What to do for sciatica?

Sciatica is of all times

The ancient Greeks already wrote about sciatica, Hippocrates himself described that sciatic pain mostly affected men between the ages of 40 and 60. He also noted that these young men often recovered spontaneously after an average of 40 days. This is fortunately still the case today.

Another well-known person in the medical world, namely Domenica Cotugno, was an Italian anatomist who wrote an entire book on sciatica in 1764. From this period on, sciatica is also known as Cutogno's disease. Cotugno distinguished symptoms of sciatica from the nagging aura that can occur in conjunction with lower back pain. The radiation of muscles from the lower back is often characterized by a dull nagging pain in the region of the hamstrings(i.e., above the knee) compared to the sharp pain in the entire leg in complaints of sciatica.

The first link between the intervertebral disc and sciatica was established in the early 20th century by Schmorl and Andrae. They described bulges of the intervertebral disc in studies in cutting room in 1929. But at that time, no direct link was made to sciatica. The idea that a bulge of the intervertebral disc (herniated disc) can cause pain was not more widely accepted until Mixter and Barr demonstrated it in a study. This study led to the first successful operation on a disc herniation at Massachusetts General Hospital in America in 1932. 

Sciatica anno 2024

All these developments have led to the idea that a protrusion of an intervertebral disc can cause an inflammatory reaction in the lumbar (low back) nerve roots. This theory continues to be explored to this day but the following is now generally accepted: 

Sciatica is another term for a sharp, radiating pain in the leg. This pain can be caused by irritation of the root of the nerve in the low back, often a herniated disc. In the medical world, this is also called a radiculopathy. 

But there are other structures that can also cause radiation. So sharp pain in the leg does not always mean that the nerve root is irritated. There can also be radiation without irritation of the nerve. So having radiation in the leg certainly does not tell the whole story. 

Radiculopathy = "Radiculo" means "root" and "-pathia" means "suffering" or "disease." So, "radiculopathia" could be translated as "disease of the root" in Latin.

There are many different possible causes of leg pain. One example is irritation of the sciatic nerve. Technically, this is a peripheral nerve(the word says, in the periphery so further away). This is a nerve that is therefore further away from the spinal canal. Because the symptoms are often very similar, these complaints of the sciatic nerve and complaints of the nerve root are often put under the same umbrella.

And to make things completely easy, there are also other causes that produce exactly the same symptoms as pressure on the nerve root or complaints of the sciatic nerve. So can we still speak of sciatica when it has nothing to do with the nerve root or sciatic nerve? It may surprise you but to all these questions there exists to this day no unequivocal answer.

The various causes of radiating pain in the leg 

One of the most common causes of radiation in the leg is a herniated disc of the intervertebral disc in the low back. To be more specific, we know that about 85% of all cases involve symptoms of the intervertebral disc causing pressure on the nerve root.

But nowadays we are a lot more careful with this kind of statement. This is because we now also know that a herniated disc does not always have to give symptoms, even when there is pressure on the nerve root! When there is pain, it seems that the inflammatory process together with the proteins that are produced in the process are largely responsible. So not just simply having a bulge!

Other causes that can cause radiating pain in the leg

A common non-neurological cause of sciatica-like pain can probably be explained from the muscles in the lower back or hip. These tender spots in the muscles of the lower back and glutes can cause symptoms that radiate down the back of the leg and thus resemble sciatica.

Piriformis syndrome

This syndrome is often mentioned and described as an entrapment of the sciatic nerve by the piriformis muscle deep in the buttock. This theory is very difficult to prove and is probably based more on a theoretical construct than that this nerve can actually be trapped by the piriformis muscle. It may be easier to find evidence for Bigfoot than to say with certainty that a nerve becomes pinched in the buttock as a result of muscle tension.

In some, very rare cases, the sciatic nerve actually runs through the piriformis muscle. So this is an anatomical variation, and in this case there may be increased sensitivity of the nerve due to the piriformis muscle. This is very rare. The symptoms that produce radiation in the leg are more likely due to sensitivities from the muscle or other muscles from the buttock region. 

Trochanter pain syndrome

This describes complaints around the large bony tubercle on the side of the hip, also called the trochanter major. Several muscles attach to this location that can cause complaints. The muscles in the buttock (gluteus medius and minimus) and the piriformis as described above all have an attachment to this lump on the side of the hip.

Also located here is a bursa called the bursa trochanterica. When pain occurs, it is because one or a combination of these muscles is irritated. The pain can be provoked particularly during activities such as walking and lying on the painful side. 

It remains a tricky story

Radiation in the leg can simply have too many causes. Even when the symptoms seem to be clearly neurological, this is not necessarily the case. It is not possible to confirm symptoms from the nerve just based on the symptoms people experience.

It has always been thought that when there is pain below the knee, radiation throughout the leg or pain that runs through the leg in a particular pattern, these are good indicators of a clear nerve root problem. But from studies today, we also now know that no single symptom is exclusively linked to actual nerve root problems.

Thus, a single symptom gives us too little information about what could possibly be going on. When there are several symptoms at once, it becomes a bit more predictable but even this is by no means foolproof: 

• Pain below the knee 
• Leg pain is worse than back pain 
• Numbness or tingling in the leg

The more of these symptoms present at the same time, the more likely it becomes that the nerve root is actually involved in the symptoms. There are still people with severe radiating pain below the knee and no bulging of the intervertebral disc on the nerve root. In addition, numbness or persistent tingling in the leg is a real symptom that the nerve is involved in the symptoms. The other symptoms, namely pain below the knee and severe leg pain, can both also result from radiation from a muscle in the low back or hip region. Persistent tingling and numbness are symptoms that can only be caused by a nerve. 

The underlying message of this is that symptoms such as having or not having aura give us surprisingly little information about what is going on. Our nervous system is very noisy and messy, to say the least. The human body is a symptom-generating machine. We often think that problems cause more or less the same symptoms in everyone, but this is simply not the case. 

The mystery of nerves

Nerves genuinely make people nervous. The whole idea of people having something on a nerve makes them anxious and worried. Common questions from our practice, "Is it something with a nerve?" or "maybe it's an entrapment of a nerve"? Something that unfortunately is often perpetuated by our profession itself and other related professions. 

But you'd be surprised how difficult it is to actually pinch a nerve. Nerves have an awful lot of space in our bodies. For example, in the low back, the space where the nerve root emerges from the canal is several centimeters in size, while the nerve itself is on average only 3-4 mm thick(1).

Even with certain movements where we increase or decrease the space in the spinal canal, there remains more than enough space for the nerve. In the neck where we can naturally move even slightly more than in the low back, we see that there is a clearance of 70-130% of the original space in the spinal canal. This means that we can increase or decrease the space approximately to 30%. 

Annoying cases of sciatica?

In most cases, sciatica will recover naturally. Usually within 3 to 6 weeks. By the way, the same is true for low back pain or acute neck pain. Many people will never have to deal with sciatica in their lives after that, and in some people it will occur once or twice at most. 

It must be said, sciatica can be really annoying. On the other hand, the period when sciatica involves serious severe restrictions is often short-lived. Nevertheless, there is a chance that these symptoms may become chronic or that these symptoms may recur much more frequently. Really severe cases can be at least partially explained by some genetic predisposition. 

Research from 2010(2) has shown that certain genes may be responsible for persistent chronic symptoms. At present, it is not yet possible to screen quickly for the presence of this gene. Too bad, because at least then you would know where you stand. Let's hope for a day when science can tell us whether we belong to this small group of unlucky people. That would undoubtedly save us a lot of headaches, time and money. Imagine: no endless series of expensive therapies, quests for miracle drugs, often against our better judgment. People are still often presented with a sausage where health professionals still see it from a different angle and what turns out afterwards to be another disappointment. 

Long-term symptoms can also be maintained by our own pain system. We now know that when symptoms are present for a long time, it may affect the way the nervous system registers pain in our brain. This is also known as sensitization. The longer symptoms are present, the more sensitive people can become to pain. Think of it as a siren constantly going off at the slightest bit of discomfort. For this reason, even a harmless signal feels like an alarm bell going off in your body(3).

What are the treatment options for sciatica?

Surgical treatment of sciatica is called a microdiscectomy. Surgery is often only an option when the sciatica is caused by a herniated disc in the low back. So this will first have to be confirmed by additional examination. But even when this is the case, surgery should only be considered in extreme cases of pain and persistent symptoms. Looking a little further back in time, there are little to no differences between people who do undergo surgery for a herniated disc and those who do not. So be extremely cautious when considering surgery in the low back spine. 

Another reason to be very cautious is that a hernia does not necessarily cause symptoms. Even when a herniated disc can be seen on imaging, it is not necessarily the reason for pain. Many people have a herniated disc without symptoms in the leg or low back. And when surgery is performed anyway, beneficial effects are only seen when intervention is done very quickly. But even this actually sounds better than it actually is. These beneficial effects never last long. After 6 months, these effects are negligible. That is, if we compare the two groups, operating and not operating after 6 months we can no longer say which group was treated in which way. Even in the 8 weeks after surgery, the results of the operated group were still slightly more favorable. But again, we see that the differences are minimal. This hopefully says enough! 

So what to do in the case of sciatica?

Change your posture a lot 

When we sit we stress the same part of the spine for too long. There is nothing wrong with sitting, only the lack of variety probably makes it annoying when symptoms of sciatica are already present. Having said this: back pain and sitting have no direct relationship to each other! The many studies conducted on the subject have found no evidence of this. But if sitting for long periods of time aggravates your pain, make sure to vary your posture a lot throughout the day.

Think of it more as a factor to be avoided during recovery but certainly not a cause of symptoms. So there is no evidence that sciatica is caused by incorrect posture or a "bad" office chair. If you love luxury and comfort treat yourself to a very nice chair(probably very expensive too), but don't buy one to help you get rid of sciatica faster or prevent symptoms in the future. 

Micro breaks 

Despite the lack of link between a lot of sitting and back pain, we do recommend that you change your posture a lot and take movement breaks during periods of long sitting. Because even when sitting is not the problem, we know that exercise is the best possible way to remedy and prevent all kinds of aches and pains. 

Medication 

No form of medication, unfortunately, will be able to completely eliminate symptoms but something is better than nothing. Paracetamol often works well for both pain and fever and is one of the safest medications when you stick to the recommended dosage. But the effect in sciatica will be small with paracetamol alone.

The group of NSAIDs all reduce inflammation in the body but can potentially cause stomach upset. These include ibuprofen, diclofenac or naproxen.

An alternative to this could be voltaren ointment. Very safe to use because this does not have to pass through the gastrointestinal system. But even this is not particularly effective because of its superficial action. When using pain medication, always consult with your doctor or medical specialist to see what best suits your situation. 

Mobilizing exercises

Mobilizations are simple exercises that you can do anywhere. They are basically active stretching exercises that move your muscles and joints in a specific way. What makes it therapeutic is especially when you do it regularly in a certain prescribed way. Enough to experience the benefits of it but not too much to trigger the painful structures again unnecessarily. Find out how far you can move comfortably and try to expand this slowly. Are you suffering from persistent symptoms and want help moving your leg correctly? Then make a appointment With our knowledgeable physical therapists!

Conclusion

Sciatica is often associated with radiating pain in the leg. This radiation is caused by irritation of the sciatic nerve. Although often associated with lower back pain, it can also be a stand-alone complaint. The causes are diverse, from pressure on the nerve root from an intervertebral disc to muscle-related conditions such as piriformis syndrome.

Treating sciatica requires a multidimensional approach. Surgery is really a last resort and has shown little long-term difference compared to wait-and-see policies. The most important thing is to keep moving, create variety in posture and do mobilizing exercises to keep the muscles and joints flexible.

Although medication provides limited relief, painkillers such as paracetamol and NSAIDs can provide temporary relief. Always consult with a medical professional about proper medication use.

Furthermore, it is important to understand that sciatica is a complex condition and individual responses to treatment may be different. An active approach and maintaining a healthy lifestyle are essential for long-term management of sciatica.

Sources:

1. Torun F, Dolgun H, Tuna H, Attar A, Uz A, Erdem A. Morphometric analysis of the roots and neural foramina of the lumbar vertebrae. Surgical Neurology. 2006 Aug;66(2):148-51; discussion 151. 
2. Costigan M, Belfer I, Griffin RS, Dai F, Barrett LB, Coppola G, Wu T, Kiselycznyk C, Poddar M, Lu Y, Diatchenko L, Smith S, Cobos EJ, Zaykin D, Allchorne A, Shen PH, Nikolajsen L, Karppinen J, Männikkö M, Kelempisioti A, Goldman D, Maixner W, Geschwind DH, Max MB, Seltzer Z, Woolf CJ. Multiple chronic pain states are associated with a common amino acid-changing allele in KCNS1. Brain. 2010 Sep;133(9):2519-27. 
3. Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2-15. 

Making an appointment