Sciatica & Sciatica-like Conditions

Sciatica is a condition related to irritation of the sciatic nerve producing low back pain with radiating pain down the leg. Pain in the back and leg can be the consequence of many different pathological processes. The classic definition of true sciatica involves the lumbar nerve roots (the nerves that exit the lower spine). However, there are also many conditions that can mimic sciatica resulting in low back and leg pain.

Signs & Symptoms

If you have experienced low back pain with shooting pain down your the back or side of your leg, then it just might be sciatica. Other sciatica symptoms include numbness, tingling, altered sensation, and weakness in the lower extremity. Usually one leg is affected, but it is possible to have both legs involved. If both legs are involved this can be a more serious sign (possible cauda equina syndrome). Other more serious signs include: loss of bowel/bladder/sexual function or loss of sensation of the inside of the thighs. A sign of true sciatica is symptoms that travel below the knee. This is a strong indication that pain is a result of sciatic nerve irritation.

Causes of Sciatica

Sciatica is not really a specific diagnosis and can have a variety of causes. You might also call sciatica a “pinched nerve”. Where the nerve is being pinched and what is doing the pinching is more complicated.

As you might know, the different nerves in your low back go to different places in your legs. Different areas of the leg are affected depending upon which nerves are involved. The middle nerves of the lumbar spine tend to affect the front of the leg. Lower nerves of the lumbar spine tend to affect the side of the leg, while nerves of the upper sacral spine tend to affect the back of the legs.

I want to mention here people often use the term sciatica to indicate spine pain or leg pain. This use is erroneous and can sometimes cause confusion. For the sake of this article, I will include several conditions which can generate back and leg pain.

Disc Pathology Can Cause Sciatica

Disc pathology is the most common reason for sciatica and is considered one of the major causes in the classic definition of true sciatica. Vertebral discs can change shape and/or herniate. A disc bulge is a change in the shape of the disc. A herniation is when the gel-like center of the disc protrudes out of the normal confines of the disc. These changes in the disc can end up putting pressure on the nerves of the spine. The disc can herniate left, right, or center. Down in the lumbar spine a central disc herniation can lead to a condition called Cauda Equina Syndrome that is serious and requires immediate surgery in order to prevent permanent loss of bowel/bladder/sexual function. A herniation to the left or right will likely put pressure on the nerve root. The symptoms depend on the amount of irritation/ pressure and the level of the disc.

Spondylosis and Spinal Stenosis

Degenerative joint disease, degenerative disc disease, and osteoarthritis that occur in the spine are lumped into the term spondylosis. Spinal Stenosis is the term used to indicate narrowing of the passageway of the nerves typically as a result of degeneration. In other words, spondylosis can lead to spinal stenosis. The loss of disc space narrows the diameter of the nerve passageways from top to bottom, and bone spurs can narrow the passage ways from front to back or side to side.

Degeneration can also narrow the diameter of the spinal canal (where the cord and several nerve roots exist). As as consequence, patients will experience more serious symptoms. In addition, some people are born with more narrow nerve passages. This puts them at even greater risk of developing stenosis and subsequently suffer neurological symptoms like sciatica. In reality anything that changes the shape or alignment of the spine can lead to stenosis such as: Injury, pregnancy, Scheunemann’s disease, or scoliosis.

Other Space-Occupying Lesions

Sciatica can rarely present owing to more serious pathology including: tumors, fractures and infections. These situations warrant immediate medical intervention. A tumor grows and occupies space that can put pressure on nerves. Fractures may lead to bone fragments impinging nerves and/or cause instability of the spine that results in nerve compression. An infection can also create changes and inflammation in the spine resulting in neuropathy. These pathologies are the first things that should be ruled out during an initial examination.

Piriformis Syndrome

There is a particular muscle in the buttocks called the piriformis. The sciatic nerve runs right under this muscle. In a small portion of the population, the sciatic nerve travels either partially or entirely through the piriformis muscle. For this reason, a contracted or overactive piriformis muscle can result in sciatica. However, piriformis syndrome is traditionally not considered true sciatica.

Femoral Neuropathy

True sciatica tends to occur from pressure of the nerves in the lower lumbar spine. Likewise, nerves can also be irritated in the same way in the upper part of the lumbar spine. When this occurs, the fibers of the femoral nerve are involved instead of the sciatic nerve. In these cases, pain is felt in the front of the thigh instead of the back or side of the thigh. The underlying causes are pretty much the same as sciatica, just in a different place affecting a different nerve.

Meralgia Paresthetica

Nerve entrapment can occur in other locations as well. The lateral femoral cutaneous nerve runs down the upper outer thigh. Pain, tingling, or numbness can occur given that enough pressure is applied across this nerve. This condition has been nicknamed the “skinny pants syndrome” owing to the tight fitting pants or belt as the underlying cause (one of the reasons I recommend elastic/stretchy material). The lateral femoral cutaneous nerve becomes entrapped around the front of the hip and groin region as the nerve passes from the pelvic area to the outer thigh. Motor vehicle accidents can also cause lesions of this nerve from contact of the seat belt. This condition is also not included in the classic definition of sciatica. However, it presents as radiating leg pain and therefor fool one to think it’s sciatica.

Iliotibial Band Syndrome and Trochanteric Bursitis

This biomechanical issue causing pain to run down the leg, and can also be associated with back pain. See the section on Hip Pain for more detail. There is a muscle called the tensor fascia latae (TFL). Tightening of the TFL can create excessive tension on a band of fibrous connective tissue called the iliotibial band (ITB). The ITB runs down the outside of the leg. In addition, tension puts pressure against the trochanteric bursa which is located around the hip bone. This whole complex of problems is referred to as ITB syndrome with trochanteric bursitis, and they usually occur altogether. Pain often starts in the side of the hip and travels down the outer thigh to the knee. Muscle spasm, swelling, and general tension can lead to nerve compression occasionally. This makes the problem look like sciatica, but again, this is not true sciatica.

Herpes Zoster (Shingles)

Have you ever had chicken pox? It’s caused by the varicella zoster virus. Like all other herpes viruses, it actually lives in your nerves imbedding itself into the DNA of the nerve cells. It is there forever. Varicella Zoster remains dormant then later becomes active again during outbreaks. When chicken pox reactivates, it is called herpes zoster or commonly “shingles”. This typically happens to older adults but can happen in younger people too. Before the full rash appears, a person can have neurological symptoms including pain and numbness. If the affected nerve is in the low back and leg, then this virus can mimic sciatica. Therefore, it too can fool people.

General Kinetic Chain Dysfunction

In some cases, pain can appear to shoot down the leg with back pain not because of a pinched nerve, but because of a problem in the kinetic chain. A kinetic chain is the link between several consecutive joints and the muscles and other soft tissue involved in that linkage. It is a head-bone-is-connected-to-the-foot-bone situation. Here is an example: A patient has a “flat foot” that rolls inwards. When that foot rolls inwards, it causes the knee to also travel inwards. This drops the pelvis on that side which leads to tilting of the lumbar vertebra. Many muscles and ligaments are stressed because of these postural changes. The result is a chain of overstressed tissues usually producing a series of trigger points or tender points down the chain. As a consequence, there is pain in the back, buttock, and the leg. Voilà!!! Kinetic chain dysfunction, but not true sciatica.

Further Considerations

As you can see, sciatica is pretty complicated. There is a long list of differential diagnoses and underlying causes. Many conditions can look like true sciatica, but only a trained physician can correctly diagnose the real issue. Sometimes it is a serious problem that requires immediate medical attention possibly requiring surgery. Other times, surgical intervention will fix nothing.

To compound the problem, studies have shown that MRIs are not as reliable as we once thought. Things like degenerative changes and disc herniations appear all the time in completely asymptomatic patients. The older we are, the more likely we are to have these findings on imaging. However, these findings have little association with the symptoms that we experience. Likewise, there are many people who are diagnosed with sciatica, but have no findings on MRI or X-ray! For this reason, exploring the underlying causes of sciatica and identifying associated mechanical dysfunctions is essential to proper treatment.

Treatment

Despite all of the confusion and all of the controversy, there are established guidelines for treatment of sciatica. This is my synopsis:

Medical Intervention

Treating sciatica with medical interventions like muscle relaxers, anti-inflammatories, pain killers, steroid injections, and even nerve blocks are an appropriate intervention on a preferably temporary basis. However, it should be understood that medicine does not address the underlying biomechanical dysfunction. Though, it can help to ease the symptoms while the body heals. I myself sometimes refer patients to medical doctors when symptoms are severe enough. Medicines that calm pain and muscle spasm actually help me to do my work. It decreases tension and guarding allowing me to more easily manipulate and rehab my patients.

Timeliness of Conservative Treatment

Sciatica that does not self-resolve in a few weeks should first be treated conservatively. This includes things like joint and muscle manipulation, physiotherapy, rehab, and massage. In addition, Injections with naturopathic/homeopathic medicines can be very helpful. We offer all this here in the office as I am certified and licensed to do so.

If Conservative Treatment Fails

If conservative therapy has absolutely no effect by two weeks, then I either change the plan, or possibly seek imaging like X-ray or MRI. I do not allow patients to remain without progress in the clinic. If I really can’t get results, then the patient is referred to another specialist.

If Treatment Plateaus

Sometimes conservative treatment is initially effective, but we reach a plateau after a time. At this point, it’s time to change course. Advanced imaging such as MRI is warranted if not previously obtained in these circumstances. I would also consider referral for orthopedic consult. However, it is sometimes necessary for insurance purposes to first refer back to the patient’s primary care physician. This is another reason it is good to be in communication with the patient’s doctors.

Surgery

In the event that I refer out for surgery, an initial consult will occur first. Sometimes the consult does not lead to surgery right away, or maybe not at all. Typically, surgery is only considered after it is established that steroid injections and other less invasive medical intervention also fails. Surgeons will also often not elect to proceed with unless it is clear from the imaging that the issue can be fixed by surgery.

Additionally, surgeons often decline to proceed if pain levels are not severe or constant. This is because outcomes after the procedure could easily be worse than what the patient started with. If surgery is to be performed, I prefer that patients and their surgeons consider less invasive surgeries that do not involve the use of hardware in the spine. Long term outcomes tend to be poor for these more invasive surgeries (though sometimes there is no other option). The addition of hardware means that the involved sections of the spine are immobilized resulting in stress of the vertebra above and below, and often lead to further surgery of those sections down the road.

Pain Management

If surgery fails, then patients are typically referred to pain management clinics. Furthermore, the healthcare community is well-aware of the opioid epidemic. Nobody wants the final outcome to be simply mitigating symptoms with pain killers and other medications. The point is that conservative therapy should come first. If the conservative approach fails, then more aggressive medical procedures should be considered. If you think you might have sciatica, please make an appointment with our chiropractor in Tulsa today.