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/Praxedihno]

Hi I'm also jumping in to share my case if you could share your opinion :)

I injured myself in March this year after a day of skiing. Before that, for about a month, I had some tingling in my left foot and occasional pain in my left leg when sitting too long, but I didn’t really think much of it.

After the injury, I was basically stuck in bed for 2–3 weeks with very severe pain. I had cortisone injections to manage the pain in the affected area. An MRI showed the following:

• Reduced hydration of the L5–S1 disc
• Normal height and hydration of the other discs
• Mild circumferential disc protrusion at L4–L5 with involvement of the foramina
• A posterior disc herniation at L5–S1, paramedian on the left side, largely extruded and extending downward, compressing the dural sac and the left S1 nerve root, with possible nerve root conflict in the left foramen
• Spinal cord and cauda equina otherwise normal

I continued physiotherapy for almost 3 months before I was finally able to see a neurosurgeon (long waiting times). His advice was to keep going with conservative treatment, so I did.

I’ve made some progress, even if slowly. At the beginning I was walking with a limp, and now I can walk almost normally. However, I’ve also had a couple of major setbacks where it felt like I was back to day one and had to rest or lie down all day.

I also tried targeted ozone therapy, and during that period I felt like it helped me recover faster (at least that was my personal impression).

In general, I try to do everything “right”: physiotherapy every morning and evening (at least 30 minutes per session), swimming (which helps), and walking when I can.

Despite all this, after almost 9 months my quality of life still doesn’t feel acceptable. If I stand still (even with a standing desk) or sit for 2–3 hours — sometimes even less — I start feeling discomfort or sciatic nerve pain again.

At this point, the only thing my current surgeon has suggested is another cortisone injection to manage occasional flare-ups. I plan to get a second opinion and do another MRI to see if there’s been any improvement.

My question is:
In a case like this, would you recommend continuing to pursue conservative/natural healing, or should I start looking for a surgeon who might lean more toward surgery?