Sciatica can be debilitating, but understanding its causes and treatments can lead to significant relief. Photo / 123rf
For people struggling with this excruciating nerve pain, a decent night’s rest is the thing they need most – and the hardest to achieve
If you’ve ever had sciatica, it’s not the type of pain you’re likely to forget in a hurry. “Pain is not always an accurate marker for the degree of injury, but nerve pain can be particularly unpleasant; sciatica has been described as like having toothache in your bottom,” says Aidan Spencer, an osteopath who frequently treats patients with the condition.
“Sciatica refers to pain down the leg along the course of the sciatic nerve, and typically the cause is compression of one of the nerves in the spine,” says Mr Michael Mokawem, a consultant spinal surgeon with Cleveland Clinic London. Often this is caused by a spinal disc protrusion. “This is a disc that bulges or protrudes, squashing one of the nerves,” he explains.
The sciatic nerve runs from the spinal cord in the lower back and extends through the buttock area to send nerve endings down the leg, and sciatica, which is usually felt down one side of the body, is a common condition affecting 40 per cent of the UK population at some point. And while most patients with acute sciatica make a good recovery, 20-30 per cent have persisting problems after one or two years.
In about 90 per cent of cases, sciatica is caused by a herniated disc with nerve root compression. Lumbar stenosis – narrowing of the area of the spine that contains the nerves or spinal cord, which can lead to irritation, or compression of the nerves – is another cause. Less frequently, tumours are a possible source.
“Sciatica often has a natural pattern lasting up to two months, assuming that the nerve isn’t too compressed, however across this time the symptoms often diminish significantly, as the swelling and thereby the pressure reduces,” says Spencer. “The impact on sleep can be profound in the early days or weeks and then often improves.”
“Often getting sciatica is just random. But there may be a genetic element to it. And some patients will say they were doing something specific, lifting something heavy, maybe twisting in an awkward manner, and it just happened as a result,” says Mokawem. A study in Norway found that occupations that involve lifting heavy objects and sedentary work, involving the handling of fairly heavy objects, are at higher risk of being hospitalised for sciatica.
“Some patients will need extra support and that might be with injections of local anaesthetic and corticosteroids to tide them over and accelerate the healing. A small number of patients will end up having an operation called a diskectomy to remove a bone fragment that’s compressing the nerve,” says Mokawem.
While the peak age for sciatica is 45-64 years, it’s also common in the 25-45 age group. “This is partly because young adults tend to be more active but also due to their disc material,” says Mokawem. Disc material has more volume and is softer in young adults, so an injury of the disc is more likely to bulge at that point.
Sciatica is very common during pregnancy, with the additional weight putting pressure on unstable joints and muscles, while fluid retention adds to the extraordinary strain on the body. “The patient gets heavier fast, and this very fact can promote problems with their lumbar spine and particularly with the sciatic nerve, while hormonal changes make the joints and connective tissue become loose. All of this plus the pressure from the uterus and baby’s head on the sciatic nerve puts it under strain,” says James Britton, an osteopath who specialises in treating patients with sciatica during pregnancy.
Getting to sleep – and staying asleep – can be a problem when the pain of sciatica is acute. Some people find it almost impossible to get a good night’s rest, leading to a cycle of discomfort and fatigue. Lying still is, in fact, a factor in the build-up of discomfort, allowing a build-up of inflammation and fluid, meaning pressure on the sciatic nerve.
“Fluid accumulation tends to progress through the course of the night. This is why sciatic pain is so bad first thing in the morning but once you start to move, things start to improve because you’re moving the fluid that’s accumulated locally away from the source of the pain,” says Britton.
On your side with a pillow between your knees
Spencer says: “It is often best to lie on the side with the painful, congested side up, in as ‘neutral’ a position as possible, using pillows to rest the top leg on and help keep the spine and pelvis untwisted.” A bolster or the long “sausage” pillows that are designed to be used to aid sleep in pregnancy work well for this.
Sleeping on your back with a pillow under your knees
“Many patients will say it’s enough to lie on their back and put a pillow under their legs for them to be comfortable enough to sleep. Sometimes flexing the knee and hip will make us feel more comfortable as opposed to having a leg straight,” says Mokawem. Spencer says: “This position helps keep the lumbar curve neutral and unstressed.”
The foetal position
“Some people might find that bending forwards, flexing the spine and curling your knees up almost into a foetal position can be more comfortable,” says Mokawem.
Elevated reclined position
A bent-forward position helps open up the narrowed spaces in the space, so sleeping in a reclining chair with the head elevated can work for some people.
Back arched while on your stomach
For a few people, sleeping on their front, which forces the back to arch, gives relief from the pain of sciatica.
Physiotherapy
Physiotherapy interventions such as exercise and manual therapy are recommended in clinical guidelines for people with sciatica. A massage belt or TENS (transcutaneous electrical nerve stimulation) machine can also be helpful.
Osteopathic treatment
“Manual osteopathic treatment can be directed to improve the health of the injured area and promote, for instance, fluid exchange around the injured area. This is essential to the body’s healing process, which is disrupted by the congestion produced by injured tissue and the inflammation that kick-starts the healing process,” says Spencer. Chiropractors can also help relieve sciatica pain.
Hot and cold compresses
Spencer says: “The use of hot and cold compresses can be useful in promoting vascular flow across the injured area which clears waste and draws in fresh, ‘clean’ blood to assist with the repair.”
A supportive mattress
Having the right kind of support while sleeping can really make a difference, says Spencer. “An aged, collapsed mattress is very unhelpful, but, contrary to the received wisdom of the past, lying on very hard surfaces is also often not ideal, unless the person is excessively heavy. A supportive but forgiving surface is ideal for most bodies.”
Moving in one unit
“Turning over in bed can be most comfortably achieved by moving the body as one unit,” says Spencer, as opposed to adopting a more cautious, incremental approach which inadvertently twists the spine. “Extending the arm (the lower one if you are turning from your side, or the one that will be upper if on your back) and sending it over with the pelvis in hot pursuit helps keep the spine aligned and avoids additional strain to the injured area.”
Gentle exercise
Once any initial intense pain has eased, gentle movement is very beneficial. “Try walking in the park on soft, uneven surfaces in preference to hard, flat ones,” says Spencer. “Pool-based therapy is very beneficial, as movement can be applied while the water supports the body weight, and reduces loading on the injured area. Initially just walking in a swimming pool can be very relieving.”
Acupuncture
Acupuncture is widely used for pain relief, and while it is still the subject of research, some has shown it is a promising alternative treatment to painkillers and other drugs for sciatica.
Painkillers
Sleep is a very important part of the repair and healing process. “If sleep is being greatly disrupted by excessive pain, especially in the early days of a sciatic episode, it is arguable that the benefits of getting sleep outweigh the downsides of a moderate and time-limited intake of pain medication,” says Spencer.
“While pain plays an important warning function, unregulated pain creates all sorts of additional problems and can feed into more long-lasting ‘chronic’ patterns. If the sufferer wishes to avoid taking painkillers, then a topical cool gel can help, as can taking arnica before bed.”
Warm water in therapeutic pools reduces swelling and eases joint pressure.