Sciatica

In one minute

Sciatica is not a disease. It is the name for pain running from the lower back or buttock down the leg, caused by a nerve root being squeezed or inflamed where it leaves the spine; doctors call it lumbar radiculopathy or lumbosacral radicular syndrome. In most people the cause is a herniated disc; a narrowed exit tunnel (foraminal stenosis), a narrowed canal, a slipped vertebra or a joint cyst can do the same. It is diagnosed by the story and a physical examination; MRI (magnetic resonance imaging) is reserved for those who do not improve or who need a procedure. Most people are much better within three months. Surgery treats the cause, not the symptom, and is considered when pain persists beyond 6 to 12 weeks or weakness develops.

What it is

The nerve roots leaving the lowest part of the spine, mainly L4, L5 and S1, join to form the sciatic nerve, which runs through the buttock and down the back of the thigh. Pressure or inflammation on any of those roots inside the spine is felt along the nerve's route, which is why a problem in the back is felt in the calf. Sciatica describes that pain. Radiculopathy means the root is also failing at its job: numbness, weakness or a lost reflex. This page explains the symptom and routes you to the page for its cause:

• Lumbar disc herniation, the commonest cause
• Foraminal stenosis, narrowing of the root's exit tunnel
• Lumbar spinal stenosis, narrowing of the canal itself, usually felt on walking
• Spondylolisthesis, one vertebra slipping forward on another
• Synovial cyst, a fluid pocket from a worn facet joint

Rarely, a tumour, an infection or a problem outside the spine (a tight piriformis muscle in the buttock, a pelvic condition) mimics the same pain. Regional reports often say "ишиас", "защемление нерва" or "радикулит"; all are names for the symptom, not its cause.

Causes and risk factors

The BMJ clinical review by Jensen and colleagues names disc herniation from age-related change as the commonest cause, followed by foraminal stenosis and, less often, cysts, tumours or causes outside the spine. A systematic review of eight studies cited in the same paper found smoking, obesity and manual labour to be the modifiable risk factors for a first episode. How common sciatica is depends on the definition: a review of 23 epidemiological studies found prevalence estimates from 1.2% to 43%, and only two of those studies used a clinical examination. In a UK primary care study, about 60% of patients with back and leg pain were clinically diagnosed with sciatica.

How it develops

A nerve root is more than a cable; it has its own blood supply and a sleeve of fluid. When disc material, bone or thickened ligament presses on it, the root swells, and escaped disc tissue triggers inflammation. Compression and inflammation together produce the shooting pain, the pins and needles and, when the fibres carrying movement are affected, weakness. The same inflammatory response digests herniated disc material over weeks to months, which is why most sciatica improves without anything being removed. Where the cause is bone or ligament, as in foraminal or canal stenosis, nothing gets digested, so the symptom tends to be slower and more dependent on posture.

Symptoms

The BMJ review lists the features that point to sciatica: pain in one leg worse than the back pain, pain radiating below the knee, numbness or tingling in the same strip of skin, a positive nerve stretch test, and a neurological deficit matching one root. The strip of skin tells the level: L5 and S1, the commonest, send pain down the back or outside of the leg into the foot; L4 sends it across the front of the thigh. Disc-related sciatica is often worse sitting and bending; stenosis-related pain is worse standing and walking and eases on sitting; foraminal stenosis has a pattern of its own, often felt at rest rather than on movement; the foraminal stenosis page describes it and cites the evidence.

Diagnosis

Sciatica is a clinical diagnosis. The surgeon asks about onset, the route of the pain and any tingling, numbness or weakness, then performs nerve stretch tests (straight leg raise, femoral stretch, slump test) and checks strength, sensation and reflexes root by root. The BMJ review cites a cohort in which one-sided leg pain in one root's territory, a straight leg raise positive below 60 degrees, one-sided weakness and an asymmetric ankle reflex together predicted sciatica from a herniated disc.

Imaging comes second. NICE (the English guideline body) advises against routine imaging in non-specialist settings; the American College of Radiology considers imaging appropriate after up to six weeks of treatment with little improvement, or sooner for red flags; the BMJ review adds when surgery is being considered. MRI is preferred over CT (computed tomography). The reason for restraint is that MRI finds herniations in people who feel nothing: the BMJ review cites a meta-analysis in which disc protrusion was present in 34% of asymptomatic people and extrusion in 2%, against 57% and 7% of those with symptoms. The finding only counts if it matches the examination.

If you send us images, include the written report and the side-view and cross-section images at the level the report names, plus a sentence on where the pain goes and what makes it worse. That sentence often matters more than the MRI.

Treatment without surgery

The first weeks are about controlling pain and staying functional while the root settles. NICE and the BMJ review agree on the basics: explain the natural course, stay active, avoid bed rest, and consider a supervised exercise programme with manual therapy alongside. NICE advises against belts, traction, acupuncture, TENS (transcutaneous electrical nerve stimulation) and ultrasound.

Medicines are modest tools. The BMJ review finds limited, conflicting benefit at most from NSAIDs (non-steroidal anti-inflammatory drugs) and systemic corticosteroids, and no convincing benefit from anticonvulsants, benzodiazepines, opioids or antidepressants; NICE's 2020 update tells doctors not to offer gabapentinoids, oral steroids or benzodiazepines for sciatica, or opioids for chronic sciatica. Any course is short, and the doctor decides.

Epidural steroid injection is the strongest non-surgical step. The 2020 Cochrane review of 25 trials found it slightly better than placebo for leg pain and disability in the short term, about 5 points on a 100-point scale, which the authors say may not be clinically important to patients. NICE reserves it for acute, severe sciatica. It buys time; it does not change the cause.

Most people do not need more. In a primary care cohort of 452 patients cited by the BMJ review, 55% reported improvement in pain and disability at one year on mainly conservative care. In the Dutch trial of severe sciatica, 61% of patients assigned to prolonged conservative care did not need surgery in the first year.

When surgery is considered

Three situations: pain persisting 6 to 12 weeks despite conservative care with a cause on MRI that matches the examination (NICE says consider decompression when non-surgical treatment has not improved pain or function); serious or progressive weakness; and cauda equina syndrome, an emergency at any hour. The BMJ review adds that referral for a surgical opinion is reasonable at 12 weeks.

Early versus delayed surgery has been tested directly for disc-related sciatica. In the Dutch trial, early surgery relieved leg pain faster and doubled the rate of perceived recovery, but at one year 95% of both groups felt recovered. The North American Spine Society (NASS) suggests operating within six months when symptoms warrant it, because earlier surgery is associated with faster recovery. In plain terms: waiting is safe if you can bear it, and surgery shortens the wait.

Surgical options

The operation depends on the cause:

• Herniated disc: discectomy, open or endoscopic. In the 2022 BMJ trial, full endoscopic discectomy gave leg pain relief no worse than open microdiscectomy at one year, with 94% of patients home the same day. See endoscopic lumbar discectomy.
• Foraminal stenosis: widening the exit tunnel, endoscopic foraminotomy.
• Canal stenosis: removing the thickened ligament and bone, endoscopic lumbar decompression.
• Synovial cyst: endoscopic facet cyst removal.
• Unstable spondylolisthesis: decompression with fusion, endoscopic lumbar fusion.

Surgery for sciatica without a cause on imaging that matches the examination is not supported by any guideline cited on this page.

How we treat it at spine.uz

Endoscopic spine surgery in Tashkent for sciatica

Send your MRI and a description of your pain on Telegram or WhatsApp. The remote opinion is free; a doctor from the team replies by voice within 48 hours, names the cause on your images and says whether it needs time, an injection or an operation. The in-person consultation and any operation are paid.

When an operation is indicated, we treat the cause through a 7 mm incision, most often under local anaesthesia with sedation rather than general anaesthesia; the anaesthetist and surgeon decide per patient. Decompression uses no screws or implants. Most patients walk on the day of surgery and go home within 24 hours. We are Tashkent's first endoscopic spine team, five surgeons operating as one team, with 27,600+ endoscopic and spine operations and a complication rate well below 1% in our own series. You leave with a written team conclusion.

Recovery and outcomes

Without surgery, most people are much better within three months. In a Danish primary care cohort cited by the BMJ review, 44% of general practice patients and 73% of chiropractic patients were better or much better at one year; a difference the authors put down to the different patient groups. With surgery for a herniated disc, leg pain drops within days; in the BMJ trial, median leg pain at one year was 7 out of 100 after endoscopic surgery, and 79% considered themselves recovered. Numbness lags behind pain and may take months. Longer pain before treatment, higher pain intensity and the belief that the problem will last were associated with a worse outcome, which is one argument for not waiting indefinitely.

Living with it and prevention

Stay active and return to work as early as pain allows; NICE names return to work as a treatment goal in itself. Stop smoking, manage weight and reduce manual load where possible, the three modifiable risk factors in the evidence. Do not request repeated MRI scans for reassurance; after a first episode they are hard to interpret and rarely change treatment. If the leg pain returns, it is usually the same cause, and the same steps apply.