Sciatica Solutions Diagnosis, Treatment, and Cure of Spinal
and Piriformis Problems
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NOTE TO READERS
THIS BOOK is not a substitute for medical advice and assistance. The
judgment of individual therapists and physicians who know you is essential.
Although the information in this book may help you identify the cause of
your sciatica, only a doctor or other professional can provide a definitive
diagnosis.
CONTENTS
Part I
SCIATICA and PIRIFORMIS SYNDROME
Chapter I
DEFINING THE PROBLEM
Chapter II
CAUSES AND TYPES OF SCIATIC-TYPE PAIN
Chapter III
THE NERVOUS SYSTEM AND SELF-DIAGNOSIS
Chapter IV
DIAGNOSTIC TESTS AND NERVE FUNCTION
Chapter V
CONDITIONS THAT CAUSE SCIATICA
Part II
CONTROL and CURE
Chapter VI
OUTSMART SCIATICA WITH TRICKS YOU CAN DO ON YOUR OWN
Chapter VII
PHYSICAL THERAPY
Chapter VIII
MEDICATIONS
Chapter IX
INJECTIONS
Chapter X
SURGERY
Chapter XI
NONMEDICAL TREATMENT AND PREVENTION
Chapter XII
NUTRITION AND LIFESTYLE
Chapter XIII
ALTERNATIVE MEDICAL APPROACHES
NOTES
RESOURCES
Part I
SCIATICA and PIRIFORMIS
SYNDROME
Chapter I
DEFINING THE
PROBLEM
HERE, IN SHORT FORM, is a classic story told to me in one variation or
another by hundreds of intelligent, sensitive patients from every walk of
life. After physical stress (including marathon sitting in a car or an office),
after a fall or other accident, after lifting something extremely heavy, or
sometimes for no apparent reason at all, they get a backache. The pain is
severe enough and lasts long enough that they go to the doctor. Often pain
and strange sensations radiate down the leg in searing, lightning-like
shocks, or there is numbness or weakness in areas of the leg, or intense pain
in the buttock. When that happens, the patient has sciatica.
Unfortunately a bout of sciatica is often a memorable experience. It’s hard
to forget something so unpleasant. If you have had sciatica, or if you have it
now, don’t despair of being able to cope. There is a great deal you can
understand and do about this condition.
In the following pages we try to demystify this often confusing complaint,
guide you in figuring out its cause, and give you tips about how to deal with
it—medically and on your own. Sciatica has a way of wearing patients
down, of making them feel defeated. We can assure you that there are many
excellent methods for dealing with this problem. Clearly, the more you
understand about it, the better off you’ll be.
EVERY YEAR tens of millions of individuals experience back pain that
causes them to seek medical attention. These people’s pain translates into
time and huge costs—lost days of work, lost activities and dollars. In 1998
alone, people with back pain spent $90.7 billion on their health care, and, as
we all know, costs are always rising!1
To some extent, the determinants of sciatica and low back pain are
different.2 Although back pain can be caused by a muscular or other
problem, sciatica is not. Sciatica is almost without exception the result of a
neurological problem in the back, or an entrapped nerve in the pelvis or
buttock. Very rarely, other neurological conditions, such as multiple
sclerosis or stroke, may account for it.
Sciatica and back pain overlap, but they are not always present together.
Some people have back pain and sciatica. Some have sciatica without back
pain, and some have back pain without sciatica. Sciatica, a special
subcategory of problem that often accompanies back pain, is often lumped
together with it, without regard to other symptoms and causes. That’s a
shame, because sciatica is widespread and deserves to be studied and
acknowledged statistically and medically.
Digging deeply enough into the literature often reveals some estimates of
its prevalence and possible treatments. Some studies have linked
occupation, height, and time spent driving with sciatica as opposed to
musculoskeletal or other types of back pain.3 Although researchers haven’t
thoroughly analyzed back pain statistics by category of problems and
symptoms, and more investigation is needed to discover how many
individuals who have backache also have sciatica, a paper in the Journal of
Neurosurgery: Spine did estimate that the prevalence of sciatica in the adult
population of the United States is greater than 5 percent, and over a lifetime
an individual has as high as a 40 percent probability of experiencing it.4
When it comes to piriformis syndrome—a compression of the sciatic
nerve in the buttock and a frequent cause of sciatica—we have more
information, but that information may not be conclusive. In 1983, an
estimate came out of the Mayo Clinic that about 6 percent of the people
who have sciatica have it because of piriformis syndrome.5 According to
that estimate, every year close to 5 million people in the United States have
sciatica caused by nerve entrapment by the piriformis muscle. Research
done in 2005 suggests that that number may be much higher.
A fairly recent study by recognized experts in the field found that 67
percent of their sciatica patients had no evidence of spine abnormalities on
imaging studies, and that for them the common means of treating sciatica as
a spine-originating symptom were not effective.6 Under 20 percent of the
1.2 million sciatica-related MRIs revealed significant spinal problems,
suggesting that piriformis syndrome may be quite common.
Writing in 1996, researchers from the Department of Neurosurgery at
Johns Hopkins University admitted that they did not know how to care for
the large group of patients who had sciatica without obvious spinal
abnormalities, but they did not consider piriformis syndrome as a possible
cause of these patients’ pain. This conclusion was, and unfortunately still is,
common.7 In that same decade, some of the most prominent back pain
specialists in the country defined sciatica as “symptoms and findings
considered to be secondary to herniations of a lumbar disk.”8 Yet this does
not take into account all the patients who have sciatica but no detectable
problem in their spines.
WHAT SCIATIC PAIN FEELS LIKE
As I mentioned before, trauma, falls, overextending yourself physically,
being cramped in an airplane or a car seat or elsewhere, and lifting
something improperly are just some of the things that can result in sciatica.
Still, I want to caution you: there’s an old rule that doctors quote ironically,
“post hoc, propter hoc.” In other words, if B happened after A, it must be
because A caused B. Put another way, you may have an automobile accident
after turning on the car radio, but that doesn’t mean that the two are related.
Causes aside, there are a number of ways that problems with nerves—in
this case, nerves in the back or buttocks—manifest themselves.
First of all, there’s pain, which can be a dull ache, a sharp sting, electric-
shock-like feelings, throbbing, or discomfort that comes and goes. It’s
always within your leg, along the course of the sciatic nerve and/or the
territory that the sciatic nerve fibers serve on your skin.
Second, numbness occurs when the nerve impulses are unable to get
through. Although numbness (which generally happens on the side of the
calf, on the top or bottom of the foot, or on the heel or sole of the foot)
seems an attractive alternative to pain, it may actually be a more important
danger signal that the nervous system is unable to communicate warnings
from the affected part of the leg back to the brain. Obviously, when you’re
numb, your insensitivity to pain may leave you open to injuring yourself
without knowing it.
Parasthesias—strange sensations—are another manifestation of various
types of nerve damage. Numbness is when you don’t feel something that is
there, such as sensation on the outside of your ankle or your foot, pressure
on your calf, or fullness in your bladder. Parasthesias occur when you feel
something that isn’t there. So, you may experience the sensation of burning
down the back of your thigh, though nothing is touching it. Electric-shock-
like flashes, tingling, tightness, pins and needles, and the sensation that you
have ants or other insects crawling on you also often appear when there is a
problem along the course of the sciatic nerve.
Parasthesias may occur when communication between the central nervous
system and the lower parts of the body is not halted but is disrupted enough
that normal patterns are distorted and misread by the brain. Like the pain
and numbness of sciatica, parasthesias are always located in the regions
served by the sciatic nerve.
There are general similarities between sciatic pain, numbness, and
parasthesias. All have their origins in the brain, spinal cord, or peripheral
nervous system. All manifest themselves in the areas served by specific
nerves—in this case the sciatic nerve. All have to do with problems in the
conduction of nerve impulses.
Another hallmark of sciatica is weakness. Weakness isn’t exactly a
feeling, but you can feel it and it can be associated with sciatica, as can
abnormally weak reflexes in the legs and feet. Nerve damage in the spinal
cord can produce weakness in a specific pattern. Some of the most common
manifestations of such nerve damage (more about this later; see page 23)
are weakness in the back of the calf and difficulty walking on tiptoe, foot
dragging or slapping, knees buckling, or difficulty rising from a sitting
position.
Warning: If you have back pain and/or symptoms of sciatica and at the
same time you suddenly experience incontinence of either bowel or bladder,
you may be suffering from nerve fiber involvement called cauda equina
syndrome. Although this condition is not fatal, it may be serious. You
should see a physician or go to an emergency room immediately.
IS SCIATICA PERMANENT?
Sciatica is unpleasant. Sometimes it’s debilitating. Often it seems as though
it will never go away. The question of how long sciatica lasts is one that has
been studied extensively over the years, and some of the conclusions are
contradictory. However, in my experience sciatica usually does go away,
with or without surgery. How quickly you can get rid of the pain, and how
completely, is variable. The discomfort may recede with almost intolerable
slowness, even taking years.9 Yet many patients who have herniated disks
find relief within 30 days. The very nature of sciatica is somewhat
mysterious, even to the people who study it and treat it every day.
It is certain, however, that surgical and nonsurgical techniques are
evolving, and the results for patients who have operations are improving
steadily. On the other hand, waiting may be as effective as having surgery.
One survey done by the Agency for Health Care Policy and Research
(AHCPR) found that, ten years later, people who had had surgery and those
who had not experienced almost the same degree of cure. In other words,
whether or not you have surgery, you are likely to recover from a bout of
sciatica—eventually. In the group studied by the AHCPR, the people who
had the more serious conditions and the most severe pain helped select
themselves for surgery. But just how often those people chose to have an
operation and how often people suffering greatly refused surgery and found
effective conservative measures hasn’t been sorted out. Nor do we know
how many not-so-awful cases chose surgery because they were frightened
that their condition wouldn’t improve without it, or for other reasons.
My experience suggests that 95 percent of sciatica patients who have seen
me in my office at least twice have gotten substantial or complete relief.
The Maine Lumbar Spine Study, which has been publishing results of
investigations into back pain since 1996, has tried to assess the difference in
recovery between patients who have had various levels of treatment. The
conclusions are far from definitive. In 1996, researchers analyzed baseline-
interview questionnaire answers from 507 patients who had been treated
surgically for sciatica caused by herniated disks and 232 patients who had
not had surgery. After a year, the group that had surgery improved more
than the group that did not have it. However, for patients who entered the
study with relatively mild symptoms, the benefits of surgical and
nonsurgical treatments were similar.
The same group of researchers assessed five-year outcomes for patients
with sciatica caused by lumbar disk herniation and found that, of the 402
patients whose results were available, 63 percent of those who had surgery
reported satisfaction with their current status, whereas 46 percent of those
who didn’t have an operation were not satisfied. Surgery seemed to bring
the most relief early in the follow-up period, but again the difference
between surgical and nonsurgical groups narrowed over the years.10
Later we’ll discuss in more detail the pros and cons of surgery, injections,
physical therapy, and other remedies. For now, it’s important to say that
there are several steps to take before you are faced with a decision about
surgery.
Regardless of the precise details of your individual case, sciatica can be so
severe that it keeps you in bed. Actually, at one time bed rest was the
prescription for this condition. Today objective empirical work has shown
that bed rest is not necessarily the best way to treat sciatica. I believe that
being up and doing about 40 percent of what you usually do is the best way
to deal with it.
A recent review of published studies about this question concluded that
staying active in itself doesn’t do much for low back pain patients and has
even less of a beneficial effect on people with sciatica. But staying active
isn’t harmful, and prolonged bed rest can cause deconditioning and other
problems. Lack of activity can weaken you generally, which is a possibly
dangerous consequence of spending too much time in bed.11 If I had to
recommend a single treatment for low back pain and sciatica, it would be to
stay active.12 (See pages 159–70 for a more thorough discussion of yoga
and exercises that will help maintain a healthy back.)
WHAT SCIATICA IS
Experiencing something unpleasant in addition to back pain is a
complicating factor in many of my patients’ stories. In some cases the back
pain has lessened or even disappeared, only to be accompanied by or
replaced by other, equally or even more uncomfortable problems, including
numbness, weakness, hot or cold or tingling or burning sensations in the
legs, or pain down the thigh or the side of the leg. The patients with extra
discomfort—a large subgroup of the millions with back pain—have
sciatica, or nerve pain.
This nerve pain is nothing new. Our ancestors had it, and so did their
ancestors. Sciatica is common enough and painful enough to have been
noticed and documented since the fifth century BC, when it was described
by Greek physicians. The Romans associated sciatica with gout, osseous
tuberculosis of the bone, hip dislocation, and polio. In the fourth century
AD, physicians believed that sciatica was characterized in part by a “strong,
severe pain emanating from the lower back and radiating into the buttocks,
perineum and even the popliteal fossa [a lozenge-shaped space at the back
of the knee joint], the calf, foot and toes.” Some ancient remedies—bed
rest, massage, heat, and passive range-of-motion exercises—are treatments
we still use with some success today. But in Roman times patients suffering
from intense sciatica were also likely to be subjected to leeches,
bloodletting, and the laying on of hot coals.13
Our understanding of sciatica has been slow to evolve over the millennia.
There was a great leap forward, however, in the early twentieth century,
with the work of William Mixter and Joseph Barr. In 1934 these two
doctors published a groundbreaking article in the New England Journal of
Medicine that changed public perception of the nature of sciatica by
establishing and confirming the link between pressure on nerve fibers
generated by intervertebral disk problems and sciatica.14
Now, thanks in part to Mixter and Barr, sciatica is broadly defined as pain
in the lower back, buttocks, hips, or adjacent areas, including skin; it also
refers to pain along the course of the sciatic nerve, which is the largest
nerve in the body (Merriam-Webster’s Medical Dictionary). The usual
places to feel sciatica are in the back of the thigh, down the back of the leg,
on the outside of the calf, on the side of the foot, and in the heel. Although
pain farther up in the back is real and legitimate and deserves attention and
treatment—and may be associated with damage to nerve fibers that may or
may not be part of the sciatic nerve—any pain you feel above the buttocks
isn’t sciatica.
Many patients who come to me know that they have sciatica, or nerve
pain. But they have a basic misunderstanding of the nature of their
condition. They believe that the cause of their pain is sciatica. Not so.
Your doctor may listen to what you have to say about what’s bothering
you, examine you, and say, “You have sciatica.” This could give the
impression that you have a diagnosis for your problem. But sciatica is a
symptom, not a cause of pain or other discomfort. Your doctor may be able
to tell you that you have sciatica, but not be able to pinpoint the exact cause
of your discomfort. Sciatica often needs attention from medical
professionals, but so do its causes.
