Sciatica is the sciatic nerve pain caused by damage to the Sciatic nerve itself. This is called neuropathic pain.
The Sciatic nerve comes from the very bottom of the spine, where it can get squashed by a prolapsed inter-vertebral disc.
The bony space for the exiting nerve may be narrow, predisposing us to this problem if the nerve becomes swollen or is pressed on by disc bulges or prolapsed disc material.
Leaking disc material is chemically irritant on the nerve root, increasing its swelling.
The nerve can also get pinched by a tight Piriformis muscle in the buttock, with a similar result.
Lower back and leg pain, or just back and hip pain.
You can suspect sciatic nerve pain because of the characteristics of the pain. This is a nasty pain. It is generally severe, with a stabbing or electric shock-like quality.
You can tell accurately where it runs down the leg, generally close to the back or side surface. It generally reaches to the foot.
Sciatic nerve pain is quite different to the “deep referred pain” which also can originate in the back, but without anything pressing on a major nerve.
Referred pain is vaguely inside the leg, hard to say exactly where. It tends to be more of a constant ache.
It is quite common for people to have both these types of pain, so it is always worth hunting for sore low back and pelvic girdle muscles.
Stretch them as you find them - it's likely to help your pain.
People with sciatica may give a history of previous attacks of pain only extending into their buttock.
Sudden very severe sciatic nerve pain is an ambulance and hospital job.
Generally I try to get a neurosurgeon rather than an orthopedic surgeon. A lot of orthopedic surgeons no longer treat back problems, although some specialize in this area of practice.
They will generally only consider operating if the pain is severe and there is objective evidence of nerve damage on examination. This is muscle weakness, tendon reflex weakness and numbness.
Radiofrequency nucleoplasty (coblation) carves channels into the disc to decompress the disc under a herniation, reducing the pressure and chemical irritative processes on nerve roots and thereby reducing pain.
Intradiscal electrothermal treatment (IDET) is similar, using a heating wire to cook the disc.
There are now lots of radiologists who carry out injections of nerve roots, using CT scans to aid placement of the needle in the hole where the nerve comes out of the spine.
Cortisone injected here can reduce the swelling of the nerve root and relieve the sciatic nerve pain. Cortisone is our most potent anti-inflammatory drug. Quercetin and Bromelain taken by mouth are good options also, used as a systemic proteolytic enzyme.
A colleague of mine, a musculo-skeletal specialist, always had a CT scan¹ done immediately he diagnosed sciatica.
Every so often he would discover something which needed urgent surgery. These were people who were able to get to his consulting rooms, so not the most severe cases.
He prescribed a Lumbar brace made of aluminium with plastic coating, avoiding actions which hurt badly and cortisone by mouth for a few days.
The dose of cortisone, as prednisolone, can range from 5mg three times a day to 25mg twice a day, with meals.
Chiropractors are taught not to manipulate a back joint in recent onset sciatic nerve pain. This is not correct if there is a lower lumbar joint with a movement block, and the correct method is used.
One cannot use the “million dollar roll” as this can definitely aggravate the situation. (This is the manipulation done on the side, involving rotation of the trunk.)
When I started using rotation manipulation treatment in the early 1970’s, one of my patients went away happily relieved of her lower back pain, only to return some hours later with nasty sciatica.
My manipulation had been the “final straw” that tore the damaged disc. This was not so easily fixed. She was very kind to me, and philosophical about the development.
I have more recently mobilized many people’s Lumbar joints in the presence of acute sciatica, without causing many aggravations (none serious) and often with some benefit.
The technique I use mostly involves distraction of the joint, combined with a very gentle rotation.
The spinal joint which requires mobilization is commonly at a different level to that with the disc prolapsed - where the sciatic nerve pain is from.
Any stiff joint in the vicinity, may increase the local muscle spasm and so the pressure on the disc and nerve.
My first teacher was an excellent, experienced country doctor. He was obliged to look after anything that landed in his lap, during the second world war. The buck stopped with him.
He had cut short his surgical training in Edinborough, not wishing to see out a war in Europe. He was an excellent surgeon. I found his advice to nearly always be spot on.
Traction for sciatica had a poor reputation, he said, because it was not continued long enough. A few days was not enough. He had come to this conclusion from experience over thirty years.
I don't remember now whether he advocated 2 weeks or 3. People laid on their back, with a harness around their waist and straps to a pulley on the foot end of the bed, and weights hanging there.
The curve of the low back was straightened out, separating the backs of the vertebrae and making more room for the nerves leaving the spine.
Over the space of a couple of weeks, the inflammatory swelling of the nerve roots diminished, reducing the sensitivity to pressure from surrounding structures.
One can get the right amount of traction without the harness, pulley and weights, by laying on a sloping surface. The angle is that of a flush panel door with one end resting on two chairs. A rubber bath mat to prevent ones top end slipping, and a sheet of plastic under hips and legs, completes the equipment. One couldn't spend a fortnight on this, probably only an hour or two at a time.
If your CT or MRI shows a contained disc herniation (where the extruded disc material has not gone far,) and examination has shown no objective evidence of malfunction of the affected sciatic nerve roots, you have an 80% chance of settling down in 6 to 8 weeks.
Large disc extrusions with the evidence of nerve root damage mentioned above is a job for a surgeon probably.
Sciatica combined with sudden loss of control of bladder or bowel is a desperately urgent situation, needing surgery within a couple of hours or so to hopefully avoid a very bad outcome.
The Piriformis muscle is found deep in the middle of the buttock. It is a small muscle underneath the largest muscle in the body, so you can’t actually feel it.
It passes horizontally from the edge of the tail bone (“Sacrum”) to the top of the thigh bone.
The Sciatic nerve sometimes leaves the pelvis through the middle of Piriformis, and can get pinched here if the muscle is tight.
This (“Piriformis syndrome”) is a relatively common cause of sciatic nerve pain and deep referred pain in the limb. It can co-exist with pressure on nerve roots by a prolapsed disc.
You hook your foot over the opposite knee, clasp your hands over your knee, and use your left hand to pull the knee down closer to your left hip.
At the same time, push your right buttock down into the bed, using both your hands and your back muscles. This is the difference from the usual rotation stretches of the back, where the buttock is allowed to rise.
If it hurts, hold it there.
After perhaps two to five minutes, when the pain of the stretch eases, deliberately use your leg muscles to move the knee down closer to the left hip. You could also think of this action as relaxing your leg and letting it move down.
Keep your pelvis level by pressing your buttock on the side you're stretching down into the bed, to stop it rising.
Attempt to move your pelvis sideways towards the side being stretched.
If you do all this with your bedclothes over you, it is easier to feel the movement of your leg, against them.
This will probably bring the pain on again, and then your just repeat the same process, even multiple times, until either your hands give up or the pain no longer worsens when your knee moves down (or it won't move down any further.)
Someone can help you by pushing the knee towards the other hip for you.
While you are doing this, you may experience pain on the inside of your thigh or in the groin. If this is a sudden cramp in your inner thigh, you will have to abandon this stretch and switch to stretching your adductors.
If it is not bad, perhaps reduce the pressure a little, continue the stretch and it may settle.
Full blown cramp or not, the pain is from spasm in the adductors and can be relieved by stretching them at the same time as the piriformis.
Leave the contralateral (opposite side) hand still pulling on your knee, or just holding onto the knee with fingers and using the weight of your arm - easier on the fingers of that hand and more comfortable stretch of piriformis.
Lay the front of your ipsilateral (same sided) forearm on your tummy, palm facing down in the groin. Make a fist with it and cock the hand back so the knuckles are pressing into your inner thigh adductor muscles, where the pain is felt.
You may find it easier to rotate your forearm, have the back of your hand against your tummy for support and to press your fingers in there.
Pushing into a muscle stretches it by bowing or splaying it out sideways. Stretching (your adductors here) prevents it from going into a full blown cramp (and is the treatment for a cramp anywhere.)
You will now have two pains, from stretching two muscles at once.
Each time your piriformis stops complaining and you relax your thigh down further, you will have to dig your fingers further into the adductors to maintain the stretch.
Pain in your groin suggests psoas and/or iliacus muscle is being stretched. This pain will usually go as the stretch is continued
Using a sling to pull the knee across and pulling against this sling to help keep the buttock on the couch...
Another way to stretch this muscle, is by direct pressure over it (ischemic compression.)
One method is to use the position in the first diagram, minus the hands - but with a tennis ball or golf ball under the middle of your buttock, right where it hurts with your weight on it.
Alternatively use an assistant with strong hands for this task.
Lay face down, flat on a table from the waist up, with legs dangling over the side and feet on the floor.
Anchor your toes of the foot on the side being stretched, and swing that heel out sideways away from the other foot.
Then have your assistant press into the buttock with fingertips, over the most tender soft point between the bones.
The pressure is kept up until your assistant feels their fingers moving inwards, as the muscle relaxes.
This is distinctly unpleasant treatment, only to be used if it is the only one possible because of a very stiff hip joint.
A lot of buttock pain, but in a good cause. A real pain in the A.., to help get rid of sciatic nerve pain in your leg.
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