Common Degenerative Conditions of Low Back: Sciatica
Sciatica refers to leg pain and may also include other symptoms such as numbness, tingling, burning, and/or weakness. Classically, symptoms start in the lower back and radiate down the back of leg along the course of the sciatic nerve. The sciatic nerve is the largest nerve in the body and originates along the lumbosacral spine and distributes down the leg into the calf, ankle and foot. Symptoms associated with sciatica can range from mild and intermittent to severe, unremitting and constant. The specific location(s) of pain is largely dependent on where the sciatic nerve is pinched.
Sciatica is not considered a diagnosis, but rather a symptom of an underlying low back (lumbar) condition. Sciatica most commonly occurs in 45 to 64 year olds (1). While sciatica can be caused by a traumatic (injury) event, it tends to develop gradually over time. The most common underlying causes of sciatica include a lumbar disc herniation, a bulging disc, degenerative disc disease, spondylolisthesis, and lumbar spinal stenosis. Additional causes include a spinal infection, tumor, and pregnancy. Environmental factors account for a large majority of cases sciatica, but there also may be genetic component. Age, gender, obesity, smoking, occupation, and health status have been identified as risk factors for sciatica.
Based on results from a systematic review, approximately 75% of patients diagnosed with acute sciatica improved in 4 weeks (2). Other specific studies have found 60% – 87% improved within 3 months (3,4) .
The diagnosis is usually made by obtaining a thorough patient history and physical examination. Diagnostic testing may be warranted based on exam findings, concerns for other underlying disease, or after trying nonsurgical treatment for a select period of time with limited improvement (usually up to 6 weeks). As noted above, the majority of those who develop an acute episode of sciatica improve within a few weeks up to a few months. Standard nonsurgical treatment options may include activity modification, physical therapy, corticosteroid or epidural steroid injections, and non-steroidal anti-inflammatory medications. Analgesic medication and muscle relaxers may be prescribed in the early phases of sciatica to alleviate pain and spams. Additional treatments for sciatica that fall under the umbrella of complementary medicine include chiropractic adjustments, acupuncture, massage, cognitive therapy, herbal medicines and supplements. Despite the increasing wide use of some of these treatments, evidence for effectiveness is lacking or conflicting in the literature. Additionally, stem cell therapies are being marketed as an alternative treatment of sciatica and other back disorders. While this appears promising, there is not a clear understanding of how stem cell therapy works and there is no long term data on effectiveness or safety.
Most patients will improve without needing surgery. In cases where there is loss of bowel or bladder control due to a lumbar condition (cauda equina), tumor, infection, progressive weakness, or symptoms worsen despite exhausting all nonsurgical options, surgery may be indicated. While one multi-center randomized trial showed that patients who underwent early microdiscectomy had faster leg pain relief than the non-surgical treatment group, however at one year there was no significant differences between the groups in regards to perceived recovery (5).
Depending on the specific underlying cause of the sciatica, the most common surgical approaches include a lumbar discectomy, laminotomy, or laminectomy. In some cases, a microdiscectomy or minimally invasive approach can be utilized to remove a herniated disc or remove bony pressure off of the affected nerve(s). Success rates approach 95% in a properly selected patient. Other approaches including laser spine surgery are being advertised as a minimally invasive alternative to traditional surgery, but there is very limited data in the literature supporting its effectiveness or safety for most spinal conditions (6,7,8).
At ShimSpine our approach focuses on providing the patient with a clear understanding of the problem and offer treatments including surgery (when appropriate) that have a high rate of clinical success and patient satisfaction and are supported in the medical literature.
- Miranda H, Viikari-Juntera E, Martikainen R, Takala E, Riihimaki H. Individual factors, occupational loading, and physical exercise as predictors of sciatic pain. Spine 2002; 27:1102-1109.
- Vroomen PC, de Krom MC, Slofstra PD, Knotternus JA. Conservative treatment of sciatica: a systematic review. J Spinal Dis 2000; 13: 463-469.
- Weber H, Holme I, Amlie E. The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam. Spine 1993 Sept 1; 18(11): 1433-1438.
- Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA. Lack of effective of bed rest for sciatica. N Engl J Med. 1999 Feb 11; 340(6): 418-423.
- Paul WC. N Engl J Med. 2007 May 31; 356: 2245-2256.
- Singh V, Manchikanti L, Calodney AK, Staats PS et al. Percutaneous lumbar laser disc decompression: an update of current evidence. Pain Physician 2013 Apr; 16(2 Suppl):SE229-260.
- Quirno M, Vira S, Errico T. Current evidence of minimally invasive spine surgery in the treatment of lumbar disc herniations. Bull Hosp Jt Dis 2016 Mar; 74(1): 88-97.
- Jo D, Lee DJ. The extent of tissue damage in the epidural space by Ho / YAG laser during epiduroscopic laser neural decompression. Pain Physician 2016 Jan; 19(1): E209214.