Naimish Baxi, MD
Naimish Baxi, MD, is a physiatrist at Hospital for Special Surgery in New York and Paramus, New Jersey. His focus is on sports medicine, spine care, pain management, and musculoskeletal medicine. HSS.edu
Sciatica nerve pain—typically some combination of burning, numbness, a tingling pins-and-needles feeling and throbbing—is very real. The cause may be tricky to determine. Here’s why the nerve can get irritated and how to get sciatica nerve pain under control, from Naimish Baxi, MD, a physiatrist at the Hospital for Special Surgery.
Sciatic nerve pain usually is felt on just one side of the body, but there actually are two sciatic nerves, one on each side. These are the largest nerves in the body, and each one is made up of five nerve roots that branch off from your spinal cord in the lower lumbar and upper sacral sections of the spine. Each sciatic nerve runs from the lower back through the butt and down the length of the leg.
From a purely semantic standpoint, true sciatica directly involves the sciatic nerve. Example: The sciatic nerve runs through the piriformis, the muscle that goes from the lowest part of the back to the back of the thigh. If this muscle becomes swollen, goes into spasm or is tight, the sciatic nerve can become irritated. One study estimated that 16% of sciatic pain cases were linked to the piriformis muscle.
Sciatica also can result from direct trauma caused by an injury involving the gluteus or hamstring muscles…or even as a consequence of hip-replacement or another type of musculoskeletal surgery. Sciatic pain also can be caused by a tumor pressing on the sciatic nerve.
Typically, when someone experiences sciatica pain, he/she is talking about pain caused by irritated or compressed spinal nerve roots, usually between the lumbar vertebrae L4 and L5…or between L5 and S1, the first sacral vertebra at the base of the spine. That compression typically is from the degeneration or herniation of one or more spinal discs. Discs are the spine’s shock absorbers, cushioning each vertebra, but they’re subject to wear and tear. Think of a disc like a jelly donut with a thick outer layer called the annulus and a filling called gelatinous nucleus. If the outer layer weakens over time, the filling can start to push out and press on the nerve roots, entrapping them and sending shooting pain down one leg. The name for this condition is lumbar radiculopathy.
The pain pathway varies depending on which nerve roots are affected. While most people feel the pain on just one side, it can be more toward the middle or even on both sides depending on where the disc damage is located. Sciatica nerve pain symptoms typically include some combination of burning, numbness, a tingling pins-and-needles feeling and throbbing.
Sciatica can affect people of all ages, often for different reasons. In younger people, it’s usually associated with some form of overuse or body mechanics—think of a high school football player who overtrains, suffers some awkward tackles and weight trains without proper form, all of which can put a lot of strain on a disc.
In older people, the cause is more likely to be age-related wear and tear of one or more discs, which happens over time and makes them vulnerable to stresses that healthy discs would otherwise absorb.
There also can be a genetic predisposition, the same way that some people are predisposed to getting arthritis in the hips or knees
The first step in treating sciatic pain is an evaluation by a physiatrist—a physical medicine and rehabilitation physician trained to treat conditions affecting the spinal cord and nerves with conservative, nonsurgical interventions. A physiatrist focuses on you and your symptoms. He/she identifies any aggravating factors as well as the factors that alleviate the pain. Here are some of the approaches he might recommend…
1. Sit less. One movement for instant sciatica pain relief often is just to stand up. Sitting, especially with poor posture, makes pain worse, sending two to three times more pressure through the lumbar discs versus when you are standing.
But this can be challenging given that most of us sit for the majority of our day—in front of a computer at work and then at home at the dinner table, on the couch and often in bed. Using a sit-to-stand desk can reduce the number of hours you spend sitting. When you do sit, choose a firm chair that keeps you upright, rather than a soft one or a couch that sucks you in, especially when you’re watching TV. If you have a long drive—a common set-up for sciatica pain—plan stops at a rest area or use a seat heater to keep the muscles that support the lumbar spine warm. Some people feel better with a lumbar roll pillow situated behind the lower back. Physical therapy is another option, so you can learn better ways to sit, stand and move.
2. Pain medication. You might find sciatica nerve pain relief with over-the-counter nonsteroidal anti-inflammatories, such as Advil or Aleve. For some people, prescription versions, including Celebrex or meloxicam, are more effective. In other cases, medications that help ease nerve pain, called nerve membrane stabilizers or neuromodulators such as gabapentin and Lyrica, may help.
3. Acupuncture. Acupuncture, which triggers the release of endorphins that disrupt pain signals, can be helpful for many people. Some studies have found that electroacupuncture using transcutaneous electrical nerve stimulation (TENS) may have an even greater effect.
4. Epidural steroid injections. Delivering steroid medication directly to the affected nerve can calm pain. How often to repeat the injection is a very individual decision based on how well you do, but generally the recommendation is no more than two or three injections, spaced out over weeks or months, in a six-month period or four injections in a year due to the systemic effects of steroids, which include hormonal dysregulation, elevated blood glucose levels, and changes in bone density, blood pressure and thyroid hormone levels. Important: Any steroid injections you might have had, such as one for arthritis knee pain relief, count toward that annual total. Oral and inhaled steroids (for pneumonia and asthma respectively) need to be factored in as well. Be sure to share your steroid history with your physiatrist.
Sciatica often comes and goes, but adopting good habits can help keep the pain at bay…
5. Lose excess weight. Being overweight puts added pressure on the lumbar spine, even more so if you sit with a rounded back.
6. Find an exercise you really like. Walking, biking, using an elliptical, swimming—any type of cardiovascular exercise can help with pain just by getting blood flowing through your body.
Reminder: You also need to optimize body mechanics for the exercise you’re doing. If you’re lifting weights with bad form or work out without warming up, you’re going to be vulnerable to pain. Good posture also is essential. Example: Running with a slightly stooped forward posture puts more stress through your lumbar spine. A physical therapist can evaluate your body mechanics and show you how to modify them and also show you the right lower-back stretches to help with warm-ups and cool-downs.
7. Improve core stability. Just as developing the muscles around the knee helps ease pain in that joint, developing muscles in the body’s core will help with spine pain. Consider the “McGill Big 3,” three exercises developed by Dr. Stuart McGill, professor emeritus of spine biomechanics at University of Waterloo, Canada. These all are static movements that most people can do on their own. Even though your spine is in a neutral position, the core muscles are engaged. To see a video of the following exercises, go to YouTube.com/watch?v=FkpLS_mgEf4.
Start
End
The vast majority of people looking for sciatica pain relief don’t need surgery, but there are three situations when it becomes necessary…
