Taming the pain of sciatica: For most people, time heals and less is more

Despite being a less common cause of low back pain, sciatica is still something I regularly see as a general internist. Primary care doctors can and should manage sciatica, because for most individuals the body can fix the problem. My job is to help manage the pain while the body does its job. When a person’s symptoms don’t improve, I discuss the role of surgery or an injection to speed things up.

What is sciatica?

Sciatica refers to pain caused by the sciatic nerve that carries messages from the brain down the spinal cord to the legs. The pain of sciatica typically radiates down one side from the lower back into the leg, often below the knee. The most common cause is a bulging (“herniated”) disc in the lower back. Discs are tire-like structures that sit between the bones of the spine. If the outer rim of the disc tears, usually due to routine pressure on the lower back, the jelly-like inner material can come out and pinch or inflame the nearby nerve. Sciatica is most common in people 30 to 50.

How do you know if it is sciatica?

The key to diagnosing sciatica is a thorough history and a focused exam. Unfortunately, many patients expect an x-ray or MRI, and doctors, often facing time constraints, order one even though we know imaging tests don’t really help us treat early sciatica any better. The symptoms of sciatica are often worse with sitting or coughing, and may be accompanied by numbness or tingling in the leg. A physical exam can confirm that the sciatic nerve is involved, and I look for weakness or diminished reflexes in the legs that suggest that someone needs early referral to a specialist. (This doesn’t happen often.) With this information, I can make an initial diagnosis and start treatment.

Treating pain… and managing expectations

Many people think (understandably) that the worse the pain, the more likely something bad is going on. However, this isn’t true for sciatica. The body can reabsorb the disc material that is causing symptoms, even for those with severe pain. So, treatment focuses on controlling pain and keeping people as active as possible. If the pain is excruciating, lying down for short periods can help, but prolonged bed rest does not. So once the pain diminishes, I tell patients to get up and start walking short distances. Since sitting increases pressure on the discs in the lower back, I recommend avoiding prolonged sitting or driving. Many people try treatments like physical therapy, massage, acupuncture, and chiropractic manipulation, but evidence suggests that while these approaches may help typical low back pain, they are less helpful for sciatica. Over-the-counter pain medicines like ibuprofen and naproxen can help. When they don’t I may recommend short-term use of stronger, prescription pain medicines.

 

 

 

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