Sciatica

Sciatica is a broad term used to describe pain that is neural in origin and refers or radiates into the leg. Often used to describe any type of back or leg pain, it should be reserved for pain that originates from the lower back and refers pain downwards from the buttocks along the course of the lumbosacral nerves. In most cases, sciatica is transient, and responds well to conservative treatment, with 90% of people improving within 4 months of symptom onset.

Fun fact: Hippocrates is said to be the first physician to use the term “sciatica”, describing ischiatic (hip) pain in men aged between 40 and 60 years. It wasn’t until the early 20^th century though that compression of the nerve root by the intervertebral disc was considered a possible cause of sciatica.

Anatomy 101

The sciatic nerve is the thickest nerve in the body, measuring approximately 2cm wide. It is formed from the nerve roots of L4, L5, S1, S2 and S3 which merge in the pelvis and then descend through the buttocks and down the back of the thigh. Just above the knee joint, the nerve divides into the tibial nerve and the common peroneal nerve which continues down the lower part of the leg. You can get a detailed description of sciatic nerve anatomy here.

The sciatic nerve provides motor supply to the hamstring muscles and parts of the groin muscle adductor magnus, as well as some muscles in the lower leg. It also provides sensory supply to the leg and foot. Compression or irritation of the sciatic nerve, particularly at the level of the nerve roots, can result in pain that radiates into the leg in specific patterns known as dermatomes, and, in some instances, result in weakness of the leg and foot.

Who gets it?

Sciatica is a common condition with a lifetime prevalence of up to 43%, though this does vary widely due to the low-quality research on sciatica to date and the variation in how sciatica is defined. Sciatica affects men and women equally and is most common in people aged 30-50. Factors including age, height, stress, smoking and exposure to vibration and manual handling can all increase the risk of developing sciatica. Most people who experience sciatica will have a history of low back pain.

In approximately 85- 90% of cases of sciatica, a herniated intervertebral disc causes lumbar nerve root compression or inflammation resulting in referred pain (sciatica) down the leg.

Diagnosing Sciatica

Sciatica can be diagnosed based on the patient’s symptoms and the findings on physical examination. Sciatica commonly develops gradually. It is often preceded by back pain, though at the time of presenting to a health professional leg pain is generally the dominant symptom. Leg pain will often follow a dermatomal distribution indicating which nerve root is compromised. Coughing, sneezing, or deep breathing may exacerbate pain.

Physically sciatica results in a reduction in straight leg raise range. Numbness and/or altered sensation may follow a dermatomal pattern, and in some instances leg strength and/or reflexes may be altered.

Sciatica is usually caused by compression of one or more nerve roots by a bulge in the intervertebral disc. However other underlying pathology such as trauma, cancer or serious infections may also cause sciatica. The presence of saddle paraesthesia, altered bowel and bladder function, and reduced sexual function could indicate cauda equina syndrome requiring immediate medical attention.

Do I need a scan?

Medical imaging (X-ray, MRI, CT scan) is not normally indicated for patients presenting with sciatica unless the clinical picture suggests an atypical presentation and more serious pathology is being considered as a cause. 

International guidelines do not recommend routine imaging for patients with sciatica.

Reliance on imaging for a clinical diagnosis can have unintended consequences. As with non-specific low back pain, people presenting with sciatica can have a range of changes on imaging, including normal age-related degenerative changes. These signs may be unrelated to the presenting symptoms.  Nevertheless, they can distract from best-practice treatment and exacerbate patient stress and anxiety, prolonging symptom resolution and potentially the pursuance of ineffective and unnecessary interventions. 

Treatment

Treatment guidelines for sciatica follow a stepwise model starting with therapeutic exercise and education, progressing to pharmacological and targeted treatment (such as ultrasound guided corticosteroid injection) if the pain is intractable.

Surgery should only be considered when conservative treatments have not been effective and radiological findings are consistent with symptoms.

Early referral to physiotherapy is important. Initial treatment for sciatica involves education and exercise, with a strong emphasis on staying active. This is an important element of conservative management, particularly for people who have had symptoms for less than 6-8 weeks. Exercise should be aligned with the patient’s symptoms and the goals and experience of the patient. You can access a general exercise program for sciatica here.

Bed rest for sciatica is NOT recommended.

Pain medication has not been shown to have a significant effect on sciatic pain. Coritcosteroids can improve pain in the short term, however they can have considerable side effects. The Dutch GP guideline therefore recommends a cautious approach to the use of pain medication for sciatica for patients with severe pain only. 

If symptoms persist following a period of conservative treatment, then the stepwise model for sciatica management recommends referral to a spinal surgeon to evaluate if there is an indication for lumbar surgery. The most common procedure undertaken for severe sciatic pain is lumbar discectomy surgery, where the portion of the lumbar disc that is compressing the nerve root is removed. Some patients will identify rapid relief of leg pain as an important treatment goal. For these patients, discectomy could be an early management option where the benefits outweigh the risks and costs.

How long’s it going to take?

In a recent study (2020), Konstantinou et al found a median time to recovery of 10-12 weeks, with most people making a full recovery in a couple of months. Only a small percentage (<3%) required spinal surgery. 

While surgery can provide rapid relief of leg pain, it carries with it an increased risk of an adverse event, such as infection or increased back pain. Studies have shown that non-surgical treatment can achieve similar outcomes albeit at a slower pace and with the potential need for delayed surgery if conservative treatment fails.

The Take Home

Sciatica is a painful, usually transient condition caused by compression of one or more nerve roots in the lower back resulting in referred pain to the leg. Stepwise treatment is recommended, commencing with physiotherapy as early as possible, with options to progress to more invasive treatment where symptoms persist. For the majority of clinical presentations, education, therapeutic exercise and advice to stay active will see an improvement within 4 months from symptom onset and a gradual return to pre-injury activities. 

Got sciatica and want to get it sorted? Give us a call.

At Movement for Life Physiotherapy, we can assess and diagnose the cause of your deep gluteal or leg pain and let you know whether you have sciatica or if there is something else going on. With a clear diagnosis and tailored management plan, we'll help get you back to the things you love sooner. 

Give us a call now or click on BOOK AN APPOINTMENT to book online.

Sources.

1. Bailey, C. S., Rasoulinejad, P., Taylor, D., et al. (2020). Surgery versus conservative care for persistent sciatica lasting 4 to 12 months. New England Journal of Medicine, 382(12), 1093-1102.
2. Dove, L., Jones, G., Kelsey, L. A., et al. (2023). How effective are physiotherapy interventions in treating people with sciatica? A systematic review and meta-analysis. European Spine Journal, 32(2), 517-533.
3. Konstantinou, K., Lewis, M., Dunn, K. M., et al. (2020). Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial. The Lancet Rheumatology, 2(7), e401-e411.
4. Liu, C., Ferreira, G. E., Shaheed, C. A., et al. (2023). Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials. British Medical Journal, 381.
5. Ostelo, R. W. (2020). Physiotherapy management of sciatica. Journal of physiotherapy, 66(2), 83-88.
6. Ryan, C., Pope, C. J., & Roberts, L. (2020). Why managing sciatica is difficult: patients’ experiences of an NHS sciatica pathway. A qualitative, interpretative study. BMJ open, 10(6), e037157.