Sciatica and Herniated Disks: What You Need to Know Part 2
Sciatica and Herniated Disks: What You Need to Know
Part 2
In Part 1 of this post, I discussed some important facts about herniated disks, their causes, diagnostic procedures, and the direction of treatments.
In Part 2 we will talk about sciatica, how it relates to herniated disks (are all sciatica cases caused by herniated disks? – the answer is below!), and the ways to treat that nagging “pain in the butt”.
Some important facts to remember:
Back pain and radiculopathy (pain caused by a nerve or a nerve root compression that travels to the buttock or the leg) are symptoms, not cause
Proper diagnosis and treatment depend on the understanding of spinal and pelvic mechanics
A significant number of patients with sciatica may have negative MRI findings for spinal causes.
According to a systematic review published in the journal "Spine" in 2016, approximately 30% of patients with sciatica had negative MRI findings for spinal causes.
Another study published in the Journal of Neurosurgery: Spine in 2018 found that up to 40% of patients with sciatica had no significant abnormality on their MRI scan.
What populations is sciatica more prevalent in?
Sciatica is a common ailment, and it can affect people of all ages and genders.
However, certain populations may be more prone to developing sciatica.
For example, studies have found that sciatica is more common in older adults, especially those over the age of 60.
This may be due to the natural degeneration of the spine that occurs with aging.
Additionally, certain occupations or activities that involve a lot of bending, twisting, or lifting may increase the risk of developing sciatica.
For example, people who work in
Construction
Healthcare
Manufacturing
may be more prone to developing sciatica due to the physical demands of their jobs.
Other factors that may increase the risk of developing sciatica include
Obesity
Diabetes
Smoking
Is sciatica more prevalent in women or men?
There is some evidence to suggest that sciatica may be more prevalent in women than men, although the exact prevalence rates can vary depending on the study.
One study published in the Journal of Pain Research found that women had a higher incidence of sciatica than men, especially in older age groups.
Another study published in the Journal of Back and Musculoskeletal Rehabilitation found that women were more likely to report sciatica symptoms than men.
The reasons for this gender difference in sciatica prevalence are not entirely clear, but some researchers have suggested that hormonal factors may play a role.
For example, fluctuations in estrogen levels during the menstrual cycle or menopause may affect the sensitivity of nerve tissue and increase the risk of sciatica.
Additionally, some studies have found that women may have a higher incidence of degenerative disc disease, which is a common cause of sciatica.
Overall, while more research is needed to fully understand the gender differences in sciatica prevalence, it does appear that women may be more prone to developing this condition than men.
Is all sciatica caused by a herniated disk?
No, not all cases of sciatica are caused by a herniated disk.
Sciatica is a term used to describe the symptoms of pain, numbness, and/or weakness that occur in the lower back, buttocks, and legs due to irritation or compression of the sciatic nerve.
The sciatic nerve is the largest nerve in the human body, and it runs from the lower back down through the back of each leg.
It's made up of several nerve roots that start in the spinal cord and merge together to form the sciatic nerve.
The sciatic nerve provides sensation and motor function to much of the lower body, including the buttocks, legs, and feet.
While a herniated disk is a common cause of sciatica, other conditions such as
spinal stenosis
degenerative disc disease
spondylolisthesis
piriformis syndrome
can also cause sciatic symptoms.
In some cases, the exact cause of sciatica may not be clear.
A thorough evaluation by a healthcare professional is important to accurately diagnose the cause of your sciatica and determine the most appropriate treatment.
One of the frequent causes is the entrapment of the sciatic nerve by the piriformis muscle (this muscle is located deep in the buttock and serves to rotate the hip).
What are the symptoms of sciatica caused by a herniated disk?
Sciatica caused by a herniated disk typically produces a sharp, shooting pain that radiates from the lower back through the buttocks and down one or both legs.
Other common symptoms include:
Numbness or tingling in the leg or foot
Weakness in the leg or foot
Burning or prickling sensation in the leg
Difficulty standing up or walking due to pain
Worsening pain after prolonged sitting, standing or walking
Loss of bladder or bowel control (in severe cases)
In my experience, patients with symptoms caused by a herniated disk most often report:
increased pain in the morning with difficulty bending forward;
radiating pain with a location that is dependent on the spine level with the herniated disk (see picture below);
specific back pain (right vs. left);
tenderness to pressure at the level of herniation;
increased but centralized pain with bending backward;
pain that is partially relieved with sitting but gets worse if sitting is prolonged.
it is very common for patients to have weak hip muscles.
It's important to note that not all cases of sciatica caused by a herniated disk will present with all of these symptoms, and the severity of symptoms can vary depending on the individual case.
It's always best to seek the advice of a healthcare professional if you are experiencing symptoms of sciatica or lower back pain.
Centralization of Pain in the Treatment of Herniated Disk and Sciatica
I have seen many patients who don’t even complain of any back pain.
Instead, they complain of foot pain or leg pain.
They think they have a problem in the area which is sore.
Therefore, they keep trying to treat a painful area, putting ice or heat on a sore spot, using pain-relieving ointments on the area, or massaging it.
Of course, nothing helps because the sore area is not the problem but rather a symptom that points to where the problem is coming from.
If pain is caused by a herniated disk pressing on a nerve root, the first order of business is to relieve that pressure.
Certain exercises help with that by moving the disk away from the nerve root.
Quite frequently, after getting the patient through these exercises, the patient says “I have more pain in my lower back now, but the leg pain is less (or gone)”.
It is very important to understand that this IS a desired outcome on the road to being pain-free.
This is called “centralization of pain” and it shows that the pressure on a nerve root is lessening.
What are symptoms of sciatica NOT caused by a herniated disk?
The symptoms of sciatica not caused by a herniated disk can vary depending on the underlying condition.
Here are some examples of symptoms associated with common causes of sciatica other than a herniated disk:
Spinal stenosis: Leg pain and/or numbness that worsens with walking or standing and improves with sitting; weakness in the legs or feet; and/or cramping or tingling sensations in the legs or feet.
Spinal stenosis is a medical condition characterized by a narrowing of the spaces within the spinal canal that puts pressure on the spinal cord and nerves.
The spinal canal is a narrow passage in the vertebral column that contains the
Spinal Cord
Nerve Roots
When this passage becomes narrow, it can cause compression of the spinal cord and nerves, leading to symptoms such as pain, numbness, tingling, or weakness in the back, legs, or arms.
Degenerative disc disease: Low back pain that radiates to the hips or legs; numbness, tingling, or weakness in the legs or feet; and/or difficulty standing or walking for extended periods.
Spondylolisthesis: Low back pain that radiates to the buttocks or legs; muscle spasms in the back or legs; and/or a feeling of instability in the lower back or legs.
Spondylolisthesis is a spinal condition where one vertebra in the spine slips out of its proper position and moves forward or backward in relation to a vertebra above or below it.
This condition can occur anywhere in the spine, but it most commonly affects the lower back.
Spondylolisthesis can be caused by a variety of factors, such as congenital defects, trauma, degenerative changes in the spine, or repeated stress on the spine.
Piriformis syndrome: Pain, tingling, or numbness in the buttocks that radiates down the back of the leg; pain that worsens after sitting for long periods; and/or pain that improves with walking.
The piriformis muscle is a small muscle located deep in the buttock region. It runs from the lower spine to the upper thigh bone, just below the hip joint.
The main function of the piriformis muscle is to help with rotating the hip joint outward, away from the body.
It also helps to keep the hip joint stable during movements like walking and running.
When piriformis becomes tight or inflamed it can compress the sciatic nerve, which runs beneath it.
This can cause pain, tingling, or numbness in the buttock and down the back of the leg.
Patients with sciatica symptoms NOT caused by a herniated disk often present with:
increased pain with standing and prolonged walking
radiating pain down the back of the leg
mild (or absent) back pain (typically from altered walking pattern)
tenderness to pressure in the buttock and back of the upper thigh --especially, if sciatica is caused by the piriformis syndrome or by the
sacroiliac joint inflammation
increased pain with putting weight on the affected side
poor balance or inability to stand on the affected leg
weak hip abductors (muscles that bring the leg away from the body)
Will the treatment be affected by what condition causes the sciatica symptoms?
The answer is YES: it is crucial to understand what causes a particular case of sciatica because it will affect what treatment approach to choose.
Let’s take spinal stenosis as the first example.
First of all, there are two types of spinal stenosis: one is called foraminal stenosis, and the other is central canal stenosis.
Let's use a simple analogy to understand foraminal stenosis and central canal stenosis.
Imagine your spine is like a multi-story building with many rooms and hallways. Each floor represents a vertebra in your spine, and each room is a nerve root exiting the building. The hallways are the central canal.
Foraminal Stenosis:
The doorways to the rooms (nerve roots) are the foramina. Over time, these doorways can become narrow, maybe due to overgrowth of bone or other issues. When this happens, there's less space for the nerves to exit.
This narrowing of the doorways is called "foraminal stenosis".
So, if a doorway becomes too narrow, the nerve might get pinched or irritated as it tries to exit, which can cause pain or other symptoms.
Central Canal Stenosis:
The central hallway of this building is like the spinal canal. It's the main passage where the spinal cord runs.
Over time, this hallway can become narrow due to various reasons like thickened ligaments, bulging discs, or bony overgrowth.
This narrowing is called "central canal stenosis".
If the hallway becomes too narrow, it can press on the spinal cord, potentially leading to symptoms.
In this article, I am discussing central canal stenosis.
People with central canal stenosis typically feel worse while standing or walking; sitting makes symptoms better.
This happens because during standing or walking or spine is in extension but when we sit it’s in flexion.
(When we talk about the spine, flexion means bending forward and extension means straightening up or bending backward).
When we bend backward, this compresses the spinal cord even more and makes symptoms worse.
When we bend forward, the central canal opens up, the pressure on the spinal cord lessens, and the symptoms disappear or become less severe.
People with central canal stenosis should avoid exercises that cause their back to extend
(such as prone back extensions and prone leg raises)
and perform exercises that flex the spine,
such as knee-to-chest stretch.
A similar scenario occurs in the case of spondylolisthesis – extension worsens the symptoms and flexion usually makes them better.
However, in many cases with herniated disks, back extensions will actually provide relief.
There are many different treatment approaches to the treatment of sciatica and lower back pain.
What is important for you is to understand what you can do at home to decrease pain and restore normal function.
I will discuss various self-treatment scenarios in a separate article.
For now, stay healthy, protect your back, and stay tuned for future posts!
References:
De Schepper, E. I., Koes, B. W., Oei, E. H., Bierma-Zeinstra, S. M., & Luijsterburg, P. A. (2016). Diagnostic accuracy of magnetic resonance imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review. Spine, 41(7), E374-E383.
Paksaichol, A., Janwantanakul, P., Purepong, N., Pensri, P., & van der Beek, A. J. (2017). Gender differences in prevalence and incidence of occupational/work-related musculoskeletal diseases: a systematic review. Journal of Pain Research, 10, 2871-2882.
Stynes, S., Konstantinou, K., Dunn, K. M., & Lewis, M. (2018). Prognosis and risk factors for non-surgical treatment outcome in sciatica: a systematic review. Journal of neurosurgery. Spine, 28(4), 347-362.
Kovacs, F. M., Arana, E., Royuela, A., Estremera, A., Amengual, G., Asenjo, B., ... & Galarraga, I. (2011). Sex differences in the prevalence and clinical course of sciatica and lumbar pain: a prospective study in primary care. Journal of back and musculoskeletal rehabilitation, 24(1), 27-35.
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