09 Aug 2013

Sciatica Pain: Not Always the Sciatic Nerve

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If you have intense pain that radiates down your leg from your low back or buttock, you may have been told that you have sciatica pain.  Treatment for sciatica is one of the most common reasons for referral to a pain doctor.

Because of its name, “sciatica” is often misunderstood as meaning a pinched sciatic nerve.  However, sciatica is actually just an old medical term (dating back over 500 years!) of radiating pain down the leg, not necessarily a problem with the sciatic nerve itself.  A pinched sciatic nerve is sometimes, but not usually, the cause of sciatica pain.  This means that the best treatment for sciatica depends on the real source of pain.

In about 9 out of 10 cases, sciatica comes from irritation of the nerve roots of the low back.  The medical term for nerve root pain is “radicular pain” or “radiculitis.”  The sciatic nerve is formed as several different nerve roots in the low back, so it makes sense that irritation of these nerves feels the same as a pinched sciatic nerve.  These nerve roots are often irritated by a bulging disc (herniated disc), which can compress the nerve root as it exits the spine.  Sometimes, a bulging disc can also have leakage of disc fluid onto the nerve.  Disc fluid contains chemicals that are very irritating and painful to the nerve root.
The spine and a herniated discA model of a herniated disc (red), close to a nerve root coming out of the spine (yellow)Photo credit: planetc1 / Foter / CC BY-SA

 

Because nerve roots are not the only cause of sciatica pain, it is important to be examined by a pain management physician to make the right diagnosis.  Medical imaging like an MRI is often needed to confirm a bulging disc or compressed nerve root, because ordinary X-rays of the low back only show bones, not discs or nerves.

The good news about treatment for sciatica is that in most cases, it will go away on its own with time without surgery.  The bad news is, it can take months or even a couple of years, and sciatica pain hurts!  A good pain management doctor can help bring that pain under control until the body heals itself.

What kinds of treatment for sciatica actually work?

First-line treatments include physical therapy and oral anti-inflammatory medications.  Unfortunately, chiropractic manipulation does not help for nerve root pain that has been present for longer than 3 months.  When these options don’t provide enough relief, I often recommend a quick and safe procedure to deliver concentrated medication (similar to cortisone) directly to the source of nerve pain in the low back.  This injection works best with real-time X-ray guidance and requires the skills of an experienced physician.  Many of my patients are surprised by how good they feel afterward, and I am able to do it comfortably with only local anesthetic.  You can to return to work on the same day.

What if it isn’t the nerve root causing sciatica?

As mentioned above, some cases of sciatica don’t come from the nerve root.  The spinal cord itself can be compressed by discs, bone spurs, or masses, causing similar symptoms of sciatica pain.  Sometimes it really is a pinched sciatic nerve: the piriformis muscle which runs over the sciatic nerve can become tight and compress the nerve.  In my practice, treatment for sciatica in these cases uses a new ultrasound technique to see the muscle and nerve, followed by targeted medication to relax the muscle and relieve the pinched sciatic nerve.  Many pain management doctors have not yet been trained in this new procedure.  There are also some rarer causes of sciatic nerve injury or irritation that I can address in my office.

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About Leo Lombardo, M.D.

Leo Lombardo, M.D. is a dual-board-certified pain physician and founder of Ventura Pain and Spine Physicians, a medical practice serving Ventura, Oxnard, Camarillo, and all of Ventura County.

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2 Responses to Sciatica Pain: Not Always the Sciatic Nerve
  1. Dr. Lombardo

    I have had sciatica pain for years, we have tried physical therapy and it didn’t work. We even tried blocks (I had three) and it didn’t work. My biggest problem is that I am on Medical, but I have been in sever pain for about 3 months, only because I have been doing a lot of bending and reaching lately. My doctor keeps on wanting to do physical therapy – fine – but I am also taking vicodin and ibuprofen and it doesn’t relieve my pain – I just want my pain gone. I am also overweight, but I am loosing weight in a proper slow fashion.

    If you could help in anyway I would be so so greatful.

    • Hi Veronica,

      I’m sorry to hear that you have been dealing with sciatica for so long. It sounds like you’ve tried a lot of the right things but that unluckily they haven’t worked well for you. Unfortunately I do not participate in Medi-Cal, and most pain specialists do not. You may want to look into getting a referral from your doctor to a pain program at an academic center (if you’re in the Ventura area, the closest might be UCLA). Academic programs tend to specialize in tough cases and often accept Medi-Cal. When I was at UCSD, we saw many patients with Medi-Cal, although there was a long wait for the initial consultation (follow-ups could be scheduled quickly once the initial visit was done).


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