What doctors wish patients knew about sciatica

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 non-operative

“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 

https://www.ama-assn.org/delivering-care/prevention-wellness/what-doctors-wish-patients-knew-about-sciatica 

Myths You Should Stop Believing About Sciatica

From msn.com

If you've ever had something affect your leg, there's a strong likelihood that it could be sciatica. Occurring due to pressure on the sciatic nerve, sciatica may affect up to 5% of all people in any given year, and over a lifetime, there's a 10-40% chance that you experience it, according to research (via StatPearls Publishing). 

And if you've ever had sciatica, you'll have known about it, without a doubt. In addition to symptoms of numbness, tingling, and inflammation, the pain that sciatica causes can be quite serious, and can happen anywhere from your butt down to your hamstring, despite the pressure on the sciatic nerve often happening in relation to your spinal disks (per the Mayo Clinic).

However, due to the varying degrees of severity in terms of symptoms, sciatica can be a pretty mysterious thing to experience, let alone to address. As a result of this, everyone seems to have an opinion about it, as well as the best way to tackle it. So what's the truth about sciatica? And what myths should you stop believing today? We'll lay it all out right here.

Myth: Sciatica Is A Condition In Itself

Perhaps the biggest myth about sciatica is that it's a fully-fledged medical condition. Well, folks, we're here to tell you that's not entirely the case. While sciatica causes distinctive sensations and pain that puts it apart from muscular pain or strain, sciatica is a symptom of another condition, and not a condition in itself, as Medical News Today states. We know, right? Mind fully blown.

The term "sciatica" is more accurately used to describe the pain caused by an impact on the sciatic nerve, which is caused by a root condition (per the Mayo Clinic). Your sciatic nerve can be compressed or pinched by a range of things, typically a spinal condition (like a herniated disc or a bone spur). Other chronic conditions, like diabetes, may also result in nerve damage and sciatica, and tumour growths can also press on the nerve. 

In addition, several risk factors could make your chances of developing sciatica more likely, one of which is simply sitting down for too long (as with a desk job), or if you have a job that's particularly physically impactful or requires lifting heavy loads consecutively.

Myth: Sciatica Is Always Treated The Same Way

A lot of medical issues can be treated in several different ways, and sciatica's no different. As a matter of fact, a treatment option that may work well for one person may not be the best course of action for another, according to Spine-Health. Lifestyle factors (like smoking) or having poorer health overall may mean that traditional treatment pathways could not have as great an impact. While sciatica is generally tackled using a combo of reducing inflammation around the pinched nerve through anti-inflammatory medication and pain relief, surgery can also be used to relieve symptoms in more severe cases.

Furthermore, the efficacy of the treatment that you undergo for sciatica can be affected by other medical and work-related factors, as research published via the National Library of Medicine discusses. Patients that have mental health conditions that accompany their sciatica, as well as individuals who have specific occupations, may find that some treatment pathways are less effective, and could be more likely to experience another bout of symptoms. In these situations, it may be worth discussing alternative treatment options with your doctor.

Myth: You Should Rest When You Have Sciatica

                                                               ©Alexei TM/Shutterstock

Okay, so we admit that this one does make sense. The traditional wisdom is that if you have a medical ailment, especially one that causes pain, then you should rest up until you're better, right? Well, this isn't entirely the case with sciatica. 

The truth is that while initial rest when you have sciatica could provide some relief, taking to bed for extended periods can cause things to get even more painful, as Healthline discusses. One of the reasons for this is that lying down for extended periods can create more pressure on your already-pinched nerve, which then just results in more profound symptoms (per Healthline).

Instead, you should aim to maintain gentle activity when you have sciatica. Try to keep going with your day-to-day life, incorporating some walking into your daily excursions, which can benefit sciatica symptoms and reduce pain (per Spine-Health). Certain stretches may also be helpful for pain relief, particularly ones that focus on your lower back and glutes, as these can increase flexibility in the nerve area and subdue symptoms. Also, make sure that when you're doing simple activities like standing and sitting down, your posture is healthy and your weight is evenly distributed.

Myth: Sciatica Won't Cause Long-Term Problems

For a lot of people, sciatica is not much more than an inconvenient twinge of pain. But be warned, folks: That twinge of pain can grow into something much more profound over time.

While long-term damage is not the usual trajectory for sciatica (which may well clear up on its own over time), in some situations, nerve damage can occur, says the Atlanta Spine Institute. Associated symptoms like incontinence (either with your bladder or your bowel) or numbness through the leg could indicate that your sciatic nerve is experiencing more severe harm.

It's for this reason that you should never ignore your sciatica symptoms, even if they're super mild. Treatment for sciatica pain is usually non-invasive and effective, and working with a doctor or a physical therapist can get you back to full health in no time, using the methods which are right for the specific condition that's causing your issues. It's important to bear in mind that the more you prolong treating your sciatica symptoms, the more likely they are to persist and lead to longer-term issues, as Johns Hopkins Medicine states.

Myth: If Your Parents Have Sciatica, You'll Get It, Too

"It runs in the family." How often have you heard that phrase concerning medical conditions? And if you've ever talked to your parents about your sciatica, chances are you've heard that from them, too. But here's the kicker: While sciatica can be influenced by genetics, it's far from a given that you'll develop it just because your parents did.

The main way that sciatica is predetermined by your heritage is when it's related to your disc health, as Spine-Health discusses. Your genetic structure may determine your likelihood of herniated or degenerated discs, which may then lead to nerve compression and sciatica symptoms. But you're far more likely to develop sciatica because of your general lifestyle and environmental factors, according to research published in the Annals of Medicine, which examined over 2,200 sciatica cases and discussed their causes. In fact, of the patients assessed, over 4 in 5 of them experienced sciatica as a result of factors in their day-to-day lives, with over 90% of hospitalized cases occurring because of lifestyle and environmental reasons. So don't blame your parents, folks. It's (probably) not their fault.

Myth: You Can't Prevent Sciatica

                                                        ©Prostock Studio/Shutterstock

One of the biggest myths out there about sciatica is that it's got a mind of its own, and if you're gonna get it, there's nothing that can stop it. But that's far from the case. 

While we can understand why people may feel that these mysterious symptoms are due to the luck of the draw, sciatica is actually very preventable, says Harvard Health Publishing. One of the main things you can do to keep it at bay is to exercise regularly. Doing aerobic exercises like running or swimming, flexibility workouts like tai chi or yoga, and resistance training can all help to keep your body healthy and reduce the likelihood of developing sciatica.

Working on your abdominals and core muscles (including your hip and back muscles) is also one of the best ways to prevent sciatica symptoms. These are the muscles that keep your spine supported, meaning that you're less likely to develop a spinal condition that leads to nerve compression. Lifestyle factors can also contribute to your likelihood of getting sciatica, like being overweight. It's also helpful to ensure you're maintaining good posture, and to avoid sitting down for way too long.

Myth: Your Sciatica Means You Have Leg Problems

Sciatica frequently announces itself by delivering a constant shooting pain through the hamstring, and as a result, it's very easy to assume that means that there's an issue with your leg. But we're here to put that common assumption to bed. 

Although sciatica does frequently produce leg pain, the root cause of it is less likely to be your leg itself, and far more commonly occurs as a result of a spinal condition, says the Atlanta Spine Institute. Issues like spinal stenosis or tumors around or on the spine may lead to your nerve becoming pinched, as may a slipped vertebrae, also known as spondylolisthesis (per the Cleveland Clinic).

However, that's not to say that the legs are never involved in the development of sciatica. If you have tight hamstrings, they can alter the position of your hips and your spine, resulting in your lower back becoming more susceptible to strain and injury (via Better Health Alaska). This may mean that your spinal discs are more likely to become damaged, leading to a compression of the sciatic nerve -- which, in turn, results in sciatica and the pain that comes with it. It's all connected, people.

Myth: Sciatica's Caused By One Single Trauma

A TV character experiencing back pain is something we've seen time and time again. They try and pick up a sofa, or something similarly heavy, they hear a click or a pop, and the next thing they know, they're sitting in a doctor's surgery, clutching their back. But when it comes to sciatica, it's not as simple as that. 

"People often think if they didn't lift that suitcase, sit on a long flight, or help a friend move they would not have pain," states White Plains Hospital's director of pain management David A. Spinner (via Everyday Health). However, the event that seems to usher in sciatica usually just prompts a problematic disk to herniate, which it was likely to do anyway, Spinner says. So no matter what you did, it would have happened at some point. (Probably time to stop being mad at your friend, then.)

It's worth bearing in mind that certain occupations might put you at greater risk of sciatica, with jobs that require a lot of physical activity like being an industrial worker increasing the likelihood of a herniated disc. Remember, though, that sciatica is common, and while it's easy to blame yourself (or someone else) for experiencing it, the fact that it happens is just, well, a fact of life.

Myth: Once Sciatica's Gone, It Won't Come Back

                                                                       ©Fizkes/Shutterstock

It's the day that a lot of people dream of. They wake up and tentatively roll out of bed, ready to experience that familiar nagging pain. And ... It's gone. Your sciatica's gone -- someone open the champagne! But while you rightly have cause to celebrate when you're finally over your sciatica, you should remember that it's not a one-and-done kinda vibe. 

In the majority of cases, sciatica will clear up within around six weeks, but in some situations, it can come back again, even if you've had treatment for it, says Spine-Health. In fact, research published in Health Technology Assessment indicates that approximately a quarter of people who recover from long-term sciatica experience a recurrence of symptoms several years later. 

It's worth considering, too, that while treatment can be effective for a lot of people, for individuals who have chronic sciatica, their standard course of action may become less helpful over time, and other treatment avenues may have to be considered. Thus, the most important thing to do when it comes to sciatica is to address what's causing it as early as possible, in order to avoid future flare-ups.

Myth: You Should Always Treat Sciatica With Medication

These days, it feels like there's medication for everything, thanks to the wonders of modern science. Surely, this should also be the case for sciatica, right? The truth, however, may surprise you. 

While sciatica can be treated using medication to reduce nerve inflammation and pain, it may not be the best way to tackle it. Research published in BMJ states that it's hard to conclude the true efficacy of treating sciatica with medication, due to the lack of high-quality existing evidence. The National Institute for Health and Care Excellence (NICE) actually recommends steering clear of various types of drugs due to this lack of evidence, plus the potential for withdrawal risk.

So how, then, do you treat sciatica? Well, there are a few different options. For some doctors, medication remains the answer, but it must be administered by a healthcare professional via an injection directly to the nerve (per Spine Universe). Others, however, prefer a physical approach. Physical therapy works to relieve pain and pressure on the nerve, leaving the body to do what it needs to do in order to heal. In some situations, doctors may also recommend surgery, but only if the sciatica is not clearing up on its own.

Myth: Exercise Makes Sciatica Worse

Okay, so we really do get this one -- and anyone who's ever tried to do specific types of exercise when they have sciatica, only to find that it's more painful, will get it too. Surely, if you have sciatica, you shouldn't be exercising at all. That'll just make it more painful. Right?

But no: Exercise can actually help you deal with sciatica significantly. It's all about the type of exercise you do, and how you do it. Exercise improves blood flow to your spine and keeps your muscles healthy. This allows your sciatic nerve to become less compressed, relieving the pain and symptoms and making it less likely for you to experience it in the future (per Spine-Health). 

Just make sure that you're not overdoing any exercise you're taking part in, beginning slowly and working your way up, and prioritizing low-impact workouts that don't impact your spine like cycling or swimming. You'll also want to avoid specific exercises and workout moves like burpees, weighted squats, bent-over rows, and any stretches or poses that involve folding your body forward, as these can put pressure on your sciatic nerve and aggravate symptoms even more (per Healthline).

Myth: You Need Surgery To Treat Sciatica

                                                       ©Create Jobs 51/Shutterstock

For many people, sciatica can not only be persistent, but painful as well. And you might assume that the only thing that will shift your sciatica once and for all is an invasive surgical procedure. We're pleased to say, though, that this isn't the case. In fact, in the vast majority of cases, sciatica can be treated without the need for surgery, with up to 95% of sciatica occurrences clearing up through other care methods combined with a little patience (per the Mayo Clinic).

There are situations, however, in which surgery may be the best choice for you. Sciatica cases that result in particularly severe pain or cause extended periods of weakness in your lower back or legs could necessitate surgical intervention. Surgery may also be required if you have incontinence that accompanies your sciatica. You may also need surgery if your sciatica is being caused by pressure on the nerve from a spinal disc. 

Fortunately, in a lot of cases, the surgeries that people need on their discs don't take long. If you find yourself needing to undergo such a procedure, you'll likely be out of the hospital in no time.

Myth: If Your Sciatica Causes Hamstring Pain, You Should Stretch It

One of the wildest things about sciatica is how it can cause pain pretty much anywhere down your leg, but this can also lead to people trying treatment options that may not work for them. This is often the case when the pain that your sciatica causes is in your hamstring. Although lurching into a good old hamstring stretch might seem like the logical thing to do, it could do more harm than good, as the Paddington Clinic Brisbane explains. The position of many hamstring stretches, which involve folding your body over your legs, can create significant pressure on your sciatic nerve and further exacerbate your pain.

This may also occur if you're incorporating downward-facing dog poses into a yoga flow, as this position can inflame the nerve. Instead, it's better to try and focus on stretching the lower back, hips, and buttocks. Try starting with a simple full back stretch. Lie on your back on a yoga mat, with your knees bent and your feet planted on the floor. Then, bring your knees up and tuck them into your chest, bringing your arms up to wrap around them, and let your lower back relax (meaning don't attempt to "crack" your spine).

Myth: Your Sciatica Will Never Go Away

                                                                      ©Fizkes/Shutterstock

While sciatica clears up relatively quickly for some people, for others, it can be quite persistent. And if you've been living with sciatica for a while (or if you know someone who has been), you might think that once you have it, it's something you're stuck with forever. This is a common misconception, states Texas Back Institute's orthopedic spine surgeon Stephen Tolhurst (via Everyday Health). "I commonly hear patients worry that there is no cure or that nothing can be done to improve their symptoms. I also hear patients worry that surgical treatment might not be successful," he says.

Fortunately, it's not true. Sciatica can -- and oftentimes will -- clear up without incident. As Tolhurst says, studies have repeatedly shown that the majority of the time, sciatica will get better. And those people who don't see an improvement with non-surgical treatments should be encouraged by the fact that if surgery is required, it's usually quite effective at clearing up the problem. So have faith, folks: This, too, shall pass.

https://www.msn.com/en-us/health/other/myths-you-should-stop-believing-about-sciatica/ss-AA1IFmUX

How to manage your sciatic pain

From cuh.nhs.uk

The good news is that 90% of people with sciatica will be better within three months. The most important thing you can do to help manage your sciatic pain is to stop the nerve being irritated, thereby allowing your body to heal itself. You will know when the nerve is not being irritated as you will not feel your leg pain. You need to be guided by your symptoms.

The main things you can address to help your symptoms are:

1. Maintain good posture.
2. Pace your activities.
3. Use medication.
4. Use ice or heat packs.
5. Sleep well.
6. Look after your general health and wellbeing.
7. Seek medical advice.
8. 
   

As unpleasant as sciatica is, it is not a medical emergency. However, you should seek urgent medical advice should you experience any of the following:

• altered sensation around your genital area
• difficulty passing or controlling urine
• numbness, pins and needles or weakness in both legs
• unsteadiness on your feet

1. Maintain good posture

It is important to minimise the pressure on your lumbar spine which will decrease the amount your nerve is irritated. To do this maintain your natural lumbar curve, by sitting up tall, and avoid slouching as this puts 10 times more pressure through your back than lying. Often when your sciatica is severe you will find reaching forward, bending and sitting painful, and are better standing or lying.

2. Pace your activities

Changing what you are doing, and your position, will mean that your symptoms are not aggravated as much. Whilst your symptoms may feel better lying down it is important to get up and move regularly as this will:

• allow you to heal more quickly
• prevents you from stiffening up
• prevents your muscles wasting.

We generally recommend no more than three days in bed.

You may need time off work if you are unable to do any activity for more than a few minutes in the early stages of severe sciatica. If you find yourself in this situation we recommend that you discuss this with your GP and/or therapist. It is important to try and return to normal activities as quickly as possible. You may need to consider a fit for work certificate, which indicates what you can do, and also a phased return to work.

3. Use medication

The use of medication needs to be discussed with your GP and/or pharmacist. Sciatica literally means your sciatic nerve is inflamed. As a result if you are able to take anti-inflammatory medications such as Naproxen or Diclofenac these may be helpful. However, these can cause heartburn or stomach problems; if you experience these, please consult your GP.

There are also other medications that were not invented as painkillers, but have been found to be very useful to treat nerve pain such as Amitriptyline and/or Gabapentin. Amitriptyline in particular seems to promote good sleep and is often prescribed to take at night-time to help with sleep disturbance.

If you are suffering with significant muscle spasm there are medications that can be prescribed for a few days to help. It is important that if you are prescribed medication, you take it if needed as it will keep you moving.

These medications do not mask your symptoms but treat them.

4. Use ice or heat packs

Whilst it would seem that ice packs would be helpful to treat inflammation, some people find that heat is more effective for them as this can relieve muscle spasm. If you use either, please ensure the sensation in your back is normal. Wrapping a damp towel around a bag of frozen peas works as well as an ice pack. A hot water bottle is also an effective heat pack. Alternatively you can buy both from pharmacies.

5. Sleep well

It is extremely important to sleep well as your body releases its growth hormone ‘repair factor’ (when your body heals itself) during sleep. Poor sleep has even been found to cause back pain. Sleep is often disturbed by pain, and therefore ensuring that all factors that can affect sleep are addressed is important (caffeine, noise, light, anxieties, mattress, pillows, temperature and so on). Sometimes it is necessary to take medication to help you sleep whilst you have sciatica and people often find that the nerve medication helps with this.

6. Look after your general health and wellbeing

Looking after your general health gives your body the best chance to heal itself. The fitter you are, the stronger your body is, and, with a better blood supply, your body can focus on healing your sciatica. If you are very stressed and/or depressed this will impair your body’s ability to heal itself.

7. Seek appropriate medical advice

If you are suffering with sciatica we recommend that you consult your GP for appropriate advice, where pain medication can be prescribed as necessary. Your GP may also feel that you would benefit from physiotherapy. A physiotherapist can advise you on how to manage your condition, recommend exercises and use manual therapy techniques to help speed up your recovery.

If your symptoms fail to improve with medication, advice and physiotherapy, it may be appropriate to see a specialist for a further opinion. Your physiotherapist can advise you about this. You might benefit from an epidural which is a steroid injection into the space next to where your nerves are irritated. Occasionally, when there is an identifiable cause to your symptoms which have not responded to other treatments surgery might be required.

https://www.cuh.nhs.uk/patient-information/sciatica/ 

Antidepressants show little to no benefit for low back pain and sciatica

From australianpharmacist.com.au

Around 4 million Australians (16% of the population) are living with back problems, with about 4 out of 5 people experiencing low back pain at some point in their lives.

Antidepressants are widely prescribed for low back pain and sciatica, with up to one in seven Australians with low back pain dispensed an antidepressant – most commonly the tricyclic antidepressant amitriptyline.

However, there is inconsistency across international clinical guidelines around their use for this indication, said Michael Ferraro, lead author of a review into Antidepressants for low back pain and spine‐related leg pain and Doctoral candidate at the Centre for Pain IMPACT, NeuRA, and the School of Health Sciences UNSW.

‘The general thought was that they might be useful in some patients,’ he said. ‘At an individual prescriber level, clinicians are more likely to prescribe an antidepressant as a second-line treatment, particularly where there might be issues with sleep or mood.’

The review looked at the effects of any antidepressant class  – including serotonin–norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants – on low back pain or spine-related leg pain (encompassing full nerve compression or referred pain into the leg). 

While not all patients with low back pain have spine-related leg pain, those who do generally have worse pain and poorer long-term outcomes, Mr Ferraro said.

‘These medicines are very widely used clinically for sciatica, but there’s barely any trial evidence to inform their use,’ he said.

One class of antidepressant is beneficial for low back pain

The main outcomes of the review were impacts on patient-reported pain intensity, adverse events and function 3 months after initiation of treatment – enough time for the medicine to have a therapeutic effect.

The review is an update of an older Cochrane review, published in 2008, with the newer review incorporating results from industry-sponsored trials that tested the SNRI duloxetine. 

‘Those trials, which were run across multiple international sites and recruited large patient populations, focused on low back pain patients,’ Mr Ferraro said. 

While the review found that only SNRIs were effective over placebo for low back pain intensity, this effect was marginal.

‘When we think about the average effect in the patients that received an SNRI versus those who received the placebo, there was only a difference of around five points out of 100,’ he said.

‘That’s what we would consider small, and it might even be so small that it’s not really a benefit that your average patient would appreciate.’

Another antidepressant helps for disability

While the evidence is uncertain on the impact of SSRIs for low back pain or spine-related pain, tricyclic antidepressants were found to have no effect on pain.

However, there was one unexpected benefit unearthed.

‘They had a small effect on disability,’ Mr Ferraro said. ‘Normally we would expect any effects on disability to be mediated via pain, so that was a little surprising.’

But to demonstrate clinical benefit, there should be evidence of effects on both pain and disability, he said.

Antidepressants probably do more harm than good in back pain

The review found a lack of evidence to determine whether use of SSRIs and tricyclic antidepressants for low back pain and spine-related leg pain lead to adverse events.

However, there was an increased risk of experiencing any adverse event when using SNRIs.

‘While we didn’t look at adverse events formally, nausea, dry mouth and dizziness  –  the typical effects you’d have with an antidepressant – would be the ones that are most likely,’ Mr Ferraro said.

The next step for the research team is further investigation into the effects of SNRIs for spine-related leg pain.

‘Members of the author team are about to commence recruitment for a randomised trial of duloxetine for spine-related leg pain or sciatica, Mr Ferraro said. ‘That will be a critical study, as it will be large enough to fill the evidence gap we identified.’

Should antidepressants still be prescribed for this indication?

Cessation of antidepressants, including tapering too quickly, can come with withdrawal effects. So should patients be initiated on a treatment that could have little or no benefit, with the potential for adverse events down the line?

‘None of the trials we included in the review actually assessed adverse events after the treatment had ceased, so that’s a really key research item that must be addressed in the future,’ Mr Ferraro said.

However, when prescribing or dispensing antidepressants for low back pain or sciatica, it’s important to point patients to evidence that the benefits, on average, are small and may not be appreciable.

‘[Pharmacists and GPs] should explain that there’s a risk of side effects – and extrapolating from other data sources – that some of those effects may be related to tapering an antidepressant if it’s not effective.’

Pharmacists are also advised to check in with patients to see how they are coping with their pain.

‘The evidence we included found a benefit [of SNRIs] within 14 weeks, after a course of 2–3 months,’ he said. ‘So if there’s no benefit within the first 3 months, it would be critical to have a discussion with the pharmacist and then the GP.’

What are the alternative treatment options?

In terms of pharmacological treatments, the Australian Commission on Safety and Quality in Health Care’s Low Back Pain Clinical Care Standard recommends non-steroidal anti-inflammatory drugs (NSAIDs) for patients with low back pain who are at low risk of NSAID-related harm.

Along with antidepressants, anticonvulsants and benzodiazepines should generally be avoided – with the risks outweighing the benefits and little evidence for their effectiveness. Opioid analgesics should only be considered in carefully selected patients, using the lowest effective dose for the shortest possible duration.

Overall, medicines should be used judiciously, with physical and psychological interventions recommended first line to improve function.

https://www.australianpharmacist.com.au/antidepressants-show-little-to-no-benefit-for-low-back-pain-and-sciatica/ 

What doctors wish patients knew about sciatica

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.”

https://www.ama-assn.org/delivering-care/public-health/what-doctors-wish-patients-knew-about-sciatica