Sciatic nerve pain often comes on suddenly, creating immediate distress. And while it usually resolves in a few weeks, the pain may linger for months or years, disrupting lives.Sciatica: A Nerve-Wracking Problem Mr. S, a 45-year-old runner with low back pain and a numb left foot, was the focus of a Clinical Crossroads article in the Journal of the American Medical Association illustrating the challenge of treating sciatic nerve problems. The Lancet, a British medical journal, featured a 33-year-old skier, hiker and soccer player with an eight-year history of sciatic pain in one leg. You can probably name several examples from your own experience. Or maybe you've had sciatic nerve problems yourself.

At least 80 percent of the world's population suffer lower back pain, with or without sciatica, at some time in their lives. The pain often comes suddenly, creating immediate distress. And while it usually resolves in a few weeks, it may linger for months or even years, changing lives and lifestyles. Potentially the most serious of lower back problems, sciatica results from compression of the sciatic nerve, the largest nerve in the human body. About the width of a thumb when it branches out from nerve roots on the lower spine, the sciatic nerve threads its way behind the hip joint, deep into the buttocks, down the hip and along the back of the leg all the way to the foot. Typically, the pain results when the nerve on one side becomes stretched or pinched usually by something which narrows its passageway such as arthritis or a bulging or herniated disk. The result can be sharp pain in one part of the hip or leg but is more likely to be some combination of pain, numbness, burning, tingling or needles and pins sensation anywhere from the hip to the toe usually on one side only. The pain typically gets worse after a long period of standing or sitting such as riding in a car and it may also be aggravated by coughing, sneezing or laughing.

Who Is Vulnerable?

Mr. S, an attorney, first experienced back pain 17 years ago playing basketball and had occasional flareups in the years to follow although he maintained an active lifestyle, running four or five days a week. Then while moving some furniture, he experienced excruciating pain radiating down his left leg. Unable to stand up straight, he sought medical attention and was given pain-killing medication and prescribed bed rest for several days. Yet even as Mr. S's condition gradually improved, he continued to experience numbness in his left calf and foot. He didn't notice any weakness and continued to run, but his running friends told him he limped while running.

Some studies have found sciatica more prevalent among sedentary persons particularly smokers and those who spend many hours behind the wheel of a motor vehicle. But as the JAMA and Lancet articles indicate, highly active persons are also vulnerable. A study showed that bed rest offered no benefits over gentle movement and actually has negative effects such as tightening of muscles and loss of strength and flexibility. Even as recently as 1997, when Mr. S was first treated, bed rest was considered a routine part of early therapy. That changed with the publication of a study in the New England Journal of Medicine [February 11, 1999] showing that bed rest failed to provide any benefits over gentle movement in terms of resolving pain and speeding the healing process. And because bed rest has negative effects such as tighter muscles and loss of strength and flexibility most doctors today tell their patients to keep moving as much as they can while avoiding heavy lifting, bending from the waist, stooping and other activities that might stress the lower back. Sitting also stresses the lower back, and soft chairs are usually considered off limits.

Anti-inflammatory medications such as ibuprofen help reduce the pain and inflammation. And in bed, a firm surface is recommended, lying on one's side back with knees bent. Some studies have found bulging or protruding discs on the scans of 60% of individuals with apparently healthy backs. Lower back pain with sciatic nerve involvement is generally more serious than simple back pain. Nevertheless, about half of patients get better in the first two weeks and 70 percent recover within six weeks. When the problem lingers or recurs, however, the treatment challenge is substantial. Mr. S, for example, saw several specialists who confirmed a sciatic nerve problem but gave him conflicting advice.

Summarizing all the findings, James Weinstein, M.D., concluded that "I would not dissuade Mr. S from running, as it appears to be a necessary part of his daily wellness routine. In fact, unless his symptom pattern changes, I would encourage it." Dr. Weinstein also recommended a conservative course in terms of testing and surgery. When tests are performed too early, he pointed out, they frequently lead to surgery that is too early, without clear indications that such is the best course.

Some experts now believe that bulging discs, once thought to be a sure indication of serious problems, may actually be normal in some people or perhaps a response to stress. Some studies have found bulging or protruding discs on the scans of 60 percent of individuals with apparently healthy backs. As many as 25 percent of patients may eventually need surgery. Several types of surgical procedures can be performed, but generally speaking, surgery is effective in only about 60 percent of patients. The 33-year-old sportsman featured in The Lancet was one notable success. Judged to have piriformis muscle syndrome entrapment of the sciatic nerve deep within the buttock, the man underwent a procedure in which a neurosurgeon carefully separated the artery and nerve in the piriformis muscle and placed a Gore-tex patch between them. The man got almost immediate relief from the pain that had tortured him for eight years and was still pain-free several months after the operation.

Non-surgical treatments include exercise, chiropractic manipulation, steroid injections, massage, ice, heat, physical therapy, acupuncture and pain management measures such as biofeedback and relaxation therapy. The trend is to focus on helping patients improve their tolerance to physical activity rather than merely fighting the pain. Physical activity has many benefits, both physical and emotional, while inactivity accentuates pain and causes weakening and shortening of connective tissues. However, the type of exercise may have to be adjusted to the symptoms of the patient. High impact activities such as running, for example, are sometimes considered risky.

Many patients report being helped by spinal manipulation, and the procedure has a good safety record when performed by a skilled chiropractor. Steroid injections work by reducing inflammation at the nerve root. While usually considered a short-term measure, injections have sometimes provided longer lasting relief. For long-suffering sciatic patients, it is easy to lose patience. While a doctor may offer no easy answers, continuing medical care is essential to monitor symptoms, make sure that the condition doesn't worsen, rule out even more serious problems...and, perhaps most important, provide counsel and support.

REFERENCES:

Bridget Doherty, "New Therapy for Sciatic Pain,"Prevention, August, 1999.


"Face Off Should Chiropractic Care Be Used To Treat Conditions Other than Low-Back or Neck Pain?" Medical Tribune 40(5):13, 1999.


Ilaria M. Merlo, Tino E. Poloni, Enrico Alfonsi, Alberto L. Messina and Mauro Ceroni, "Sciatic Pain in a Young Sportsman," The Lancet, March 22, 1997.


"Sciatica," Patient Notes, Postgraduate Medicine, July, 1997.


James N. Weinstein, "A 45-Year-Old Man with Low Back Pain and a Numb Left Foot," JAMA, August 26, 1998.