Sciatica

Writer: Dr Harold Gunatillake FRCS
Contributor to e Magazines, Sunday Sri Lankan Newspapers, Expatriate tabloids websites, and others

At some stage or other during your active years, some may get sciatica. Sciatica or sciatic pain starts on one side of the lumbar spine (lower back), and radiates down the back of one of the lower extremities. You never experience sciatic pain bilaterally. It is a pain resulting from pressure or irritation of the sciatic nerve, a large nerve extending from the lumbar region, along the back of the thigh and supplies motor fibers to the muscles of the thighs and legs.  The picture (courtesy WebMD) shows the position and the distribution of the sciatic nerve.

The common symptoms of sciatica are important to know to differentiate the excruciating pain from other similar pains in the region. Sciatic pain shoots down or as we call it radiates along the back of the leg. Such pain is worse on sitting, as the nerve tends to stretch in that position. Walking, lying down, and movements that extend the spine (such as shoulder lifts) may relieve symptoms.

Early stages the pain may be mild and tingling or burning down the leg, is more common due to irritation of the sciatic nerve at its root.
If adequately not treated at this stage, weakness, numbness, or difficulty moving the leg or the foot may be noticed.

Shooting pains make it difficult to stand up from the sitting position. Lying down in bed in certain positions the pain may subside.

Sciatic pain originates suddenly; most times you are not aware how it originated. Most situations it lasts for a few weeks and disappears, to recur again, with similar trigger movements.

Most people who get sciatica are between the ages of 30 and 50. Women develop the problem during the time of pregnancy due to pressure on the sciatic nerve from the developing uterus. The worst situation is after bending with the knees kept straight and lifting some heavy object, or in older people due to degeneration of the lumbar vertebrae.

Unless you seek specialist treatment the condition could be debilitating and become permanent. Proper examination by a specialist is required with necessary investigations to diagnose and management

Spinal Stenosis
Quite a common condition seen these days is spinal stenosis, diagnosed through a MRI scan. This is a situation where the spinal canal which encloses the lower end branches of the spinal cord, can get narrowed causing pressure on the nerves. Immediate decompression of the bones from behind may be required without delay, before permanent vascular supply is cut off to the nerve sheaths.

Another uncommon condition that causes sciatica is Spondylolisthesis, a condition in which one vertebra slips forward over the one below, commonly at Lumbar 5 and Sacral 1 segment disc space.

Herniated disk

In the forward bent position to lift objects (flexion) the vertebrae seems to get open at the back bordering the spinal canal. This open situation of the vertebra makes the spine unstable and the disks could herniate (bulge) into the canal, and cause direct pressure on the nerves that branch out of the lower end of the spinal column. We call this a process of herniation of the disk, which  really cushions between vertebrae for flexible mobility of the spine. These disks also get weaker as you age and become more vulnerable to injury. These disks have a collection of gel in the center (core) and invariably gets pushed out (herniated) through its outer lining and presses on the roots of the sciatic nerve. The above picture (courtesy WebMD) shows clearly a disk that has herniated and pressing on the spinal cord.

In most situations the local symptoms are minimal and may subside within weeks to recur on further similar flexion movements of the spine.

Learn to flex at the hips and knees before bending to lift objects. This relaxes the hamstring muscles at the back of the thigh, joining the hip bones to the back of the upper tibia bone, at the knee joint.

Piriformis Syndrome

The piriformis is a muscle found deep inside the buttocks within the pelvic bones. . It connects the lower sacral segments to the upper thighbone (hip) and runs directly over the sciatic nerve. If this muscle goes into spasm, it can put pressure on the sciatic nerve, triggering symptoms of sciatica. Piriformis syndrome is more common in women
A fat wallet in your hip pocket can trigger pressure on the piriformis muscle and cause the syndrome.

Preventing Sciatica
If you've had sciatica once, there's a chance it will return. But there are steps you can take to reduce the odds:

  • Exercise regularly.
  • Maintain good posture.
  • Avoid sitting position as much as possible
  • Bend at the knees to lift heavy objects and keep your back straight.
  • Keep an object close to you. The farther away you hold it from your body, the more it stresses your back.
  • Never hold an item higher than your armpit or lower than your knees.
  • Don't move something that weighs more than 20% of your body weight.
  • Don't pivot, twist, or turn while lifting..

These steps can help you avoid back injuries that may lead to sciatica.
Diagnosis
Your specialist will give you a full neurological examination, and then request for an MRI, to get more information about the location and cause of the sciatic pain.

Late complications
If you find it difficult to control your bladder or bowels you need to see a specialist without delay. Bowel and bladder controls are done by nerves of the autonomic system and pressure damage to those nerves may be the cause of such symptoms.

Another late complication of sciatica is weakness and wasting of muscles of the lower extremity on the side that is affected. Loss of sensation of the skin also may be observed in certain areas.

Medications
Initially nonsteroidal anti-inflammatory drugs may relieve the pain. After being investigated by the specialist, he may send you to a physiotherapist to follow a course of spinal exercises. Pelvic traction therapy seems to relieve pain, in my experience, as such traction releases pressure on the spinal cord and the herniation of the disk may revert back.
Warm showers help to relieve the pain. (Tip- bend your back and let warm water fall on the lumbo-sacral region, for immediate relief)
Sometimes local steroid injections into the tender areas may relieve the pain.

Surgery
Serious mistakes most people go through are due to the fear of the knife and decide on alternate  therapies, including chiropractic adjustments, acupuncture, massages, and herbal medications and so on. When the specialist suggests the only option to relieve the pain is surgery and removing a portion of the herniated disk pressing on the sciatic nerve, most patients would delay the procedure as much as possible, and then trying the above alternate procedures for years, sometime. Most of them go in search of famous ayurvedic physicians for oils and ‘pattus’ which are of no avail with disk herniation.

The operation (laminectomy and decompression) may not be popular mainly because delaying cause permanent damage to the structures and relieving the pressure late by surgery may not be successful.

Protecting your spine
AS much as you take precautions to minimize heart disease, controlling your blood pressure, and exercise daily as part of your health program, you need to take steps to prevent damage to your spine.
You can injury your spine while playing contact sports like rugby, or training as an athlete, or playing golf. There have been many school boys who have had paralysis of spine whilst playing rugby.
Most people do sedentary jobs and at weekends do much work at home, like washing the car, cleaning the garage, mooring the lawn, and so on. These activities can cause back aches and injuries and fortunately they are temporary. Regular workouts at the gym will help to prevent such wreckage.

Exercising with an inflatable ball could be most beneficial to become mobile to prevent back injuries.
The bottom line is- keep your spine mobile by doing the proper exercises.
Do most of the spine exercises in the supine position when the spine is completely at ease.
Avoid bending down (flexing) in the upright position with knees straight. Always bend your knees and at the hips when you pick up heavy objects.

Protect your spine as much as you protect your heart.

(Some ref: to WebMD Oct 2, 2011)

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