Sciatica

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What is Sciatica?

Sciatica is a description for leg pain which is due to an irritated nerve in the lower back. It is a symptom, not a diagnosis, in the same way that having a runny nose is a symptom of a cold (diagnosis). The commonest cause of sciatica is due to a bulging interverterbal disc, which is a rubbery shock absorber sitting between each bone in the spine.

Medication (short term)

Pain Killers are most effective when combined. Make sure that you have no medical problems which stop you from taking certain pain killers (eg allergy, stomach ulcer, kidney trouble).
Nerve-specific pain killers which can really help with sciatica pain include the anti-epilepsy medications, including gabapentin or pregabalin. The antidepressant amitriptyline is also commonly recommended by doctors. Click links below to NHS sites with more information about these medications

Gabapentin and Pregabalin

Back brace

As a short-term measure, back braces can be very useful. Even though they provide only a modest amount of support to the lower back, they can be useful in helping to reduce both back pain and leg pain in the short term. Braces can help with reducing the need for regular pain killers, or  for when you anticipate that an activity such as housework is likely to aggravate your back pain. There is no scientific evidence to prove that back braces provide any improvement in back pain and, as such, they are not recommended by NHS advice sites. There is a thriving back brace industry, however, with sites such as Amazon allowing unbiased feedback from buyers- this online feedback speaks for itself.

Exercise

Robin McKenzie is a famous physiotherapist who wrote the best-selling book called “Treat Your Own Back”. The focus of many of these home-based exercises is on spinal extension.

This makes sense, since most movements that we make are in the a flexion position, from sitting, to reaching for objects. The only extension-based movements that we are likely to make are if we hang washing on a washing line, or if we have overhead shelves where we reach upwards. There is a separate article which looks at how our flexion muscles are used all the time, but we unwittingly let our extension muscles waste away, creating an imbalance in the way our spines are loaded.

Another movement that we tend to ignore is spinal rotation, choosing instead to move the whole body in a clockwise or anticlockwise position. Over time, this leads to loss of rotation, from the neck where this loss is more obvious, to the lumbar spine, where the stiffened joints at the back of the spine cause back pain.

Spinal manipulation

A chiropracter, osteopath and many physiotherapists apply manipulation which sometimes works wonders for sciatica. It’s important to follow up this intervention with exercises.

Back stretches

Gradually build up the amount of exercise that you can do as the sciatica starts to ease, which typically happens within six weeks of symptom onset. Non-impact exercise is probably best as some scientific publications suggest that jogging tends to aggravate back pain. A cross-trainer machine is usually found in a typical gym which provides a cardiovascular work out while keeping good posture (don’t stoop or slouch when you get tired!)

Spine-friendly classes

Yoga, pilates, Tai Chi, to name just a few of the types of group exercise classes that focus on core musculature, but also on spinal posture.
Please refer to the Spinal News section of this website for articles written by spinal professionals about exercises for the spine. Also, the Directory page is ever-expanding with links to local classes.

MRI

MRI is a 25-40 minute risk-free investigation (if you have no contraindications such as a pacemaker or other non-removable metallic objects near sensitive structures in the body), which shows us the state of the spinal intervertebral discs, how much room is available for the spinal nerves and what muscles around the spine are being used regularly (reflected by the bulk of the muscle and whether there is any fatty infiltration). It is useful for helping to establish the cause of sciatica, but also whether postural or mechanical issues have led to the current sciatica symptoms. These observations can help to both treat the immediate cause of the sciatica, but also guide long-term postural alignment and exercises, to reduce the risk of further sciatica episodes in the future.

Infection

Rarely, sciatica can be related to spinal infection, with infective tissue or pus compressing or irritation nerve roots, either within the spine itself, or in the psoas muscle where the spinal nerves create a network of nerves to the periphery, including the sciatic and femoral nerves. MRI is the most sensitive method of detecting spinal infection, but other types of images can be useful too, including nuclear medicine bone scans (less specific compared with MRI).
People who are at a higher risk of spinal infection include those who have recently had an invasive spinal procedure such as surgery or an epidural injection, people with diabetes, people who take long-term steroids and people who have a less robust immune system for various reasons such as chemotherapy or alcoholism.

Cancer?

People with known cancer are at risk of having the cancer spreading to the spine. This situation, called spinal metastasis, begins as increasingly severe back or neck pain, which doesn’t get better. With time, the pain spreads to include an arm or leg, depending on the location of the spinal metastasis. This situation is an emergency requiring prompt MRI investigation, since if the metastasis is treated before it gets very large, the treatment of the metastasis tends to be less complicated and has a higher chance of success in avoiding long term disability. The types of cancer that are more likely to spread to the spine include lung cancer, breast cancer, prostate cancer, thyroid cancer, malignant melanoma and the bone marrow malignancies such as multiple myeloma or lymphoma.

Cauda equina syndrome?

Cauda equina syndrome is a rare symptom indicative of significant pressure on the nerve which supply the bladder and bowel (cauda equina compression). As the nerves to the bladder and bowel are fragile, then any pressure on them should be removed as quickly as safely possible, to reduce the risk of long-term continence issues.

The symptoms relating to cauda equina syndrome include sciatica, reduced sensation in the saddle area (perineum, private parts, genitalia), hesitancy when trying to pass urine, poor flow of urine, the feeling of incomplete bladder emptying, loss of the ability to gain an erection in males.
Cauda equina syndrome is recognised as an alarming condition requiring prompt MRI investigation and, if the MRI confirms cauda equina compression, then emergency management from a spinal surgical service.

The Society of British Neurologic Surgeons and British Association of Spinal Surgeons have jointly published a one page summary outlining the correct management of suspected cauda equina syndrome.

Here’s the link to download the article:​​ UK standard of care for suspected cauda equina syndrome 2016

This is an MRI of the lumbar spine, showing the spontaneous resolution of a slipped disc. The vast majority of slipped discs spontaneously improve, but the problem tends to repeat itself if the spine isn’t properly balanced by paying attention to posture and good alignment.

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