Treatment of Sciatica
Possible treatments for sciatica include…
- Manual therapy
Just as there are many causes of sciatica, so there are many treatments. For each of the causes I detail the recognised treatments below.
Treatment for Sciatica caused by Disc problems
Disc problems can heal themselves over time. It’s very important not to aggravate the disc through overly vigorous treatment. What we call long-lever manipulations are best avoided, other than from very experienced manipulators. And it’s important to ask “What are you hoping to achieve through the use of this technique?” Because it isn’t going to “put the disc back in”!
Manual therapy – physio, osteo, chiro, massage.
There is plenty of evidence that manual therapy can help to speed up the resolution of sciatica, related to disc problems. Although there’s little research that attempts to differentiate between nerve compression sciatica and non nerve compression sciatica related to disc problems. There is an implicit assumption that disc related sciatica is all due to nerve compression (but this isn’t true – see the causes of sciatica article).
As an aside – a good manual therapist doesn’t only do manual therapy. The most valuable service a good clinician/therapist can provide when treating sciatica is in guiding you through the rehabilitation process. It shouldn’t only be about the hands-on treatment. Some manual therapy techniques can even do harm – especially if they are badly executed. Many people have come to me for second opinions, stating that they have felt worse after manipulation of the spine from another clinician. While I prefer not to comment on specific cases, from the descriptions I’ve had, I think it likely that some of these people had “unstable disc problems” which were probably aggravated by inappropriate manipulation.
Manual therapy can and does help many people with disc problems. Just be sure that the clinician is experienced in the evaluation and rehabilitation of people with lower back problems.
Surgery is an obvious treatment for disc problems. However, thankfully, it is not promoted as a first-line approach. Because – as mentioned above – many people can rehabilitate from disc problems without surgery.
For disc-related nerve compression sciatica that is not improving over 8-12 weeks, surgery becomes a real consideration.
The most common surgery is micro-discectomy. A very small incision is made, and the piece of offending disc material is removed. This – in my experience – can lead to an overnight improvement in sciatic symptoms.
Any surgeon will tell you that there are no guarantees, and that there are risks. They should also give you an idea of the probability of a positive outcome. If you’d like to hear more from a spinal surgeon, listen to this podcast episode with Mr Ioannis Fouyas.
Laminectomy (see below) may be combined with microdiscectomy.
Cortisone injections (intended to reduce inflammation) are not recommended in the clinical guidelines, simply because they are often ineffective. However, they do sometimes help.
An old form of treatment, sustained traction has largely been discredited. Over the last 15 years there has been increasing interest in pulsed traction. IDD Therapy is perhaps the best-known in the UK. It is described as non-surgical spinal decompression treatment. It involves being strapped to a treatment couch with the pelvis being pulled away from the rib cage. The proponents attest that traction can be targeted to specific spinal joints.
Treatment for Sciatica caused by Spondyloarthropathies
Again, there’s a lot that manual therapists have to offer. And again, it’s not just about the hands-on treatment. The combination of relieving techniques and overall guidance often makes a big difference.
Cortisone injections – often under XRay guidance – can be effective at reducing symptoms. The symptoms may come back again. All this is really doing is killing the inflammation for a while – it’s not really changing the underlying degenerative condition.
As the facet joint degenerates, there is often boney proliferation around the joint margins. This thickening of the joints can directly compress the spinal nerve from the back (the disc would irritate it from the front typically), narrowing the intervertebral foramen (hole) through which the nerve exits the spinal canal.
The lamina is the arch of the vertebra that attaches the facet joint to the vertebral body. Surgeons remove the whole rear portion of the vertebra, exposing the nerve roots as they pass through the spinal canal. This surgery is commonly combined with microdiscectomy for disc problems.
Treatment for Sciatica caused by Spondylolisthesis
The most important intervention is lifestyle modification and exercises to stabilise the spine. These may be Pilates “core-stability” type exercises, or similar. It’s usually important to avoid backward-bending activities/exercises with anterolisthesis (forward slippage).
There are types of exercises that often aggravate spondylos – anything jarring, like trampolining, running, jumping (landing is the problem) are probably best avoided.
Manual therapy may have some benefits in some cases. Again, it’s important to consult a clinician experienced in the management of spondylos.
Spondylos come in degrees of severity – categorised by number. Grade 1 is up to 25% slippages, grade 2 up to 50%, grade 3 up to 75% and grade 4 over 75%. Grades 3 and 4 will almost certainly require surgical re-alignment and stabilisation.
Grade 1 can be managed through non-surgical approaches, and Grade 2 is often manageable without resorting to surgery.
Treatment for Sciatica caused by Tumours
Surgery and/or chemo and/or radiotherapy – targeted at the underlying cancer.
Treatment for Sciatica caused by Spinal Stenosis
Laminectomy (as per spondylarthropathies) and “opening up the spinal canal” can be effective. But it’s fair to say that surgery for spinal stenosis is less effective than it is for disc problems. As for other problems, spinal surgery is generally a last resort. But may be necessary – particularly when the stenosis is severe and resulting in significant pain and disability, as it can do. Spinal Stenosis is just a more challenging problem, much more common with advancing age.
It is always worth trying lifestyle modifications and exercise for spinal stenosis. Again, a clinician experienced in this area should be consulted.
Treatment for Sciatica caused by Piriformis syndrome
Manual therapy – targeting the piriformis itself, and related tissues – is often effective at resolving piriformis syndrome. This often involves stretching and massaging the tight muscle. Sometimes Trigger Pointer therapy is used, with or without dry-needling (this is like acupuncture without the Eastern philosophy).
I believe that piriformis syndrome is often secondary to a spinal problem – commonly a non nerve compression disc problem. So, it’s important to identify whether there is a cause of the piriformis syndrome, or is it the only problem.
When I had sciatica in my 20s 2 therapists (one massage, one osteo) were convinced I had piriformis syndrome. Certainly, when they palpated by piriformis they were able to aggravate the pain in my leg. But the piriformis tension was secondary to my underlying L4L5 disc herniation – as I later learned.
An important part of the rehabilitation – exercises can speed up the resolution of this syndrome. Typically stretching the piriformis; these can be static passive stretches, or tense/relax muscle energy techniques.
Treatment for Sciatica caused by Strains
It speeds up the rate of healing. A good clinician will guide you to a faster resolution, along with preventative advice. This is where manual therapy tends to improve sciatica more quickly.
Treatment for Sciatica caused by Pregnancy
Often effective, depending on the cause of the sciatica, manual therapy has a lot to offer pregnant women with sciatica. This may include encouraging the baby to move if it is judged to be sitting on the sciatic nerve.
Often important in stabilising the spine and pelvis with changing weight distribution.