Sciatica is term used to describe pain that travels down the leg from the lower back or buttock. It is a type of nerve pain commonly caused by pressure on the nerves in the back by a disc bulge/ herniation (slipped disc).
Symptoms.Most patients complain of a sharp, burning, electric shock like pain in one or both legs and back pain/ stiffness. This is often accompanied by tingling sensation, numbness and/or leg weakness. Movement, coughing and sneezing may intensify the pain.
Treatment
Pain management specialists focus on holistic management and use a combination of injections, medication and physiotherapy in most cases. Injections are safe, effective, non-surgical interventions and the options include nerve root blocks and epidurals.
Injections for Sciatica/ Slipped Disc
These involve placing needles under x-ray guidance, close to the site of actual problem. Once in the correct place, a mixture of medicines is injected to reduce the pain and inflammation. The resulting pain relief is generally quicker and can be long lasting, giving time to patients to to engage in physiotherapy and strengthen the supporting muscles. Asthese injections deliver the medication close to the problem site, more drug reaches where it is required thereby increasing the chances of successfully reducing the leg and back pain
Pain, no matter how trivial, is an unwelcome guest. It can be associated with undue suffering and disability which everyone would like to avoid. It is helpful to understand the types of pain one may experience. Pain can be categorized as acute or chronic pain.
Acute pain is the pain that is present after an injury until healing occurs. Pain in this situation is a protective response bringing our attention to the affected area and helping us protect, rest the affected tissue providing an opportunity for healing. As the tissue heals, the pain gradually abates.
Chronic or persisting pain is pain that persists even after the usual time required for healing. It is important to understand that chronic pain does not always signify on-going damage. Nerves have a memory (plasticity in medical terms) whereby they develop changes that remain even after the original inciting problem is corrected. A simple example to explain this is persisting leg pain even after the amputation of the affected part. There are numerous mechanisms to explain this and your doctor can help you understand these better.
The impact ofchronic pain is not limited to the involved person but also affects their loved ones and family members. The longer it persists the more chances that it will have an impact on multiple aspects of your life including your ability to work, sleeping pattern, mood, social life, relationship with family and friends, etc. Hence it is important to take corrective measures to reverse or control the condition as soon as possible.
The management varies depending on the actual pathology, severity, comorbidities, patient preferences, available resources/ expertise, and many other factors. At your first consultation with me, you can expect a detailed assessment including history, examination, and review of investigations. This is aimed at identifying the underlying reason for pain so that an appropriate personalized management plan can be made. Some more tests may be requested as necessary. Close liaison with specialists in other fields such as neurology and surgery is maintained to formulate the best plan tailored to your condition and requirements. Some of the common pain treatment modalities include:
Medical management
I normally review your current medications and any existing medical problems prior to suggesting new medications or changes to current medications. Therefore it is a good idea to carry a detailed list of your medications and make of list of the ones you may have tried previously. Doses of medications tried previously are equally important as some medications if not used in the right doses for the required duration are unlikely to be effective.
Different types of pain may need treatment with different medications, for example pain of inflammatory origin maybe be effectively managed with anti-inflammatory medication and pain due to irritation of nerve may need medication which helps to desensitize the nerves. Hence the importance of identifying the likely pain generators prior to prescribing medications.
Interventional procedures
In certain situations, I suggest procedures such as
Injections/ radiofrequency procedures that help to reduce the pain signals being transmitted by the nerves to your brain
Injections directly into a joint space/ around the area of problem such as a tendon or bursa which can help reduce the inflammation more effectively than medications taken orally. These procedures along with being therapeutic may also help the consultant confirm the diagnosis
Regenerative medicine has opened new avenues where cells from your body are used to promote healing and reduce pain. Awareness of options such as Platelet-Rich Plasma (PRP) and stem cells is increasing and new research in this area is improving our understanding day by day.
Some interventional procedures can be done in the outpatient setting, whereas others will require a day case admission. This depends on the procedure being performed and your general health, other medical problems. We aim to reduce your pain as much as possible by offering you most appropriate interventions keeping your goals and preferences in mind and with an integrated multi-specialty team approach based on the biopsychosocial model of pain you have the best chances of managing your pain.
Role of Physiotherapy
There are few common elements in management of mostchronic painsituations like weakness accompanied by disuse of affected part for long time will require gradual mobilization and strengthening. A good chronic pain physiotherapist offers more than physiotherapy. They play an important role in
Patient education regarding their condition, do’s and don’ts specific to their condition,
Setting realistic goals-dividing exercises into smaller achievable steps
Help patients understand and implement pacing of activities
Promoting compliance, increasing confidence and making you self reliant
Challenging your unhelpful thoughts, mitigating any false believes and minimising catastrophisation
Role of Psychology
Chronic pain can generate significant distress, anxiety and depression and all these, in turn, can magnify perceived pain. This is a normal human reaction which is often more visible to friends and family. Addressing these factors can help in reducing perceived pain and in improving quality of life. Psychologists can help you by challenging maladaptive beliefs, attitudes and emotions. They can help by
Teaching coping and self-help strategies
Relaxation techniques- these can be a useful tool especially in dealing with sleep disturbances and periods of increased pain
Sciatica is term used to describe pain that travels (radiates) down the leg from the lower back or buttock. It is a type of nerve pain and a number of cases are caused by pressure on the nerves due to disc bulge in the low back. This is most commonly seen in middle-aged adults and men are more susceptible. The term sciatica originated from the sciatic nerve, which is the single largest nerve in our body. This nerve is responsible for a significant proportion of leg sensation and movement. Sciatica represents pain in the area supplied by the sciatic nerve.
Radicular pain/ radiculopathy are medical terms which doctors use when describing this condition. There are numerous reasons for having leg pain and every leg pain is not sciatica. Commonly people misinterpret sciatica as a disease and need to be explained that it is a symptom of the underlying problem.
2. What are symptoms of sciatica?
The severity and symptoms many vary considerably. In severe cases the affected individual may find it difficult to walk or even stand up straight.
Some of the commonly observed symptoms include
Sharp, burning, stinging, shooting, electric shock or cramps like pain in one or both legs often as far down as the foot. Movement, coughing and sneezing can intensify the pain
Tingling, pins and needles and/or numbness in leg or foot
Muscle weakness with difficulty in weight bearing or walking.
Buttock/low back pain and stiffness.
3. What causes sciatica?
Disc herniation:Spine is formed of many bones called vertebrae arranged one above the other. In between these vertebrae are discs, which are like cushions or shock absorbers. The discs are made up of an outer tough substance and an inner soft jelly like substance. Herniation of the disc can occur if there is splitting or crack in the outer layers allowing the inner jelly like substance to protrude through the crack. This can cause inflammation and compression of the nerve roots in the vertebral column. Slipped disc is a commonly used term for this condition. There is an increased susceptibility to disc herniation as we age because the soft, jelly like substance dries out and shrinks with time, making the disc more fragile.
Spinal stenosis:Stenosis means narrowing. The narrowing can be of the central canal of the spine or the passageways/ tunnels from which the nerves exit the spine. Besides disc problems, arthritis of the spinal joints or thickening of ligaments can also cause/ contribute to the narrowing.
Spondylolisthesis:In this condition there is a problem with the alignment of vertebrae, where one vertebra is more forward or backwards, which can narrow the spaces for nerves and produce sciatica as a result.
Piriformis syndrome:In this condition piriformis muscle in the pelvis is responsible for pressure on sciatic nerve.
Trauma/ fractures
Spinal tumors and infectionsare rare causes of sciatica
4. Can it resolve on its own?
Fortunately most cases of sciatica resolve within a period of weeks to months with conservative treatment. Specialist input and treatment can help. Painkillers, heat or cold pack, altered activity levels and physical therapy may be suggested depending on your condition. An injection of steroids into the epidural space within the spine can provide short-term pain relief in sciatica. Persistent pain can lead to changes in the nerves (referred to as plasticity). This can be a source of persistent pain even if the original inciting event is resolved … hence the importance of managing these sooner than later.
Having seen numerous cases over the years, I would say that it is not easy to predict the course. It can resolve but to what extend depends on numerous factors- some are modifiable and others are not. The recovery period varies from individual to individual.
5. What are the warning signs I need to be watch for?
Some symptoms point towards a serious problem and require urgent medical attention. Ignoring these could lead to permanent nerve damage. Some of these include
Loss of urinary control/ inability to pass urine
Loss of control over stools
Numbness around the bottom
Worsening leg weakness / loss of control
6. What can I do to reduce my risk of having sciatica?
Though it’s not possible to completely eliminate the risk of sciatica, however adopting a healthy life style can help in reducing the risk. This includes
Giving up smoking
Regular exercises
Right posture and work ergonomics
Healthy diet and maintaining weight in the normal range
Using proper manual handling techniques while lifting to avoid back injury
Stress Management
7. What investigations are generally considered for sciatica?
Your doctor may request for investigations such as magnetic resonance imaging (MRI) scan and blood tests. Sometimes computerized tomography (CT) scans may also be required. X-rays are not as helpful and they can provide only limited information.
Bulging discs on an MRI scan are not an uncommon finding. It is important not to get fixated on the MRI findings. A bulging disc is not permanent and can reverse. The investigation results should be interpreted in combination with patient history, examination findings to assess their significance.A number of patients with severe MRI findings may be asymptomatic and vice versa.
8. What are the other treatment options?
Sciatica is different from common ailments we all suffer and hence taking professional help is recommended. Your doctor can help to confirm that you have sciatica and help identify the cause. A range of different options- non surgical (such as injections- nerve root blocks, epidurals, piriformis injection etc) or surgical may be considered. There is no one solution for sciatica pain and the options are numerous – some with good evidence and others with not so robust evidence.
Generally a multimodal multidisciplinary approach is preferred as this helps in addressing not only the pain but also the impact of pain on one’s life. I ensure that the patient understands the nature or problem and the do’s and don’ts. Time spent in explaining the conditions and the expected course goes a long way in fostering realistic expectations. I generally use a combination of the modalities mentioned below to enhance the chances of quicker recovery.
Pain relief: Pain reduction achieved by medicines help to maintain activity and improves physiotherapy compliance. The medications used depend on the type and severity of pain, duration of symptoms and individual factors such as co morbidities and allergies. Some of the commonly prescribed pain killers include
Non steroidal anti-inflammatory drugs (NSAIDs) This includes drugs such as DIclofenac, Naproxen, Aceclofenac, Ibuprofen etc. NSAIDs are prescribed to reduce the pain and inflammation during periods of acute sciatica although the evidence supporting their use is not very robust. The risk benefit ratio needs to be evaluated while prescribing any drugs.
Neuropathic pain killers This group includes antidepressants and anticonvulsants both of which are well known painkillers for nerve pain. It generally takes a few weeks for the full effects of these drugs to become apparent. Effects such as reduced anxiety and sedation can be used beneficially by tailored selection to suit individual patients. Their use is supported by the NICE guidelines, UK.
Opioids Weak opioids such as tramadol are often prescribed during pain flare up episodes. It is a good practice to be aware of the side effects of a medicine prior to using it.
Muscle relaxants These are used for short duration to relieve any muscle spasm contributing to the back pain.
Spinal Injections:
The use of epidural steroids/ Nerve root blocks has been shown to have beneficial improvements in leg pain and disability scores in short term. Steroids help by their anti-inflammatory and analgesic (pain relieving) effect. Epidural steroids are preferred to oral steroids as they are given close to site of actual problem and have less adverse effects.
Physiotherapy:
Physiotherapy is an essential component of sciatica treatment. Your physiotherapist can help with posture advice, do’s and don’ts relevant to your condition, understanding the concept of pacing of activities, setting practical goals, teaching strengthening exercises for core, leg muscles and manual handling techniques.
Surgery:
If a combination of above fails to provide adequate relief then surgical options such as discectomy (operation to remove bulging part of the disc or separated disc fragments) and microdiscectomy can be considered for sciatica resulting from disc bulge. Surgical options will vary depending on the cause of sciatica and sometimes may be the first choice, depending on the actual pathology and its severity.
