From lamilano.it
There's a pain that affects many people and is hard to ignore. It starts in the lower back, passes through the buttocks, and travels down the leg in a precise, almost stubborn path, even to the feet. Sometimes it burns, sometimes it stabs, sometimes it feels like an electric shock. It's what is commonly referred to as sciatica. "So-called sciatica (more correctly, lumbosciatica) is one of the most common, yet most misunderstood, spinal conditions," says Luca Proietti, associate professor of Orthopaedics and Traumatology at the Catholic University of the Sacred Heart and director of the Spinal Surgery Unit at the A. Gemelli IRCCS University Hospital in Rome. "The first misunderstanding to clear up is precisely this: sciatica is not a disease, but a signal. It's the body's way of warning you that something is irritating or compressing the sciatic nerve, the longest nerve in our body."
What is sciatica? "To truly understand sciatica, you have to imagine this nerve as a long biological highway that starts in the lumbar region, passes through the pelvis, and runs down the leg to the foot. As long as everything is functioning properly, its work remains invisible. But," explain the Gemelli specialists, "when something interferes (compression at its exit from the spine, inflammation, a narrowing of the spinal space), the nerve 'protests,' and it does so very clearly. The pain traces the path of the nerve fibres with surprising precision, so much so that many patients can pinpoint their exact route."
It is precisely this characteristic that distinguishes sciatica from common back pain. Often, in fact, the most intense pain is not localized in the back (in the lumbar spine), but along the leg. It can begin as a discomfort in the buttock and develop into a sharp pain that travels down the thigh, sometimes to the calf or foot. This—as experts describe—can be accompanied by tingling, numbness, and, in the most severe cases, a feeling of weakness that makes leg movement uncertain and makes walking difficult, reducing walking autonomy. Another distinguishing feature is that "the pain tends to affect only one side of the body, almost as if the nervous system were telling its story from only one direction. But even in this case, there are exceptions, and sciatica can also be bilateral."
The origin of the problem
But if the pain manifests in the leg, the problem often stems elsewhere. In most cases, the cause is in the spine. "It can be linked to a bulging or ruptured intervertebral disc (as in a herniated disc)," explains Proietti, "compressing a nerve root; the same can happen in spondylolisthesis (vertebral instability). In other cases, the progressive narrowing of the spinal canal, perhaps due to osteoarthritis, reduces the space available for the nerves. Scoliosis, too, by causing spinal deformity, can lead to sciatica, which develops slowly over years; its onset is more immediate in cases of vertebral fractures, even pathological ones (related to tumours). There are also situations in which the disorder does not originate in the spine, but rather in muscular structures, as in the case of the piriformis muscle, or from poor daily habits: postures held for too long, repetitive movements, or improperly performed efforts."
Precisely because of this variety of causes, diagnosis cannot be relied on intuition or a search on Doctor Google or Doctor ChatGpt. "Understanding the origin of the pain," Proietti explains, "requires a thorough clinical approach, starting with listening and observation. A specialist examination allows us to assess how the pain is distributed, how the body reacts to movement, and the state of muscle strength and reflexes. Instrumental tests, such as MRI, are an important aid, but they should not be performed immediately: they should only be performed when the clinical picture requires it, to confirm and further investigate what emerges from the specialist medical evaluation or a simple X-ray of the lumbar-sacral spine."
The key word: movement. One of the most surprising and almost paradoxical aspects concerns sciatica treatment. "When the pain is intense," Proietti emphasizes, "the patient's spontaneous reaction is to remain still, to rest completely. Yet, in most cases, prolonged immobility actually worsens the situation. Sciatica tends to improve more easily when the body continues to move, gradually and under supervision (perhaps by a good physical therapist). It's not about forcing, but rather preventing the spine from becoming stiff and the muscles from losing strength and elasticity. This is why physical therapy plays a key role: through targeted exercises, it helps restore balance, mobility, and function. Medications can be useful for controlling pain and inflammation in acute phases, but they alone are not the solution. Recovery requires a broader approach, which also includes correcting daily habits: avoiding sudden movements, alternating positions, and not overloading the back with incorrect movements."
Surgery is only available for the most severe cases. Only in a minority of cases is more invasive treatment necessary. "When pain persists over time (beyond 20-30 days of conservative therapy) despite treatment, or when neurological deficits appear, such as a loss of leg strength detected by electromyography (EMG), surgery may be indicated. Modern techniques, such as minimally invasive micro-discectomy, now allow for targeted intervention, with rapid recovery times and early rehabilitation, allowing for a rapid return to mobility. The procedure is performed through a small incision; with the aid of a surgical microscope, the expelled disc fragment is then identified and removed to free the nerve root. In cases of spinal instability, stabilization procedures are used, using titanium screws and rods (sometimes it is also necessary to replace an intervertebral disc with a titanium support); in this case too, the procedures have become less invasive and more accurate."
And there are also rarer but more serious situations in which the body sends out important warning signals. "The onset of difficulty controlling the bladder or bowel, marked leg weakness, or loss of sensation in specific areas requires immediate evaluation by a spine surgeon, as they may indicate a neurological condition, such as 'cauda syndrome,' which requires urgent treatment."
The importance of a multidisciplinary approach.
Although highly specialized, managing sciatica also requires a multidisciplinary approach, which also helps reduce the risk of complications. "This, we recall, was also the focus of a recent conference we organized at the Gemelli Hospital, 'Complications in Spinal Surgery,' which brought together neurologists and neurosurgeons, vascular surgeons, anesthesiologists, and abdominal surgeons." The future of spinal surgery "inevitably depends on a multidisciplinary approach," emphasizes Giulio Maccauro, full professor of Orthopaedics at the Università Cattolica del Sacro Cuore and director of the Orthopaedics and Traumatology Unit at the Gemelli Hospital. "Collaboration between different specialists today not only improves clinical outcomes, but also prevents and manages complications more effectively. It is precisely with this goal in mind that we have promoted dedicated opportunities for discussion and training, because shared cultural and scientific growth represents one of the most important tools for making treatments increasingly safe, personalized, and innovative."
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