Sciatica

Sciatica takes several forms, each with its own specific characteristics. Acute sciatica is often manageable with medical treatment and can cause pain for 4 to 8 weeks. Chronic sciatica persists for more than 8 weeks and may require surgical treatment. Although rare, more serious cases do occur. These include paralysing sciatica, which can impair motor function in the leg. Hyperalgesic sciatica is characterised by the intensity of the pain, even when painkillers are taken. Finally, sciatica can be associated with severe pathologies such as cauda equina syndrome, which involves other nerve roots, causing urinary and intestinal problems and perineal anaesthesia (around the anus and sexual organs).

Sciatica can cause a wide range of symptoms, from temporary discomfort to acute, incapacitating pain. Some symptoms are specific to the nerve root affected, but the main ones include sharp pain that can radiate from the lumbar region down the affected leg, tingling, numbness or burning sensations along the leg, and more rarely muscle weakness that makes walking difficult. The pain is often exacerbated by certain sitting or standing positions, while walking or the application of heat can alleviate it.

Sciatica is most often caused by compression of the nerve roots or the sciatic nerve. In 90% of cases, sciatica is caused by a herniated disc. This herniation generally compresses one or more spinal nerve roots (L4-L5, L5-S1) at the base of the sciatic nerve, causing direct compression or inflammation.
Lumbar disc herniation results from wear and tear associated with ageing of the intervertebral disc, as with osteoarthritis of other joints in the body.
Other causes of sciatica include:

In rare cases, sciatica may be caused by tumours, infections or fractures of the lumbar spine.

There are no specific risk factors for developing a herniated disc and sciatica. Herniated discs are the result of the natural ageing of the intervertebral disc, linked to genetic transmission factors (one parent with a herniated disc, other family members have a greater risk of developing the same pathology.

Lower back pain should not be confused with a herniated disc. Low back pain is pain caused by muscular fatigue due to the natural wear and tear of the intervertebral discs, as they have to compensate for discs that are mechanically less efficient. (Common) lower back pain is treated with exercise and physiotherapy.

The main aims of sciatica treatment are to relieve pain and treat the underlying cause.

Conservative treatment of sciatica

In 80-90% of cases, sciatica resolves itself over time, in an average of 6-8 weeks. The aim of the conservative approach is to help manage pain without the use of long-term medication:

• Anti-inflammatories and muscle relaxants can provide relief.
• Applying heat or cold can be soothing.
• Mobility helps to avoid stiffness (on the other hand, avoid bed rest, move around within the limits of the pain).
• Epidural infiltrations can be performed.
• Stretching exercises and the gradual resumption of physical activity, sometimes physiotherapy, may be prescribed.

Most of the time, these non-invasive treatments allow the patient to get better within a few weeks.

Surgical treatment of sciatica

Surgery may be considered if disabling pain persists after 3 months of conservative treatment (sometimes less if the pain is unbearable) and impairs daily activities, or if the patient has worrying neurological problems. The aim is to remove the cause of nerve compression to eliminate leg pain, although back pain may persist. Depending on the cause, a herniated disc or ossifications may be removed to free the nerve.
The operation is performed under general anaesthetic. It generally provides excellent relief from sciatic pain.

Microdiscectomy

Microdiscectomy, or herniectomy under the microscope, is the most common surgical approach for treating sciatica caused by a herniated lumbar disc. A small portion of the disc below the nerve root and/or the bone above it is removed. Microdiscectomy uses minimally invasive techniques with a small incision and little tissue damage. The procedure takes between 30 minutes and 1 hour. Lumbar herniectomy can also be performed using biportal endoscopy for a quicker, less invasive recovery.

These techniques can be used to treat other causes of sciatica, such as a narrow lumbar canal. The future trend is to treat patients solely by endoscopy, because of the faster recovery.

Post-operative

The surgical procedure requires at least one night's hospitalisation for appropriate medical follow-up. Mobilisation is encouraged from the day of the operation. Although sciatica or crural pain is generally relieved immediately, full recovery of sensory and motor functions may require additional time.

Comme toute intervention chirurgicale, il existe certains risques généraux et d’autres plus spécifiques comme la brèche durale. Ces derniers sont relativement rares.

To prevent the onset or recurrence of sciatica, it is advisable to:

• Avoid sedentary behaviour, particularly prolonged static positions
• Exercise regularly to maintain flexibility and muscle strength

Une douleur sévère et qui dure, des symptômes tels qu’une faiblesse musculaire importante ou une perte de sensation justifient une consultation médicale. Une prise en charge rapide favorise une guérison complète et évite l'aggravation ou la chronicisation des douleurs.

Diagnosis is based on the patient's history and a thorough clinical examination of the back and legs. Advanced imaging tests may be required to identify the precise cause of the nerve irritation. MRI is currently considered to be the examination of choice, as it offers the best visualisation of disc and neurological structures.
Hôpital de La Tour has a multidisciplinary team specializing in the treatment of sciatica and spinal pathologies.

What are the signs of sciatica?
Warning signs include a sharp pain that spreads from the buttock down the leg, often accompanied by tingling sensations, and possible weakness in the affected leg.

How long does sciatica pain last on average?
In the majority of cases, acute sciatica pain disappears spontaneously in 6 to 8 weeks with simple measures such as rest and painkillers. However, around 5% of patients develop a chronic form that persists for more than 3 months.

How can the pain caused by sciatica be relieved?
Applying heat or cold to the affected area can relieve the pain. Exercise, stretching and moderate physical activity are also beneficial.

What is the difference between sciatica and lumbago?
Lumbago refers to pain in the lower back, whereas sciatica involves pain radiating down the leg as a result of compression or irritation of the sciatic nerve.

Can sciatica lead to paralysis?
Yes, in rare cases, severe and prolonged compression of the sciatic nerve can cause major neurological problems such as disabling muscle weakness or even paralysis of the lower limbs. This is why prompt medical attention is essential in such cases.

Is sciatica always caused by a disc problem?
No. Although a herniated disc is a frequent cause of sciatica, especially in younger patients, other pathologies may be involved, such as a narrowing of the spinal canal (lumbar stenosis).

Can sciatica relapses be prevented?
There is no sure way of preventing recurrences, but the risk of lower back pain can be reduced by maintaining a good level of physical activity, avoiding excess weight and adopting good posture. A herniated disc is above all a consequence of the natural ageing of the disc, which most often manifests itself in lower back pain.

Does sciatica heal completely after surgery?
In most cases, surgery provides excellent relief by removing the cause of nerve compression.

When does sciatica need to be treated surgically?
Surgery is generally considered when severe sciatic pain persists despite several months of conservative medical treatment, or when sciatica leads to severe neurological problems (rare).