Sciatica (neuralgia)

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Sciatic neuralgia, commonly called sciatica, is a sharp pain felt along one of the two sciatic nerves. Located at the back of each leg, they are the largest nerves in the body (see diagram). They join the spine at the lower back, at the height of the lumbar and sacral vertebrae (just above the coccyx).

The pain mainly affects the buttock and thigh, and often extends to the foot. Most often, pain only affects one side of the body.

Sciatica, low back pain or herniated disc?

In cases of low back pain, “kidney tower” or “lumbago”, the pain is usually localized in the lower back and buttocks. It is of variable intensity and may or may not limit movement.

In sciatica, pain is usually felt on one side of the body, in the buttock and all the way down the leg to the foot; sometimes also in the lower back.

Disc herniation is an abnormal protrusion of part of an intervertebral disc from the spine. It is one of the main causes of low back pain or sciatica.

Causes
Sciatica is not a disease in itself. It is a sign that the sciatic nerve is irritated. Most cases are due to a herniated disc, which compresses one or the other of the 5 roots of the sciatic nerve. Symptoms vary slightly, depending on the root affected. (The root is the part of the nerve that joins the spinal cord inside the spine.)

Sciatica can also be caused by any of the following factors.

Narrow lumbar canal (spinal canal stenosis). A narrowing of the canal (into which the nerves are inserted) can cause compression of the nerve roots in the lumbar vertebrae region, and sciatica. This mainly occurs in the elderly.
Piriform syndrome. It is caused by inflammation of a pelvic muscle called the piriform (pear-shaped) or pyramidal muscle. If this muscle is contracted and swollen, it can put pressure on the sciatic nerve and irritate it. Athletes and people who train inadequately are more susceptible.
Facetary syndrome. This syndrome originates in the joint facets, thin joints located at the top and bottom of each vertebra (not to be confused with the intervertebral discs, another structure that allows the articulation of vertebrae). Poor posture or false movement can create a slight misalignment of these facets. Back pain and sometimes sciatica may result.
Trauma. A fall, a car accident or any other situation that causes a blow to the back can cause damage to the nerve roots.
Other causes. Osteoarthritis or metastases that would put pressure on the sciatic nerve can cause back pain and, more rarely, sciatica. Both of these situations occur mainly in the elderly.
Evolution

In most people with sciatic neuralgia, symptoms resolve within 4 weeks. However, it often tends to reappear if nothing is done to prevent it. Sciatica may also be associated with chronic low back pain.

When to consult?

When sciatica-like symptoms develop, it is best to consult a physician for an accurate diagnosis.

If it is sciatica and the treatments fail to relieve the pain or it gets worse, see a doctor again.

Consult a physician in emergency if:

the back pain is so intense that it’s hard to bear;
symptoms of sciatica are accompanied by urinary or fecal incontinence (or retention), impotence, loss of sensation in the area of the perineum and inside the thighs, or difficulty standing or climbing stairs;
in addition to sciatica symptoms, rapid and unexplained weight loss occurs.

Symptoms, people at risk and risk factors of sciatica (neuralgia)

References
Symptoms
Intense pain in the lower back or buttock that radiates to the thigh, calf and foot. Pain can occur as an electric shock, or be mild but constant. It is usually accentuated when sitting, coughing and exercising, and relieved when lying down.
tingling, numbness and muscle weakness in certain areas of the affected leg and foot
Persons at risk
People with osteoarthritis or certain forms of arthritis.
Pregnant women. The weight of the abdomen, combined with increased secretion of a hormone that softens tissues, and the uterus that can compress the sciatic nerve, can cause sciatica.
Risk Factors
Practice a sport or work that frequently requires lifting heavy loads, bending or twisting the trunk.
Stay seated for several hours at a time.
Do little physical activity.
Overweight.
Poor posture.
Have weak abdominal muscles.

Basic preventive measures

Regular exercise helps maintain flexibility and muscle strength in the back and abdomen. Gentle, symmetrical and stretchy exercises are best. Note that walking or swimming are excellent for strengthening the lower back muscles. When cycling, make sure the seat and handlebars are properly adjusted.
Always do a few warm-up exercises before engaging in strenuous physical activity.
Stay aware of your posture as often as possible: back straight, look straight, shoulders back.
If you have to stand up for a long time, use a low stool on which you will rest your feet in turn, alternating every 5 to 10 minutes.
If you have to sit for long hours, allow yourself rest periods to stretch and stretch, and change positions. Make sure you have a chair that supports your lower back.
To lift a heavy object, do not tilt the torso forward and avoid twisting movements. Squat down, bending your knees while keeping your back straight, and stand up, holding the object close to your body.
To catch something that is behind you, do not twist the trunk. Instead, pivot on your feet to turn around.
Prefer backpacks to handbags, and use both shoulders to carry the backpack.
For a good position during the night, choose a comfortable mattress and a pillow that does not create a too large angle at the neck.

Medical treatments for sciatica (neuralgia)

Important. In case of sciatica, it is preferable to remain active, in a moderate way. In the past, it was recommended to keep the bed. Nowadays, we know that this does not bring any therapeutic benefit and that by remaining active, we promote healing (see “Physical Activities” below). That said, if the pain is so severe that you have to rest in bed, it’s okay to do it, but no more than 48 hours. If the pain is not relieved by rest or is unbearable, it is better to see a doctor again.

Sciatic neuralgia is usually well treated within a few weeks. When neuralgia is caused by a specific disease, recovery or control with medication usually results in the disappearance of symptoms.

In pregnant women, sciatica tends to disappear after delivery.

Medication
Various medications can be used to relieve pain. The first is acetaminophen or paracetamol (Tylenol®).

Non-steroidal anti-inflammatory drugs (NSAIDs) available over the counter also have an antipain effect, in addition to being anti-inflammatory (for example, ibuprofen (Advil®, Motrin®) and acetylsalicylic acid (Aspirin®)). However, they are no more effective than acetaminophen in relieving symptoms, according to studies. Moreover, their usefulness in case of sciatica is questioned. Most of the time, inflammation is not the cause. However, if adequate acetaminophen dosage does not provide effective pain relief, non-steroidal anti-inflammatory drugs may be chosen and the result observed to be better. Ask about precautions and contraindications.

If pain is resistant to these drugs, muscle relaxants, higher doses of non-steroidal anti-inflammatory drugs or narcotics prescribed by the doctor may be used.

Local injections of a mixture of analgesics and corticosteroids may also be used. These treatments offer short-term relief, but no long-term benefit.

Some practical advice

The most comfortable sleeping positions would be on the side, with a pillow between the knees and under the head. You can also lie on your back, with your knees and head and shoulders slightly raised by pillows.

During the first 48 hours, applying cold to the painful area can ease the pain. To do this, use an ice bag wrapped in a towel. Apply to painful area for 10 to 12 minutes. Repeat application every 2 hours or as needed.

Thereafter, heat can be beneficial. It helps to relax aching muscles. A hot water bath is ideal. Otherwise, apply a heat source (a warm damp towel or heating pad) several times a day.

Note. Heat and cold applications on aching muscles have long been used. However, recent studies cast doubt on their real usefulness in relieving back pain4. There is more evidence to support the use of heat than cold.

Physical activities

It is best not to stop normal activities for more than 24 to 48 hours. Studies show that people who stay active recover more quickly1. Staying active helps relieve muscle tension and preserves muscle mass. If pain is severe, bed rest for 1 or 2 days is acceptable. However, gentle activities should be resumed as soon as possible, as soon as the pain becomes tolerable, as this promotes healing.

When pain is present, it is advisable to limit yourself to daily physical activities and a few light physical exercises, such as walking. These gentle activities will not aggravate the problem. On the contrary, they are beneficial. Exercise stimulates the production of endorphins, hormones that inhibit the transmission of pain messages.

Thereafter, the intensity of physical exercise can gradually be increased. Swimming, stationary cycling or other low-impact exercises are generally beneficial.

Physiotherapy

If the pain has lasted more than 4 to 6 weeks, a physiotherapist is recommended to help you recover. Various exercises and stretches to correct posture, strengthen back muscles and improve flexibility are offered. To be effective, exercises must be practiced regularly.

Physiotherapy treatments may also include gentle massage, heat exposure and electrotherapy.

Massages. The massages performed are generally superficial, slow and regular maneuvers that help to soften the painful area.
Heat. Different sources are directed towards sore muscles: infrared rays, warm wraps, hot balneotherapy (in Europe, thalassotherapy is often integrated into the treatment of sciatica and back pain).
Electrotherapy. Ultrasound, transcutaneous electrical stimulation or TENS, ionizations, lasers, etc. also relieve pain by blurring nerve messages.
Surgery
If the pain persists for more than 3 months despite the treatments provided, surgery may be considered. If the sciatica is related to a herniated disc, surgery is required in less than 5% of cases. Surgery will remove pressure from the spinal disc on the sciatic nerve.

Sciatica (neuralgia) – Our doctor’s opinion

I have evaluated several patients with back pain and sciatica in my career. After the evaluation, usually without an X-ray examination, I tell them that there is nothing special to do and that everything will return to normal over time.

A lot of people look at me like I’ve lost my mind. Hard to believe this intense pain will go away on its own! Besides, what about this recommendation not to rest too long?

As with many other health problems, medical practices are changing. What was believed to be true a few years ago is no longer necessarily true. For example, we now know that prolonged bed rest is harmful and that there is no point in having surgery too quickly. Also, the usefulness of cold applications and anti-inflammatory drugs is questioned. The human body has a great capacity for self-healing and, in the vast majority of cases, herniated discs resolve over time.

The role of the doctor is to make a good assessment to eliminate the rare serious causes of sciatic back pain. Thereafter, with compassion, patience, appropriate analgesia and a follow-up appointment a few weeks later are recommended.

 

Sciatica (neuralgia): complementary approaches

Osteopathy. Many scientific articles demonstrate the effectiveness of osteopathy in relieving back pain. However, very few experts have looked at its effectiveness in relieving sciatica in particular. A study was conducted with 40 people suffering from sciatic neuralgia caused by a herniated disc. Osteopathy proved to be more effective in the short term than medical treatment of hernia by chemionucleolysis and also effective in the medium term (12 months)2.

Recognized use Peppermint (Mentha x piperita). The German Commission E recognizes the power of locally applied peppermint essential oil to relieve neuralgia. However, no clinical studies validate this use.
Dosage
Rub the affected area with a mint essential oil preparation (see Peppermint fact sheet for possible preparations). Repeat if necessary.

Commission E, WHO and ESCOP recognise the use of the aerial parts of nettle in external and internal use to relieve arthritic, rheumatic or sciatic pain.
Dosage
Consult our Nettle sheet.

Traditional use St John’s wort (Hypericum perforatum). The use of St. John’s wort in the relief of neuralgia dates back to the ancient Greeks. In addition, Commission E recognizes the effectiveness of St. John’s wort oil in external application to relieve muscle pain. However, these traditional uses have not been confirmed by scientific data.
Dosage
Make a local application of St. John’s wort oil, 1 to 3 times a day. The oil is obtained by macerating fresh flowering tops in olive oil.

Traditional use Balsam Fir (Abies balsamea). Traditionally, turpentine essential oil (different from fir essential oil, distilled from needles) was used to relieve sciatica and several other neuralgias. Turpentine is a substance distilled from the gum of various conifers, including balsam fir and pine.
Dosage
There are commercial preparations with fir gum for topical applications (lotion, oil or ointment), but you can also make an emulsion with 50% vegetable oil and 50% fir gum, or mix 3 drops of turpentine essential oil with a little vegetable oil: apply this emulsion on the painful area.

Approaches to Consider Somatic Education. Somatic education methods make it possible to reharmonize the structure of the body and to develop body awareness. They take into account the whole body by using touch and movement to eliminate tension. For this, they have a beneficial effect for the prevention and treatment of sciatica. Among the approaches, the Alexander Technique and the Trager are particularly recommended by Dr. Andrew Weil3. For other approaches, see our Somatic Education fact sheet.

Approaches to consider Chinese Pharmacopoeia. Du Huo Ji Sheng Wan (angelica and mistletoe pills) is prescribed to treat sciatica.

Approaches to consider Yoga. According to Dr. Weil, yoga has a special place in the prevention and treatment of sciatica3. It is by strengthening the back, softening the body and reducing nervous tension and stress that it would be beneficial to the patient.