What You Should Know About Sciatica and Nonsurgical Treatment
Expert Commentary by Ryan C. Enke, MD and Jordan Miller, DPT, CSCS
Sciatica is a pain that is usually accompanied by numbness, tingling and occasionally weakness along the course of the sciatic nerve. The nerve is the thickest in the body and is formed from nerve roots that exit the spine in the lower back and sacrum, and extend into the buttocks and down the back of each leg to the toes.
Six Causes of Sciatica
Common causes of sciatica, which may respond to physical therapy or treatment from a physiatrist (eg, injections, medications) include pregnancy, trauma and:
Compressed Lumbar Disc is also called lumbar radiculopathy. Most cases will heal without surgery. “This is one of the most common causes of sciatica that I treat and about 90% of patients with this condition will have a good response to conservative treatment,” Ryan C. Enke, MD told SpineUniverse. “This includes nonsteroidal anti-inflammatory drugs, medications that affect the nerves like gabapentin, and epidural steroid injections. I use x-ray to guide the injection which pinpoints the exact location of the lesion [where nerve is compressed]. Serious side effects like infection, major bleeding, and nerve injury are rare at 1 in 100,000, so this is a very safe procedure. The injection is used to reduce the pain so that physical therapy can be incorporated into the conservative treatment.”
Jordan Miller, DPT, CSSC, a practicing physical therapist agrees, “When a patient has an acute disc their pain needs to be reduced so we can do our job. If the patient has not had an epidural steroid injection, we may use a topical steroid combined with electric stimulation or ultrasound to move the medication directly into the area where the lesion [where the nerve is compressed] is. We also use lumbar traction to reduce the size of the disc herniation and combine this with exercises, which are individualized to the patient. Some patients may feel the relief of their symptoms by extending the back and others by flexing, so exercises are specific to the patient. Core strength and stability is key to reducing the risk of further injury. Most patients also have some muscle spasm or joint stiffness, which can be relieved by massage therapy and joint mobilizations. Kinesio tape may also be utilized to relieve pressure and relax muscles.”
Lumbar Spinal Stenosis is a condition that both Drs. Enke and Miller feel can be more difficult to treat due to the mechanical nature of the compression on the nerves which most commonly are caused by a combination of osteoarthritis, disc bulging and narrowed spinal holes (called neuroforamen). “Epidural steroid injections are typically used along with medication to control the symptoms of stenosis,” Dr. Enke explained.
“Physical therapy for stenosis typically consists of traction, exercises, and modalities to lessen pain and inflammation,” Dr. Miller said.
Spondylolisthesis can be caused by trauma or degeneration of the spine, and conservative care is frequently helpful.
“Extension typically worsens symptoms, so we focus on flexion-based exercises,” Dr. Miller told SpineUniverse. “We utilize therapeutic exercises to the extent they are tolerated for abdominal strengthening and core stabilization. We try to increase hip extension to reduce stress on the lumbar spine. Modalities can also be used to control inflammation and alleviate muscle tightness or spasms, and in certain cases, trunk bracing may be indicated.”
Piriformis Syndrome. According to Drs. Enke and Miller, piriformis syndrome can respond favorably to conservative treatment. “I have found an ultrasound-guided piriformis injection to be effective for this condition,” Dr. Enke commented.
“When we see a true piriformis syndrome, we try to look for a cause. Is the patient involved in a job or a sport where they are shortening or overusing the muscle? We then individualize an exercise program based on what we find structurally with the patient. In many cases, the piriformis muscle is over utilized due to muscle weakness in the hips, so strengthening is key. Sciatic nerve mobilization can also be useful in helping to increase the mobility of the sciatic nerve, and Instrument Assisted Soft Tissue Mobilization or Graston along with deep tissue massage is effective.”
Pregnancy can bring on sciatic symptoms in many women, which can make a difficult situation miserable. “For pregnancy-related sciatica, we try to lessen symptoms and restore normal function through gentle exercise, massage, and hot or cold therapy. We focus on the pelvic girdle as well as core stabilization and may use Kinesio tape to stabilize the pelvic girdle due to ligamentous laxity of the hips,” Dr. Miller said.
Trauma to the gluteal area can bring on inflammation and spasm around the sciatic nerve. “We focus first on relieving pain and inflammation with modalities, and gentle exercises based on what we find on examination and how extensive the trauma was. Light spinal mobilization and massage have been shown to create natural painkillers in the body and alleviate tight muscles. As patients progress, more rigorous exercises are given to strengthen their core musculature and get them back to their regular activities, whether that is a job or a sport,” Dr. Miller concluded.