, an orthopaedic surgeon at Henry Ford Health, took time to discuss what patients need to know about sciatica. Henry Ford Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Sciatica is often misattributed
“Sciatica is a big catchall term that’s frequently got multifactorial issues, but is often misattributed,” Dr. Taliaferro said. “Generally, what people would call sciatica is pain in the back and buttock that could—or could not be—radiating down further into the leg.”
“That’s why it’s this weird thing that everybody thinks any back pain is sciatica,” he said. “The sciatic nerve comes from the nerve roots of the back, but it doesn’t necessarily mean it always causes back pain. That’s why it’s this catchall term that frequently gets misattributed, similar to what happens with the flu.”
Symptoms can be acute or chronic
“Most people, when they have sciatica, it’s acute to start off. It’s acute, sudden back pain that can sometimes radiate into the buttocks and generally develops into leg pain,” Dr. Taliaferro said. “That’s the typical pattern that people experience—that pain where it’s either something flares up or you have a disc herniation, you have a sudden onset and then it slowly evolves into leg pain if it’s a pinched nerve.”
“Atypical symptoms that you should see a doctor about are anything where there’s numbness or weakness in the legs, or bowel or bladder dysfunction,” he said. “Those are red flags that are not typical of sciatica and should be evaluated.”
“Generally, numbness and weakness in the legs means that the nerve is getting very compressed where it’s not functioning; it’s not just irritated and causing pain. It means that there’s enough compression to cause it to be dysfunctional,” Dr. Taliaferro said. “Then the bowel and the bladder function, that’s usually a very large disc herniation that’s pushing on the nerve roots, specifically the sacral nerve roots that are running through the low back.
“Those are the nerve roots that control the bowel and the bladder,” he added, noting that “those are symptoms that are not normal and should be evaluated.”
It is extremely common
In the U.S., about 40% of people experience some form of sciatica during their lifetime. Yet it rarely happens before 20 years old unless it is injury related.
“Most studies say people will experience back or buttock pain at least once in their life,” said Dr. Taliaferro. “Certainly, there are people who experience it more than others.
“But unfortunately, one of those unifying things of being human is having back and or buttock pain in the sciatica family,” he added.
There are different types
“It’s people who have back-predominant or buttock-predominant pain,” Dr. Taliaferro said. “In my practice, those people are generally more in pain from the joints of the lower back. That’s the more common of the two.
“When people have sciatica that radiates down the legs, usually past the knee, that usually can be more coming from a pinched nerve in the back,” he added, noting “they overlap each other significantly.”
Sciatica has common causes
“Typically, it’s degenerative changes that can happen as we age,” said Taliaferro. “That’s one of the more common types where if you have arthritis in the back, that can cause the back and butt pain.”
“But that arthritis can also irritate the nerve roots going to the legs, especially if they’re causing narrowing or stenosis,” which is a condition that occurs when the space inside the backbone is too small, he said. “The other common cause is a disc herniation where people have a small disc herniation or even a large disc herniation that pinches the nerve up in the back. But because that nerve is wired in our brain to our legs, our brain interprets that as leg pain.”
Age is a main risk factor
“As we age, gravity is constant, so it wears and tears on the low back and that’s the biggest risk factor for sciatica,” Dr. Taliaferro explained. “But certainly, young people can have disc herniations as well.”
“So, in general, it is aging and wear and tear on the structures of the low back, but certainly can happen in younger patients as well,” he said.
Pregnant people can have sciatica
“When you have the child, that’s away from your centre of gravity and pulling everything forward,” Dr. Taliaferro said. “Having a large mass at your waist that’s forcing you forward is going to put a lot of stress on the joints of the low back.”
“Also, during childbearing in preparation for delivery, ligaments in the woman’s body generally get more lax to allow for childbirth and sometimes that can allow for a little bit more instability of the low back,” he said. “Now, you could also have compression of nerves where people have disc herniations in pregnancy, so that’s slightly different.
“But for the most part, run-of-the-mill sciatica in pregnancy is just due to the fact that you have a large mass in front of you that puts a lot of stress on the joints of the low back,” Dr. Taliaferro added.
You don’t always need an MRI
“People think that for any back and leg pain that you need to run to get an MRI [magnetic resonance imaging] immediately, but that has led to a lot of overuse of MRIs and a lot of extra cost to the system,” Dr. Taliaferro said. “It’s not great for looking at bones very well. It looks more at soft tissues than anything else.
“There’s information that you can get out of a plain old X-ray that you can’t get out of an MRI,” he added. “So, what’s really important is not all diagnoses need to be made with an MRI. It certainly has its role but talking to an orthopaedic or spinal surgeon—either operative or nonoperative—is important and not just rushing to get an MRI.”
“Most of sciatica improves no matter what you do, especially the run-of-the-mill low back pain when you overdo it,” Dr. Taliaferro said. “That gets better no matter what you do and running to get an MRI every time is really overkill and a pretty big cost to the system.”
Treatment is mainly nonoperative
“The vast majority of run-of-the-mill sciatica—where it’s back and buttock pain—can be treated nonoperatively,” said Dr. Taliaferro, noting that “multimodal pain therapy is the best for that.”
For example, “if people have inflammation, you want to treat that with anti-inflammatory medications such as Aleve, Motrin, Mobic, ibuprofen,” he said. “But we also know that people get really stiff because if they’ve had back pain, their back doesn’t want to move.”
That is when “muscle relaxants are used to allow your back to start moving again because the key is getting moving again,” said Dr. Taliaferro. “And then sometimes if it’s really bad nerve pain, we add gabapentin or neurontin to improve nerve pain.”
Another option is “topicals such as lidocaine, which absorbs through the skin and numbs up the area,” he said. But “the vast majority of these episodes will be treated with physical therapy.”
“There are also other nonoperative treatments—and this is where our pain-management colleagues come into play—where you can do epidurals or you can do more joint-based injections, depending on what the symptoms are,” Dr. Taliaferro said. “Most people get better over two to six weeks, but surgery in this scenario, if there’s no neurologic findings, generally is always the last option and that’s after you’ve exhausted other treatments.”
Get up and move
“A lot of people think that you should stay in bed for a long time if you have sciatica pain,” Dr. Taliaferro said. “It’s fine to relax and take it easy for a day or two, but you really want to start getting up and moving because that shortens the length of duration of symptoms.”
“It’s fine to take a break, but then you need to start getting up and moving to keep that light aerobic activity working,” he emphasized.
Stretch hamstrings, strengthen core
“When our back tightens up and we have pain, our hamstrings get really tight because we don’t want our pelvis moving very much,” Dr. Taliaferro said. “So, doing hamstring stretches is really important.”
“Then isometric core strengthening is also important,” he said, noting that means “strengthening the abdominal and back muscles without moving the joints of the low back.”
For example, that’s “planks, which everybody hates. No one is super comfortable, but that gets your back muscles strong,” Dr. Taliaferro said. But the key is without moving the joints because the whole goal is to keep you steady.”
Beyond that is “light aerobic activity. When people are actively hurting, the best thing is if you can get into a pool because that takes the weight of gravity off, but allows you to keep moving against resistance,” he explained. “Other ones that are great are yoga and Pilates for the same reasons—it’s a lot of isometric holds and a lot of stretching.
“And that’s been shown to get people a shorter timeframe of pain in this scenario is the quicker return to light aerobic activity,” he added.
Avoid poor lifting techniques
“Always lifting properly is really important, not deadlifting with your back. Instead, soft lifting with your legs, not with your back,” Dr. Taliaferro said. “If you’re lifting a laundry basket off to the side and twisting at the same time, it’s usually a combination of things that provokes this pain or twisting while doing something active.
“It’s the combination that causes this to flare up, but it’s hard to predict because I’ve had people get flareups sneezing,” he added. “We use our back for everything and that's the problem. You use it to sleep, use it to eat, you use it to do anything. There’s never really one thing, but generally the main provocateur is the bad lifting techniques.”
Visit your doctor if pain persists
“Whenever anybody feels uncomfortable, it’s a good idea to visit your doctor,” said Dr. Taliaferro. “I don’t think people need to run to spine surgeons by any stretch of the imagination, but at the same time, whenever someone’s not getting better with routine care—taking an anti-inflammatory over the counter, relax for a few days, stretch, keep aerobic activity going—over a course of a week or two, then that’s the time to involve your physician.”
“Most sciatic cases get better with time, but the caveat to that is numbness, weakness, bowl or bladder dysfunction. That’s never normal, so that’s always when you go in sooner,” he reiterated. “But if nothing is working and it’s still severe, that’s the time to visit your doctor because then we can get a little bit stronger medication and try other things such as injections.”
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