This is a very general term typically used to describe leg pain caused by irritation of the sciatic nerve. The sciatic nerve is formed from several nerves (L4, L5, S1, S2 and S3 spinal nerves) that originate in the lumbar spine (your low back). So sciatic nerve pain can actually originate from either irritation of any one or more of the nerves in your low back or after the nerve has fully formed outside of your spine as it runs down the back of your leg (e.g. piriformis syndrome). You may experience low back and leg symptoms, which may include one or more of the following: pain, numbness, tingling, or weakness.
The most common cause of sciatica is from nerve irritation originating in your low back. This can be from a disc herniation that presses on a nerve in your spine (herniated disc), a disc tear that leaks out irritating chemicals on the neighboring nerve(s) that causes low back and leg pain (annular tear), improper alignment of your spine (spondylolisthesis) or the combination of arthritis in your spine (facet hypertrophy) with a disc bulge that crowds the nerve(s) in your low back (spinal stenosis) or all of the above.
Treatment for this condition, as with all disease states, depends on first identifying the cause. This is crucial so that treatment can be targeted directly at the root cause of your pain versus just generally treating your symptoms with medications that can have multiple side effects and do not help confirm a diagnosis. In addition, early, appropriate targeted therapies can decrease the chance of your pain in becoming a chronic problem and could potentially prevent future occurrences.
If this is an acute problem, the majority of these symptoms will resolve within a week or 2. The key is to continue to stay active as much as possible which may be difficult secondary to the pain, numbness and/or weakness. First line treatment involves anti-inflammatories (ibuprofen ie advil, naproxen ie aleve) with the addition of a muscle relaxant at times. Other medications may be added to your regimen which would include: antiseizure medications to help decrease the nerve pain, antidepressants which, at low doses, can help with nerve pain and allow you to rest better or even opioids though they typically are not as helpful for nerve pain and not indicated on a long term basis. Physical therapy can also be initiated to help with your pain and more importantly, teach you how to strengthen the muscles of your spine so that this is less likely to occur in the future. Inactivity, such as prolonged sitting and lying down, can potentially worsen your condition as your spinal muscles begin to deteriorate from lack of use. This can lead to increased pain and disability increasing the likelihood of you hurting yourself even further. If you experience weakness to the point that you find it difficult to walk and/or you feel as if you are dragging your foot, then you should be evaluated by a health care professional, particularly a spine specialist, immediately.
If your pain continues after several weeks, it is important to be evaluated by a spine specialist as soon as possible. The longer you deal with the pain, the chance of this becoming a lifelong problem increases. Time is pain and waiting to see a spine specialist for even several weeks can be detrimental to your full recovery. Even if your symptoms are improving, seeing a specialist is recommended as it can help to specifically diagnose your problem, prevent future occurrences and improve your chances to returning back to a normal lifestyle quickly. In addition, if you have already established your care, if your pain ever returns, you can be seen and treated quickly as all the necessary diagnostic studies have already been performed.
In most instances, x-rays are not needed unless your pain persists beyond several weeks and/or there is associated trauma or you have risk factors that would suggest you may have fractured your back. Along those lines, an MRI is not necessary unless you continue to have symptoms after appropriate treatment is initiated (see recent John Hopkins study March 2013). Keep in mind that you and your symptoms need to be treated not any findings from x-rays and/or MRIs. These studies are only needed to support your specific clinical diagnosis after being evaluated.
If your pain continues or does not improve after a week or two, more specific targeted therapies may be warranted. This will not only provide a specific diagnosis but potentially alleviate your pain without the need for medication use. This may include epidural steroid injections (see transforaminal vs interlaminar). Not all epidural steroid injections are the same and make sure you know which type you are getting and why. Some are less invasive and more specific to your pain and not all physicians know how to perform them. There are even instances that a nonphysician may be asked to perform your procedure. Keep in mind they have no formal training to perform these procedures or even handle complications if it occurs. Make sure you request specific credentials, most importantly, ask if they are board certified in pain management from the American Board of Anesthesiology (ABA) or radiology. Providers may state that they are board certified from other organizations but the only recognized authority for pain management is through the ABA.
Opioids are not first line in treating this condition. In most instances, they are only a crutch to help with the pain but are not targeted at the specific cause of your pain and can have multiple side effects including the potential of addiction. Oral steroids can also be used but are not very specific. Steroids can be more effective if placed at the site of the nerve irritation versus taking them by mouth. It is important that you be evaluated by a spine specialist if these are offered to you as treatment options.
If your symptoms persist and/or worsen, further studies may be needed or you may be referred to see a spinal surgeon. As more than 90% of cases are nonsurgical especially during the acute phase, seeing a spine surgeon is not necessary initially as this may delay proper treatment waiting for your consultation. That being said, surgical emergencies occur if your weakness steadily worsens and/or you have difficulty controlling your bladder and bowel function. This includes losing your urine and/or bowel function without noticing it or not being able to urinate or changes in the frequency of your bowel movements that are not related to any medication use (ie pain medications can constipate you).
If your pain persists and there is no reasonable “fix” for the underlying problem, other, more advanced minimally invasive surgeries may help decrease your pain by >50% without the use of oral “pain” medications. (see spinal cord stimulation and intrathecal drug delivery systems)
Seeing a spine specialist early in the course of symptoms will provide you the best chance at full recovery without relying upon medication use. You owe it to yourself to take control of your pain. Waiting to be treated only hurts one person and that person is you.