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Sciatica - A Guide

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Sciatica is the name given to any sort of pain that is caused by irritation or compression of the sciatic nerve.

Introduction
Symptoms of sciatica
Causes of sciatica
Diagnosing sciatica
Treating sciatica
Preventing sciatica

 

Introduction

Sciatica is the name given to any sort of pain that is caused by irritation or compression of the sciatic nerve.

The sciatic nerve is the longest nerve in your body. It runs from the back of your pelvis, through your buttocks, and all the way down both legs, ending at your feet.

When something compresses or irritates the sciatic nerve, it can cause a pain that radiates out from your lower back and travels down your leg to your calf (see Sciatica - symptoms for more information). Sciatic pain can range from being mild to very painful.

A slipped disc is the most common identified cause of sciatica, but in some cases there is no obvious cause (see Sciatica - causes for more information).

Types of sciatica

There are two types of sciatica:

  • acute sciatica, which lasts up to six weeks
  • persistent (chronic) sciatica, which lasts longer than six weeks

Most cases of acute sciatica will pass without the need for treatment. A combination of self-help measures such as over-the-counter painkillers, exercise and hot or cold packs can usually relieve the symptoms.

For persistent sciatica, you may be advised to try a structured exercise programme under the supervision of a physiotherapist. In very rare cases, surgery may be needed to control the symptoms.

Outlook

Most people find their sciatic pain goes away naturally within a few days or weeks. However, see your GP if:


  • you experience any other symptoms together with your back and leg pain, such as weight loss or loss of bladder or bowel control
  • you experience increasingly more pain and discomfort
  • your pain is too severe to manage with self-help measures

In these cases, your GP should check whether there is a more serious problem causing your pain.



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Symptoms of sciatica

Sciatica is different to general back pain; the pain of sciatica hardly affects the back at all but radiates out from the lower back, down the buttocks and into one or both of the legs, right down to the calf.

Sciatic pain can range from being mild to very painful and can last for weeks or months. If it lasts for more than six weeks, it is considered persistent (chronic) sciatica.

Other symptoms

If you have sciatica, you may also experience the following symptoms around your legs and feet:

  • numbness
  • tingling
  • muscle weakness 
  • loss of tendon reflexes

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Causes of sciatica

Slipped (herniated) disc

A slipped (or herniated) disc is the most common identified cause of sciatica.

Your spine is made up of vertebrae, discs and nerves. Vertebrae are the blocks of bone that make up the structure of your spine and protect the nerves.

The vertebrae are supported and cushioned by discs. The discs are made from a tough, fibrous case thhat contains a softer gel-like substance. A slipped disc occurs when the outer part of the disc ruptures (splits), allowing the gel inside to bulge and protrude outwards between the vertebrae. When this presses against the sciatic nerve, it can cause sciatica.

As a person gets older the discs start to become harder, tougher and more brittle. Repeated strain on the back means there is a greater chance of a hardened disc splitting and rupturing.

Spinal stenosis

Spinal stenosis is the narrowing of nerve passages in the spine. It occurs when the bones, ligaments or discs of the spine squash the nerves of the spine (usually the sciatic nerve) causing pain, usually in the lower back and legs. It usually affects people in late middle age and older.

Causes of spinal stenosis include:

  • age-related changes in the spine
  • changes in the ligaments of the spine
  • diseases of the bone, such as Paget's disease

Other causes

Less commonly, sciatica may be caused by:

  • infection
  • injury
  • a growth within the spine, such as a tumour

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Diagnosing sciatica

If the symptoms of sciatica are mild and do not last longer than six weeks, a medical diagnosis is not usually needed. This is because mild, short-term (acute) sciatica is normally not a cause for concern and will resolve without treatment.

However, if your sciatica symptoms are severe or the condition continues for more than six weeks, see your GP to rule out any serious conditions that could be causing your sciatica.

Passive straight leg raise test

Your GP should be able to confirm that the pain is being caused by the sciatic nerve using the passive straight leg raise test.

This test involves lying flat on your back with your legs straight. The GP will ask you to raise one leg and they will then raise your foot up. If this causes pain or makes your pain worse, it is usually an indication that your pain is being caused by the sciatic nerve.

Red flags

Your GP will also ask you questions about your medical history and individual circumstances. They are looking for warning signs that your sciatica is caused by a serious condition, such as cauda equina, an infection of the spine, or cancer.

GPs refer to these warning signs as 'red flags'.

Red flags that suggest cauda equina syndrome are:

  • numbness in your bottom, lower back and leg
  • loss of bladder and/or bowel control
  • feeling of weakness in your leg and foot 

Red flags that suggest cancer or infection are:

  • you are over 50 years of age and have never had any previous back pain
  • you have a history of cancer
  • you have symptoms of fever, chills or unexplained weight loss
  • you have had a recent bacterial infection, such as a urinary tract infection
  • you inject illegal drugs, such as heroin or cocaine (a leading risk factor for spinal infections)
  • you have a condition that weakens your immune system, such as HIV
  • you have a structural deformity of the spine

If you have one or more red flags, your GP will probably recommend that you have further investigations. If you have any red flags that suggest cauda equina, they will make sure you are admitted to hospital straight away.

Further investigations may include a blood test to rule out infections.

If your GP feels there is a significant risk that you may have a serious condition, such as cancer or a spinal fracture, they may also refer you for an MRI (magnetic resonance imaging) scan.

MRI scans use strong magnetic waves to build up a detailed picture of the inside of your body. An MRI scan should be able to detect any problems with the nerves and structure of your spine.

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Treating sciatica

Treating acute sciatica

Most cases of acute sciatica can be treated at home, as outlined below.

Painkillers

Over-the-counter (OTC) painkillers are usually effective in relieving pain. Painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are thought to work best. Ibuprofen is usually recommended rather than aspirin because there is less chance of adverse side effects. Children who are under the age of 16 should not take aspirin.

NSAIDs may not be suitable if you have asthma, high blood pressure, liver disease, heart disease or a history of stomach and digestive disorders. In these circumstances, paracetamol is likely to be a more suitable painkiller for you. Your GP or pharmacist will be able to advise you.

If OTC painkillers are not effective in relieving your pain, your GP may prescribe a mild opiate-based painkiller, such as codeine, or if your symptoms are very severe, a muscle relaxant such as diazepam.

Diazepam can make you feel sleepy, so you should not drive if you have been prescribed this medication. After your course of medication has ended, you should wait at least 24 hours before driving.

Diazepam will also make the effects of alcohol worse so avoid excessive drinking while you are taking the medication. Diazepam has the potential to be habit-forming, so your GP will not usually prescribe more than a seven-day course of the medication.

Exercise

If you have sciatica, it is important for you to remain as physically active as possible. While bed rest may provide some temporary pain relief, prolonged bed rest may be unnecessary. Recommended exercises include walking and gentle stretching exercises.

If you have had to take time off work due to sciatica, you should aim to return to work as soon as possible.

Compression packs

Many people find that using either hot or cold compression packs helps to reduce pain. You can make your own cold compression pack by wrapping a package of frozen food in a towel. Hot compression packs are usually available from larger pharmacies. You may find it effective to use one type of pack after another.

Treating chronic sciatica

Chronic sciatica usually requires a combination of self-help techniques and medical treatment. Treatment options are outlined below.

Painkillers

The long-term use of NSAIDs as a method of controlling pain is not usually recommended because they can cause problems with your stomach and digestive system, such as ulcers or internal bleeding.

If you need pain relief over a long time, the painkillers listed below may be used:

  • paracetamol
  • codeine (paracetamol is often prescribed in combination with codeine)
  • a tricyclic antidepressant, such as amitriptyline
  • gabapentin (where nerves are thought to be inflamed) or, in capsules, a similar drug called pregabalin

Amitriptyline was originally designed to treat depression but doctors have now found it is also useful for treating nerve pain. You may experience some side effects when taking amitriptyline, including:

  • drowsiness
  • dry mouth
  • blurred vision
  • constipation
  • difficulty urinating

Do not drive if you find that amitriptyline makes you drowsy. Amitriptyline should not be taken by people with a history of heart disease.

Gabapentin was originally designed to prevent seizures in people with epilepsy. However, like amitriptyline, it has been found to be useful for treating nerve pain.

Possible side effects of gabapentin include:

  • drowsiness
  • dizziness
  • tiredness
  • loss of coordination

Do not drive if you find that gabapentin is making you drowsy.

Do not suddenly stop taking gabapentin as you may experience withdrawal symptoms such as anxiety, insomnia, nausea, pain and sweating. If you want to stop taking gabapentin or no longer need to take it, your GP will arrange for your dose to be slowly reduced over the course of a week so you do not experience withdrawal symptoms.

Injection of a corticosteroid

If other methods of pain relief have not worked, your GP may refer you to a specialist for an epidural steroid injection. This delivers strong anti-inflammatory medication directly to the inflamed area around the nerves of your spine. This should release the pressure on your sciatic nerve and reduce your pain.

Exercise and physiotherapy

As with acute sciatica, if you have chronic sciatica you should try to remain as physically active as possible because this will reduce the severity of your symptoms. It is also recommended that you continue to work or return to work as soon as possible.

Regular exercise will help to strengthen the muscles that support your back. Exercise also stimulates the production of endorphins, which are natural painkilling chemicals.

Your GP may recommend a suitable exercise plan for you or refer you to a physiotherapist. A physiotherapist can teach you a range of exercises that strengthen the muscles that support your back and improve the flexibility of your spine. They can also teach you how to improve your posture and reduce any future strain on your back.

Cognitive behavioural therapy (CBT)

Some studies have shown that CBT can help in the management of chronic pain that is caused by sciatica.

CBT is based on the principle that the way we feel is partly dependent on the way we think about things. Research has shown that people who train themselves to react differently to their pain, by using relaxation techniques and maintaining a positive attitude, show a decrease in the levels of pain that they experience.

They are also more likely to remain active and take exercise, further reducing the severity of their symptoms.

Surgery

Surgery may be an option to treat cases of chronic sciatica when:

  • there is an identifiable cause, such as a slipped or herniated disc
  • the symptoms have not responded to other forms of treatment
  • the symptoms are getting progressively worse

The type of surgery that will be recommended for you will depend on the cause of your sciatica. Some surgical options include:

  • discectomy: where the part of the herniated disc pressing on your nerve is removed (this is the most common type of surgery required)
  • fusion surgery: if a vertebra has slipped out of place, it may be possible to fuse it into place using a bone graft supported by metal rods
  • laminectomy: a procedure often used to treat spinal stenosis, this removes or trims the arch of a vertebra (bone) to relieve the pressure on the nerves

Many people have a positive result from surgery, but as with all surgical procedures, spinal surgery carries some risks. There is a risk of infection and of the surgery failing, and a low risk that your spinal nerves will be damaged during surgery. This could result in muscle weakness.

Before opting for spinal surgery, your surgeon will discuss the relative risks and benefits with you.

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Preventing sciatica

Lifting and handling

One of the biggest causes of back injury, particularly at work, is people lifting or handling objects incorrectly. Learning and following the correct method for lifting and handling objects can help prevent sciatica.

  • Think before you lift: can you manage the lift? Are there any handling aids you can use?
  • Start in a good position: your feet should be apart with one leg slightly forward to maintain balance. When lifting, let your legs take the strain - bend your back, knees and hips slightly but do not stoop or squat. Tighten your stomach muscles. Do not straighten your legs before lifting as you may strain your back on the way up.
  • Keep the load close to your waist: keep the load as close to your body for as long as possible with the heaviest end nearest to you.
  • Avoid twisting your back or leaning sideways: especially when your back is bent. Your shoulders should be level and facing in the same direction as your hips. Turning by moving your feet is better than lifting and twisting at the same time.
  • Keep your head up: once you have the load secure look ahead, not down at the load.
  • Know your limits: there is a big difference between what you can lift and what you can safely lift. If in doubt, get help.
  • Push, do not pull: if you have to move a heavy object across the floor, it is better to push it rather than pull it.
  • Distribute the weight evenly: if you are carrying shopping bags or luggage, try to distribute the weight evenly on both sides of your body.
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