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Sciatica

Sciatica is a group of symptoms associated with pressure or irritation to the sciatic nerve, this can include pain down the leg, numbness, tingling or pins and needles as well as altered muscle strength and deep tendon reflexes. Here lies the problem, the sciatic nerve is made up L4, L5, S1 and S2 spinal nerve roots predominantly, which means the symptoms experienced by the patient can vary widely depending on where the pressure and irritation is. Disc problems, spondylolisthesis, degenerative stenosis, piriformis syndrome and inflammation can all cause irritation and pressure to the sciatic nerve, this is why, in my opinion, sciatica should never be a diagnosis on its own but part of a bigger picture including what is causing the complaint. We can often identify the nature of the lesion causing the sciatica by the pattern and description of the symptoms the patient experiences, however, very rarely do we see those text book cases of loss of sensation, loss of muscle strength, changes in reflexes and pain over a specific distribution related to a spinal nerve root. If we know what is causing the issue, we know things which can help, our approach will be very different though depending on what is causing the sciatica.
Disc
Probably the one that most people have heard of and the most misunderstood, they do not slip, they bulge, prolapse, herniate or sequestrate. However, bulges, prolapses, herniations and sequestrations also happen in a good deal of the population with no history of low back pain (Brinjikji, Luetmer et al, 2015). Equally if you have a disc derangement and sciatica only sometimes is it from frank compression onto the nerve root as it exits the spine, more commonly it is from inflammation around the disc derangement which irritates the nerve. If it is frank compression, depending on the extent of the symptoms, there are some things which we can do, however, personally if I see significant loss of muscle strength I believe it is beyond my scope of practice as a chiropractor. However conservative care should be exhausted before considering surgery.
Inflammation

As suggested above when inflammation occurs in the wrong areas it can irritate an exiting nerve root and give the patient sciatic symptoms, this quite commonly happens when there is a new disc derangement of some description. The inflammatory mediators which a present through the process typically sensitise the nerve via chemical irritation. These cases are typically transient, lasting up to 3-4 months in some cases, but as the symptoms reduce the patient typically has a full recovery with no loss of function despite the presence of the disc derangement (which does not necessarily need correcting). Having said that a number of these cases will present with a reduced straight leg raise which suggests that something is stopping the nerve sliding in and out of the spine, this something is typically a sticky gu which is left as a result of the inflammatory process. With these cases we would most likely get the patient doing nerve flossing/sliders aimed at getting the sliding in and out of the spine, hopefully getting the nerve to let go of the sticky gu and increase the straight leg raise.

Degenerative stenosis
The patient history with these cases typically looks something like this, age more than 48 years, bilateral symptoms, leg pain more than back pain, pain during walking/standing, and pain relief upon sitting (Peterson, laslett and Juhl, 2017). These symptoms are typically generated from degenerative changes in the spine giving rise to nerve root compression on loading, which is why standing and walking typically aggravate the problem. There is nothing which we as physical therapists can do about the degenerative changes however as this study below suggests:
‘A combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity’ (Schneider, Ammendolia et al, 2019)

Spondylolisthesis
Where one vertebra slips on top of another, typically forwards, although it can be in any direction. This typically happens either during puberty and growth, and has an association with sports, or at the opposite end of life as the spine degenerates. Spondylolisthesis are often incidental findings in the young and adult populations as they are typically stable and do not cause any problems, however occasionally they become unstable and can create sciatic symptoms if any of the exiting nerve roots are compressed, in these instances our best option is to try and avoid aggravating it while creating stable spine using exercises. In the most severe of cases surgery is necessary to stabilise the joints between the two vertebra and prevent any symptoms but there are plenty of people who live happy, healthy and very active lives with this condition.

Cauda equina
This is a unique and very rare condition which is typically treated as a medical emergency. For any one who has had sciatica you have probably been asked if you have had any changes in your bowel and bladder function? The reason for that is the nerves which supply your sphincters, genitals and saddle area (imagine sitting on a horse), can get compressed under the right circumstances such as a large central disc herniation. This would probably present as sciatica in both legs as well as changes to sensations over the saddle area and changes in bowel and bladder function, hence why it is treated as a medical emergency and not really a chiropractic case in my opinion.

To conclude, sciatica is not as simple as that, but once we work out what is the cause of the sciatica there is typically something which can be done to aid your recovery.

Brinjikji, Luetmer et al, (2015) Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27
Peterson, Laslett and Juhl, (2017), Clinical classification in low back pain: best evidence diagnostic rules based on systematic reviews, BMC Musculoskeletal Disorders, 18:188
Schneider, Ammendolia et al, (2019), Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis A Randomized Clinical Trial, JAMA, 2(1):e186828. doi:10.1001/jamanetworkopen.2018.6828

 

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