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MY SCIATICA HURTS!

Q: I’ve had sciatic pain down the back of my right leg for 2 weeks. What should I do?

I’m glad you asked!

I’ll respond based on my training and experience as a physical therapist and will talk you through a conservative approach to managing acute sciatica.

Here’s a link if you want to know more about me…
http://www.myblankhurts.com/aboutus-bios.php

What is sciatica anyway?

Sciatica is pain, tingling, or numbness caused by an irritation of the nerve roots of the sciatic nerve. The sciatic nerve is formed by the nerve roots exiting the spinal cord of the lower back. Branches of the sciatic nerve extend through the buttocks and down the back of each leg to the ankle and foot. The pain, tingling or numbness often extends from the low back, to the buttocks and the back of the upper and lower leg (though it’s possible for back pain to be absent). The lower down the leg the pain extends, the more significant the involvement typically. The pain can be one sided (unilateral) or two sided (bilateral), though most often it is unilateral.

What causes sciatica?

It’s most commonly caused by:
1. Herniated intervertebral disc / discs (herniated nucleus pulposus - HNP) - the center (nucleus) of the cushion (the disc) between the vertebra of your spine seeps out of it’s normal confines, causing the disc to bulge. If the bulge of the disc is significant enough, it pushes out into areas normally occupied by the nerves, thus irritating / compressing the sciatic nerve roots in the low back. This disorder is rarely associated with a single injury or incident; it is caused by the accumulated effects of months or even years of forward bending and lifting and / or sitting in a slumped, forward bent posture.
2. Spinal stenosis - bone abnormality that narrows the spinal space causing vulnerability to inflammation of the disc, which can create pressure on the nerve. Spinal stenosis occurs more commonly in older adults.
3. Piriformis syndrome - compression of the sciatic nerve as it passes through the piriformis muscle of the hip.

Other potential causes include facet joint osteoarthritis or other arthropathies (spinal joint diseases), spinal cord infection or tumor, or spondylolisthesis (spinal degeneration that leads to instability and resultant shifting of vertebrae on each other).

According to the AAFP (American Academy of Family Practice www.aafp.org), only 4% of back pain patients actually suffer from sciatica. Of those with sciatica, only 1% has bladder involvement and / or symptoms down both legs.

Who can help?

A first step in taking care of the pain is to obtain a proper diagnosis of the problem and its cause. Any of the following clinicians should be able to assist with a diagnosis and treatment recommendation:

Family practice doctor
Internist
Osteopath
Orthopedist
Chiropractor
Physical therapist

What is the evaluation like?

The clinician should do a physical examination and ask you a number of important questions regarding your pain and overall health which will help her determine the need for diagnostic tests such as x-rays, CT scan or MRI. Some clinicians advocate x-ray and / or MRI, while others, especially if you are otherwise healthy and with insignificant history, will recommend conservative treatment for 6 weeks, and then x-ray and MRI testing only if your pain doesn’t improve.

What will make it better?

Once any potential red flags from the evaluation are addressed and emergency medical causes are ruled out such as cauda equina syndrome, tumor or infection, and the most likely cause has been determined, conservative care is recommended for at least the first 6 weeks. Should symptoms not improve or should they worsen, you should be further evaluated for steroid injections or surgery.

What is conservative care?

1. Ice and / or heat
2. Acetaminophen (Tylenol) or NSAIDS (non-steroidals like Advil)
3. Normal activities of daily living as long as symptoms do not worsen
4. Prescribed exercise program incorporating flexion or extension and stabilizing (depending on the cause)
5. General fitness that incorporates aerobic and stretching exercises that do not worsen the pain
6. Ergonomics education (lifting and posture training) to minimize exacerbation
7. Spinal joint mobilization (physical therapists, osteopaths, chiropractors)
8. Spinal manipulation (perhaps osteopaths and chiropractors)
9. Return to work
10. Close clinical monitoring
11. Self-care education

I would start with a PT, and one that is an orthopedic certified specialist or has been practicing in orthopedics for 5+ years. These therapists see A LOT of sciatica. You can find a local PT that is a member of the American Physical Therapy Association by going to www.apta.org. On the home page you’ll find a “find a PT” button.

Potentially helpful products:

Lumbar roll – DEPENDING ON THE CAUSE of your sciatica, a lumbar roll can help to keep the spine in a more optimal position to relieve pressure on the nerve roots when sitting at your desk, in your car, and at home.
I found one here at Relax the Back for 17.95

And another here at The Price Saver for 12.95

Body pillow – A body pillow can help keep the pelvis and spine in its best position for relief during sleep. A physical therapist can help with the best position DEPENDING ON WHAT’S CAUSING your sciatica. I found some at Bed Bath and Beyond here
And at Relax the Back here

Treat Your Own Back by Robin McKenzie, PT – Robin McKenzie is a PT that developed a back exercise program that can be very successful for patients with sciatica, depending on the pathology. Her method can be especially effective for patients with herniated discs, but can cause more pain for patients with spinal stenosis. Many physical therapists are trained in the McKenzie method. This book is intended for self-care. I think it’s best used in conjunction with a physical therapist.

Helpful Videos:

Here’s a link to an intro to McKenzie exercises on You Tube

Dr. Aaron Filler MD, PhD
Dr. Filler has an MD from the University of Chicago, a PhD from Harvard University, and is also a Fellow of the Royal College of Surgeons in England. He is an expert in spine and nerve pain based in Santa Monica, CA. www.nervemed.com

These two videos are produced by Dr. Filler for commercial and educational purposes. He has plenty of plugs for his practice, his technologies and techniques, but at the same time, he is an expert in his field and in these videos he provides a good deal of insight about back pain, sciatica, its causes, and options. He calls Piriformis Syndrome one of the most under diagnosed causes of sciatica, and the reason for many unsuccessful back surgeries.

Piriformis Syndrome Video

Do You Really Need Back Surgery Video

Other helpful sites:

Medline Plus – from the National Library of Medicine and National Institutes of Health
http://www.nlm.nih.gov/medlineplus/

You can learn more about sciatica at My Blank Hurts! by clicking here

Good luck, and good health!

Meredith Soelberg, MPT, MBA