If you develop a pain that starts in your lower back or buttock and radiates down your leg, your problem may be sciatica. Sciatica is the result of nerve root entrapment or irritation, or lumbar radiculopathy syndrome.
Patients with sciatica may also have numbness, “pins and needles” sensation, muscle weakness, and reflex changes. Symptoms may be worsened by twisting, sitting, coughing, or sneezing.
Sciatica is a symptom that is typically caused by a lumbar disc herniation or lumbar spinal canal narrowing (stenosis), resulting in irritation or compression of the affected nerve root. These symptoms can be brought on by wear and tear over time or by an injury causing a rupture or herniation of a disc, when the inner contents (a gel-like nucleus) protrudes through the torn outer ring (annulus) affecting the adjacent nerve roots.
The symptoms of sciatica can be distinguished from low back pain and referred low back pain by the radiation of pain into the buttock and leg and by clinical findings. An estimated 5-10% of patients with low back pain have sciatica.
The majority of patients with sciatica have a favorable outcome with natural resolution of symptoms in several months. However, in contrast to low back pain, some patients with sciatica tend to have more persistent and severe symptoms with prolonged disability.
Patients with sciatica should tell their doctor about the specific duration and character of their symptoms. The doctor will perform a history and physical examination. After appropriate conservative care, x-rays and MRI scans can confirm lumbar nerve root compression.
Conservative treatment is aimed at pain reduction. Initial treatment starts with cold packs or heat, NSAIDs (non-steroidal anti-inflammatory medications), muscle relaxants, and pain medications.
Education about proper mechanics (bending and lifting), physical therapy, and epidural steroid injections may also help patients return to full activity.
Some patients do not respond to nonsurgical care and experience persistent disabling sciatica. These patients may benefit from surgery.
The role of surgery is to remove the disc herniation or stenosis (narrowing of canal) that is pressing on the affected lumbar nerve to ease the leg pain and associated symptoms of numbness and weakness. This decompression surgery does not reliably reduce low back pain.
The timing of surgery is multifactorial, based on the duration and severity of symptoms. There is consensus that a cauda equina syndrome (bladder or bowel paralysis) is an absolute indication for immediate surgery. In general, there is a greater than 90% chance of successful resolution of sciatica after surgery.
The surgery can be performed with a microdiscectomy, laminotomy, laminoplasty, or laminectomy technique as indicated by the need for exposure of the affected nerve roots.
In the recent SPORT clinical study (Spine Patient Outcome Research Trial), a randomized, multi-site trial that the HSS Spine Service participated in, patients who underwent surgery for a lumbar disc herniation achieved greater improvement than non-operative treated patients in relief of sciatica, physical function, and bodily pain.