Sciatica: To Treat or Not to Treat, That is the Question.

Having seen my fair share of sciatica in clinical practice over the years I always have to decide with each individual case how do I best help the person who is suffering in front of me. 

Now when I say sciatica it can all get a little confusing as often patients with any type of back pain and or leg pain are diagnosed or self-diagnosed with sciatica. Even more confusingly the sciatic nerve itself, which is in fact two nerves bundled together in the buttock region is not usually the main source of the problem, although we do occasionally see irritation from small tight muscles in the buttock. 

Clinically sciatica is a term used to describe pain that travels or radiates downwards from the buttock region in to the back of the lower limb along the course of the lumbosacral nerve roots. Patients will often describe the pain as shooting, sharp or even electric in nature, they may also experience some sensory changes such as pins and needles, tingling or numbness, plus some motor changes or weakness in some of the muscles of the lower limb.

So, if the problem is not coming from the sciatic nerve, then what is going on? Well, the sciatic nerve has its origins in the lumbosacral region of the spine as nerve roots emerge and then join together to form the sciatic nerve in the buttock region before it goes on its merry way down the leg. It is here in the spinal region where we commonly find the cause of the symptoms that we call sciatica, with the number one cause being some degree of disc pathology affecting the nerve roots.

The disc may become herniated and compress nerve roots and or inflammatory and immunological processes may affect the nerve roots resulting in symptoms. Of course, we must not just assume that the problem is always due to a disc injury and always have good differential diagnosis and clinic reasoning to consider other causes such as lumbar or foraminal stenosis, spondylolisthesis, spinal infection, pelvic fracture, malignancy or causa equina syndrome.

In order to do this, we must take a good and thorough case history gaining as much information as possible from the patient regarding the onset and history of their symptoms, the description and distribution, aggravating and relieving factors and any treatment received already.

We must of course carry out a detailed neuromusculoskeletal (NMSK) examination of our patient. This can only be done face to face and without rush. This will include observation and palpation, active range of motion tests, neurological testing, both motor and sensory and any special tests such as straight leg raise or slump test. These are a barrage of tests to gain information and should be used as so, no one test on its own is reliable. For example, passive segmental lumbar spine motion testing has been shown to have poor validity and reliability.  

It is worth while becoming good at all these tests, so that you are as accurate as possible in order to assess the findings and make you diagnosis or evaluation. If you are a clinician, you may be thinking of patients you have seen in the past who are in severe pain and you may have struggled to examine them. You must do your best to gain as much information as possible for without a proper NMSK examination then some of the treatment options available to you will be limited.

So, what about treatment, if we have come to the conclusion that the patient has ‘sciatica’ from disc pathology what are we going to do.

Explanation and Education is key, patients will often be going through all kinds of emotion, such as fear, shock, anxiety or even anger and we must aim to reassure the patient that we are here to help and that symptoms are not here for ever and commonly do improve within 8-12 weeks.

Patient may already be taking over the counter analgesics or stronger painkillers from their GP and we must again reassure that the patient that this is fine, no matter what our philosophical bias is. They can also, depending on the duration of the problem incorporate the use of ice or heat to modify and calm symptoms with appropriate dosage advised.

Often patients are fearful of movement thinking they will cause more damage, but again reassure them that gentle movements are much better than prolonged periods of inactivity or bed rest. This may be general exercise like walking or pottering or more specific exercises such as stretches or mobility, later stages will often call for strength movements.

Is hands on care indicated? Well this will depend on the patient and the symptoms but often gentle manual therapy can be of use. It is important to explain to the patient that there are no magic moves or tricks despite what they see on social media and that the aim is to help calm the symptoms in order to get them moving again. Expert patient handling is a worthwhile skill to master as it in itself can have a strong desensitising effect on the patient’s nervous system

We must avoid outdated theories such as moving bones or discs back into place or un-trapping nerves and those who have invested the time to become skilled in manipulation would consider it unwise to put high forces and extreme torsional leverages into the tissues.  There are many manual techniques demonstrated in The Applied Technique Hub Membership that can used and modified safely and effective for patients with sciatica. Manual treatment should not usually be performed in a routine way, by that I mean, doing the thing every time hoping for a change, the treatment should be individualised and adapted as the clinical picture changes.

The timing and frequency of care should be adapted, we may see or call the patient more frequently in the early stages and then less as they make progress. Be mindful of mindless time filing prolonged treatment which can often serve to irritate the nervous system and symptoms as well as have the potential to create dependency.

A word of caution however, symptoms that are not resolving or indeed getting worse should ring alarm bells in your head and swift referral back for medical opinion is indicated. Certain cases may require further scanning, injection therapy or surgical intervention. In either case you may well see the patient again once their pain is under control for rehabilitation.

Jamie Archer