Sciatica

1. Introduction

  • Definition: Sciatica refers to pain radiating along the path of the sciatic nerve, which runs from the lower back through the hips, buttocks, and down each leg. It is typically caused by compression or irritation of the nerve.
  • Epidemiology: Affects 10–40% of the population during their lifetime, with higher prevalence in middle-aged individuals (40–50 years).
  • Significance: While most cases resolve with conservative treatment, severe or untreated sciatica can lead to functional disability and poor quality of life.

2. Causes and Risk Factors

  • Causes:
    • Herniated disc (most common): Protrusion compressing the sciatic nerve.
    • Spinal stenosis: Narrowing of the spinal canal.
    • Spondylolisthesis: Vertebral slippage causing nerve compression.
    • Piriformis syndrome: Spasm or tightness of the piriformis muscle irritating the nerve.
    • Trauma or tumours: Rare causes compressing the nerve.
  • Risk Factors:
    • Sedentary lifestyle or prolonged sitting.
    • Heavy lifting or twisting movements.
    • Obesity and poor posture.
    • Age-related degenerative changes.

3. Pathophysiology

  • Compression or irritation of the sciatic nerve causes inflammation and pain along its distribution. This can result from mechanical pressure (e.g., herniated disc) or chemical irritation from inflammatory mediators.

4. Symptoms and Features

  • Common Symptoms:
    • Radiating pain along the back of the leg, often unilateral.
    • Numbness, tingling, or muscle weakness in the affected leg.
    • Worsened pain with sitting, bending, or coughing.
  • Red Flags (urgent evaluation required):
    • Saddle anaesthesia.
    • Loss of bowel or bladder control (cauda equina syndrome).
    • Severe, progressive weakness in the legs.

5. Complications

  • Chronic pain and disability if untreated.
  • Muscle weakness and atrophy in severe cases.
  • Permanent nerve damage in rare instances, particularly with cauda equina syndrome.

6. Diagnosis

  • Clinical Features: History of radiating leg pain and neurological examination to identify sensory or motor deficits.
  • Imaging:
    • MRI or CT scan: For herniated disc, spinal stenosis, or tumours.
    • X-ray: Useful for detecting spondylolisthesis or degenerative changes.
  • Electrodiagnostic Studies: Nerve conduction studies to assess the extent of nerve damage.

7. Management Overview

  • Goals: Relieve pain, reduce inflammation, and restore function.
  • Approach: Combination of lifestyle modifications, conservative therapies, medications, and advanced interventions for refractory cases.

8. Treatment Options with Cost (USD)

  • Conservative Management:
    • Physical therapy: ~$50–$150/session.
    • NSAIDs (e.g., ibuprofen): ~$5–$20 per pack.
    • Heat and cold therapy: Minimal cost.
  • Medications:
    • Gabapentin or pregabalin: ~$30–$100/month.
    • Muscle relaxants (e.g., cyclobenzaprine): ~$10–$30/month.

9. Advanced Treatment Options with Cost (USD)

  • Epidural Steroid Injections: ~$1,000–$2,000 per injection for severe inflammation.
  • Surgical Interventions:
    • Microdiscectomy: ~$15,000–$50,000.
    • Laminectomy: ~$20,000–$40,000.

10. Pharmacological Treatment

  • First-line: NSAIDs or acetaminophen for pain relief.
  • Adjunctive: Gabapentinoids for neuropathic pain, muscle relaxants for spasms.
  • Severe Cases: Corticosteroids (oral or epidural) to reduce inflammation.

11. Medication Tables

Table 1: Doses and Side Effects

DrugIndicationDoseCommon Side Effects
IbuprofenFirst-line pain relief400–800 mg every 6–8 hoursGI upset, kidney issues
GabapentinNeuropathic pain300–3,600 mg/dayDrowsiness, dizziness
PregabalinNeuropathic pain75–300 mg/dayWeight gain, sedation
CyclobenzaprineMuscle spasms5–10 mg up to 3 times dailySedation, dry mouth
MethylprednisoloneSevere inflammation4–8 mg/day (oral)Weight gain, mood changes

Table 2: Brand Names and Approximate Costs (USD)

DrugBrand NamesApprox. Cost
IbuprofenAdvil, Motrin$5–$20 per pack
GabapentinNeurontin$30–$100 per month
PregabalinLyrica$100–$300 per month
CyclobenzaprineFlexeril$10–$30 per month
MethylprednisoloneMedrol$20–$50 per pack

12. Lifestyle Interventions

  • Engage in regular low-impact exercises such as walking, swimming, or yoga.
  • Maintain proper posture and ergonomic workspaces to reduce spinal stress.
  • Use supportive footwear to minimise strain on the lower back and legs.
  • Avoid prolonged sitting or heavy lifting.

13. Monitoring Parameters

  • Symptom resolution, including pain reduction and improved mobility.
  • Monitor for medication side effects, especially with long-term NSAID or gabapentinoid use.
  • Evaluate for progression of symptoms, particularly red flag signs like cauda equina syndrome.

14. Patient Counseling Points

  • Educate on the importance of staying active and avoiding bed rest, which can prolong symptoms.
  • Advise on the correct use of medications and potential side effects.
  • Explain the potential for recurrence and the role of lifestyle changes in prevention.
  • Discuss when to seek immediate medical attention for red flag symptoms.

15. Special Populations

  • In Elderly: Increased risk of medication side effects (e.g., NSAIDs and renal impairment); use lowest effective dose.
  • In Pregnancy: Avoid NSAIDs; focus on physical therapy and lifestyle adjustments.
  • In Athletes: Gradual return to sports with tailored physical therapy programs.

16. Prevention

  • Regular exercise to strengthen core and back muscles.
  • Maintain a healthy weight to reduce pressure on the spine.
  • Practice proper lifting techniques (e.g., lift with the legs, not the back).
  • Address ergonomic factors at work and home.

17. FAQs

  1. What is sciatica?
    Answer: Pain radiating along the sciatic nerve due to compression or irritation.
  2. What causes sciatica?
    Answer: Common causes include herniated discs, spinal stenosis, or piriformis syndrome.
  3. How is sciatica treated?
    Answer: Through medications, physical therapy, and in severe cases, surgery.
  4. Can sciatica go away on its own?
    Answer: Yes, most cases resolve within a few weeks with conservative care.
  5. What exercises help sciatica?
    Answer: Stretching exercises like the piriformis stretch or gentle yoga.
  6. What are red flag symptoms of sciatica?
    Answer: Saddle anaesthesia, bowel/bladder incontinence, or severe leg weakness.
  7. How is sciatica diagnosed?
    Answer: Based on clinical symptoms and confirmed with imaging like MRI.
  8. Are steroid injections effective for sciatica?
    Answer: Yes, they can provide temporary relief for severe inflammation.
  9. Can sciatica recur?
    Answer: Yes, especially if underlying causes or risk factors are not addressed.
  10. What is the role of surgery in sciatica?
    Answer: Surgery is reserved for severe cases with persistent pain or neurological deficits.
  11. Can sciatica affect both legs?
    Answer: Rarely, bilateral symptoms may indicate more severe conditions like cauda equina syndrome.
  12. Is bed rest recommended for sciatica?
    Answer: No, staying active is more beneficial for recovery.
  13. How long does sciatica last?
    Answer: Most cases improve within 4–6 weeks.
  14. Can weight loss help with sciatica?
    Answer: Yes, reducing weight decreases pressure on the lower back.
  15. Are alternative therapies like acupuncture effective for sciatica?
    Answer: Some patients find relief, but evidence is limited.