What is a Sciatica and how to treat it successfully?
Sciatica is an umbrella term used for any injury, illness or irritation of the Sciatic nerve which the biggest and longest nerve in the body.
The Sciatic nerve starts from your lumbar spine (lower back) and travels down the back to the leg to the toes. The Sciatic nerve is a big nerve; it will be more or less the thickness of your thumb as it passes down the thigh. The nerve will then sperate into different branches at knee level (see picture above).
When irritated, the patient will feel pain, tingling, or/and numbness at the back of the thigh, the calf or the toes depending on the severity of the entrapment.
Sometimes the patient might lose muscle strength (As the nerve is irritated it will not give the right information to the muscles which in turn will not contract accordingly).
So if you do not have symptoms down the leg, you do not have a sciatica…
…that does not mean your problem is better or worse, it is just a definition thing.…
… and not all symptoms down the leg are sciatica either….
For most cases (but not always), a sciatica is caused by a bulging intervertebral disc that pushes on the nerve as it comes out of the spine (also called nerve roots).
There are several types of pathways within a nerve, and depending where the bulge presses onto, it will compress only certain fibres. This is why patients suffering from sciatica present with such a diversity of symptoms.
Throughout my career, I had two cases where the patients showed very serious sciatica signs (major loss of muscle strength and no reflexes which are signs of very big entrapment) but completely pain-free! Both went back to normal sporting activities within nine months.
The most common presentation is pain down the leg with no sign of serious nerve entrapment.
Between 13% and 40% of people will experience an episode of sciatica during their lifetime.
Men are most affected and generally afflicted in their 40s. The main cause factors are obesity, smoking, depression and frequent heavy manual labour involving flexion-based lifting.
Women tend to be affected slightly later in their 50s and 60s.
Sciatica in those younger than 50 yrs is generally caused by a lumbar disc herniation. For the over 60s, sciatica is generally associated with lumbar spinal stenosis (caused by normal age-related changes).
What can be done to treat a sciatica?
The guidelines are clear:
You must stay as active as you can.
In reality, this might prove too difficult. I recently treated a patient who could not put their weight onto one leg or sit without causing major pain down their leg. They had to lie on their back in the car!
When in front of a recent onset of sciatica (or any back pain for that matter), we generally propose to first find the movement or position that reduces the pain to acceptable level. Most often than none, lying on your tummy with a couple of pillows works well. We will also ask the patient to stop sitting or bending altogether. It sounds very restricting but, trust me, when you have a painful sciatica, you will do anything to stop the pain…
“Benji has a post-grad. diploma in McKenzie MDT, a well-known method of assessment and treatment which works miracles for patients with back and neck pain. The lying prone technique is the first part of a series of tests and treatment techniques which have helped hundreds of patients at the clinic alone. Benji makes sure that all our clinicians follow the same management pathway which guarantee the same level of skills throughout the clinic.”
Painkillers are also very important. I will not say it enough, painkillers work… …when used well. Patients are not keen on starting a course of painkillers or have tried some and stopped because they did not feel they helped. There are a lot of different ways to decrease pain with medications and not everyone responds in the same manner to one type of painkillers. Take Cocodamol for example. Most people can take it without any effect, others found them too strong or give them bad tummy ache. Alternative drugs, such as Tramadol or Gabapentin for example, might be offered and be well tolerated… We cannot prescribe painkillers at the clinic but will liaise with your GP to work out what painkillers might be best for you. And once you start improving, with the help of your GP, we will reduce them again.
Physios have a wide toolbox to help patients progress.
Massages are extremely useful as they decrease the pain and help mobilise tissues more easily.
I often recommend the use of a TENS machine which decrease pain efficiently (only when it is on).
Some patients respond well to acupuncture, a service we offer at the clinic.
Throughout the treatment, we will advise on what activity can be started again and at what intensity or duration. The recommendations can be very precise, such as walk 5 min x3 per day, but patients feel reassured that they are well looked after and that any increase of movement/loading on the their spine is made in a controlled manner.
Just like you get from an osteopath or a chiropractor, we can do spinal joints mobilisations/ manipulations once we have ensured they are safe to conduct. These techniques can be very successful. They improve movement and bring short-term pain relief. But they do not, as often advertised, put the disc back into place or re-align the spine. These are big bad myths. Manipulating a patient with an acute sciatica can be risky if the right tests are not conducted properly and, unfortunately, I remember 3 patients who had to get an emergency operations following spinal manipulations that were done too early and unsafely (not a the clinic, obvs!).
As soon as it safe to do so, we will start Sciatic nerve mobilisation techniques which mobilise the Sciatic nerve safely and, in theory, release it from the bulge compression. Nerve mobilisations are extremely useful when we encounter patients suffering from chronic (i.e., long-term) sciatica.
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As the patient progresses, the loading on the spine increases. Patients will be asked to sit longer, move more and gently return to work. A patient-specific programme will be issued and regular hands-on sessions will be offered until the patient has returned to normal.
Return to sports will be considered once the patients is symptom-free and that there are no signs of entrapment anymore. We will also ensure that their strength and proprioception are back to normal.
And what happens if nothing helps?
Unfortunately, some sciatica do not improve.
After 3 months, if no improvement is made despite intense (good) physiotherapy, a MRI is recommended. Not before.
The MRI scan is necessary to confirm the lesion and make sure that a referral to a neurosurgeon is the right course of action.
Neurosurgery will consist on releasing the pressure of the bulge from the nerve root. There are several techniques to achieve this. The most common techniques are the removal of material for the middle of the disc or simply removing the bulge itself. We call them microdiscectomy.
And they are extremely successful!
Recovery rates after conventional microdiscectomy were found to be 66% at 4 weeks and 75% at 8 weeks post-op.
Post Discectomy Physiotherapy will help the patient to recover quicker and more safely.
Our post-op protocol will focus on:
Scar care
Return to normal movement
General strengthening
Return to work
Return to Sports
We’re here to support you through every step of your recovery. If you have any questions or would like to discuss a treatment plan tailored to your needs, please don’t hesitate to get in touch with us.
email: info@benjiphysio.co.uk
07760615804