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Sciatica
Sciatica
Sciatica
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Sciatica
Other namesSciatic neuritis, sciatic neuralgia, lumbar radiculopathy, radicular leg pain
Anterior view showing the sciatic nerve going down the right leg
Pronunciation
SpecialtyOrthopedics, neurology
SymptomsPain going down the leg from the lower back, weakness or numbness of the affected leg[1]
ComplicationsLoss of bowel or bladder control[2]
Usual onset40s–50s[2][3]
Duration90% of the time less than 6 weeks[2]
CausesSpinal disc herniation, spondylolisthesis, spinal stenosis, piriformis syndrome, pelvic tumor[3][4]
Diagnostic methodStraight-leg-raising test[3]
Differential diagnosisShingles, diseases of the hip[3]
TreatmentPain medications, surgery,[2] physical rehabilitation
Frequency2–40% of people at some time[4]

Sciatica is pain going down the leg from the lower back.[1] This pain may extend down the back, outside, or front of the leg.[3] Onset is often sudden following activities such as heavy lifting, though gradual onset may also occur.[5] The pain is often described as shooting.[1] Typically, symptoms occur on only one side of the body;[3] certain causes, however, may result in pain on both sides.[3] Lower back pain is sometimes present.[3] Weakness or numbness may occur in various parts of the affected leg and foot.[3]

About 90% of sciatica is due to a spinal disc herniation pressing on one of the lumbar or sacral nerve roots.[4] Spondylolisthesis, spinal stenosis, piriformis syndrome, pelvic tumors, and pregnancy are other possible causes of sciatica.[3] The straight-leg-raising test is often helpful in diagnosis.[3] The test is positive if, when the leg is raised while a person is lying on their back, pain shoots below the knee.[3] In most cases medical imaging is not needed.[2] However, imaging may be obtained if bowel or bladder function is affected, there is significant loss of feeling or weakness, symptoms are long standing, or there is a concern for tumor or infection.[2] Conditions that can present similarly are diseases of the hip and infections such as early shingles (prior to rash formation).[3]

Initial treatment typically involves pain medications.[2] However, evidence for effectiveness of pain medication, and of muscle relaxants, is lacking.[6] It is generally recommended that people continue with normal activity to the best of their abilities.[3] Often all that is required for resolution of sciatica is time; in about 90% of cases, symptoms resolve in less than six weeks.[2] If the pain is severe and lasts for more than six weeks, surgery may be an option.[2] While surgery often speeds pain improvement, its long term benefits are unclear.[3] Surgery may be required if complications occur, such as loss of normal bowel or bladder function.[2] Many treatments, including corticosteroids, gabapentin, pregabalin, acupuncture, heat or ice, and spinal manipulation, have only limited or poor evidence supporting their use.[3][7][8]

Depending on how it is defined, less than 1% to 40% of people have sciatica at some point in time.[4][9] Sciatica is most common between the ages of 40 and 59, and men are more frequently affected than women.[2][3] The condition has been known since ancient times.[3] The first known modern use of the word sciatica dates from 1451,[10] although Dioscorides (1st-century CE) mentions it in his Materia Medica.[11]

Definition

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Sciatica often results in pain radiating down the leg.

The term "sciatica" usually describes a symptom—pain along the sciatic nerve pathway—rather than a specific condition, illness, or disease.[4] Some use it to mean any pain starting in the lower back and going down the leg.[4] The pain is characteristically described as shooting or shock-like, quickly traveling along the course of the affected nerves.[12] Others use the term as a diagnosis (i.e. an indication of cause and effect) for nerve dysfunction caused by compression of one or more lumbar or sacral nerve roots from a spinal disc herniation.[4] Pain typically occurs in the distribution of a dermatome and goes below the knee to the foot.[4][6] It may be associated with neurological dysfunction, such as weakness and numbness.[4]

Causes

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Risk factors

[edit]

Modifiable risk factors for sciatica include smoking, obesity, occupation,[9] and physical sports where back muscles and heavy weights are involved. Non-modifiable risk factors include increasing age, being male, and having a personal history of low back pain.[9]

Spinal disc herniation

[edit]
Main article: Spinal disc herniation

Spinal disc herniation pressing on one of the lumbar or sacral nerve roots is the most frequent cause of sciatica, being present in about 90% of cases.[4] This is particularly true in those under age 50.[13] Disc herniation most often occurs during heavy lifting.[14] Pain typically increases when bending forward or sitting, and reduces when lying down or walking.[13]

Spinal stenosis

[edit]
Main article: Lumbar spinal stenosis

Other compressive spinal causes include lumbar spinal stenosis, a condition in which the spinal canal, the space the spinal cord runs through, narrows and compresses the spinal cord, cauda equina, or sciatic nerve roots.[15] This narrowing can be caused by bone spurs, spondylolisthesis, inflammation, or a herniated disc, which decreases available space for the spinal cord, thus pinching and irritating nerves from the spinal cord that become the sciatic nerve.[15] This is the most frequent cause after age 50.[13] Sciatic pain due to spinal stenosis is most commonly brought on by standing, walking, or sitting for extended periods of time, and reduces when bending forward.[13][15] However, pain can arise with any position or activity in severe cases.[15] The pain is most commonly relieved by rest.[15]

Piriformis syndrome

[edit]
Main article: Piriformis syndrome

Piriformis syndrome is a condition that, depending on the analysis, varies from a "very rare" cause to contributing up to 8% of low back or buttock pain.[16] In 17% of people, the sciatic nerve runs through the piriformis muscle rather than beneath it.[15] When the piriformis shortens or spasms due to trauma or overuse, it is posited that this causes compression of the sciatic nerve.[16] Piriformis syndrome has colloquially been referred to as "wallet sciatica" since a wallet carried in a rear hip pocket compresses the buttock muscles and sciatic nerve when the bearer sits down. Piriformis syndrome may be suspected as a cause of sciatica when the spinal nerve roots contributing to the sciatic nerve are normal and no herniation of a spinal disc is apparent.[17][18]

Deep gluteal syndrome

[edit]
Main article: Deep gluteal syndrome

Deep gluteal syndrome is non-discogenic, extrapelvic sciatic nerve entrapment in the deep gluteal space.[19] Piriformis syndrome was once the traditional model of sciatic nerve entrapment in this anatomic region. The understanding of non-discogenic sciatic nerve entrapment has changed significantly with improved knowledge of posterior hip anatomy, nerve kinematics, and advances in endoscopic techniques to explore the sciatic nerve.[20][21] There are now many known causes of sciatic nerve entrapment, such as fibrous bands restricting nerve mobility, that are unrelated to the piriformis in the deep gluteal space. Deep gluteal syndrome was created as an improved classification for the many distinct causes of sciatic nerve entrapment in this anatomic region.[21] Piriformis syndrome is now considered one of many causes of deep gluteal syndrome.[20]

Endometriosis

[edit]

Sciatic endometriosis, also called catamenial or cyclical sciatica, is a sciatica whose cause is endometriosis. Its incidence is unknown. Diagnosis is usually made by an MRI or CT-myelography.[22]

Pregnancy

[edit]

Sciatica may also occur during pregnancy, especially during later stages, as a result of the weight of the fetus pressing on the sciatic nerve during sitting or during leg spasms.[15] While most cases do not directly harm the woman or the fetus, indirect harm may come from the numbing effect on the legs, which can cause loss of balance and falls. There is no standard treatment for pregnancy-induced sciatica.[23]

Other

[edit]

Pain that does not improve when lying down suggests a nonmechanical cause, such as cancer, inflammation, or infection.[13] Sciatica can be caused by tumors impinging on the spinal cord or the nerve roots.[4] Severe back pain extending to the hips and feet, loss of bladder or bowel control, or muscle weakness may result from spinal tumors or cauda equina syndrome.[15] Trauma to the spine, such as from a car accident or hard fall onto the heel or buttocks, may also lead to sciatica.[15] A relationship has been proposed with a latent Cutibacterium acnes infection in the intervertebral discs, but the role it plays is not yet clear.[24][25]

Pathophysiology

[edit]

The sciatic nerve comprises nerve roots L4, L5, S1, S2, and S3 in the spine.[26] These nerve roots merge in the pelvic cavity to form the sacral plexus and the sciatic nerve branches from that. Sciatica symptoms can occur when there is pathology anywhere along the course of these nerves.[27]

Intraspinal sciatica

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Left: Illustration of herniated spinal disc, superior view. Right: MRI showing herniated L5-S1 disc (red arrow tip), sagittal view.

Intraspinal, or discogenic sciatica refers to sciatica whose pathology involves the spine. In 90% of sciatica cases, this can occur as a result of a spinal disc bulge or herniation.[14][28] Sciatica is generally caused by the compression of lumbar nerves L4 or L5 or sacral nerve S1.[29] Less commonly, sacral nerves S2 or S3 may cause sciatica.[29]

Intervertebral spinal discs consist of an outer anulus fibrosus and an inner nucleus pulposus.[14] The anulus fibrosus forms a rigid ring around the nucleus pulposus early in human development, and the gelatinous contents of the nucleus pulposus are thus contained within the disc.[14] Discs separate the spinal vertebrae, thereby increasing spinal stability and allowing nerve roots to properly exit through the spaces between the vertebrae from the spinal cord.[30] As an individual ages, the anulus fibrosus weakens and becomes less rigid, making it at greater risk for tear.[14] When there is a tear in the anulus fibrosus, the nucleus pulposus may extrude through the tear and press against spinal nerves within the spinal cord, cauda equina, or exiting nerve roots, causing inflammation, numbness, or excruciating pain.[31] Inflammation of spinal tissue can then spread to adjacent facet joints and cause facet syndrome, which is characterized by lower back pain and referred pain in the posterior thigh.[14]

Other causes of sciatica secondary to spinal nerve entrapment include the roughening, enlarging, or misalignment (spondylolisthesis) of vertebrae, or disc degeneration that reduces the diameter of the lateral foramen through which nerve roots exit the spine.[14] When sciatica is caused by compression of a dorsal nerve root, it is considered a lumbar radiculopathy or radiculitis when accompanied by an inflammatory response.[15]

Extraspinal sciatica

[edit]
Illustration of fibrovascular bands restricting mobility of the sciatic nerve in multiple directions, like a splattering of glue

The sciatic nerve is highly mobile during hip and leg movements.[32][33] Any pathology which restricts normal movement of the sciatic nerve can put abnormal pressure, strain, or tension on the nerve in certain positions or during normal movements. For example, the presence of scar tissue around a nerve can cause traction neuropathy.[34]

A well known muscular cause of extraspinal sciatica is piriformis syndrome. The piriformis muscle is directly adjacent to the course of the sciatic nerve as it traverses through the intrapelvic space. Pathologies of the piriformis muscle such as injury (e.g. swelling and scarring), inflammation (release of cytokines affecting the local cellular environment), or space occupying lesions (e.g. tumor, cyst, hypertrophy) can affect the sciatic nerve.[27] Anatomic variations in nerve branching can also predispose the sciatic nerve to further compression by the piriformis muscle, such as if the sciatic nerve pierces the piriformis muscle.[35]

The sciatic nerve can also be entrapped outside of the pelvic space and this is called deep gluteal syndrome.[19] Surgical research has identified new causes of entrapment such as fibrovascular scar bands, vascular abnormalities, heterotropic ossification, gluteal muscles, hamstring muscles, and the gemelli-obturator internus complex.[20] In almost half of the endoscopic surgery cases, fibrovascular scar bands were found to be the cause of entrapment, impeding the movement of the sciatic nerve.[36][37]

Diagnosis

[edit]
Straight leg test sometimes used to help diagnose a lumbar herniated disc

Sciatica is typically diagnosed by physical examination, and the history of the symptoms.[4]

Physical tests

[edit]

Generally, if a person reports the typical radiating pain in one leg, as well as one or more neurological indications of nerve root tension or neurological deficit, sciatica can be diagnosed.[6]

The most frequently used diagnostic test is the straight leg raise to produce Lasègue's sign, which is considered positive if pain in the distribution of the sciatic nerve is reproduced with passive flexion of the straight leg between 30 and 70 degrees.[38] While this test is positive in about 90% of people with sciatica, approximately 75% of people with a positive test do not have sciatica.[4] Straight leg raising of the leg unaffected by sciatica may produce sciatica in the leg on the affected side; this is known as the Fajersztajn sign.[15] The presence of the Fajersztajn sign is a more specific finding for a herniated disc than Lasègue's sign.[15] Maneuvers that increase intraspinal pressure, such as coughing, flexion of the neck, and bilateral compression of the jugular veins, may transiently worsen sciatica pain.[15]

Medical imaging

[edit]

Imaging modalities such as computerised tomography or magnetic resonance imaging can help with the diagnosis of lumbar disc herniation.[39] Both are equally effective at diagnosing lumbar disk herniation, but computerized tomography has a higher radiation dose.[6] Radiography is not recommended because disks cannot be visualized by X-rays.[6] The utility of MR neurography in the diagnosis of piriformis syndrome is controversial.[16]

Discography could be considered to determine a specific disc's role in an individual's pain.[14] Discography involves the insertion of a needle into a disc to determine the pressure of disc space.[14] Radiocontrast is then injected into the disc space to assess for visual changes that may indicate an anatomic abnormality of the disc.[14] The reproduction of an individual's pain during discography is also diagnostic.[14]

Differential diagnosis

[edit]

Cancer should be suspected if there is previous history of it, unexplained weight loss, or unremitting pain.[13] Spinal epidural abscess is more common among those who have diabetes mellitus or immunodeficiency, or who have had spinal surgery, injection or catheter; it typically causes fever, leukocytosis and increased erythrocyte sedimentation rate.[13] If cancer or spinal epidural abscess is suspected, urgent magnetic resonance imaging is recommended for confirmation.[13] Proximal diabetic neuropathy typically affects middle aged and older people with well-controlled type-2 diabetes mellitus; onset is sudden, causing pain, usually in multiple dermatomes, quickly followed by weakness. Diagnosis typically involves electromyography and lumbar puncture.[13] Shingles is more common among the elderly and immunocompromised; typically, pain is followed by the appearance of a rash with small blisters along a single dermatome.[13][40] Acute Lyme radiculopathy may follow a history of outdoor activities during warmer months in likely tick habitats in the previous 1–12 weeks.[41] In the U.S., Lyme is most common in New England and Mid-Atlantic states and parts of Wisconsin and Minnesota, but it is expanding to other areas.[42][43] The first manifestation is usually an expanding rash possibly accompanied by flu-like symptoms.[44] Lyme can also cause a milder, chronic radiculopathy an average of 8 months after the acute illness.[13]

Management

[edit]

Sciatica can be managed with a number of different treatments[45] with the goal of restoring a person's normal functional status and quality of life.[14] When the cause of sciatica is lumbar disc herniation (90% of cases),[4] most cases resolve spontaneously over weeks to months.[46] Initially treatment in the first 6–8 weeks should be conservative.[4] More than 75% of sciatica cases are managed without surgery.[14] Smokers with sciatica are strongly urged to quit in order to promote healing.[14] Treatment of the underlying cause of nerve compression is needed in cases of epidural abscess, epidural tumors, and cauda equina syndrome.[14]

Physical activity

[edit]

Physical activity is often recommended for the conservative management of sciatica for persons who are physically able.[3] Bed rest is not recommended.[47] Although structured exercises provide small, short-term benefit for leg pain, in the long term no difference is seen between exercise or simply staying active.[48] The evidence for physical therapy in sciatica is unclear though such programs appear safe.[3] Physical therapy is commonly used.[3] Nerve mobilization techniques for sciatic nerve are supported by tentative evidence.[49]

Medication

[edit]

There is no one medication regimen used to treat sciatica.[45] Evidence supporting the use of opioids and muscle relaxants is poor.[50] Low-quality evidence indicates that NSAIDs do not appear to improve immediate pain, and all NSAIDs appear to be nearly equivalent in their ability to relieve sciatica.[50][51][52] Nevertheless, NSAIDs are commonly recommended as a first-line treatment for sciatica.[45] In those with sciatica due to piriformis syndrome, botulinum toxin injections may improve pain and function.[53] While there is little evidence supporting the use of epidural or systemic steroids,[54][55] systemic steroids may be offered to individuals with confirmed disc herniation if there is a contraindication to NSAID use.[45] Low-quality evidence supports the use of gabapentin for acute pain relief in those with chronic sciatica.[50] Anticonvulsants and biologics have not been shown to improve acute or chronic sciatica.[45] Antidepressants have demonstrated some efficacy in treating chronic sciatica, and may be offered to individuals who are not amenable to NSAIDs or who have failed NSAID therapy.[45]

Surgery

[edit]

If sciatica is caused by a herniated disc, the disc's partial or complete removal, known as a discectomy, has tentative evidence of benefit in the short term.[56] A modest reduction in pain is seen after 26 weeks, but not after one year (about 52 weeks).[47] If the cause is spondylolisthesis or spinal stenosis, surgery appears to provide pain relief for up to two years.[56]

For non-discogenic sciatica, the surgical treatment is typically a nerve decompression. A decompression seeks to remove tissue around the nerve that may be compressing it or restricting movement of the nerve.[57][58][59]

Alternative medicine

[edit]

Low to moderate-quality evidence suggests that spinal manipulation is an effective treatment for acute sciatica.[3][60] For chronic sciatica, the evidence supporting spinal manipulation as treatment is poor.[60] Spinal manipulation has been found generally safe for the treatment of disc-related pain; however, case reports have found an association with cauda equina syndrome,[61] and it is contraindicated when there are progressive neurological deficits.[62]

Prognosis

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About 39% to 50% of people with sciatica still have symptoms after one to four years.[63] In one study, around 20% were unable to work at their one-year followup, and 10% had surgery for the condition.[63]

Epidemiology

[edit]

Depending on how it is defined, less than 1% to 40% of people have sciatica at some point in time.[9][4] Sciatica is most common between the ages of 40 and 59, and men are more frequently affected than women.[2][3]

See also

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References

[edit]
[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Sciatica

View on Grokipedia
from Grokipedia
Sciatica is that radiates along the path of the , the longest and widest nerve in the , which originates from nerve roots in the lower () spine (L4 to S3), travels through the and , and extends down the back of each leg to the foot. Typically affecting only one side of the body, it manifests as a symptom rather than a standalone condition, often resulting from compression, , or of the or its contributing roots. The condition can range from mild discomfort to severe, debilitating , with symptoms worsening during activities like coughing, sneezing, or prolonged sitting. Common symptoms include sharp, burning, or electric-shock-like pain starting in the lower back or buttock and extending to the , calf, or foot, often accompanied by numbness, tingling (), or muscle weakness in the affected . In severe cases, it may cause difficulty controlling the leg muscles, leading to , or loss of bowel/bladder control, which requires immediate medical attention as it could indicate . The provides to the muscles in the back of the and lower while supplying sensation to the back of the , lower , and sole of the foot. The primary cause of sciatica is a herniated or bulging disk that presses on a , accounting for about 90% of cases, though other etiologies include , , bone spurs (osteophytes), , or rarely, tumors, abscesses, or hematomas. often involves both mechanical compression and inflammatory responses around the , contributing to the pain. Risk factors encompass age (peaking in the 20s–50s due to disk issues, or later for degenerative changes), , (which affects health), occupations involving heavy lifting, twisting, or prolonged sitting (e.g., truck drivers or machine operators), and sedentary lifestyles. Epidemiologically, sciatica has a lifetime of 10%–40% and an annual incidence of 1%–5%, with no significant difference and rare occurrence before age 20 absent trauma. Most cases resolve spontaneously within weeks to months through conservative management, including pain relievers, , and lifestyle modifications, though persistent or severe symptoms may necessitate epidural injections or like microdiscectomy. typically involves a physical exam, imaging (MRI or CT), and ruling out differentials like or vascular issues.

Overview

Definition

Sciatica is a medical condition characterized by pain that radiates along the path of the , originating in the lower back and extending through the hips, , and down the back of each , typically affecting only one side of the body. This radiating pain, often accompanied by sensations such as tingling or numbness in the , distinguishes sciatica as a symptom rather than a standalone . The term "sciatica" derives its name from the , the longest and widest nerve in the , which originates from the ventral rami of spinal L4 through S3 in the . This nerve travels from the through the greater sciatic , branching into the tibial and common peroneal in the lower thigh. The historical use of the term traces back to origins, with reportedly coining "sciatica" from ischios, meaning hip, to describe pain in the pelvic and leg regions associated with this nerve. Sciatica differs from lumbar radiculopathy in that it specifically involves irritation, compression, or inflammation of the or its distribution, whereas lumbar radiculopathy refers more broadly to dysfunction of a root, often at the L4-S1 levels. Although lumbar radiculopathy is the most common underlying cause of sciatica, the latter term emphasizes the peripheral nerve pathway involvement beyond the spinal root.

Signs and Symptoms

Sciatica manifests primarily as originating in the lower back or buttock and radiating along the path of the into the leg. This is often described as sharp, shooting, burning, or resembling an electric shock, varying in intensity from mild to severe. It typically affects only one side of the body and follows the distribution of the , which arises from the (L4-S3 roots) and extends from the lower spine through the buttocks and down the posterior thigh. Associated sensory symptoms include numbness, tingling (known as ), or pins-and-needles sensations in the affected leg or foot, reflecting irritation of the nerve roots. Muscle weakness may also occur, particularly in the leg or foot, impairing activities such as walking or standing on the toes. These symptoms arise due to compression or affecting the nerve's sensory and motor fibers. The pain pattern commonly adheres to the dermatomal distribution of the L5 or S1 nerve roots, with involvement most frequent at the L5-S1 level, and extends below the in the of cases, distinguishing it from localized . This radiation aligns with the sciatic nerve's pathway, potentially reaching the calf, ankle, or foot. Symptoms are frequently aggravated by actions that increase intrathecal pressure or nerve tension, such as coughing, sneezing, or prolonged sitting, and may intensify with movement like bending or lifting. Conversely, lying down in a often provides relief by reducing pressure on the nerve.

Causes and Pathophysiology

Primary Causes

The primary causes of sciatica involve compression or irritation of the sciatic nerve roots, most commonly originating from structural abnormalities in the spine or surrounding tissues. Spinal disc herniation is the most frequent cause, accounting for approximately 90% of cases, where the soft inner material of an protrudes through its outer layer and impinges on adjacent nerve roots. This typically occurs at the L4-L5 or L5-S1 levels, which bear significant mechanical stress and are prone to degeneration. Spinal stenosis, particularly , represents another major etiology, especially in older adults, resulting from the narrowing of the that entraps nerve roots. This narrowing arises from degenerative changes such as (bone spur) formation, thickening of the ligamentum flavum, or , leading to chronic compression of the pathway. Spondylolisthesis is a common cause, where one slips forward over another, narrowing the or foramina and pinching roots. Piriformis syndrome causes sciatica through extraspinal compression of the by the in the gluteal region, often due to muscle tightness, spasm, or anatomical variations where the nerve passes through or beneath the muscle. This condition is less common than spinal causes but can mimic from origins. Less common compressive causes include rare space-occupying lesions such as tumors, abscesses, or hematomas that exert mass effect on the nerve.

Risk Factors

Several non-modifiable risk factors contribute to the development of sciatica. Age is a primary factor, as degenerative changes in spinal discs and joints, such as herniation or bone spurs, typically peak between the ages of 30 and 50, increasing the likelihood of nerve compression. Previous back injuries or trauma can predispose individuals to sciatica by weakening spinal structures and promoting chronic instability. Conditions like diabetes elevate risk through associated peripheral neuropathy, which can exacerbate nerve sensitivity and inflammation along the sciatic pathway. Pregnancy represents another non-modifiable risk, particularly in later trimesters, due to hormonal changes that loosen ligaments and the added mechanical stress from weight gain. Modifiable occupational factors significantly heighten susceptibility, especially in professions involving repetitive heavy lifting, frequent twisting, or prolonged awkward postures, which strain the lower back and promote disc protrusion. Exposure to , as experienced by truck drivers or machine operators, further increases risk by accelerating spinal wear and fatigue. Jobs requiring extended sitting, such as office work, contribute by compressing spinal tissues and reducing circulation to the discs. Lifestyle choices also play a key role in modifiable risks. , defined as a (BMI) greater than 30, amplifies intra-abdominal pressure and spinal loading, thereby elevating the chances of disc herniation and sciatic irritation. impairs disc nutrition by reducing blood flow and oxygen delivery to spinal tissues, fostering degeneration over time. A , characterized by inactivity or poor , compounds these effects by weakening core muscles that support the spine.

Underlying Mechanisms

Sciatica arises from disruptions in the or its contributing lumbosacral roots, primarily through intraspinal mechanisms involving mechanical and chemical insults. compression, often from herniated intervertebral discs or , induces a cascade of pathological changes including local , perineural , and demyelination of fibers. This compression impairs axoplasmic flow and venous drainage, leading to ischemic changes and heightened mechanosensitivity along the pathway. Additionally, exposure of the to the nucleus pulposus of a herniated disc triggers chemical irritation via proinflammatory substances, such as and matrix metalloproteinases, which directly sensitize nociceptive endings without requiring significant mechanical pressure. Extraspinal mechanisms contribute to dysfunction through peripheral sites of or trauma, distinct from central spinal pathologies. at locations like the or fibrotic bands compresses the , resulting in localized ischemia due to vascular compromise and reduced endoneurial blood flow. Direct trauma, such as from pelvic fractures or prolonged surgical positioning, can cause stretch injury or contusion, leading to intraneural hemorrhage and secondary along the trunk. These processes exacerbate irritability by promoting focal demyelination and aberrant ectopic firing in sensory axons. The inflammatory cascade amplifies sciatic pain through the release of mediators from damaged disc material and activated immune cells. Herniated discs liberate cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and IL-8, alongside chemokines that recruit macrophages and neutrophils to the site, perpetuating a cycle of edema and tissue remodeling. Prostaglandins, derived from arachidonic acid metabolism, further sensitize peripheral nociceptors by lowering activation thresholds and enhancing synaptic transmission of pain signals to the dorsal horn. This peripheral sensitization integrates with neurogenic inflammation, where neuropeptides like substance P contribute to vasodilation and plasma extravasation around the nerve. In chronic sciatica, neural adaptations manifest as central sensitization, wherein repeated nociceptive input remodels spinal and supraspinal circuits, lowering pain perception thresholds. Glial activation in the spinal cord elevates markers like the 18kDa translocator protein (TSPO), indicating sustained microglial and astrocytic responses that release additional cytokines and prostaglandins, fostering hyperexcitability in wide-dynamic-range neurons. This results in temporal summation of pain (wind-up) and expansion of receptive fields, transforming acute radicular discomfort into persistent, widespread hypersensitivity. Such adaptations persist even after resolution of the initial insult, complicating symptom management.

Diagnosis

Clinical Evaluation

The clinical evaluation of sciatica begins with a detailed to assess the onset, which is often acute and unilateral, involving lumbar pain radiating to the buttock and . The duration of symptoms is evaluated to distinguish acute episodes (typically lasting weeks) from chronic cases persisting beyond three months, while pain radiation is noted for its dermatomal pattern, often extending below the along the distribution. Aggravating activities such as coughing, sneezing, prolonged sitting, or spinal flexion are inquired about, as they exacerbate nerve root irritation. Red flags warranting urgent attention include bowel or bladder dysfunction, , or progressive lower extremity weakness, which may signal requiring immediate referral. Physical examination includes provocative tests to identify neural tension. The straight-leg raise test, or Lasègue's sign, is performed by passively elevating the affected with the knee extended; it is positive if is reproduced between 30 and 70 degrees of hip flexion, indicating lumbosacral irritation, with higher sensitivity when radiates below the . The crossed straight-leg raise test involves raising the unaffected ; it is positive if occurs in the symptomatic at around 40 degrees, suggesting a central disc herniation with high specificity. The slump test assesses neural tension in a seated position through sequential maneuvers: neck flexion, trunk flexion, extension, and ankle dorsiflexion; a positive response, reproducing , indicates or dural irritation. A comprehensive follows to evaluate deficits in the L5 and S1 distributions. testing may reveal diminished ankle jerk (Achilles reflex) for S1 involvement or reduced for L4, though the latter is less common in isolated sciatica. Muscle strength is assessed, particularly foot dorsiflexion (L4-L5) and great toe extension (L5), with weakness suggesting ; patients may exhibit difficulty with heel or . Sensory testing involves light touch or pinprick along the lateral leg and dorsum of the foot for L5 or the sole and posterior calf for S1, identifying or altered sensation in these dermatomes.

Imaging Studies

Imaging studies play a crucial role in confirming pathology when clinical evaluation suggests , providing visualization of structural abnormalities that may cause nerve compression. These modalities are typically reserved for cases with persistent symptoms, neurological deficits, or failure of conservative management, as routine is not recommended for acute, uncomplicated sciatica. (MRI) is considered the gold standard for evaluating sciatica due to its superior ability to visualize soft tissues, including disc herniations, , and impingement. It uses magnetic fields and radio waves to produce detailed cross-sectional images without , allowing precise identification of the site and extent of compression on the sciatic nerve roots. However, MRI is contraindicated in patients with non-MRI-compatible implants, such as certain pacemakers or cochlear implants, due to potential risks from the magnetic field. Computed tomography (CT) scans are particularly useful for assessing bony abnormalities, such as in cases of or contributing to sciatica, especially when MRI is unavailable or contraindicated. CT provides high-resolution images of structures through the use of X-rays and computer , often enhanced with (contrast dye injection) for better delineation of the and nerve roots. A key limitation is the exposure to , which necessitates judicious use, particularly in younger patients or those requiring repeated imaging. Plain X-rays serve as an initial screening tool to detect spinal alignment issues, such as or fractures, that may underlie sciatic symptoms, though they offer limited insight into soft tissue pathology like disc herniations or nerve involvement. These radiographs are quick, cost-effective, and widely available but are not sufficient for confirming compression on their own. Electromyography (EMG) combined with nerve conduction studies (NCS) is employed to assess the severity of damage in ambiguous cases where alone does not fully explain symptoms, measuring electrical activity in muscles and the speed of signals to identify levels. These tests help differentiate involvement from peripheral neuropathies by detecting patterns in affected muscle groups. While generally safe, they can cause temporary discomfort from needle insertion or electrical stimulation.

Differential Diagnosis

Differential diagnosis of sciatica is essential to distinguish it from other conditions presenting with lower extremity pain, as accurate identification guides appropriate management and prevents misdiagnosis. Sciatica typically involves unilateral radiating pain along the distribution, often below the knee, accompanied by potential sensory or motor deficits, whereas mimics may lack this radicular pattern or involve different etiologies such as systemic, vascular, or musculoskeletal issues. Lumbar radiculopathy, frequently the underlying cause of sciatica, must be differentiated based on the extent of radiation and specific involvement; while sciatica often refers to S1 radiculopathy with pain extending below the , other lumbar radiculopathies (e.g., L4 or L5) may present with pain limited to the or calf, necessitating root-specific like MRI to confirm the level of compression. Peripheral neuropathies, such as those associated with or chronic alcohol use, typically cause symmetric, distal sensory symptoms in a stocking-glove distribution without associated or radicular pattern, contrasting with the unilateral, proximal-to-distal radiation of sciatica; can help distinguish by showing diffuse axonal involvement rather than focal root compression. Vascular conditions like peripheral artery disease produce intermittent claudication with leg pain triggered by exertion and promptly relieved by rest, often accompanied by diminished distal pulses or skin changes, unlike sciatica's pain exacerbated by sitting or coughing; ankle-brachial index testing aids in differentiation. Other common mimics include hip osteoarthritis, which causes localized groin or anterior thigh pain worsened by hip rotation and lacking radicular features, confirmed by reduced hip range of motion and radiographic joint space narrowing; sacroiliitis, presenting with buttock pain and sacroiliac joint tenderness provoked by maneuvers like compression or distraction; and spinal tumors, which lead to progressive neurological deficits such as bowel/bladder dysfunction or bilateral symptoms, requiring urgent MRI for mass detection.

Management

Conservative Approaches

Conservative approaches to managing sciatica emphasize non-invasive strategies to alleviate pain, improve function, and prevent without relying on medications or . These methods are typically recommended as first-line interventions for most patients, particularly in the acute phase, and can lead to significant symptom relief in up to 90% of cases when initiated early. Physical activity plays a central role in conservative management, with guidelines advocating the continuation of light exercises to maintain mobility and avoid muscle weakening. Patients are encouraged to engage in low-impact activities such as walking, swimming, or yoga, starting as soon as tolerable, to promote blood flow and reduce stiffness, while avoiding prolonged bed rest beyond 1-2 days, as extended inactivity exacerbates symptoms. The McKenzie method, an extension-based exercise protocol, has shown low-to-moderate certainty evidence of superiority over other interventions for reducing pain and disability in sciatica up to 6 months, by centralizing symptoms and improving spinal mechanics through repeated prone press-ups and standing extensions. Physical therapy is a cornerstone of these approaches, focusing on targeted , strengthening, and to address biomechanical contributors to nerve irritation. Stretching exercises for the and are commonly prescribed, as they help alleviate tension on the ; for instance, hamstring stretches have demonstrated effectiveness in reducing intensity in associated with sciatica, while piriformis stretches increase muscle length to decrease nerve compression. Gentle yoga poses such as the child's pose can also help stretch the lower back and glutes, potentially relieving pressure on the sciatic nerve. Strengthening core muscles through exercises like pelvic tilts and bridges enhances spinal stability, and posture promotes neutral alignment to minimize disc pressure, with overall physiotherapy interventions supported by evidence for short-term relief and functional improvement. Early incorporation of these therapies can positively influence long-term by facilitating recovery. Heat and cold therapy provide simple, accessible relief by modulating and muscle spasms. Cold packs applied for 15-20 minutes several times daily in the first 48-72 hours help numb acute pain and reduce swelling around the , while transitioning to packs thereafter—or alternating both—promotes circulation and relaxes tight muscles, with guidelines recommending low- settings to avoid burns. Lifestyle modifications further support symptom management by addressing modifiable risk factors. Weight loss is recommended for overweight individuals, as obesity is a established risk factor for sciatica, with very low-quality evidence indicating that weight reduction programs may improve pain and quality of life in related low back conditions, though direct high-quality data for sciatica remains limited. Ergonomic adjustments, such as using supportive chairs with lumbar support during work, maintaining neutral spine posture while sitting or standing, and optimizing sleep positions (e.g., side-lying with a pillow between the knees), reduce mechanical stress on the lower back and sciatic nerve, helping to prevent flare-ups. Additional natural methods that may offer relief include acupuncture and therapeutic massage. Acupuncture involves inserting thin needles into specific points on the body and has provided pain relief for some patients with sciatica according to certain studies. Therapeutic massage can relax muscles, reduce tension, and improve circulation, offering symptom relief in certain cases. These approaches may be considered alongside other conservative measures. Patients should consult a healthcare provider if pain persists beyond several weeks, worsens, or is accompanied by concerning symptoms such as severe weakness, numbness in the groin or buttocks area, or loss of bowel or bladder control, as these may require further medical evaluation.

Pharmacological Treatments

Pharmacological treatments for sciatica primarily aim to reduce and through medications that target different aspects of the condition, such as musculoskeletal strain, nerve irritation, and spasms. These are typically used as first-line options in conservative management, with selection based on symptom severity and patient factors like comorbidities. Evidence for many agents is limited, showing modest benefits over in systematic reviews, but they remain commonly prescribed due to their established role in symptom control. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are often the initial choice for alleviating sciatica-related pain and inflammation by inhibiting synthesis. Ibuprofen is typically dosed at 400–600 mg every 6–8 hours as needed, up to 2400 mg daily, while naproxen is given at 250–500 mg twice daily, up to 1000 mg. Monitoring for gastrointestinal risks, including s and bleeding, is essential, particularly in older patients or those with history; co-administration of inhibitors like omeprazole (20 mg daily) is recommended for high-risk individuals. Despite their widespread use, meta-analyses indicate only small, non-significant pain reductions compared to in the short term. For mild to moderate pain without significant inflammation, acetaminophen serves as a safer analgesic alternative, particularly when NSAIDs are contraindicated due to renal or gastrointestinal issues. It is dosed at 500–1000 mg every 4–6 hours, not exceeding 4000 mg daily to avoid hepatotoxicity. Guidelines note its limited standalone efficacy for sciatica but support its use in combination with other therapies for additive pain relief. Opioids, such as codeine or tramadol, are reserved for short-term use in severe, refractory cases due to risks of dependence, constipation, and overdose; weak opioids may be considered at low doses (e.g., codeine 30–60 mg every 4–6 hours) only if other options fail, with NICE advising against routine or long-term (>3 months) prescription. Neuropathic pain agents, including , , and amitriptyline, are employed for -related symptoms like radiating pain or in chronic sciatica. starts at 300 mg three times daily, titrated up to 3600 mg daily, while begins at 75 mg twice daily, up to 300 mg twice daily; amitriptyline is used off-label at low doses of 10–25 mg at bedtime for chronic cases, increasing to 75 mg if tolerated. These medications modulate signaling, but evidence is mixed: shows short-term pain relief in some chronic cases, whereas and amitriptyline demonstrate no clinically significant benefit over in meta-analyses, with common side effects including , drowsiness, and . They are generally trialed after NSAIDs fail, with careful monitoring for dependency risks in gabapentinoids. Muscle relaxants like are prescribed sparingly for associated muscle s contributing to sciatica discomfort, typically at 5–10 mg three times daily for short durations (2–3 weeks) to minimize . Meta-analyses confirm modest improvements in with muscle , with patients about 4.7 times more likely to report relief by day 14 compared to , though adverse effects like drowsiness occur in over half of users. Due to and limited evidence specific to sciatica, they are used adjunctively and avoided in elderly patients or those with .

Interventional Procedures

Epidural steroid injections (ESIs) deliver corticosteroids into the to reduce inflammation around the compressed , providing targeted relief for in sciatica. They are indicated for patients with persistent symptoms (typically 4-12 weeks) despite conservative management, particularly when caused by disc herniation. Transforaminal, interlaminar, or caudal approaches are used under imaging guidance ( or CT). Meta-analyses show moderate evidence for short-term (up to 3 months) reduction (mean difference ~1-2 points on 10-point VAS) and improved function, with ~50-70% of patients experiencing clinically meaningful relief, though long-term benefits (>6 months) are limited and repeat injections (up to 3-4 per year) may be needed. Risks include transient increase (5-10%), (1-3%), (<0.01%), and rare neural damage; they are contraindicated in active or . ESIs can delay or avoid in select cases but are not superior to in all reviews.

Surgical Interventions

Surgical interventions for sciatica are typically reserved for cases where conservative treatments have failed to provide adequate relief, particularly when symptoms persist beyond 6 to 12 weeks or when there is evidence of progressive neurological deficits. These procedures aim to directly address the underlying structural causes, such as disc herniation or , by relieving pressure on the roots. Common surgical options include microdiscectomy for herniated discs and for spinal stenosis, with decisions guided by imaging confirmation of nerve compression and the severity of symptoms like severe leg pain, , or numbness. Microdiscectomy is the most frequently performed surgery for sciatica caused by lumbar disc herniation, involving the removal of the herniated disc fragment through a small incision, often using minimally invasive techniques with a microscope to minimize tissue disruption. This procedure effectively decompresses the affected nerve root, leading to significant relief of leg pain in approximately 80-90% of patients, though back pain may persist in some cases as the surgery does not stabilize the spine. It is particularly indicated for patients with radicular pain confirmed by MRI showing disc material impinging on the nerve. Laminectomy, also known as decompression surgery, is employed when sciatica results from , where bony overgrowth narrows the and compresses nerve roots. In this procedure, a portion of the (the lamina) is removed to widen the and alleviate pressure, often combined with trimming of or spurs. It provides good outcomes for leg pain and function in patients with stenosis-related sciatica unresponsive to non-surgical management, with success rates around 70-80% for symptom improvement. Indications for surgery generally include persistent severe sciatica lasting more than 6-12 weeks despite conservative care, progressive motor weakness, or acute emergencies like , which requires immediate intervention to prevent permanent damage. In non-emergent cases, is elective and aimed at accelerating recovery for those with unacceptably slow improvement. Potential risks associated with these surgeries include infection (occurring in 1-2% of cases), recurrent disc herniation (5-10% for microdiscectomy), dural tears leading to spinal fluid leaks, and rare nerve or vascular injury, which may result in worsened pain or neurological deficits. Overall, complications are relatively low with modern techniques, but patients should be informed of the possibility of incomplete relief or the need for revision in a small percentage of cases.

Complementary Therapies

Complementary therapies for sciatica encompass non-invasive approaches such as , massage therapy, chiropractic manipulation, and mind-body exercises like and , which aim to alleviate pain and improve function through mechanisms beyond conventional medical interventions. These therapies are often sought by patients experiencing symptoms from lumbar radiculopathy, with evidence suggesting potential short-term benefits when used adjunctively. However, their efficacy varies, and they are generally recommended only alongside standard care due to gaps in robust, long-term data. Acupuncture involves the insertion of fine needles at specific trigger points along the body to target irritation and associated pathways. A and of randomized controlled trials found that significantly reduces intensity in the short term compared to sham treatments or no intervention, with a mean difference of -0.89 on a 0-10 visual analog scale (95% CI: -1.30 to -0.48). Another confirmed its effectiveness over analgesics for sciatica relief, reporting higher overall response rates (risk ratio 1.21, 95% CI: 1.16-1.25) and improved safety profiles, including fewer adverse events like gastrointestinal issues. These benefits are attributed to acupuncture's potential modulation of neuroinflammatory responses, though optimal protocols (e.g., session frequency) remain under investigation. Massage therapy employs manual manipulation of soft tissues to reduce muscle tension, improve circulation, and relieve pressure on the sciatic nerve, particularly in cases involving muscle spasms or tightness (such as piriformis syndrome). Evidence from systematic reviews on low back pain, including radicular symptoms, suggests massage may provide short-term reductions in pain intensity and improvements in function, though studies specific to sciatica are limited and of low to moderate quality. It is generally considered safe when performed by qualified practitioners and is recommended as an adjunctive option rather than a standalone treatment. Patients should consult a healthcare provider before initiating massage therapy, especially if pain persists, worsens, or is accompanied by neurological symptoms. Chiropractic manipulation employs high-velocity, low-amplitude spinal adjustments to restore mobility and reduce compression in the region. For acute sciatica cases, particularly those with disc protrusion, a randomized double-blind demonstrated that active manipulation provides greater relief than simulated interventions, with significant improvements in leg scores at 2 and 4 weeks post-treatment. Preliminary evidence from cohort studies also suggests that early spinal manipulation may lower the risk of subsequent opioid reliance in sciatica patients, with adjusted hazard ratios indicating a 71% reduction compared to non-manipulative care. However, its use carries risks in severe cases involving significant neural compression, such as , where manipulation is contraindicated due to potential exacerbation of neurological deficits; reviews emphasize caution and screening via before application. Evidence is stronger for acute presentations than chronic sciatica, with less robust support for long-term outcomes. Yoga and Pilates focus on gentle, controlled poses and movements to enhance spinal flexibility, , and posture, thereby reducing pressure on the . In patients with nonspecific and sciatica accompanied by disc extrusions, a of yoga therapy reported significant reductions in pain intensity and disability over 8-12 weeks, with improvements in the Oswestry Disability Index averaging 15-20 points greater than in control groups receiving usual care. Pilates exercises similarly show low-quality evidence of medium effect sizes for pain reduction in low back conditions, including radicular symptoms, through mechanisms like improved flexibility and pelvic alignment, as seen in short-term follow-up data from systematic reviews. These interventions are typically low-risk when supervised, promoting gradual progression to avoid aggravating nerve irritation. Despite these findings, substantial evidence gaps persist in complementary therapies for sciatica, including limited high-quality, long-term randomized trials assessing sustained pain relief beyond 6 months and comparisons to active controls. Systematic overviews highlight inconsistencies in study designs, small sample sizes, and unclear credibility of positive results, leading to recommendations against their use as monotherapy; instead, they should integrate with conventional approaches like for optimal outcomes. Further research is needed to clarify mechanisms, standardize protocols, and evaluate cost-effectiveness in diverse populations.

Outcomes and Prevalence

Prognosis

The prognosis for sciatica is generally favorable, with most cases resolving spontaneously or through conservative care without long-term sequelae. Approximately 80-90% of patients experience significant improvement or full resolution within 12 weeks, and the majority show substantial relief within 4 to 6 weeks. Chronic sciatica, defined as persistent symptoms beyond this period, occurs in fewer than 10% of cases, often linked to underlying structural issues like unresolved disc herniation. Several factors influence recovery trajectories, including patient demographics and clinical characteristics. Younger age is associated with faster resolution, as older individuals may face delayed due to reduced tissue repair capacity. The absence of comorbidities, such as or , similarly improves outcomes by minimizing secondary nerve irritation or . Early intervention enhances recovery rates. Complications, though uncommon, can impact quality of life if not addressed promptly. Chronic pain syndrome may develop in refractory cases, leading to ongoing neuropathic discomfort and functional limitations. Foot drop, resulting from prolonged sciatic nerve compression and associated weakness, can cause gait instability and requires targeted rehabilitation. Post-surgical recurrence of symptoms occurs in a subset of patients undergoing discectomy or laminectomy, often due to re-herniation or scar tissue formation. Emerging regenerative therapies offer hope for improving prognosis in persistent cases. Platelet-rich plasma (PRP) injections, which deliver growth factors to promote disc repair and reduce , have shown promise in small randomized controlled trials from 2023 to 2025, with participants reporting reduced pain and improved function compared to standard care. These approaches may lower the risk of chronicity, though larger studies are needed to confirm efficacy.

Epidemiology

Sciatica has a lifetime prevalence ranging from 10% to 40% among adults, with annual incidence rates estimated at 1% to 5% in the general population. Point prevalence estimates vary widely across studies, from 1.2% to 43%, reflecting differences in diagnostic criteria and populations studied. These figures indicate that sciatica is a common condition, particularly as a complication of low back pain, affecting approximately 20% to 40% of individuals with low back pain episodes. Demographically, sciatica peaks in incidence during the 30- to 50-year age group, with rare occurrences before age 20 unless associated with trauma. There is no significant difference. Occupational patterns reveal higher rates among manual laborers and those in physically demanding jobs, where annual incidence can reach 34% in high-risk categories compared to 2.2% in the general . Geographically, prevalence is elevated in industrialized nations such as the , , and , mirroring patterns in due to factors like aging populations and occupational exposures. Recent trends indicate a with rising rates, with and identified as independent risk factors for sciatica across genders, contributing to increased cases globally since 2020. As of 2025, market forecasts project continued growth in affected populations through 2034, driven by these demographic and lifestyle shifts.

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