Sciatica or sciatic pain can be debilitating. If you are suffering from it, you would know exactly what I mean.
Today we will discussed sciatica and what you can do about it to help yourself.
What is sciatica?
For most parts, medical journals and textbooks agree that sciatica is nerve pain in the legs or buttock region that is commonly caused by herniated discs in the lumbar spine.
Lumbar disc herniations typically occur on one or two spinal levels. This means it will only compress, if applicable, 1-2 nerve roots.
The sciatic nerve, however, is formed from five nerve roots (L4, L5, S1, S2, S3) and the nerve itself doesn’t start before the pelvis.
This is where sciatica becomes a terribly confusing term.
If sciatic pain is pain from the sciatic nerve, then a lumbar disc herniation cannot cause sciatica because the sciatic nerve cannot be found around the lumbar spine.
The preferred, and more accurate term, to describe sciatic pain is radiculopathy.
This is why sometimes you may hear medical doctors or chiropractors referring to your symptoms as a lumbar radiculopathy.
They are not trying to be difficult. They are trying to be more accurate.
Patients with lumbar nerve root compression (radiculopathy) typically describe their symptoms as a radiating or sharp, shooting pain at the buttock or leg. Some patients may experience numbness and tingling (paresthesia) at the affected area.
While majority of patients do recover without treatment (70-80%), some patients will continue to experience significant pain and disability.
Why does my sciatic pain hurt?
Before we discuss what may help or relieve your sciatica, it is probably a good idea to have some background information on why does your sciatica hurt.
Most people are familiar with the compressed nerve roots etiology. With the compression mechanism, it is theorised that the herniated disc comes in contact with a nerve root to cause radiculopathy.
Alternatively, it is also possible for osteophyte formation (bony bumps) around the neural foramen (hole in which the spinal nerve roots exit the spinal column) to entrap spinal nerves to give the same radicular symptoms.
There are also assumptions that the pain may be from an inflammation of the nerve roots.
With all of this in mind, there are two premises to which your sciatica hurts:
• A structural, biomechanical impingement of the nerve itself
• An inflammation of the spinal nerve as a result of the impingement or irritation to the affected nerve root
Unfortunately, both mechanisms do not explain a disc herniation patient’s pain experience in full.
Here are a few things to consider:
First, with the current body of scientific literature, experts and academics agree that most radicular symptoms will resolve by themselves regardless of treatments (including no treatment).
Second, it is also agreed that disc herniations do shrink or regress over time. Curiously, while majority of the symptoms do improve as the herniation regressed (or time really, as per the previous point), not all research is about to demonstrate this relationship.
In short, it’s possible that your pain persists even though your disc protrusion have completely regressed (i.e. back to before).
Thirdly, despite the well-accepted inflammation etiology of sciatica, medication such as oral steroids and NSAIDs have never been demonstrated to be superior to placebo treatments.
If your pain is truly coming from inflammation of the nerve, then why aren’t drugs that address inflammation making patients feel better?
Tough question there!
Hopefully this give you an appreciation of the complexity of your pain experience and there are no straight answers to help with your confusion.
This is why an evidence-based approach is fundamental to achieving good treatment results.
Do I need a lumbar spine MRI?
The Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy Clinical Guideline published by North American Spinal Society did recommend for MRI imaging for patients with radicular pain symptoms.
Since then, virtually all recent guidelines have taken a 180 degrees turn to recommend AGAINST imaging in the absence of red flags.
I have discussed the details of the recommendations in Do I Need A MRI? Research consistently shows that magnetic resonance imaging can lead to unnecessary tests, referrals, and intervention, increased health care costs, worse symptoms, delayed recovery, and poorer quality of life.
It’s pretty intense! A simple seemingly harmless, radiation-free scan can open a Pandora’s box to lead to poorer treatment outcomes.
These negative effects are measurable, and repeatedly reported across multiple major studies.
Of course there are exceptions to every rule.
If you have one of the following red flags, do seek immediate medical attention. In these scenarios, it is likely that you will be referred for a MRI scan.
• Severe or progressive neurological deficits (e.g. sudden loss of strength in the legs)
• Loss of urinary or bowel control
• Fever, chills, night sweat
• Sudden weight loss
• Recent trauma
If you have been referred for imaging studies and you are not sure if that is right for you, speak to your doctor about it. Your doctor should provide an evidence-based, clinical guideline congruent rationale for their referral.
If not, seek a second opinion with another medical doctor or orthopaedist.
How do I relieve sciatic nerve pain?
This is where the gold is!
Oral steroids don’t seem to work better than placebo. A study conducted in 2015 looked at 269 patients found no difference in pain outcomes between the prednisone-treated group and the placebo-controlled group at both three weeks and one year follow up.
Interestingly, the study reported that the steroid-treatment group performed better with disability scores – a 5.6% improvement over the control group. However, a later study found that 11% was the minimum clinically important difference required for patients to be able to perceive a true difference.
In short, the statistically significant improvement in reported disability scores is not clinically meaningful enough to make a difference in the patient’s disability experience. Furthermore, there’s no difference between prednisone and placebo pills for pain.
Oral NSAIDs – Nonsteroidal Anti-Inflammatory Drugs
I am quite sure oral medication has never been demonstrated to be superior to placebo in any large study, which begs the question of why are medical doctors prescribing it?
Way back in 1993, a study looked at the effects of Piroxicam in a group of 208 patients found that the placebo-controlled group performed just as well as the medication group.
More than 20 years later in 2016, a Cochrane review — the crème de la crème health-related clinical trials — found the pain relief associated with NSAIDs treatment for sciatica to be insignificant.
In research language, insignificant means no relationship could be established (i.e. it doesn’t work).
If we are unable to demonstrate that oral medications are superior to placebo in over two decades, why is the average general practitioner still prescribing NSAIDs or oral steroids for sciatica?
It’s shocking right?
If medications don’t work, what about spinal injections?
To give some perspective on the issue, the Danish national guidelines do not recommend epidural injections of local anesthetic and steroid for lumbar radiculopathy.
The NICE guideline (United Kingdom) allows for the recommendation of spinal injection in view of that these patients would otherwise be considered for surgery.
I think the general consensus is that spinal injection is not the pain solution. However, if the injection is going to delay surgical intervention, it is worth a shot.
So, medications and spinal injection both aren’t particularly outstanding for sciatic pain patients. What about surgery?
Here is the interesting part, there is minimal, low quality evidence that surgery can improve symptoms in the short-term (6 to 12 weeks) and provided faster relief than conservative treatments.
I guess to cut or not to cut, in a longer term perspective, comes down to if you are prepared to assume the risks that come with surgery and/or the cost of treatments between surgery and conservative care.
You may think surgery is more expensive. However, most insurers have better provision for surgery (easily five-digit coverage) than conservative treatments such as chiropractic (as low as $500).
Virtually all major guidelines (US, UK, Denmark) recommended exercise!
Unfortunately, there is no fairy-tale ending here. Exercise, while found to be effective, only resulted in a small improvement. There is no evidence to suggest that some exercises are superior than others.
So, what exercises to do and how to program a recovery come down to a chiropractor’s or physiotherapist’s clinical experience to determine what is best for the patient on a case by case basis.
Anecdotally, I seem to get fairly good results among clients with long-standing radiculopathy using exercise and education alone.
I wonder if the combination of different exercises across time resulted in a cumulative effect that clinical trials are unable to account for.
Of course it’s important to note that conservative treatments are just as good orthopaedic surgeries in the longer term.
I am just going to put it out there. NICE (UK) guidelines specifically recommended against traction (or non-surgical spinal decompression) for sciatica.
We are definitely starting to see spinal decompression increasing in popularity here in Singapore. Both chiropractors and physiotherapists alike are starting to offer these expensive treatments.
I have written about why they are a good revenue stream previously.
On a more serious note, you should 100% watch the exposé CBC did ten years ago before going for a spinal decompression treatment. It’s quite mind blowing.
Other forms of manual therapy such as spinal mobilisation and other type of hands-on soft tissue therapy can be offered in conjunction with exercise. However, there is no good evidence to suggest that they are useful when used alone (i.e. without exercise).
In short, use chiropractic adjustments and the likes with exercise if you like. However, it’s 100% optional!
How to make sense of all of this information?
I know this is probably not the most enjoyable reading for sciatica.
My intention of writing this is to disseminate adequately referenced evidence-based content so you can make the right treatment choices.
For a quick summary:
• Most radicular symptoms resolve by themselves within 8 to 12 weeks.
• The disc herniation or “slipped disc” you find on your MRI is not the concern, most of them will regress over time even without treatment.
• If your buttock pain or leg pain is not going away, try conservative care first.
• Exercise works the best. However, the improvement can be small.
• There is insufficient to suggest manual therapy such as chiropractic adjustments or soft tissue therapy or stretching may help. However, they can be performed together exercise as a treatment program. Clinical guidelines do not recommend manual therapy as standalone treatments.
• Spinal decompression (non surgical) should be avoided.
• Oral medications while commonly prescribed do not work. Both oral steroids and NSAIDs not perform better than placebo.
• Epidural injections are generally not recommended but can be considered as a last resort option.
• Low quality evidence to suggest surgery provide better outcomes in the short-term. However, no difference in results between surgery and conservative care in the longer-term.
If you need additional help to navigate your sciatica, book in for an appointment with me via the form below. I provide solution-focused pain management that is congruent with all major clinical guidelines.
At Square One Active Recovery, I aim to make myself redundant to you in as little as four to seven visits.
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*We do not offer short-term pain solutions such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.