Patients with sciatica usually experience pain in the lumbar spine, and almost invariably the pain will be unilateral. A common characteristic is that pain may be radicular to the ipsilateral affected extremity. Often, patients may describe pain or a burning sensation deep in the buttocks, and frequently they will describe paresthesia that accompanies the pain. Less commonly there is associated ipsilateral leg weakness. These patients may describe the affected leg feeling heavy. A straight-leg raise has variable sensitivity and specificity and may or may not be present depending on the underlying cause. The straight-leg test is a passive examination. The straight-leg test is performed by having the patient lay in a relaxed, supine position. The examiner then lifts the leg from the posterior aspect flexing at the hip joint and keeping the knee in full extension, or keeping the leg straight. Typically pain that is reproduced between 30 to 70 degrees of hip flexion and experienced primarily in the back is likely due to a lumbar disc herniation. Pain and parenthesis that are felt in the leg are likely due to lateralizing compression of a peripheral nerve. While not absolute, musculoskeletal causes of the pain will usually reproduce pain above 70 degrees of flexion and below 30 degrees of flexion.

Sciatica is a clinical diagnosis, and therefore, a thorough history and physical examination are necessary for a complete evaluation and diagnosis. Imaging is initially of little value. If warranted, plain films of the lumbosacral spine may evaluate for fracture or spondylolisthesis. Noncontrast CT scan may be performed to evaluate fracture if plain films are negative. Additionally, pain that has been persistent for 6 to 8 weeks and not responding to conservative management should be imaged. In this case, MRI is the imaging modality of choice. In cases where the neurologic deficit is the present or mass effect is suspected, immediate MRI is the standard of care in establishing the cause of the pain and ruling out pressing surgical pathology.[7][8]

Patient Education

• Use of hot or cold packs for comfort and to decreased inflammation
• Avoidance of inciting activities or prolonged sitting/standing
• Practicing good, erect posture
• Engaging in exercises to increase core strength
• Gentle stretching of the lumbar spine and hamstrings
• Regular light exercises such as walking, swimming, or aquatherapy
• Use of proper lifting techniques

Medical Therapies

• A short course of oral NSAIDs
• Opioid and nonopioid analgesics
• Muscle relaxants
• Anticonvulsants for neurogenic pain
• In the event oral NSAIDs are insufficient, a course of oral corticosteroids may be beneficial
• Localized corticosteroid injections
• Deep tissue massage may be helpful
• Physical therapy consultation
• Surgical evaluation and correction of any structural abnormalities such as disc herniation, epidural hematoma, epidural abscess or tumor

A thorough differential list is important in considering a diagnosis of sciatica and should include. 

• Herniated lumbosacral disc
• Muscle spasm
• Nerve root impingement
• Epidural abscess
• Epidural hematoma
• Tumor
• Potts Disease, also known as spinal tuberculosis
• Piriformis syndrome

Piriformis Syndrome

Piriformis syndrome is a specific condition of special mention as it is often misdiagnosed and unrecognized. The piriformis muscle connects the sacral spine to the upper portions of the femur and aids in hip extension and leg rotation. Due to the proximity of the sciatic nerve, any injury or inflammation to the piriformis muscle can cause "sciatica symptoms." Often overuse injuries, particularly in runners or other endurance athletes, cause inflammation of the piriformis muscle and the ensuing symptoms mimic sciatica. Therefore, these patients tend to have increased pain from the application of direct pressure to the piriformis muscle, increased pain when walking up inclines or stairs and decreased range of motion of the hip joint. Piriformis-specific stretches, as well as hamstring stretches, are helpful to release this muscle tension and to treat this painful condition. In addition, rest from the activity causing the pain is helpful.[9]

Most cases of sciatica resolve in less than 4 to 6 weeks with no long-term complications even if no medical therapy is sought. In more severe cases or cases where the neurologic deficit is present, the patient may have a more prolonged course of recovery. However, recovery is still excellent. Some studies have shown that poor occupational mechanics, psychological depression, and poor socioeconomic situations lead to an increased chance of chronic, recurrent sciatica.

In general, sciatica can be managed conservatively. If the spinal mass effect is diagnosed, for example, an epidural abscess or epidural hematoma, an immediate consultation with a spinal surgeon should be obtained.

Clinicians should always look for and inquire about red flags when evaluating sciatica or in patients who present with any low back pain. Simple sciatica is a benign disease and presence of red flags would prompt much more consideration of the differential diagnosis to ensure a more serious underlying medical or surgical cause of the back pain is not present. A history of IV drug abuse is a risk for epidural abscess and seeding of bacteria anywhere in the body (endocarditis, cerebral abscess, among others). Additionally, those whom have HIV, diabetes, or are immunocompromised have a much higher risk of all infections, and epidural abscess must be considered. Any history of bowel or bladder incontinence, urinary retention, or lower extremity weakness suggest acute neurologic deficit and should prompt more aggressive workup. Anticoagulant use is a risk for all sources of bleeding including epidural abscess. A history of trauma, malignancy, or tuberculosis may suggest fracture, metastasis, and more serious causes of the back pain should be ruled out before a simple diagnosis of sciatica is used. And lastly, fevers, night sweats, chills would not be typical symptoms seen in simple sciatica and thus should prompt further consideration in the workup.

The key to sciatica is patient education. There are many causes of sciatica and the disorder is best managed with a team of healthcare professionals that includes an orthopedic surgeon, physical therapist, neurologist, rehabilitation nurse, and a pain specialist. Unless there is an acute compression of the spinal nerves, the majority of cases of sciatica are best managed conservatively. Patients should be encouraged by the clinician and nurse to lose weight, stop smoking and enroll in a physical therapy program. Bed rest should be limited. The pharmacist should caution the patient against the use of prescription-strength medications to avoid dependence and other adverse effects and if narcotics are used, they should assist the team in making sure the course is very short and not refilled. Surgery should only be undertaken when conservative methods have failed but the patient must be educated on the risks of surgery and the potential complications. Finally, even after surgery participation in regular exercise is essential.[10][11] (Level V)

Outcomes

The outcomes of patients with sciatica are difficult to analyze. Every surgical study measures different parameters as good-outcome and hence the data are either misinterpreted or hyped. In general, patients with chronic pain (more than 6 months) have a poorer outcome following surgery than patients with acute pain (less than 6 months). Some studies report a cure rate of more than 75% but then there are other studies that report cure rates of less than 50%. There are several newer orthopedic procedures to manage sciatica and all report success rates of 70% and above in the short term. Irrespective of the short-term result, the majority of patients with sciatica tend to have residual or recurrent pain in the long term. Many continue to be dependent on pain medications, are disabled and have a poor quality of life.[2][12][13] (Level V)