From personal experience, both as a practitioner and a sufferer, I'm intimately familiar with the agony of sciatica. Over 20 years ago, I endured a ruptured lumbar disc (L5/S1). Once a passionate marathon enthusiast, walking suddenly became a challenge. This ordeal offered me a profound understanding of the condition and effective strategies to tackle it. For me, a blend of surgery, manual therapy, and exercise was the answer. Within a year, I was back to competing in Ironman races.
However, it's heartening to note that most sciatica patients don't require surgery. While intense cases might necessitate it, a mix of conservative manual therapy and exercise can yield impressive results for the majority.
Article Index:
What is Sciatica?
Sciatica is a prevalent medical condition resulting from the impingement or irritation of the sciatic nerve. Originating in the lumbar region of the spine, the sciatic nerve extends through the hips, buttocks, and lower extremities. Compression or irritation of this nerve may lead to symptoms such as pain, paresthesia, or muscular weakness in the impacted limb.
The sciatic nerve:
Emerges from the Sacral Plexus, originating from the nerve roots of L4 through S3.
Traverses the gluteal region, extending towards the knee. At this point, it bifurcates into the tibial and peroneal nerves.
The sciatic nerve holds the distinction of being the longest and broadest singular nerve in the human body, with its thickest segment reaching approximately the width of an adult thumb.
It is important to differentiate between true sciatica and the colloquial usage of the term. Medically, sciatica refers to leg pain confined to a particular distribution of lumbosacral nerve roots, following a dermatomal pattern that typically encompasses the L4-S2 regions.
Frequently, patients presenting with low back and leg pain do not display the dermatomal pain pattern typically associated with sciatica; however, the condition is often still diagnosed as such. For those who do not exhibit pain in a nerve root distribution (dermatomal pattern) specific to the lumbosacral region, a more precise diagnosis would be "nonspecific radicular pain."
Please Note
It is worth noting that dermatomal inconsistencies are prevalent. While dermatomal patterns provide general information regarding sensory changes, there is a lack of consensus among experts on these sensory patterns. Additionally, significant crossover exists between spinal nerve levels, and variations can be observed among individuals (9).
Causes of Sciatica
Sciatica-related symptoms may arise from a variety of sources, including disc herniation, foraminal stenosis, spinal stenosis, or entrapment of the sciatic nerve along its course. This article will discuss sciatica-like manifestations caused by disc herniation and sciatic nerve entrapment throughout its trajectory.
Lumbar Spinal Discs
Intervertebral discs serve as pliable, cushion-like structures situated between the vertebrae in the spine, affording shock absorption and flexibility. The lumbar spine houses five intervertebral discs, designated L1-L5.
These discs play a crucial role in preserving proper spinal alignment and facilitating spinal movement. However, they may also be a source of discomfort and additional symptoms if damaged or degenerated.
Common lumbar spine intervertebral disc conditions include:
Disc herniation: The nucleus pulposus protrudes through the annulus fibrosus, irritating adjacent nerves and potentially causing pain, numbness, and leg weakness. Lumbar disc herniation is most prevalent between ages 30 and 50, with males experiencing twice the number of herniations compared to females (2). The majority of disc herniations transpire at the spinal column's lower levels (L5/S1).
Degenerative disc disease: Over time, discs may degenerate and lose their shock absorption capabilities, leading to pain, stiffness, and diminished mobility.
Disc bulge: Characterized by the annulus fibrosus bulging outward without rupturing, a disc bulge can exert pressure on nearby nerves.
Disc protrusion: This condition occurs when the annulus fibrosus bulges and ruptures, but the nucleus pulposus remains within the disc.
Disc extrusion: In cases of disc extrusion, the nucleus pulposus breaches the annulus fibrosus and extends beyond the disc, potentially causing severe pain and neurological symptoms.
It is essential to recognize that radiographic evidence of disc herniation does not consistently correlate with the severity of low back pain experienced by the patient or accurately predict their prognosis (4). Asymptomatic individuals may present with a full-blown disc herniation (10).
Encouragingly, most instances of sciatica resulting from disc herniation do not necessitate surgical intervention. Numerous cases exhibit no significant neurological dysfunction attributable to disc herniation.
Red Flags
The following red flags necessitate immediate emergency medical care. Patients should seek urgent attention if they experience:
Severe muscle wasting and atrophy.
Recent onset of bowel or bladder incontinence.
Saddle anesthesia, characterized by a loss of sensation in the buttocks and perineum (the region between the anus and scrotum in males or between the anus and vulva in females). This may be indicative of Cauda Equina Syndrome – a neurosurgical emergency – resulting from the compression of nerve roots below the spinal cord level, occasionally due to a prolapsed disc.
Intense sciatica following a fall or other trauma, which could suggest a potential spinal fracture.
Severe or progressive weakness in the leg or foot, which may indicate a critical nerve injury or compression necessitating prompt treatment.
Fever or other signs of infection, potentially signaling an infection requiring medical intervention.
In summary, if you exhibit any of these red flags in conjunction with sciatica symptoms, it is imperative to seek immediate medical evaluation to ascertain the underlying cause and obtain appropriate treatment.
Disc Injuries - Myths & Reality
While discussing lumbar discs and sciatica, it is essential to address two prevalent myths.
Myth #1: The first myth posits that a large disc protrusion, frequently observed on MRI or CAT scan images, signifies that the issue cannot be resolved through conservative care (non-surgical care, manual therapy, and exercise).
Although surgical intervention can offer rapid relief from back pain symptoms in specific patients with lumbar disc herniations, it is noteworthy that surgery does "not demonstrate a benefit over conservative treatment in midterm and long-term follow-ups" (14).
Myth #2: The second myth assumes that extruded or sequestered disc fragments are less likely to resolve than contained protrusions. Contrarily, migrating fragments tend to resolve more quickly and frequently than contained protrusions (6,7).
This phenomenon occurs because larger disc protrusions elicit a higher degree of inflammation surrounding the protrusion. Once the disc fragments separate and inflammation diminishes around these fragments, coupled with a decrease in disc bulging, the body can reabsorb the fragments (8).
Key Point: The immediate necessity for surgery often depends on the presence of neurological dysfunction (red flags) and the patient's ability to maintain a certain degree of functionality.
Conclusion
Sciatica symptoms may arise from disc herniation, foraminal stenosis, spinal stenosis, or sciatic nerve entrapment. A majority of individuals over the age of forty have disc bulges, most of which are asymptomatic and do not cause pain or functional impairment. Furthermore, most disc herniations can be treated with conservative therapy initially as long as no red flags are present.
Key Points:
Most people in our society have disc bulges, which may never evolve into a significant issue. However, degenerative spinal conditions are progressive and warrant monitoring. Over time, damage to the disc could advance to the point of rupture with sequestration, depending on various factors.
It is crucial to recognize that minor issues, which resolve quickly, could eventually develop into more complex problems. These severe issues often take years to manifest, and thus, a disc herniation might be the culmination of a long-standing degeneration process that began as a seemingly minor event.
"Disc herniation is the result of an ongoing process!" It is rare for a healthy disc to suddenly herniate, except in cases of severe trauma such as a motor vehicle accident (13).
In part two “Sciatica – Causes and Diagnosis” we will discuss non-discogenic causes of Sciatic. This includes fibrous band tethering and direct compression. We will also include a section on physical examination tests that we use to evaluate cases of Sciatica.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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References - Part 1
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Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain. N Engl J Med 1994; 331:69-73.
Borenstein DG, O'Mara JW Jr, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects. J Bone Joint Surg Am 2001;83-A:1306–1311.
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Taylor CS, Coxon AJ, Watson PC, Greenough CG. Do L5 and s1 nerve root compressions produce radicular pain in a dermatomal pattern? Spine (Phila Pa 1976). 2013 May 20;38(12):995-8.
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.
Erwin WM, DeSouza L, Funabashi M, Kawchuk G, Karim MZ, Kim S, Mӓdler S, Matta A, Wang X, Mehrkens KA. The biological basis of degenerative disc disease: proteomic and biomechanical analysis of the canine intervertebral disc. Arthritis Research & Therapy 2015;17:240.
Rade M, Pesonen J, Könönen M, Marttila J, Shacklock M, Vanninen R, Kanka anpää M, Airaksinen O. Reduced Spinal Cord Movement With the Straight Leg Raise Test in Patients With Lumbar Intervertebral Disc Herniation. Spine, Volume 42, Number 15, 1 August 2017, pp. 1117-1124(8).
Thistle, S. (2019, April 28). Chiropractic Care for Disc Patients. RRS Education.
Gugliotta M, da Costa BR, Dabis E, Theiler R, Jüni P, Reichenbach S, Landolt H, Hasler P. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016; 6(12): e012938.
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