We all have aches and pains in our backs -- but few are quite as distracting as the nerve pain of sciatica. I learned this the hard way when a friend recently suffered from a bout of sciatica that had her limping around for weeks. After several sleepless nights, she visited an orthopedist who prescribed a round of steroids to cut the inflammation (as readers know, I am not a fan of steroids because of their multiple adverse side effects) and extensive physical therapy. While the treatment seems to have worked -- for now -- I still wanted to find out how she could avoid use of steroids in the future. The good news: There are options for this all-too-common "pain in the butt."
Battle of the bulge
The problem stems from the sciatic nerve, the largest nerve in the body, which runs down each side of the lower spine, through the buttocks, down the back of each leg and into the feet. Surprisingly, sciatica doesn't necessarily involve pain in the back -- the pain often radiates from other points along this nerve. Sciatica is merely a symptom -- the actual problem is caused by compression of the nerve itself. Finding the cause of that pressure isn't always easy.
In many cases, a bulging spinal disk (aka a slipped disk, ruptured disk, herniated disk, etc.) puts pressure on the nerve as it exits the spine. But the two aren't always related (and this is where diagnosis and treatment of sciatica gets a bit murky). A study published in The New England Journal of Medicine found instances of bulged and protruding disks in people with no symptoms of back or leg pain. "It can be misleading," says Douglas R. Johnson, MD, medical director of the Inpatient Rehabilitation Unit at Charlton Memorial Hospital in Fall River, Massachusetts, and coauthor of Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain (Broadway). "Lots of people with terrible back and leg pain have no disk problems at all, and lots of people with no back or leg pain can have ruptured disks. It's tricky. The disk problem is really only a piece of the puzzle."
So if the problem isn't a bulging disk, what is it? According to Dr. Johnson, another common (but less well-known) cause of sciatica-like pain is based in our muscles. "Many cases are actually from muscle tightness, the spasms of which can cause a radiating pain down the leg," he explains. "Most people think of muscle pain as an aching pain, but muscles also can suffer a much deeper and severe form of pain called myofascial pain." Myofascial pain can mimic the burning, stabbing pain associated with sciatica caused by a bulging disc. On top of that, there's piriformis syndrome, where the piriformis muscle, which is found deep in the buttocks, irritates the sciatic nerve due to muscle tightness. In a study published recently in the Journal of Neurosurgery: Spine, researchers used relatively new nerve-imaging technology called magnetic resonance neurography to get detailed images of the sciatic nerve in 239 patients whose sciatica had not improved after being treated for a damaged disk. They found that 69% of the patients had piriformis syndrome.
How can you know?
This is no time for self-diagnosis. "You need to see your regular doctor in order to know [what's causing the problem]," says Dr. Johnson. There are tests that your doctor can do to differentiate between nerve pain and muscle-type pain -- as well as rule out other serious health problems such as a tumor, narrowing of the spinal canal or degenerative disk disease -- which can help direct a course of action. (A thorough exam will include reflex tests in the affected leg and a straight-leg raising maneuver, among others.) Once you've established the root of the pain you're experiencing, you can move on to treatment.
Your next moves
According to Dr. Johnson, because sciatica results from so many different factors, the best intervention is one that's tailored to each individual. Depending on the cause and severity of your sciatica, here are some remedies to consider...
Wait it out. Disk-related sciatica usually goes away on its own in six weeks or so. If your pain isn't severe, mild exercise, such as walking and stretching, can help your recovery.
Be aggressive. If your sciatica is more severe or the pain is muscular, talk to your physician about aggressive physical therapy. "Unless they're in excruciating pain, we treat most people with physical therapy," says Dr. Johnson. That's because most people suffering from back and leg pain tend to avoid working the afflicted areas -- the exact opposite of what you need.
Try chiropractic care. Often when the source of the sciatica has been established, manipulative therapy can aid in easing the pain.
Seek multiple opinions. If your doctor recommends surgery to alleviate your sciatica, keep this in mind: Surgeons tend to be "overly optimistic" about the results of back surgery -- in one survey, nearly 40% of patients had no measurable reduction in back pain postsurgery, even though their doctors had assured them of the results. Before you go under the knife, get a second (and third) opinion. "Talk to as many people as possible," says Dr. Johnson. "Get some surgical opinions as well as some nonsurgical opinions. I generally recommend a physiatrist's opinion, as well. There are a number of studies that show that people who go to physiatrists for the treatment of back pain get very good outcomes."
Get back to normal. Once you have a bad back, you always have a bad back, right? Wrong. "The idea that you need to be very careful or you can never get back to normal activities doesn't turn out to be true," explains Dr. Johnson. In fact, if you keep your muscles stretched and strong, it's possible to put your back problems behind you -- for good.
Note: If your back pain or sciatica is accompanied by bowel or bladder incontinence and/or progressive weakness in your legs, seek immediate medical attention. Unless treated quickly, these symptoms signal a severe problem that can lead to permanent damage.