Sciatica Treatment

Sciatica is pain along the course of the sciatic nerve, which forms in the lower back from several nerve roots, runs through the buttock and down the back of the thigh, and divides below the knee to supply the calf, the foot and the toes. The pain is a symptom of something pressing on or irritating one of those roots, so the work of a consult is to find what that something is.

A disc that has bulged or herniated in the lower back is the commonest cause. Narrowing of the spinal canal with age, a vertebra that has slipped forward on the one below it, arthritis of the small spinal joints, and tightness of the piriformis muscle deep in the buttock account for most of the rest. Pregnancy, a fall and a long period of heavy lifting can each bring it on.

It is typically one-sided, and it follows a line instead of spreading across the back: down the buttock, behind the thigh, into the calf, sometimes as far as the toes. People describe it as burning, shooting or electric, often worse on sitting, coughing, sneezing or straining, and eased by standing or by lying flat. Pins and needles, numbness or weakness in the same leg point to the nerve root being compressed and not merely irritated.

Your doctor starts with where the pain runs, because the line it follows names the nerve root involved. They ask how it began, what makes it worse, whether it is one leg or both, whether you have noticed numbness, weakness or a foot that catches on steps, and whether there has been any change in bladder or bowel control.

The examination tests power in the ankle, the big toe and the knee, checks sensation over the areas each root supplies, and taps the ankle and knee reflexes. Raising the straight leg while you lie on your back reproduces the pain when a root is compressed, and the angle at which it does is recorded so it can be compared later. Your doctor also examines the hip and the buttock, since hip arthritis and a tight piriformis both send pain down the leg without involving the nerve root.

Most sciatica needs no imaging at first, because the majority settles over six to eight weeks with treatment. An MRI of the lumbar spine is arranged where there is weakness or numbness that is getting worse, where the pain has not improved after six weeks of proper treatment, where surgery is being considered, or where the history raises the possibility of infection, a fracture or a tumour. Nerve conduction studies are used where the picture does not fit a single root.

Treatment begins with pain relief that lets you keep moving, because bed rest beyond a day or two slows recovery. Your doctor prescribes medicines for nerve pain alongside ordinary painkillers, builds the dose up over a few weeks, and adds a short course of a muscle relaxant where spasm is part of the problem. Physiotherapy starts once the sharpest pain has eased: exercises for the core and the hip, stretches for the hamstring and the piriformis, and advice on sitting, lifting and sleeping positions.

Where the pain is severe or is not settling, an injection of steroid around the affected nerve root is given as a Day Care procedure. You come in for the morning, the injection is placed under imaging guidance, and you go home the same day. It reduces the swelling around the root and often buys the months in which the disc itself shrinks back, which is what most herniated discs do on their own.

Around four in five people improve within six to eight weeks, and sitting tolerance and walking distance are the two things worth tracking week to week. Numbness can lag behind the pain by months. Surgery is considered where severe pain persists past six to twelve weeks of proper treatment, or sooner if weakness is progressing, and your doctor refers you to a spine surgeon at that point.