Sciatica
Everything you need to know
Sciatica is pain that radiates from the lower back along the sciatic nerve. You can probably relieve sciatica without surgery, but surgery can be effective in some cases, too. Learn your options here.
The sharp, shooting nerve pain of sciatica can take your breath away. Although sciatica is common—affecting up to 40% of adults—there are many misconceptions about what sciatica is.
Definition
What Is Sciatica?
Sciatica is not a disorder itself but is a general term used to describe the pain that occurs when nerve roots in the lumbosacral spine (low back) become compressed (pinched), irritated, or inflamed, often from a herniated disc or other narrowing of the spinal canal (called stenosis). Sciatica may be accompanied by numbness/tingling and muscle weakness.
“Sciatica means that there is irritation or a problem with the sciatic nerve that usually emanates from the low back, from the nerve roots in the spine,” explains orthopedic surgeon Jeffrey C. Wang, M.D., who is chief of the orthopaedic spine service and co-director of the University of Southern California Spine Center in Los Angeles. The nerve irritation or compression activates the sciatic nerve and causes pain and other symptoms down the leg on the path of the affected nerve, he says.
Not all radiating pain in the butt area or down the leg is sciatica. In most cases of sciatica, the pain extends down past the knee, Dr. Wang says. Also, true sciatica is caused by impingement (pinching) or inflammation of the sciatic nerve, while sciatica-like symptoms can stem from joint or muscle problems. It is important to work with your doctor to determine the cause of sciatica to find the best treatment to relieve your pain.
Sciatic Nerve
What Is The Sciatic Nerve?
The sciatic nerve is the longest and largest nerve in the body; its diameter is about three-quarters of an inch. It originates in the sacral plexus; a network of nerves in the lower back (lumbosacral spine). The lumbosacral spine refers to the lumbar spine (lumbo) and the sacrum (sacral) combined, way down at the base of your spine and above the tailbone (coccyx).
The sciatic nerve exits the sacrum (pelvic area) through a nerve passageway called the sciatic foramen. At the upper part of the sciatic nerve, two branches form; the articular and muscular branches. The articular branch goes to the hip joint (articular means related to a joint). The muscular branch serves the muscles of the leg.
The sciatic nerve has several smaller nerves that branch off from the main nerve. These nerves—the peroneal and tibial nerves—enable movement and feeling (motor and sensory functions) in the thighs, knees, calves, ankles, feet, and toes.
Symptoms
What Are Common Sciatica Symptoms?
Sciatica is the most common symptom of lumbar radiculopathy, a condition described as pain, and sensations such as numbness or tingling, muscle weakness, or poor reflexes found along the path of a nerve.
“Radiculopathy” means irritation or injury to a nerve root that causes pain and other symptoms that radiate away from the affected nerve root. In the case of sciatica, usually the pain is felt as low back pain that radiates down the leg.
Pain is the hallmark sciatica symptom. Although sciatica symptoms may be felt anywhere along the sciatic nerve, classic sciatica radiates from the low back into the butt, and down the leg to below the knee. In fact, your doctor will usually check for sciatica if you have low back pain. Less commonly, sciatica pain may be felt starting in the buttocks or hip area and radiates down the leg.
What it feels like
What Does Sciatica Feel Like?
Sciatica pain is often described as electric, burning, or sharp. The nerve pain can vary from mild to excruciating and can worsen when you bend down, twist your spine, or cough.
Although you have two sciatic nerves (one on each side of your body), sciatica symptoms typically only occur on one side of the body. If you have radiating pain down both of your legs, it is less likely that the pain is caused by a pinched sciatic nerve, Dr. Wang says.
In addition to pain, if the sciatic nerve is compressed, the muscles it serves may become weak. It may be hard to bend your knee, bring your thighs together (adduction), and point your foot and/or toes upward or downward.
Sciatica pain has both aching and sharp components that radiate from the lower back to the middle or lower butt. It also often travels down the leg.
While many experience chronic, or nagging, pain, in some cases, people with sciatica have reported the pain as an intense, knifelike sensation that can become unbearable to the point of debilitation.
It can also feel like:
- Low back pain
- Pain in the buttocks
- Aching in the upper hip region (associated with disc ruptures)
- Pain aggravated by coughing, sneezing, or straining
- Numbness
- Weakness
- Tingling
Causes
What Causes Sciatica?
In short, anything that compresses or pinches the sciatic nerve (particularly where it exits the spine) can cause sciatica, Dr. Wang says. Some of the most common include:
- Herniated discs: The rubbery disc in between the vertebrae in the lower back may bulge or herniate, causing irritation and/or compression of sciatic nerve roots. A herniated or bulging disc is the most common cause of sciatica.
- Degenerative disc disease: With age, vertebral discs may start to wear down. If the discs become too thin, the space between each vertebra becomes compressed, putting pressure on the sciatic nerve root. If the outer covering of the discs wear down, fluid from the disc may leak out and irritate the sciatic nerve.
- Bone spurs: An overgrowth of bone (osteophyte) on the vertebrae can put pressure on sciatic nerve roots. These bone spurs often form near vertebra affected by osteoarthritis.
- Spinal stenosis: Spinal stenosis is a narrowing of the space that the spinal cord and sciatic nerve roots travel through, causing compression. This narrowing may be caused by arthritis or aging.
- Spondylolisthesis: The vertebrae are designed to be stacked one on top of the other for stability. If one vertebra in the lower back slips forward over the vertebra below it (spondylolisthesis) it can press down on the sciatic nerve.
- Vertebral fracture: The sciatic nerve can be compressed if the part of the vertebra that forms a joint (pars interarticularis) cracks or fractures, which is known as spondylolysis.
- Piriformis syndrome: The piriformis muscle typically runs on top of the sciatic nerve in the buttocks and can compress the sciatic nerve if the muscle becomes too tight. The symptoms may get worse after sitting for a long time, walking up stairs, walking, or running. The piriformis muscle is a flat band-like muscle that runs from your sacrum (the triangular bone below your spine) to the top of the thigh bone in the hip joint.
Other conditions can mimic the symptoms of sciatica, but are not truly caused by sciatic nerve impingement, Dr. Wang explains. For example, sacroiliac joint dysfunction is a joint problem in the pelvis that causes pain in the buttock that may radiate down into the upper leg.
A tight iliotibial band (the tendon that runs the length of your outer thigh) or hamstring muscle can mimic the radiating symptoms of sciatica. Additionally, “stress on the spine from pregnancy can cause radiating back pain, that is not typically sciatica in the classic sense,” Dr. Wang says.
“If radiating pain stays in the buttock area and doesn’t travel down the thigh or travels only halfway down the thigh, then it is less likely to be sciatica,” Dr. Wang says.
Another severe condition called cauda equina syndrome (often caused by a herniated disc pressing on the cauda equina nerve roots at the end of the spine) can be mistaken for sciatica. In addition to radiating pain and weakness, cauda equina syndrome may lead to bowel or bladder incontinence. Cauda equina syndrome is a medical emergency and can lead to permanent problems. See your doctor right away if you are having symptoms.
When Sciatica May Indicate a Serious Condition
While CES disorders are often caused by spinal disc degeneration, there are a number of medical conditions that are not directly related to vertebral disc problems that cause sciatica-like pain and problems.
A dislocation or fracture of the hip can stretch or compress the sciatic nerve, leading to pain and dysfunction similar to symptoms of disc-related sciatica. Similarly, a fracture in the lower spine, as well as spinal tumors, can cause sciatic nerve compression and result in pain and other sciatica symptoms. In rare cases, cancer may spread to the spine, inflaming the cauda equina nerve roots and causing symptoms similar to disc-related CES.
CES may also be caused by infections, exposure to toxins, and inflammatory issues. In particular, human immunodeficiency virus (HIV), cytomegalovirus (a common herpes virus), and tuberculosis are known to trigger CES. When infection causes CES, your immune system may overreact and cause inflammation of the sciatic nerve, causing further pain and complications.
Because the underlying conditions may present serious health issues, you should seek immediate help for any of these symptoms. Research shows that early intervention is key to minimizing CES complications. This is especially true of severe, acute cases that involve decompression of the cauda equina nerve roots.
Other serious underlying conditions that mimic sciatica and may need immediate medical attention include:
Shingles: This is a reactivation of the herpes zoster virus that can mimic sciatica on the affected leg. Although most people recover from shingles, there can be serious complications, including vision loss and bacterial superinfection of the skin rashes.
Endometriosis: Endometriotic tissue may migrate and put pressure on the sciatic nerve, causing pain.
Ovarian cysts: Large ovarian cysts may compress the sciatic nerve, causing pain in the pelvis and legs.
Uterine enlargement associated with late pregnancy: The pressure on the pelvic region caused by pregnancy can lead to forward pelvic tilt and create pain patterns similar to sciatica.
Diagnosis
How Is Sciatica Diagnosed?
When searching for the cause of sciatica symptoms, spine specialists “usually start with the spine just because the most common cause of sciatica is pinching or compression of the sciatic nerve roots in the spine, most commonly from a herniated disc,” according to Dr. Wang.
Your doctor will take a medical history and ask questions such as what makes the symptoms feel better or worse and where the symptoms are felt. Then, during a physical exam, your doctor will see what movements make your symptoms worse and will test for muscle strength, decreased sensation, and reflexes.
“If there is a deficit and the symptoms are consistent with that same nerve root, we start to think that the cause is probably a pinched nerve and we can localize the cause to a specific nerve root,” Dr. Wang explains.
One exam is called a straight leg raise test, where you lay on a table face up and your doctor slowly lifts one leg up to see if it aggravates your symptoms and at what point your symptoms start. This test stretches the sciatic nerve, so if there is any pinching, the test will cause sciatica symptoms. Also, if symptoms increase when you bend a certain way and or change the position of your spine, that is a sign that the sciatica symptoms may be coming from your spine.
To confirm the diagnosis, your doctor will likely order an imaging study. X-rays will find bony problems and an MRI will pinpoint where the nerve compression is located, Dr. Wang explained.
Nonsurgical Treatments
What Are Some Nonsurgical Sciatica Treatments?
Most patients with sciatica symptoms or lumbar radiculopathy improve over time and respond well to non-surgical treatments, such as medication, exercise and special sciatica stretches, and physical therapy (PT). Spinal manipulation, such as chiropractic care, also can help reduce sciatica symptoms. In most cases, sciatica gets better in four to six weeks.
“Standard treatments for sciatica include PT, exercise, avoiding activities that aggravate symptoms, as well as OTC non-steroidal anti-inflammatory drugs (NSAIDs),” Dr. Wang says. “If that doesn’t work and the pain is acute, the next step is usually injection of an epidural steroid injection or a nerve root block.”
In some cases, a short course of oral steroids may be considered before trying steroid injections. Under a doctor or health care provider’s advice, over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) may help reduce swelling and sciatic pain. There are many types of OTC medication, such as acetaminophen (Tylenol), ibuprofen (including Advil), or naproxen (Aleve).
Exercises for Sciatica
For sciatica related to muscular and spinal disc issues, the following exercises, under the direction of your health care provider, may lessen the pain and discomfort:
- Aerobic exercise: Walking, slow jogging, swimming, cycling, dancing, and other activities that increase your heart rate and improve your overall physical health may help reduce sciatica symptoms. (However, avoid running or walking on rough, uneven terrains, as this may worsen your condition.)
- Strength training: Exercises using free weights or weight machines, or isometric exercises, which involve contracting muscles without obvious movement, are an important component in reducing sciatica.
- Flexibility training: Yoga, tai chi, Pilates, and similar activities that increase both flexibility and strength can help improve your posture and take pressure off the sciatic nerve.
Specific Stretches for Sciatica
While the following specific stretches may alleviate sciatica symptoms, you should always plan any exercise program under the supervision of your health care provider.
The yoga sphinx pose:
- Lie on your stomach with your chin on the floor or mat, arms by your sides, and feet together or slightly apart.
- Tuck your tailbone and draw your belly button in. Your belly button should lift off the mat.
- Engage your legs by lifting your kneecaps, and rotate your thighs inward to create length in the lower back.
- Position your forearms parallel to each other with your hands on the mat and elbows directly under your shoulders. (Putting your hands together may make this easier on your shoulders.)
- Gently and slowly push yourself on your forearms, gradually arching your back, and slowly inhale as you lift your head and chest.
- Exhale as you slowly lower your head and torso back down to the mat.
- Stay in sphinx pose from several breaths to a few minutes, depending on your comfort.
*If this pose seems too difficult or painful, you can modify it by placing folded blankets or towels underneath your hip bones until the stretch is comfortable.
The sciatic nerve slider:
(Phase 1)
- Begin in a seated position on a raised surface without back support.
- Lift your head up until you are extending your neck and looking up to the ceiling.
- Stick out your chest until you are arching your lower back.
- Raise the leg that is affected by sciatica until the knee is straight and your toes are pointing up toward your knee.
(Phase 2)
- Drop your leg slowly and fully until it is dangling.
- Gently bend your neck forward until your chin is against your chest.
- Allow your lower back to round forward into a slightly slouched position.
- Repeat both phases several times, working slowly up to 20 repetitions.
Perform four to six times a day.
Surgery
Do You Need Sciatica Surgery?
Most patients with sciatica symptoms or lumbar radiculopathy respond well to non-surgical treatments, such as medication, exercise and special sciatica stretches, and physical therapy.
“If your quality of life is good, and you are still able to work and do the things you want to do, there is no reason to have surgery,” Dr. Wang notes. However, if a person comes into his office and can barely sit down, can’t work, and can’t take care of their family, surgery may be the best option.
“If you try the conservative treatments and the pain doesn’t get better, if you have progressive neurologic weakness that is not improving, or have incapacitating pain, surgery may be considered sooner than later,” Dr. Wang says. “I always consider surgery as a last step,” Dr. Wang says, adding that decision to perform surgery usually comes naturally for people.
Sometimes, sciatica and lower back pain can be serious and require surgery. Surgical treatment for sciatica is recommended for patients with:
- Loss of bowel and/or bladder function (this is a symptom of the rare condition cauda equina syndrome)
- Severe leg weakness
- Non-surgical sciatica treatment is ineffective or no longer reduces sciatica pain
- Progressively worsening pain
For the right patient, surgery can be very effective. In a small 2020 study in New England Journal of Medicine patients with sciatica due to a herniated disc who had surgery reported much lower pain levels than the people who underwent PT only.
Medical guidelines also state that for patients with severe symptoms, discectomy for a herniated disc with radiculopathy (radiating pain) “is suggested to provide more effective symptom relief” than nonsurgical treatments such as PT and steroid injections.
“Studies have shown that surgery can be very successful for sciatica, especially when there is real nerve compression, whether it is from a herniated disc, spinal stenosis, disc degeneration, bone spurs, or spondylolisthesis,” Dr. Wang explains. “The type of surgery selected depends on the cause of sciatica.”
Surgery Types
What Type of Sciatica Surgery Do You Need?
The type of surgery recommended depends on the diagnosis, number of spinal levels requiring treatment and surgical goals. In general, “we try to do the smallest surgery possible,” Dr. Wang says.
Most surgeries to relieve sciatica are called spinal decompression surgeries, which are procedures the spine surgeon performs to remove whatever is pressing on the sciatic nerve—such as a disc herniation. Some patients need a combination of these surgeries to relieve sciatica symptoms.
Many patients undergo decompression surgery in an outpatient or ambulatory spine center without being hospitalized. Also, many of these procedures can be performed using minimally invasive spine surgery (MISS). In a MISS, surgeons use special instruments and visualization tools (such as tiny cameras) that allow them to operate using very small incisions.
The benefits of the minimally invasive approach include less pain and a faster recovery after surgery in part because there is less cutting through soft tissues (eg, ligaments, muscles). This approach also is linked to a lower risk for infection and less blood loss from surgery.
Minimally invasive surgery is a good option for patients who have a herniated disc or spinal stenosis in only one vertebrae. For patients who need surgery in multiple vertebrae or a more complex surgery, a traditional open surgery may be best.
Microdiscectomy
“If sciatica is caused by a herniated disc in the lumbar spine, which is one of the most common reasons for sciatica, then a simple minimally invasive microdiscectomy is used,” Dr. Wang says. “The results of microdiscectomies are typically very good.”
Microdiscectomy involves a small incision, is a short surgery, and is typically performed in the outpatient setting, Dr. Wang notes. During either procedure, the surgeon removes the entire disc or the portion of the disc compressing nerve(s). In some cases, an artificial disc replacement is placed to help restore space and movement between the vertebrae.
Laminotomy and Laminectomy
Laminotomy and laminectomy are commonly used to treat spinal stenosis and involve removing a part of the spine called the lamina—a thin bony plate that protects the spinal canal. The lamina is located at the back or posterior spine between two vertebrae. The difference between these procedures is the amount of lamina removed to access bone, disc, or other soft tissue compressing spinal nerve roots.
Laminotomy involves partial removal of the lamina.
Laminectomy involves total removal of the lamina.
By partially or entirely removing a lamina, the surgeon can access the bulging or herniated disc from the posterior spine. Of course, the surgeon may remove other tissue (eg, bone spur) pressing on a spinal nerve root at a particular spinal level (eg, L4-L5).
Foraminotomy
Foraminotomy enlarges the hole (called a foramen) where the spinal nerve root exits the spinal canal. A small incision is used to remove small pieces of bone that are pinching the sciatic nerve root.
Interspinous Spacers
Small devices called interspinous spacers are sometimes used for people with spinal stenosis to help keep the spinal canal open, so the nerves are no longer pinched.
Spinal Fusion
In patients with spinal instability from spondylolisthesis or degenerative disc disease at different levels of the spine, spinal fusion of the vertebrae may be required, Dr. Wang says. This is a more extensive surgery designed to strengthen the spine and prevent painful movements. In spinal fusion, the spinal discs in two or more vertebrae are removed and the vertebrae are fused (joined together) by bone grafts and/or metal devices that are screwed into place.
The good news is that sciatica goes away over time in many people with conservative therapies, and that surgical options also have a high success rate, Dr. Wang says. The most important step is to see your doctor to make sure there are no urgent problems and to find the underlying cause of sciatica.
Outlook for Sciatica
In general, the outlook for people with sciatica is good. That said, improvement may be slower than for simple back pain issues. Keep in mind that sciatica can have multiple causes, so the most important thing is to get an accurate diagnosis from a provider with experience treating sciatica.