Sciatica: A Real Pain in the Butt

THE MANY FACES AND CAUSES OF SCIATICA
Sciatica merely describes a path of pain and is not a specific diagnosis. The use of the term "sciatica" does not specify a cause.

Defined, "sciatica" is a description of a particular path of pain following the sciatic nerve as it traverses the buttock (hip) and/or continues down the back of the thigh, outside of the leg and perhaps the foot. As our article title denotes, sciatica can be a real pain in the buttocks.

Generally, the worse the condition, the further down the leg the pain travels and may even affect the foot. However, there are certain cases that although severe, only affect the hip area or buttock. It suffices to say that the symptom picture can be quite varied from one individual to another. Although most commonly associated with nerve compression from a low back disc condition, there are many causes of sciatica, some of which are not back related. Interestingly enough even those cases originating from a low back condition may not exhibit any back pain.

Some authorities would argue that if the origin of pain is not compression of a nerve root in the lower back, the result is not a "true sciatica", but a pseudo-sciatica. Synonyms for sciatica would be sciatic neuralgia or sciatic neuritis.

ANATOMY OF THE SCIATIC NERVE

The sciatic nerve is about 1/2 inch in diameter and is known to be the longest and largest nerve in the human body. The nerve originates in the lower spine as nerve roots exit the spinal cord (between the vertebrae in the spine), and combine to extend all the way down the back of the leg to the toes.

It is thus composed from a combination of 5 nerve roots exiting holes known as foraminal openings between vertebrae in the lower lumbar and sacral region. These include the following nerve roots: L4, L5, S1, S2, and S3. Nerve roots in the lumbo-sacral area of the spine are named by the vertebrae above. Thus if the nerve root exits between L5 and S1 it would be considered the L5 nerve root. By understanding this one can correlate the area of symptoms with a specific spinal level.

The five nerves combine anterior to (in front of) the piriformis muscle to become the sciatic nerve. This nerve then travels down the back of each leg, branching out to innervate specific regions of the leg and foot. It should be mentioned here that a spasm of this piriformis muscle where the nerve crosses the sciatic notch can cause sciatic neuralgia and often mimic symptoms of a herniated lumbar disc.
Just above the back of the knee, the sciatic nerve divides into two nerves, known as the peroneal and tibial nerves, going to various parts of the lower leg:

• The peroneal nerve innervates the shin and outer aspect of the leg down to the upper foot.
  
• The tibial nerves innervates the posterior portion of the leg and traverses all the way to the feet to innervate both the heel and sole of the foot.
  

The sciatic nerve supplies both motor input (eliciting muscle movement and reflexes) as well as sensory innervation.

SYMPTOM PICTURE OF SCIATICA

Pain: searing , stabbing, usually intermittent pain is generally the overwhelming symptom. The pain can be felt in the low back, buttock, posterior and outer side of the thigh or leg and possibly all the way to the toes. The pain is most often felt in certain positions, while walking or while straightening the leg. It may occur on both sides (bilaterally), but it is more often one-sided (unilateral). Pain is sometimes exacerbated by sneezing, coughing, laughing or pushing during a bowel movement (Valsalva's Maneuver).

Numbness/tingling: sometimes the pain is either accompanied by or replaced by numbness and tingling known as paresthesia or radiculopathy.

Weakness: in the most severe cases of sciatica there is actually impairment of the motor nerve functions causing weakness in the leg and/or foot. The most common sign of such would be foot drop or the inability to pull the big toe up toward your knee (aka: lack of dorsiflexion).


CATEGORIES OF CAUSES

Mechanical Spinal Nerve Compression: most often from a herniated, ruptured or extruded disc but can be from severe misalignment or vertebral subluxation.
Compression by Muscle Spasm: most commonly known as a "Piriformis Syndrome" whereby the muscle underlying the gluteus maximus (buttock) is spasmed applying pressure to the sciatic nerve underneath. This is known to clued physicians as an "entrapment neuropathy" and is often misdiagnosed as a low back disk herniation because it mimics many of the symptoms of such. This can prudently be differentially diagnosed from a disc herniation by either MRI studies, CT scan or just a good old fashion history and exam including questions regarding pain during coughing, sneezing and bowel movements.
Trauma to the Sciatic Nerve: bruising, puncture wounds, or over-stretching injuries to the nerve itself can produce the symptoms of sciatica.
Spondylolisthesis: this is a slippage of one vertebral body on top of another and may be a result of fracture or a genetic defect in the pars interarticularis. If in the L4 to S1 region, sciatic neuritis symptoms can occur. Although many authors seem to describe a compression of nerve roots resulting from a spondylo-listhesis, it has been my experience both clinically and in my review of the literature that the most accepted authorities believe the nerve root irritation to be a result of traction or stretch of the nerves vs. an actual compression.
Spinal Tumors: space occupying lesions, of the spinal vertebrae, spinal cord, cauda equina, or surrounding muscles or sciatic nerve itself can cause sciatic symptoms.
Sacro-iliac Joint Sprain or Subluxation: this is actually one of the least understood or recognized conditions causing sciatica, but in this clinician's experience is one of the most common causes of sciatica not resulting in pain extending below the knee. Coughing and sneezing does not increase the symptoms in this case and often Kemp's sign will NOT be positive. Subluxation or sprain of the sacro-iliac joint leads to a referred sciatica in this case. This is generally best treated by a chiropractic physician.
Chemical Irritation: although not even known or considered by most practicing physicians, chemical radiculalgia is one of the physical results of back dysfunction and can be the primary cause of sciatica. This is an actual irritation to nerve roots caused by the swelling pressure of inflammation against the nerve. It is a major factor in what is called the "cycle of pain". It may be interesting to note that it has been this practitioner's experience that this is often the factor that is most concerning when dealing with the sequela of a disc herniation or injury. It is the overwhelming reason that Lumbar Epidural Steroid Injections have been so effective in relieving the symptoms of herniated or ruptured disc conditions. It leads some researchers to believe that inflammation may play an even greater roll in symptomatology than the mechanical pressure of displaced disc material.
Viscerally Referred Pain: although not as common as some of the other causes of sciatic symptoms, paresthesias, pain and odd sensations may be felt along the sciatic nerve distribution as a result of problems with internal organs. For example, problems with the prostate gland or female organs can refer sensations along the sciatic nerve. This can easily be ruled out by a thorough examination.

TREATMENT OF SCIATICA

Certainly the best treatment practices for sciatica would include addressing the cause in addition to alleviating the symptoms. Thus the approach may be different dependent on the cause. Sitting, driving and arising from the sitting position is usually a problem for all sciatica sufferers and thus one of the most recommended items would be a pressure relieving seat cushion. One type is known as a memory foam seat wedge. The 2nd type is a gel seat cushion that is wedged for ultra comfort.  Make sure that the cushion you select has a cut-out for the coccyx or tailbone and that it is solid, fairly dense memory foam or a solid type of gel. Ice is nice in the case of sciatica and heat should generally be avoided in acute cases.

Other treatment protocol is more causal specific and usually requires a battery of prescribed and self-care. Some of these are listed below:

DON'TS
Avoid irritation and stretching of the nerve during the healing process. This would eliminate toe touching with the leg straight.

Avoid running, fast walking or other physical activities that increase pain.

Avoid heavy lifting, stooping, squats or prolonged bending.

Avoid sitting on soft overstuffed chairs or couches or desk chairs that fall away when leaned against.

Avoid fast movements.

Avoid arising out of bed w/o first turning on your side

Avoid stomach sleeping or sleeping on your back with both legs straight out.

Avoid straightening the involved leg when sitting.

DO'SDo see a physician or chiropractor for a proper diagnosis and treatment. Depending on findings your doctor of choice may suggest: spinal adjustments or manipulation, deep tissue massage of the buttocks, core muscle strengthening and stretching, repair of a disc herniation, oral anti-inflammatories, lumbar corset or lumbar epidural cortisone injections. Lumbar traction and/or gravity inversion may be advisable in some cases. For less common causes like tumors or referred pain from internal organs, your doctor will likely refer you to a specialist for further investigation.
When sleeping on your back, keep at least the involved leg slightly bent with an orthopedic bed wedge or soft fluffy pillow.

When side sleeping, place a soft pillow between your legs starting at the knee and positioned downward from there.

Do utilize a memory foam seat wedge to keep good posture and remove pressure from the sciatic nerve when seated or driving. For chronic sciatica seated workers should consider the purchase of a nimble ergonomic chair like the Bodybilt task chair.

Heart Healthy Living and Yet My Heart Was Broken

One expects that if they live a healthy lifestyle there should be an absence of heart disease and a portrait of a healthy heart. However, this does not always ring true and my self-portrait is testimony to such. Actually, as friends and family might attest to, I have always been a little different. Some of my friends think I eat cardboard and birdseed, but this is far from the truth. Organic foods and healthy eating can often be very tasty and highly misunderstood. I probably exemplify the phrase “healthy lifestyle”. I do eat what some might call health food, organic when I can and almost always low fat/low sugar. For much of my life I suffered an addiction to sugar, so today I exercise great discipline in this regard. When I do eat sweets (generally only on the weekends), they are made from whole grain flours, utilize either palm oil or coconut oil and are generally sweetened with agave nectar, fruit juices or real maple syrup. I eat many meals out, but I’m selective in my choice of both the restaurant, menu items and cooking technique. Did you know that you can maintain a healthy eating style while traveling or eating out, even at fast food restaurants? I’ll get more into this later or perhaps in another post.

I’m also a fitness fanatic, self-proclaimed at 14 years of age after my heart was broken from rejection by the first girl I asked out on a date. She was a cheerleader and I was NOT a jock. I was not terribly overweight, but I was a sugarholic and had what one might call a pudgy, non-athletic appearance. So, I began running and working out at a time when the only runners were those on a track team and when working out with weights was for jocks or bodybuilders. Gyms were not air-conditioned and so-called “health clubs” were exclusively for the wealthy country club goers. Inspired by the likes of Jack Lalane, Steve Reeves (Hercules) and Paul Bragg I was determined to be fit, ripped and most importantly to have a date with the girl who turned me down.

This became a lifestyle for me, continued throughout college and carried over into my education and professional career. I had originally intended to be what is now called an exercise physiologist, yet that field of education did not exist at the time. I started with physical ed and pre-med in college with the intention of being the world’s guru to fitness. Wow, isn’t it amazing how being rejected by a pretty girl so greatly influenced my life?

Well, unexpectedly, I hurt my back in an accident and my treatment and recovery for such sparked my interest for becoming a chiropractic physician. So, that is exactly what I did. As I always say: “life is what happens while you’re making other plans.” Actually, it was a way I could live and preach all the healthy living techniques I was incorporating into my own life.

I LIVED A HEALTHY LIFESTYLE, SO WHY WAS MY HEART SICK?

To summarize and make a long story short, I’m a health and fitness nut; lived and breathed it. Ironically, but true, I recently almost died of a heart problem. How can that even be? I never smoked, rarely drank alcohol, lived a healthy lifestyle and yet in March 2008 I was suffering grade IV congestive heart failure. This was quite an eye-opener for me. I realized that there are circumstances beyond our control and no matter how “good” we are, we can still get sick. I had no heart disease, no coronary disease, no atherosclerosis and nonetheless, my heart just short-circuited. I developed a severe arrhythmia whereby my heart was beating out of control and not pumping blood. Fluid was building up in my stomach, liver, lungs and I was literally drowning in my own secretions. Thanks be to God and the expert medical care of Dr. John Seger (electro-physiologist), my heart has a normal sinus rhythm again. Dr. Seger performed ablation, a surgery whereby the short circuit pathways of my heart’s rhythm were blocked by overheating the cells in specific areas of my heart muscle. He also prescribed a small amount of a beta blocker called Bystolic to calm my heart and lessen the fight/flight response to stress. In addition and on my own accord, I take health supplements and continue my healthy lifestyle.

WHAT’S TO BE GAINED FROM THIS EXPERIENCE?

Some might say that all my health efforts were wasted because I got very sick in spite of my healthy lifestyle and ode to clean living. To accept such would be a tragedy because I believe in my heart of hearts that I would not have survived the incident nor returned to my current state of health if I had lived a less than healthy lifestyle. In addition, my fairly quick return from the "jaws of death" and return to fitness would have been hendered if I had not followed up my surgery with a good supplement program, healthy eating, stress reduction and an awareness of my body’s feedback.

I live, I breathe, I feel very lucky, and I’m here to tell you about it. I’ve learned that the integration of western conventional medicine with traditional alternative methods is often imperative. I’ve realized that a broken heart is not always a bad thing and that when one door slams shut, another pops open. I did find the love of my life and I’m still here to share life’s challenges and rewards with her.

SO WHAT’S NEXT?

I’m concepting what might be the neatest, life-changing wellness, health-spa-retreat ever conceived. We've selected a choice spot in the mountains, to be revealed later. The concept will integrate western and eastern philosophies of health care under the cloak of both conventional medicine and alternative medicine. Here, guests will learn how to live well and be well while working toward current health and fitness goals and overcoming their obstacles to such.

Be Well !