Introduction

Sciatica is a set of symptoms including pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve, or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of the leg and foot. In addition to pain, which is sometimes severe, there may be numbness, muscular weakness, pins and needles or tingling and difficulty in moving or controlling the leg. Typically, the symptoms are only felt on one side of the body.

Although sciatica is a relatively common form of low back pain and leg pain, the true meaning of the term is often misunderstood. Sciatica is a set of symptoms rather than a diagnosis for what is irritating the root of the nerve, causing the pain. This point is important, because treatment for sciatica or sciatic symptoms will often be different, depending upon the underlying cause of the symptoms.

Sciatica falls under a more general condition of nerve entrapment, in which a nerve or nerve root is incorrectly positioned leading to pain.  If incorrectly positioned, the nerve could be compressed or entrapped leading to a wide-range of symptoms including prickling, stabbing, burning, or numbness.

How it Happens

Sciatica is generally caused by the compression of lumbar nerves, sacral nerves, or far less commonly, by compression of the sciatic nerve itself. When sciatica can also be caused by compression of a dorsal nerve root.Pseudosciatica or non-discogenic sciatica, which causes symptoms similar to spinal nerve root compression, is caused by the compression of peripheral sections of the nerve, usually from soft tissue tension in the hip or lower extremities.

Conditions

Herniation of the Spinal Disk

One cause of sciatica is a spinal disk herniation, pressing on one of the sciatic nerve roots. The spinal discs are composed of a tough spongiform ring of cartilage with a more malleable center. The discs separate the vertebrae, allowing room for the nerve roots to properly exit through the spaces between the vertebrae.  Herniation of a disc occurs when the liquid center of the disc bulges outwards, tearing the external ring of fibers, extrudes into the spinal canal, and compresses a nerve root against the vertebra, thus causing sciatica.

Spinal Stenosis

Other compressive spinal causes include spinal stenosis, a condition wherein the spinal canal narrows and compresses the spinal cord and/or sciatic nerve roots. This narrowing can be caused by bone spurs, vertebral dislocation, inflammation, or herniated disk which decreases available space for the spinal cord, thus pinching nerves from the spinal cord that travel to the sciatic nerve and irritating them with friction.

Piriformis Syndrome

In 15% of the population, the sciatic nerve runs through the piriformis muscle rather than beneath it. When the muscle shortens or spasms due to trauma or overuse, it can compress or strangle the sciatic nerve beneath the muscle. Conditions of this type are generally referred to as entrapments; in the particular case of sciatica and the piriformis muscle, this condition is known as piriformis syndrome. It has colloquially been referred to as "wallet sciatica" since a wallet carried in a rear hip pocket will compress the muscles of the buttocks and sciatic nerve when the bearer sits down. Piriformis syndrome may be the major cause of sciatica when the nerve root is normal.

Treatment

Many cases of sciatica are treated with different modalities. Evidence of effectiveness for these measures are however limited.  Some of these measures include:

• Anti-inflamatory medications
• Physical therapy and stretching exercises
• Epidural steroid injects: no long term improvements in outcomes but some short term benefits
• Non-surgical spinal decompression
• Chiropractic

Surgery

Surgery speeds resolution of pain, however two years post surgery outcomes are equivalent.

Intradiscal Electrothermoplasty

A needle is inserted into the affected disc, guided by x-ray. A wire is then threaded down through the needle and into the disc until it lies along the inner wall of the annulus. The wire is then heated which destroys the small nerve fibers that have grown into the cracks and have invaded the degenerating disc. The heat also partially melts the annulus, which triggers the body to generate new reinforcing proteins in the fibers of the annulus.

Radiofrequency Discal Nucleoplasty

A needle is inserted into the affected disc, although instead of a heating wire, a special radio frequency probe is used. This probe generates a highly focused plasma field with enough energy to break up the molecular bonds of the gel in the nucleus, essentially vaporizing some of the nucleus. The result is that 10-20% of the nucleus is removed which decompresses the disc and reduces the pressure both on the disc and the surrounding nerve roots. This technique may be more beneficial for sciatica, since nucleoplasty can actually reduce the disc bulge, which is pressing on a nerve root. The high-energy plasma field is actually generated at relatively low temperatures, so danger to surrounding tissues is minimal.

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