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Sciatica pain can be a frustrating and debilitating condition. All too often standard treatment with medication is ineffective and surgery should be reserved as the last option. Fortunately, with recent advances in conservative sciatica treatment procedures, many chronic sciatic pain sufferers have been able to find long-term relief.
Symptoms of Sciatica:
- Buttock pain
- Thigh pain
- Lower leg or foot pain
- Weakness in the leg or foot (foot drop)
Common Causes of Sciatica:
- Disc herniations
- Piriformis syndrome
- Facet arthropathy (Arthritis)
- Disc degeneration
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A Deeper Look into Sciatica
The term sciatica is not a diagnosis but actually a description of irritation of the sciatic nerve. And yes, it can literally be a pain in the butt or the leg or even in the foot. The sciatic nerve is the largest nerve in our body. It is created by contributions from spinal nerves that originate in our low back and sacrum. Nerve fibers from L3 (lumbar) through S4 (sacral) join together and run down the back of our leg as the sciatic nerve. Just above the knee the sciatic nerve splits into the tibial nerve and the peroneal (fibular) nerve. The tibial nerve goes to the back of the leg and bottom of the foot and the peroneal nerve goes to the front of the leg and top of the foot. Because the sciatic nerve covers so much territory it can cause a wide variety of symptoms.
Symptoms of Sciatica
- Buttock pain
- Pain in the thigh
- Pain in the lower leg or foot
- Weakness in the leg or foot (foot drop)
Although the term sciatica means there is inflammation to the nerve, the most common cause of the inflammation is pressure and irritation as a result of disc degeneration and protrusion. Pathological causes such as cancer that has metastasized from the gastrointestinal or genitourinary systems as well as tumors or infection of the nerve must be tested for and ruled out. Fortunately, in the vast majority of cases the cause of the inflammation is either mechanical or compressive in nature:
Causes of Sciatica
Mechanical – Mechanical inflammation is caused by abnormal alignment and motion of the spine and pelvis or impaired strength and stability of the immediate and supportive musculature.
Compression – Compressive inflammation is caused by disk, ligament or bone causing pressure on the nerves or spinal cord.
There are a number of conditions that can cause compressive lesions. Because the terminology used is often a source of confusion to sciatica sufferers, I am including the following list of frequent offenders with a brief description:
Stenosis – This is a narrowing of the spinal canal (where the spinal cord is located) or the intervertebral foramen (where the nerve exits). Stenosis of the spinal canal, often called central stenosis is diagnosed by measuring the size of the canal from front to back. A dimension of 13 mm or more is considered normal. 10 to 13 mm is considered relative central stenosis and 9 mm or less is considered absolute stenosis. Central stenosis can be congenital or degenerative. Congenital means that it grew that way. Degenerative means that over time wear and tear has caused disc bulging, arthritic development in the joints, swelling of the ligaments or a combination of these factors that has resulted in stenosis.
Spondylolisthesis – The literal meaning is slippage of the vertebra. The slippage can be due to a separation between the front and back portions of the vertebra in what is called a” pars defect.” It also can be from degeneration of the joints in the back of the spine, called facets. The slippage of the vertebra can cause compression of spinal cord and stretching of the spinal nerve roots.
Facet Arthropathy/Arthritis – This describes additional bone deposits in the small directional joints in the back of the spine, the facet or zygapophaseal joint. Once again, excessive stress causes degeneration of the joints and the body’s response is to fortify the overtaxed joint by depositing more bone. Facet arthropathy, as mentioned before can be a contributing factor to spinal stenosis or it can create sciatica all on its own by directly irritating the exiting nerve.
Piriformis Syndrome – In this condition the sciatic nerve is irritated by compression from the piriformis muscle. The piriformis muscle lies deep in the gluteal muscles and its primary action is to rotate the leg outwards. It is estimated that in 15% of the population the sciatic nerve actually pierces the piriformis muscle making it more susceptible to compression. Compression of the sciatic nerve by the piriformis muscle is classified as an entrapment neuropathy. One cause of entrapment neuropathies that you won’t find on Wikipedia is Functional Neurologic Imbalance. Functional Neurologic Imbalance can cause increased posterior pelvic muscle tone. The tone (tension) of the piriformis muscle as well as the gluteal and other posterior muscles of the pelvis is regulated by the part of our brain stem called the pontomedullary reticular formation, PMRF for short. When the PMRF is over active it can produce increased contraction in the posterior pelvic muscles that in turn can compress and irritate the sciatic nerve.
Diagnostic Procedures to Determine the Cause of Sciatica
Physical Examination – Solving a mystery requires carefully gathering all of the available facts that pertain to the case. Likewise, the place to start to solve the mysterious cause of sciatic pain is with a thorough history. Additionally, specific biomechanical, orthopedic and neurologic test should be performed. Careful examination will reveal signs of tension or compression on the sciatic nerve. Special attention should be given to subtle or gross losses of muscle strength. In particular the strength of muscles that lift the toes and foot, turn the foot in and out, and push the toes and foot down, as these are powered by the nerves that are most commonly affected in sciatica. Muscle stretch reflexes (deep tendon reflexes) of the upper and lower extremities should be tested. Sensation should be tested with respect to light touch, pain/temperature and vibration where indicated. Pathological tests should be performed to rule out lesions of the spinal cord or brain. Where neurogenic or vascular claudication is suspected as the underlying cause to leg pain, specialized tests for vascular compromise should be performed. When the common causes of sciatica are not supported by the standard tests it is necessary to use more discriminative functional testing. Evaluation procedures employed by Functional Neurologists can be particularly beneficial. As mentioned previously in the overview on piriformis syndrome, imbalances in our central nervous system (cerebral hemispheres, brainstem, cerebellum and spinal cord) can adversely affect the tone of our musculature and posture. This cause of sciatica and a host of other pain syndromes frequently go undetected since these evaluation procedures are unknown to most health care providers. (For more information on Functional Neurology please check the “Patient Resources” button on the toolbar on this website).
Diagnostic Imaging and Special Testing – Once a thorough history and physical examination have been completed, recommendations can be given for diagnostic imaging and special testing where indicated. The most common tests for sciatica sufferers are as follows:
- Electrodiagnostic studies. EMG/NCV
Treatment for Sciatica Sufferers
Once all of the appropriate evaluation and testing has been completed, an accurate working diagnosis can be arrived at. Providing that underlying pathology has been ruled out, we’re left with the previously mentioned causes of mechanical irritation and compression. Fortunately, now there are safe, effective, conservative treatments for most causes of sciatica.
Treatment for Mechanically Induced Sciatica – To review, mechanical irritation to the sciatic nerve is caused by abnormal alignment and motion of the spine and pelvis or impaired strength of the supportive musculature. The most appropriate treatments for sciatica caused by mechanical irritation are physical medicine modalities such as massage therapy, chiropractic adjustments and physical rehabilitation. Acute mechanically induced sciatica may only require a few sessions of massage therapy and instructions in stretching to be resolved. Sciatica that is being caused by compression typically is not as simple to treat.
Treatment for Sciatica Due to Compression – As I explained before, compressive inflammation is caused by disc, ligament or bone causing pressure on the nerves or spinal cord. Sciatica that is being caused by compression usually requires either surgical or non-surgical decompression. The most common surgical decompression procedure is known as a discectomy/laminectomy. This involves making an incision in the back muscles and surgically removing bone and disc material that has created the compression of the nerve or spinal cord. Non-surgical spinal decompression involves the use of a sophisticated computer controlled machine that gently stretches the spine, creating a vacuum in the disc that draws the protrusion back into the disc and away from the nerve and spinal cord. Decompression is not traction. For more information, click here.
Many chronic sciatic pain sufferers experience relapses that increase in both frequency and severity. This often is an indicator that the underlying cause of the sciatic irritation has not been addressed. What we have learned over decades of treating chronic pain sufferers is that a comprehensive three-step treatment approach is often the only answer to lasting relief of sciatica. This has led to the development of an integrated treatment approach utilizing the following:
- Non-surgical Spinal Decompression
- Massage therapy
- Class IV laser therapy
- Low/non-force spinal adjustments
- Nutritional therapy
- Physical rehabilitation
- Functional neurology
Step Number One – Reduction of pain and inflammation
The first priority in the treatment of pain condition is to address the cause of compression and inflammation. To do this we often combine the use of chiropractic adjustments, non-surgical decompression, functional nutrition, massage therapy and cold laser treatment. With a comprehensive treatment plan, once pain is under control we begin transitioning treatment to correct the underlying biomechanical problems.
Step Number Two – Correction of Alignment and Motion
Faulty biomechanics are the root cause of most cases of many pain syndromes. To address this, a combination of well researched treatment modalities collectively known as chiropractic biophysics (CBP) is employed. CBP is a crossover of chiropractic and physical therapy procedures and consists of the following:
- Mirror image exercises to retrain muscles
- Postural adjustments to restore nerve and joint function
- Postural traction to reshape ligaments
When pressure and inflammation have been reduced and alignment and motion have been improved, the final step is stabilization.
Step Number Three – Strengthening and Stabilizing
This final phase of treatment relies predominantly on physical rehabilitation and functional neurology treatments. Physical rehabilitation includes procedures you are probably familiar with such as retraining proper motion, enhancing balance and improving strength and endurance. Unless you took a detour and researched the functional neurology section of our website, this method of treatment is probably new to you. Previously I mentioned that piriformis syndrome can be caused by reduced output of the region of our brainstem known as the PMRF. Another common functional neurologic condition that can cause sciatic pain is an imbalance in the activation of our cerebellar hemispheres. The cerebellum is the back lower part of our brain and it consists of two hemispheres. The cerebellum is involved in an amazingly diverse array of neurologic functions, however, for the purpose of this example I will focus on its role in stabilization of the spine. To simplify; the left side of our cerebellum controls the tone of the stabilizing muscles on the left side of our spine and the right side controls the stabilizing muscles on the right. Research has demonstrated that the stability of our spine does not originate in the large muscles that move the trunk (the abdominal and erectorspinae muscles), but instead is controlled non-voluntarily by what are known as the intrinsic muscles of the spine. So, if the output of your cerebellum is imbalanced side to side, it is likely that the tone (tension) of your spine stabilizing muscles is also imbalanced side to side. Correction of these functional neurologic imbalances can often be accomplished through the use of safe and pain-free treatments such as:
- Eye exercises
- Vestibular (balance) therapy
- Auditory (sound) stimulation
- Joint manipulation
- Light stimulation
- Vibration therapy
Because of the complex nature of the causes of sciatica and the diverse treatments that are often necessary to successfully resolve it, sciatica is often a pain in the butt for the healthcare provider as well as the patient. Treatment with oral medication or injections is often ineffective or at best results in only temporary relief. Fortunately with the recent advances in conservative treatment procedures outlined in this article, many chronic sciatic pain sufferers have been able to find long-term relief. It is probably apparent at this point that treating sciatica successfully begins with an accurate diagnosis of its cause. If you or someone you love is suffering with sciatica I invite you to contact our office and schedule a complimentary consultation.