Features November 2012 Issue

When Your Back Hurts Your Legs

Seek an evaluation and treatment to ease the pain of sciatica and avoid complications.

To put it simply, sciatica is a pain in the butt…and the legs.

Sciatica refers to pain or burning sensations originating in the spine and spreading from the buttocks and hip to the legs. In severe cases, sciatica can cause debilitating leg weakness.

Sciatica results from irritation of the sciatic nerve. Symptoms include pain and burning that radiate from the butocks down the back of the thigh and knee and occassionally into the foot. It also may present as numbness or tingling in the legs.

Fortunately, most people don’t require an operation to gain relief from sciatica, and if they do, surgery often is successful. Just be sure to seek an evaluation to identify the true cause of your leg pain and avoid any complications.
“For most patients, the prognosis is favorable,” says Daniel Mazanec, MD, associate director of Cleveland Clinic’s Center for Spine Health. “Medically, we’re looking for significant improvement in six weeks, often faster.”

A Painful Problem
Most often, sciatica is a product of a herniated spinal disc or foraminal stenosis, a narrowing of the openings through which nerves exit the spine and travel throughout the body. Each condition causes a pinching of these nerves—usually the fifth lumbar (L5) and first sacral (S1) nerves—leading to pain along the sciatic nerve, which runs from the spine to the foot.

Although some sciatica patients experience back pain, the dominant symptom is pain, numbness, or tingling radiating from the buttocks down the back of the thigh and knee and occasionally into the foot. The L5 nerve controls the ability to bend the foot upward, and if it’s severely compressed or injured, some patients experience a debilitating “foot drop.”
“The concern with sciatica, although uncommon, is an injury to the motor part of the nerve, not just pain, but some damage in the ability to use the leg,” Dr. Mazanec says. “If you have foot drop, you literally can’t raise your foot. You drag your toes. …That can be significantly functionally impairing, especially if you’re active.”

Leg pain and other symptoms also may result from “pseudo-sciatica,” or non-spinal causes, such as piriformis syndrome, a tightening of the piriformis muscle in the buttocks. Sometimes, the symptoms can be mistaken for hip arthritis or trochanteric bursitis, an inflammation of the bursa sac in the hip. In rare cases, a tumor or infection may produce sciatica-like symptoms.

Identification and Treatment
A good physical exam can separate spine-related sources of sciatica from these other causes. As part of that exam, your physician will check the strength of your leg muscles and test your reflexes. Your doctor may order a simple X-ray to look at the alignment of your spine, but most sciatica patients do not require more detailed imaging studies unless they are treated with injections or surgery, Dr. Mazanec advises. In some cases, an electromyogram may be necessary to determine the cause of leg and foot numbness.

About 75–80 percent of sciatica patients gain relief from conservative treatments: nonsteroidal anti-inflammatory medications, muscle relaxants, physical therapy, and oral or injectable steroids.

“A fair trial of conservative treatment is six to 12 weeks,” Dr. Mazanec says. “If you’re at six to 12 weeks and the symptoms in the leg are still severe and significant, that’s when surgery is indicated. And, if someone doesn’t have a foot drop initially and then two weeks later has it, that might push someone to surgery sooner than later.”
Surgery is more than 90 percent successful at easing leg pain with a spinal origin, but it’s less reliable at relieving back pain, Dr. Mazanec adds.

“If 90 percent of your pain is in your back and 10 percent is in your leg, you’re not really a surgical candidate,” he explains. “If it’s the reverse and it’s been a few months and you’re miserable and you’ve done everything medically to get better, surgery is a very good option for leg pain,” he says. “It’s important to make that leg vs. back distinction.”