Sciatica

Sciatica is pain traveling from the low back or buttock down the back of the leg, along the sciatic nerve. Most often this happens because a herniated disc is pressing on a nerve root at L4-5 or L5-S1.

It is a symptom, not a diagnosis. The useful question is what is squeezing or irritating the nerve.

What it is

Pain traveling from the low back or buttock down the back of the leg, following the sciatic nerve.

The usual cause is a disc herniation pressing on a nerve root, most often at L4-5 or L5-S1. Spinal stenosis looks much the same in older patients.

Piriformis and deep gluteal syndromes can mimic it. That is why the exam matters.

How it usually presents

• Sharp, electric or burning pain down the leg, often past the knee.
• Numbness or pins and needles in one strip of skin.
• Weakness: trouble raising the foot or standing on tiptoe.
• Worse with sitting, coughing or sneezing.

How we treat it

• Find the spine level involved with an exam and, when needed, EMG and nerve conduction testing.
• Epidural steroid injection aimed at the affected root.
• Physical therapy once the acute inflammation is under control.
• Surgical referral when weakness keeps getting worse or treatment does not work.

To be assessed, call us or request an appointment. If this began with a crash or a fall, see accident and injury care.

What usually gets missed

Weakness is the finding that changes how urgent this is. It is also the one most often not tested. A patient can describe severe leg pain and get weeks of conservative care. All that time, nobody checks whether they can lift their toes or stand on tiptoe on that side.

Weakness that keeps getting worse, and any change in bladder or bowel control, turns this from a clinic problem into a same-day emergency. Cauda equina compression (pressure on the bundle of nerves at the bottom of the spine) is uncommon. But the window for surgical decompression is measured in hours. That is why we ask about it at every visit here, not only the first.

What to expect over time

Most disc-related sciatica improves over six to twelve weeks. This is one of the few areas where the scans really do improve along with the symptoms. Disc material that has pushed out gets absorbed by the body over months. Large pieces often clear up more fully than small contained bulges.

Pain that has not improved by twelve weeks, or that comes with growing muscle weakness, is the point where waiting costs more than acting. An epidural injection at that stage is not a last resort. It is what buys the window for rehab.

Sources

• Jensen RK et al. Diagnosis and treatment of sciatica. BMJ (Clinical research ed.), 2019. PubMed 31744805
• Dove L et al. How effective are physiotherapy interventions in treating people with sciatica? A systematic review and meta-analysis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2023. PubMed 36580149
• Ostelo RW. Physiotherapy management of sciatica. Journal of physiotherapy, 2020. PubMed 32291226
• Park JW et al. Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain. The bone & joint journal, 2020. PubMed 32349600