Let’s dive into five causes of sciatic pain! In this article, we’ll look into five musculoskeletal conditions leading to Sciatica: Disc Injury, Spinal Stenosis, Degenerative Disc Disease, Peripheral Nerve Entrapment, and Cauda Equina Syndrome.
We’ll also discuss the symptoms and treatment options available to help you to manage this condition effectively. This article offers information on different conditions but diagnosis of the cause of sciatic pain should be performed by a qualified professional.
Sciatica, a condition characterized by pain, numbness, and weakness along the sciatic nerve (from the low back, into the glute and along the back of the thigh and lower leg to the foot), affects a significant amount of the population.
According to the American Academy of Orthopaedic Surgeons, around 40% of individuals will experience sciatica at some point in their lives (American Academy of Orthopaedic Surgeons, n.d.).
In This Article:
Sciatica Symptoms
Sciatica manifests with several hallmark symptoms, including:
Radiating pain from the lower back or buttocks down the leg
Numbness or tingling sensation along the affected leg
Weakness or difficulty moving the leg or foot
Pain aggravated by coughing, sneezing, or prolonged sitting or standing
Emergency medical referral: for sudden onset of severe lower back pain, neurological deficits such as bilateral leg weakness or numbness around the buttock and groin (saddle anesthesia), new onset of urinary or fecal incontinence, progressive neurological symptoms, recent spinal trauma, or signs of spinal cord compression.
Understanding the Causes of Sciatica
Sciatica can stem from various underlying conditions, each contributing to nerve compression or irritation. Here are some of the primary causes:
1. Disc Herniation (with radiculopathy)
General Features:
Disc lesions with radiculopathy (pinching of the nerve root) involve nerve root irritation and/or spinal cord compression typically due to disc herniation (bulging). The severity varies based on the extent of herniation:
Disc protrusion: intact inner nucleus, thinned outer annular fibers (lots of pain, less neuro signs)
Disc extrusion: annular fibers rupture, some nucleus extrudes (may show radicular signs)
Sequestration: nucleus fully herniated beyond annulus (more neuro signs, less pain)
These conditions usually occur between ages 30-50, and are more common in males. The most frequent sites are L5-S1 and L4-L5 discs, often postero-lateral bulges.
Important History Questions:
During your assessment, you might be questioned about any previous low back pain episodes, particularly if they were caused by events like lifting heavy objects. Additionally, you’ll be asked to describe the type of pain you experienced, such as whether it was sharp, shooting, or following a specific dermatomal pattern.
You’ll also be asked if you have experienced any numbness, muscle weakness, changes in bowel or bladder function, leg pain that extends past the knee, or if bending forward, coughing, or sneezing worsens the pain. Lastly, you may be asked if lying down with your knees bent provides any relief from the pain.
Signs and Symptoms:
Manifestations include sudden onset of Lower back Pain (LBP), potential leg pain past the knee, and dermatomal-patterned sharp pain. Numbness over the affected dermatome and pain exacerbation with coughing, sneezing, or bending forward are common.
If you're feeling some discomfort, just lie down with your knees bent. You might also want to lean away from the side that's giving you trouble. You can tell if your muscles are weak by walking heel-to-toe or doing a muscle test.
Sciatica Treatment - Disc Herniation (with radiculopathy)
The management approach for sciatica due to disc herniation involves various strategies aimed at centralising and controlling pain while addressing inflammation. Rehabilitation techniques such as McKenzie extension/flexion, ice application for 20 minutes every hour during the initial 48 hours, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and Bowens release can be beneficial.
Additionally, Chiropractic adjustments like flexion distraction, side posture manipulation (with minimal rotation), and patient education on pain-relieving postures, including bracing during coughing or sneezing, and proper methods for getting up from bed or a chair, are essential.
Lifestyle modifications, such as weight management and staying active, along with nutritional guidance, should be introduced after the acute phase. Correcting other spinal biomechanics and implementing core stability and lumbar stabilisation protocols further contribute to effective management.
2. Spinal Stenosis
General Features:
Spinal stenosis commonly affects individuals in their 50s or older, with a higher occurrence in males. It involves compression of the spinal canal contents, potentially causing neural compression. Disc protrusion or narrowed spinal canal from various causes like congenital defects, disc degeneration, ligament thickening, or bony protrusions and facet hypertrophy can also contribute to stenosis. Neurogenic claudication (pain with standing or walking), characterised by lower extremity pain due to cauda equina compression rather than muscle ischemia, is a key diagnostic term.
Important History Questions:
You might be asked if the pain is worsened by exercise and relieved by rest, if there is bilateral leg pain, or a history of vascular issues, especially in the legs. You’ll also be asked about pain patterns, such as if you experience relief with bending forward and aggravation with bending backward.
Signs and Symptoms:
Symptoms often include back pain with claudication or sciatic-type leg pain, worsened upon standing but relieved by lying or sitting. Walking short distances may lead to calf cramping and pain, progressing to unbearable pain and numbness.
Walking may become unsteady, but activities like biking can be easier due to the canal opening. Uphill walking might be more comfortable than downhill. Patients often adopt a flexed forward posture to alleviate pressure.
Sciatica Treatment - Spinal Stenosis
Treatment for spinal stenosis is tailored to address its underlying cause and specific type. Emphasizing forward bending exercises is crucial as they reduce lumbar lordosis and minimize stress on the spine, while extension movements should be avoided to prevent increased of symptoms.
Chiropractic manipulations such as flexion adjustments like Side lying (BLR) flexion/flexion and flexion distraction techniques can be beneficial. During acute flare-ups, NSAIDs can help manage pain.
Rehabilitation focusing on core body strength, starting with the spine slightly flexed, is important for long-term management. If symptoms persist despite conservative care, a referral for surgical evaluation may be necessary.
3. Degenerative Disc Disease
General Features:
In degenerative disc disease, the intervertebral discs lose their water content and elasticity, becoming thinner and less resilient. As a result, they may bulge, herniate, or develop tears, causing symptoms such as chronic lower back pain, stiffness, and reduced mobility. The degeneration of these discs can also lead to other spinal conditions, including spinal stenosis.
Important History Questions:
You may be asked if the pain is worsened by exercise and relieved by rest if there is bilateral leg pain. You’ll also be asked about pain patterns, such as recurring low-grade pain and discomfort, pain after activity, or if you experience relief with flexion and aggravation with extension.
Signs and Symptoms:
Symptoms often include a slowly developing dull, achy joint pain following activity, morning stiffness. Back pain with walking or sciatic-type leg pain, worsened upon standing but relieved by lying or sitting. Pain relieved with rest and decreased range of motion (unable to tie their shoes)
Sciatica Treatment - Degenerative Disc Disease
Management of lumbar spinal stenosis from degenerative disc disease involves prioritizing rest positions that minimize patients' symptoms, as the condition can only provide symptomatic relief rather than a cure.
Heat therapy is often effective in alleviating discomfort, along with NSAIDs for pain management.
Chiropractic techniques can be used as tolerated, with adjustments made to accommodate a reduced range of motion. Remedial massage therapy can help alleviate muscle tension. Stretching exercises targeting tight hip flexors and erectors, using techniques like piriformis release or passive stretching, are beneficial.
Improving diet, incorporating supplements like glucosamine, and increasing activity levels with a focus on aerobic and cardiovascular fitness are recommended. Patient education on postural changes is also important for long-term management.
4. Piriformis Syndrome
General Features:
Piriformis syndrome involves irritation or compression of the sciatic nerve as it passes near or through the piriformis muscle. While the sciatic nerve typically runs under the muscle, in 15% of people, it may run between two muscle bellies, increasing the risk of piriformis syndrome. Patients often report buttock and posterior leg pain, typically without trauma but can occur due to strain or overuse.
Important History Questions:
Key questions include tracing the pain distribution along the sciatic nerve and identifying any specific positions that trigger or exacerbate symptoms, such as sitting cross legged or on a wallet. While the condition is often non-traumatic, you’ll be asked about any previous history of injury, which could contribute to symptom onset.
Signs and Symptoms:
Symptoms commonly include buttock and/or posterior leg pain, accompanied by pins and needles, numbness, and tingling along the sciatic nerve's course. Notably, there are typically no neurological signs present.
Sciatica Treatment - Piriformis Syndrome
Treatment for piriformis syndrome typically starts with stretching exercises, massage, and avoiding activities that contribute to symptoms such as running and bicycling.
Specific interventions include remedial massage, releasing the piriformis muscle, Chiropractic treatment involves adjusting the lumbar spine and sacroiliac joints to correct biomechanical faults, and incorporating stretches for thigh muscles. Strengthening exercises targeting the abdominal muscles, glutes, hamstrings, and quadriceps are essential for long-term management.
Patients are advised to remove their wallet from the back pocket to reduce pressure on the piriformis muscle. NSAIDs may be prescribed if necessary, and in some cases, a local anesthetic injection may be required for symptom relief.
5. Cauda Equina Syndrome
General Features:
Cauda equina syndrome is an acute neurocompressive disorder in the lumbar spine requiring immediate medical referral, characterized by compression of the cauda equina, resulting in severe neurological symptoms below the lesion level. Typically, it begins around the L2 vertebral body level and can occur at various spinal levels, including L3-4, L4-5, and L5-S1.
Important Questions:
If you have experienced any recent difficulties with urination or defecation, any changes in sensation around the gluteus, groin or tight area (known as saddle anesthesia), or a history of lower back pain, and any potential trauma.
Signs and Symptoms:
Symptoms may include lower back pain following heavy lifting or twisting, often presenting as bilateral sciatica. Patients may experience unilateral or bilateral motor and/or sensory loss in the lower extremities, saddle anesthesia, urinary retention, bowel/bladder dysfunction, muscle weakness in affected nerve root areas, and sexual dysfunction.
Pain might be absent, with complaints solely focused on bladder control and saddle anesthesia. Various causes can lead to cauda equina syndrome, including central disc prolapse, vertebral protrusion into the canal due to infection or tumour, epidural abscess or hematoma, spinal anesthesia, and late-stage atherosclerosis.
Sciatic Treatment - Cauda Equina Syndrome
For acute cases or severe symptoms of cauda equina syndrome, immediate referral for surgical decompression is essential to alleviate pressure on the spinal cord and prevent permanent neurological damage.
Common Mistakes to Avoid with Sciatica
To effectively manage sciatica, it's crucial to correctly diagnose its cause and also to steer clear of common pitfalls:
Mistake to Avoid: Neglecting to address underlying contributing factors to sciatica, such as poor posture, muscle imbalances, or improper lifting techniques. Failing to address these factors may result in persistent or recurrent symptoms despite treatment efforts.
Actionable Tip: Practice proper posture and body mechanics to minimize pressure on the spine and reduce the risk of exacerbating sciatica symptoms. Avoid heavy lifting, maintain a neutral spine position, and take regular breaks from sitting or standing for prolonged periods.
Conclusion:
In conclusion, sciatica can stem from various causes, including disc injury, spinal stenosis, and peripheral nerve entrapment. By understanding the underlying mechanisms and diverse causes of sciatica, individuals can pursue appropriate treatment strategies tailored to their specific needs, with a diagnosis from a qualified professional.
If you're experiencing symptoms of sciatica and would like to know more, reach out to us, and we'll assist you in reclaiming a pain-free lifestyle through your recovery journey.
Written by: Dr. Trent Whittaker (B Chiro Sci, M Chiro)