Having experienced sciatica firsthand, both as a practitioner and a patient, I know its pain all too well. Over 20 years ago, a ruptured lumbar disc (L5/S1) turned my marathon passion into a struggle to walk. Through this journey, I discovered effective strategies to manage sciatica. For me, a combination of surgery, manual therapy, and exercise led to recovery, allowing me to return to Ironman competitions within a year.
The Good News
We have a 90% success rate in reducing or eliminating pain and improving function for sciatica patients. By combining manual therapy with targeted exercise, we often achieve remarkable results. Fortunately, most sciatica sufferers don’t require surgery. Even in severe cases, conservative approaches like manual therapy and specific exercises usually lead to significant improvements or complete resolution of the condition.
Article Index:
What is Sciatica?
Sciatica is a common condition caused by the compression or irritation of the sciatic nerve, which originates in the lower spine and extends through the hips, buttocks, and down the legs. When this nerve is affected, it can lead to pain, tingling, or muscle weakness in the affected leg.
The Sciatic Nerve:
Emerges from the sacral plexus, with nerve roots originating from L4 to S3.
Travels through the gluteal region down to the knee, where it splits into the tibial and peroneal nerves.
As the longest and widest nerve in the body, the sciatic nerve can be as thick as an adult thumb at its broadest point.
It's crucial to distinguish true sciatica from general leg pain. Medically, sciatica refers to pain that follows a specific nerve root pattern, usually corresponding to the L4-S2 regions, and not just any lower back or leg discomfort.
Often, patients with low back and leg pain don't show the typical dermatomal pain pattern linked with sciatica, yet they are still diagnosed with it. For those who don't have pain following the specific nerve root distribution in the lumbosacral region, the more accurate diagnosis would be "nonspecific radicular pain."
Note:
It's essential to recognize that dermatomal inconsistencies are common. While these patterns offer general insights into sensory changes, experts have no universal agreement on their exact distributions. Significant overlap exists between spinal nerve levels, and individual variations are frequently observed.
Causes of Sciatica
Sciatica can stem from various sources, including disc herniation, foraminal stenosis, spinal stenosis, or the entrapment of the sciatic nerve along its pathway. This section will focus on sciatica-like symptoms caused by disc herniation and nerve entrapment.
Lumbar Spinal Discs
Intervertebral discs are cushion-like structures between the vertebrae of the spine, providing shock absorption and flexibility. In the lumbar spine, there are five intervertebral discs labelled L1-L5. These discs are crucial for maintaining spinal alignment and enabling movement. However, when damaged or deteriorated, they can lead to significant discomfort and other symptoms.
Common Lumbar Disc Conditions:
Disc Herniation: Occurs when the inner core (nucleus pulposus) pushes through the outer layer (annulus fibrosus), irritating nearby nerves. This can cause pain, numbness, and leg weakness. Lumbar disc herniation is most common between ages 30 and 50, with men experiencing it twice as often as women. The lower levels of the spine, notably L5/S1, are most frequently affected.
Degenerative Disc Disease: As discs age, they lose their shock-absorbing ability, leading to pain, stiffness, and reduced mobility.
Disc Bulge: The annulus fibrosus bulges outward without rupturing, which can put pressure on adjacent nerves.
Disc Protrusion: The annulus fibrosus bulges and ruptures, but the nucleus pulposus remains within the disc.
Disc Extrusion: In this severe condition, the nucleus pulposus breaks through the annulus fibrosus and extends beyond the disc, potentially causing intense pain and neurological symptoms.
It's crucial to understand that the presence of a disc herniation on imaging doesn’t always match the level of pain a patient feels or predict how they'll recover. Surprisingly, some people with severe disc herniation experience no symptoms at all.
The good news is that most cases of sciatica caused by disc herniation don't require surgery. In many instances, there's no major neurological damage linked to the herniation, making conservative treatments highly effective.
Red Flags
If you experience any of the following red flags along with sciatica symptoms, seek emergency medical care immediately:
Sudden, severe muscle wasting and atrophy.
Recent loss of bowel or bladder control.
Saddle anesthesia (numbness in the buttocks, groin, or inner thighs), which could indicate Cauda Equina Syndrome, a serious condition caused by nerve compression.
Intense sciatica following a fall or trauma, potentially signalling a spinal fracture.
Severe or worsening leg or foot weakness suggests a critical nerve issue.
Fever or signs of infection could point to a spinal infection.
If you notice these symptoms, urgent medical evaluation is essential to identify the cause and initiate the proper treatment.
Disc Injuries - Myths & Reality
Regarding lumbar discs and sciatica, it's crucial to debunk two widespread myths that often lead to misconceptions.
Myth #1:
A large disc protrusion seen on an MRI or CAT scan means conservative care (non-surgical treatment, manual therapy, and exercise) won’t work.
Reality:
While surgery can provide quick relief for some patients with lumbar disc herniations, studies show that surgery does not offer a significant advantage over conservative treatment in the mid to long-term. This highlights the value of exploring non-surgical options before jumping to conclusions.
Myth #2:
Extruded or sequestered disc fragments are less likely to heal than contained protrusions.
Reality:
Interestingly, larger, migrating fragments often resolve more quickly than contained ones. This is because a significant disc protrusion triggers a strong inflammatory response. As the inflammation subsides and the fragments separate, the body can reabsorb them, leading to natural healing.
Key Point: The need for immediate surgery usually hinges on the presence of neurological dysfunction (red flags) and whether the patient can still maintain some level of function.
Conclusion Part 1
Having walked the challenging path of sciatica both as a patient and a practitioner, I understand the intense pain and the impact it can have on your life. My journey from a ruptured lumbar disc to returning to Ironman competitions underscores the effectiveness of a comprehensive approach to treatment. Recovery is possible through a combination of manual therapy, targeted exercises, and, in some cases, surgery.
The Good News: We have a 90% success rate in reducing or eliminating pain and improving function for sciatica patients. Most importantly, surgery is not always necessary. Many patients find significant relief through conservative treatments, allowing them to regain control of their lives.
In the next part of this series, "Sciatica Part 2: Causes and Diagnosis," we'll delve into the non-discogenic causes of sciatica, such as fibrous band tethering and direct compression, and explore the physical examination tests we use to evaluate sciatica cases.
References - Part 1
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Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain. N Engl J Med 1994; 331:69-73.
Borenstein DG, O'Mara JW Jr, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects. J Bone Joint Surg Am 2001;83-A:1306–1311.
Dullerud R, Nakstad PH. CT CHANGES AFTER CONSERVATIVE TREATMENT FOR LUMBAR DISC HERNIATION. Acta Radiologica, 1994;35:415-419.
Komori H, Shinomiya K, Nakai O, Yamaura I, Takeda S, Furuya K. THE NATURAL HISTORY OF HERNIATED NUCLEUS PULPOSUS WITH RADICULOPATHY. Spine, 1996;21:225-229.
Ikeda T, Nakamura T Kikuchi T, Senda H, Tagagi K. Pathomechanism Of Spontaneous Regression Of The Herniated Lumbar Disc: Histologic And Immunohistochemical Study. J Spinal Disord, 1996;9:136-140.
Maigne J-Y, Deligne L. Computed Tomographic Follow-up Study Of 21 Cases Of Nonoperatively Treated Cervical Intervertebral Soft Disc Herniation. Spine, 1994;19:189-191.
Taylor CS, Coxon AJ, Watson PC, Greenough CG. Do L5 and s1 nerve root compressions produce radicular pain in a dermatomal pattern? Spine (Phila Pa 1976). 2013 May 20;38(12):995-8.
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.
Erwin WM, DeSouza L, Funabashi M, Kawchuk G, Karim MZ, Kim S, Mӓdler S, Matta A, Wang X, Mehrkens KA. The biological basis of degenerative disc disease: proteomic and biomechanical analysis of the canine intervertebral disc. Arthritis Research & Therapy 2015;17:240.
Rade M, Pesonen J, Könönen M, Marttila J, Shacklock M, Vanninen R, Kanka anpää M, Airaksinen O. Reduced Spinal Cord Movement With the Straight Leg Raise Test in Patients With Lumbar Intervertebral Disc Herniation. Spine, Volume 42, Number 15, 1 August 2017, pp. 1117-1124(8).
Thistle, S. (2019, April 28). Chiropractic Care for Disc Patients. RRS Education.
Gugliotta M, da Costa BR, Dabis E, Theiler R, Jüni P, Reichenbach S, Landolt H, Hasler P. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016; 6(12): e012938.
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DR. BRIAN ABELSON, DC. - The Author
With over 30 years of clinical practice and experience in treating over 25,000 patients, Dr. Abelson created the powerful and effective Motion Specific Release (MSR) Treatment Systems.
As an internationally best-selling author, he aims to educate and share techniques to benefit the broader healthcare community.
A perpetual student himself, Dr. Abelson continually integrates leading-edge techniques into the MSR programs, with a strong emphasis on multidisciplinary care. His work constantly emphasizes patient-centred care and advancing treatment methods. His practice, Kinetic Health, is located in Calgary, Alberta, Canada.
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