sciatica - Low back pain

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Sciatica is a common condition characterized by pain that radiates along the path of the sciatic nerve, which branches from the lower back through the hips and buttocks and down each leg. It typically affects only one side of the body and can vary in intensity from mild to severe. Here's a detailed breakdown:

1. Definition of Sciatica

Sciatica is not a diagnosis in itself, but a symptom of an underlying medical condition. It refers to pain that results from irritation or compression of the sciatic nerve—the longest and thickest nerve in the body.

2. Anatomy of the Sciatic Nerve

  • Originates from the lumbosacral plexus (L4 to S3).

  • Exits through the greater sciatic foramen.

  • Travels beneath the piriformis muscle in most individuals.

  • Extends down the posterior thigh, and splits into the tibial and common peroneal nerves near the knee.

3. Causes of Sciatica

  • Herniated lumbar disc (most common)

  • Lumbar spinal stenosis

  • Degenerative disc disease

  • Spondylolisthesis

  • Piriformis syndrome

  • Trauma

  • Tumors or infections affecting the spinal cord or nerve roots

4. Clinical Features

Pain Characteristics:

  • Sharp, shooting, or burning pain radiating from the low back down the buttock and posterior leg.

  • Can go as far as the foot or toes.

  • Usually unilateral.

Associated Symptoms:

  • Numbness or tingling (paresthesia)

  • Muscle weakness in the leg or foot

  • Loss of reflexes (ankle jerk)

  • Pain aggravated by prolonged sitting, coughing, or sneezing

5. Assessment in Physiotherapy

Subjective Assessment:

  • Location, duration, and intensity of pain

  • Aggravating and relieving factors

  • Functional limitations (e.g., difficulty walking or bending)

Objective Assessment:

Observation:

  • Antalgic posture or gait

  • Muscle atrophy (chronic cases)

Palpation:

  • Tenderness over lumbar spine or piriformis muscle

Range of Motion (ROM):

  • Limited lumbar spine flexion or extension

Neurological Tests:

  • Sensory loss (dermatomal pattern)

  • Motor weakness (myotomal testing)

  • Reflex changes (e.g., diminished ankle reflex)

Special Tests:

  • Straight Leg Raise (SLR) Test: Reproduces sciatic pain at 30–70° elevation.

  • Slump Test: Neuromeningeal tension test.

  • Crossed SLR Test: More specific but less sensitive.

Functional Assessment:

  • Gait analysis

  • Sit-to-stand, squatting, lifting capacity

6. Imaging & Diagnosis

  • MRI: Most accurate for herniated discs and spinal stenosis.

  • CT scan: When MRI is contraindicated.

  • X-ray: To rule out fractures, alignment issues.

  • Electromyography (EMG): To identify nerve root pathology.

7. Treatment Options

A. Conservative Management

1. Pharmacological (prescribed by physician):

  • NSAIDs (e.g., ibuprofen)

  • Muscle relaxants

  • Oral corticosteroids

  • Neuropathic pain meds (e.g., pregabalin, gabapentin)

B. Physiotherapy Management

Goals:

  • Reduce pain and inflammation

  • Improve mobility and posture

  • Strengthen core and lower limb muscles

  • Educate to prevent recurrence

1. Acute Phase (0–2 weeks):

  • Rest (short-term, not prolonged bed rest)

  • Cold packs for pain and inflammation

  • Gentle neural mobilization (if tolerated)

  • Positioning to reduce nerve tension (e.g., lying supine with knees bent)

2. Subacute Phase (2–6 weeks):

  • McKenzie Extension Exercises (for discogenic sciatica)

  • Pelvic tilts, bridging, and core strengthening

  • Piriformis stretching

  • Neural Mobilization Techniques (nerve glides)

  • Postural correction

  • Manual therapy: Spinal mobilizations if indicated

3. Chronic Phase (>6 weeks):

  • Progressive strengthening (glutes, hamstrings, back)

  • Aerobic conditioning (e.g., walking, swimming)

  • Education on ergonomics, body mechanics

  • Home Exercise Program (HEP)

C. Interventional Management

  • Epidural steroid injections: Temporary relief

  • Nerve root blocks: Diagnostic and therapeutic

D. Surgical Options

Surgery is considered if:

  • Conservative treatment fails (6–12 weeks)

  • There is severe neurological deficit (e.g., foot drop)

  • Presence of cauda equina syndrome (urgent!)

Common Procedures:

  1. Microdiscectomy: Removal of herniated disc fragment

  2. Laminectomy: Removal of lamina to decompress nerves

  3. Spinal Fusion: For instability or spondylolisthesis

8. Prognosis

  • Most cases improve within 4–6 weeks with conservative treatment.

  • Recurrent episodes are possible, especially without lifestyle changes.

  • Surgery can be highly effective for properly selected patients.

9. Patient Education

  • Avoid prolonged sitting

  • Maintain good posture and ergonomics

  • Weight management

  • Regular exercise and stretching

  • Lifting techniques (bend knees, not back)


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