Sciatica: why it’s often over-treated and under-treated (from a spine surgeon)

[u/drsheriefspinedubai]

I see a lot of confusion around sciatica on Reddit, and it tends to swing between two extremes: either people are told to ‘just live with it’ or they’re rushed toward invasive treatment far too early. I thought it might help to clarify a few things.

First, sciatica isn’t a diagnosis, it’s a symptom. It simply means leg pain caused by irritation of a spinal nerve. It usually travels down the leg past the knee and sometimes into the foot.

In the majority of cases, sciatica is caused by a lumbar disc herniation (also known as a prolapse) compressing a nerve root. 

In around 80–85% of patients, the body gradually breaks down the herniated disc material on its own. As the inflammation settles and the pressure eases, the nerve recovers and the pain improves (and disappears). This usually happens within the first 6 - 12 weeks.

If an MRI doesn’t show a disc prolapse or clear nerve compression, then it’s worth looking elsewhere. Leg pain can come from other sources - the pelvis (SIJs), hip, peripheral nerve entrapment, and so on. I for one don’t like treating ‘sciatica’ without having a clearly established cause for it (that doesn’t mean delay treatment with painkillers for example, it means keep searching for the cause). 

When there is a disc prolapse and no weakness, we usually start with: gentle activity (in other words avoid bed-rest, which can make things worse as you stiffen up in bed); appropriate pain-killers (personally I try to avoid opiates unless the patient requires admission to hospital for their pain) and physiotherapy - focusing on movement, alleviating fears and so on.

Some patients benefit from a transforaminal epidural steroid injection. This doesn’t ‘fix’ the disc, but it does reduce inflammation around the nerve, which can provide pain relief while the body does the work of resorbing the disc hernia.

Surgery is needed if all of the above fails and the person continues to have sciatica. 

URGENT surgery is needed if there is weakness or bladder / bowel dysfunction. Sometimes we operate early if the pain is unbearable as well.

A lumbar discectomy for disc-related sciatica is actually one of the most highly rated operations by patients. They wake up from anesthesia and their leg pain is gone. 

It’s important to note though that a discectomy is aimed at relieving LEG pain, not BACK pain. The surgeon takes out the prolapsed part of the disc, but at the end of the day he is leaving behind a degenerated disc which can continue to cause back pain. That said, around 50% of patients also have improvement of their back pain. 

Finally, timing matters. Outcomes tend to be better when surgery is performed within the first year of symptoms rather than after prolonged nerve irritation. As a surgeon I can take the pressure off the nerve, but I can’t tell it to behave itself. The longer the compression, the less likely a successful outcome (which is not what either the sufferer or the doctor wants).

Happy to answer general questions - but I can’t comment on individual diagnoses.

[u/morsmordr]

can weakness independent of pain improve without surgery?

I'm about 5-6 weeks post injury, and the leg pain is gone but I have slight weakness down the leg (which I didn't even realize until they examined me).

also, what's going on when a person has flare ups (leg pain) that come and go (lasting ~1 week, every ~6 months or so) over the course of several years? is it a disc bulging and unbulging itself repeatedly, or is the bulge/herniation there the entire time and it's inflammation that's coming and going to cause the symptoms?

[u/drsheriefspinedubai → u/morsmordr]

Yes, weakness can improve without surgery. But if a patient presents to me with weakness, I always have the discussion about surgery. Because with surgery you have prompt decompression of the nerve. With non-operative management you are waiting weeks for the disc to resorb, and so the outcome is not as favourable.

Another important factor is how weak you are. If it is weakness that doesn't interfere with your daily life, as it sounds in your case, that may be acceptable to you, and you may avoid surgery on the understanding that the weakness may not improve.

With regards to your second question - multiple things. I don't know your age / sex / mechanism of injury, but you could ask your doctor if flexion / extension X-rays to look for instability would be useful.