What is Sciatica and How Do I Treat It?

David Falk, M.D., a fellowship-trained orthopedic spine surgeon with The Maryland Spine Center, part of The Orthopedic Specialty Hospital at Mercy in Baltimore, Maryland, responded to questions from Celebrity Parenting Magazine regarding the nature of sciatica, its treatment, when surgery may be warranted, and other related issues. 

What is sciatica?
Sciatica refers to pain that radiates into the buttocks and down the back of the leg in the path of the sciatic nerve, the largest nerve in the body. You can think of the sciatic nerve as a thick cable made up of smaller wires (or smaller nerves) that originate in the low back and come together to form the thick sciatic nerve.

People who experience sciatica typically will report a sharp, stabbing pain extending from the low back and down the leg, potentially into the foot. This may be associated with numbness/tingling or it may just be purely painful. It may also be associated with weakness.

The term “sciatica” is not a diagnosis in and of itself, but rather a description of a classical symptom associated with nerve compression in the spine. The nerve compression could occur for a variety of reasons commonly related to disc degeneration and arthritis in the low back.

When does sciatica most commonly occur?
Although just about anyone could experience sciatica, it most commonly appears in adults between their 30s and 50s as early degenerative changes in the spine result in less space for the spinal nerves, which can lead to a “pinched nerve” and the symptoms of sciatica.

Do women suffer from sciatica more than men?  If so, why?
In general, both women and men experience sciatica at similar rates. However, during pregnancy (and immediately after), sciatica flares can occur in part due to hormones causing ligaments to loosen, as well as changes in weight distribution. 

What causes sciatica?
Sciatica is commonly caused by bulging discs or a lumbar spine herniation. You can think of a bulging disc as a pimple that has not yet popped, but is protruding from the surrounding tissue to put pressure on the nerve. A herniated disc is [more like] a popped pimple: the disc material is out[side] of the disc itself, no longer where it is intended to be and putting pressure on a spinal nerve.  

Sciatica can also occur in patients who have spinal stenosis, which is narrowing of the spinal canal (the pipe that holds all the nerves). Other causes for sciatica include degenerative disc disease, bone spurs and tumors, but thankfully, the latter are quite rare.

Is there a way to prevent sciatica from occurring? Or, if you feel it coming on, is it possible to prevent it from getting worse?
Prevention is often considered the best treatment. Critical to this is maintaining strong core muscles, practicing good lifting techniques, and [keeping] good posture.

If symptoms occur, I encourage patients to be as active as they can tolerate, letting pain be their guide. Prolonged sitting or prolonged time in bed can actually make things worse.

Early evaluation and initiation of conservative treatment with anti-inflammatory medications and focused physical therapy also has a high likelihood of providing symptom relief.

How long do sciatic episodes typically last?
The duration of sciatica-type symptoms is highly variable, but thankfully, 80 to 90% of patients improve without needing surgery over six to 12 weeks. I will say that again: as painful as these episodes can be, the overwhelming majority will get better without surgery.

What are some treatments for sciatica, and how effective are they?
First-line treatment for sciatica is conservative, non-surgical treatment. This includes anti-inflammatory medications, such as Aleve (Naproxen) or Advil/Motrin (ibuprofen), but may also include a short course of oral steroids. Physical therapy is also a mainstay, and it is important that patients do their exercises not just when they go to therapy, but also daily at home. For patients who fail to experience significant relief with oral medications and physical therapy, focused epidural steroid injections can be considered. You can think of this as taking the whole box of oral steroids and dumping it all right around the nerve in an effort to reduce the inflammation.

If someone were to fail non-operative treatment with oral medications, physical therapy and/or epidural steroid injections, surgical intervention could be considered. Other reasons to consider surgery include weakness (like a foot drop, for example), complete loss of bowel or bladder control, or intractable pain, meaning the patient keeps coming in and out of the emergency room or is unable to walk due to the severity of their symptoms.

In what cases should someone who has sciatica have surgery?  Is this commonly done?  What are the benefits and risks of having surgery if you have sciatica?
Surgery is generally reserved for patients who fail six weeks of conservative treatment or meet one of the other categories mentioned above (weakness, loss of bowel/bladder control, or intractable pain).

Thankfully, over 80% of people will get better with conservative treatment, but that certainly still leaves a [large] group of people who may request surgical intervention.

The goal of surgical treatment is to take the pressure off the nerve. To that end, the exact type of surgery that a spine surgeon may recommend may differ depending on where/how the nerve is being compressed.

For a lumbar disc herniation or disc protrusion, the most common procedure performed for the patient who fails non-operative treatment is a microdiscectomy. In this surgery, a very small incision is made over the back of the spine to allow the surgeon to take the pressure off the nerve by removing the herniated disc material. Only the herniated/loose fragments of the disc are removed, but not the entire thing.  The disc material has a consistency similar to crabmeat, but it can cause severe pain when it is compressing the nerve.

This surgery is highly effective in providing rapid relief of the sciatica pain and allows for restoration of function.

In addition to the risks of all surgery, such as bleeding and infection, risk specific to microdiscectomy include reherniation of disc, recurrence of symptoms or injury to the nerve itself, though these are, in general, relatively uncommon.

Certainly, surgery is effective for the right patients, but it is not always necessary, as the vast majority of patients experience sciatica will improve without requiring surgical treatment.

Dr. Falk sees patients and performs surgeries at The Maryland Spine Center on the Mercy Medical Center campus in downtown Baltimore. The Spine Center is a comprehensive spine care center with access to state-of-the-art facilities, on-site diagnostic imaging services and physical and occupational therapy.