I. Introduction

Definition of sciatica

Sciatica is a common physical condition, affecting approximately 1.6 percent of the overall population.[1] This condition primarily manifests as intense pain originating from the sciatic nerve, extending from the lower back, through the buttocks, and down the legs, ultimately reaching below the knee. In addition to the characteristic pain, sciatica can also manifest as numbness or tingling sensations. Sciatica symptoms are caused by nerve root entrapment, which may lead to decreased sensitivity, alteration in reflex and/or muscle weakness in entrapped nerve root distribution.

Brief explanation of its prevalence and impact

The diverse sciatica symptoms highlight the complexity of sciatica, affecting individuals beyond just pain. It not only impacts physical health but also has profound mental and emotional implications. Persistent discomfort and limited mobility can diminish overall well-being.

Risk factors for sciatica

A study of 2946 women and 2727 men showed that neither gender nor body mass influenced the development of sciatica, although body mass may be related to lower back pain in general. Height can be a risk factor for sciatica, although this seems to be important only in men aged 50-64. The frequency of sciatica is related to age. The association of sciatica with psychological stress has been reported.

II. Understanding Sciatic Nerve and Its Pathway

Explanation of the sciatic nerve

Before discussing the symptoms or causes of Sciatica, we must first understand the what the sciatic nerve is and where it is located. The spinal column is made up of four segments, cervical, thoracic, lumbar and sacral. Spinal nerves are formed at the spinal cord from two roots, a sensory root at the back and a motor root at the front. Pairs of spinal nerves exit the spine through bony canals on each side and are named for the vertebra directly above where they exit.

The fourth and fifth lumbar spinal nerves and the first three sacral spinal nerves leave their bony canal and join together to form the sciatic nerve in the pelvis (Fig. 1.1b). Sciatica can result from damage to the spinal nerves that form the sciatic nerve anywhere from the cauda equina to their joining together in the pelvis and from damage to the sciatic nerve anywhere before it divides above the knee. [2]

Illustration of the nerve pathway

III. Common Sciatica Symptoms

A. Radiating Pain:

• Sciatica is characterized by pain that radiates from the lower back down the leg. This pain follows the path of the sciatic nerve, which typically runs from the lower back, through the buttocks, and down the back of each leg. The sensation can vary from a mild ache to a sharp, burning pain.
• Intensity Comparison: It’s essential to note that sciatic pain is distinct from general lower back pain. The pain experienced in the leg is often more severe and intense than the pain felt in the lower back.

B. Tingling and Numbness:

• Sciatica may manifest with sensations like tingling and numbness in the affected leg. This occurs due to the compression or irritation of the sciatic nerve. Tingling is often described as a prickling or “pins and needles” sensation, while numbness refers to a reduced ability to feel or sense touch.
• Affected Areas: Tingling and numbness commonly occur in the buttocks, thigh, calf, and foot of the affected leg. The distribution can vary depending on the specific nerve roots affected.

C. Muscle Weakness:

• Sciatica can lead to muscle weakness, particularly in the leg or foot served by the affected nerve. This weakness may make it challenging to lift the toes or foot, resulting in difficulty walking or instability.
• Impact on Mobility: Muscle weakness can significantly impact mobility and daily activities. Individuals may notice a decreased ability to perform tasks that involve the affected leg, such as walking, standing, or climbing stairs.

D. Shooting Pain and Electric Shock Sensation:

• Sciatica can cause shooting pains or electric shock-like sensations along the path of the sciatic nerve. These sensations are often sudden and intense, creating a sharp, stabbing, or burning feeling.
• Triggers: Activities such as sneezing, coughing, or sudden movements may trigger shooting pain. Prolonged sitting or standing can also exacerbate these sensations.

E. Worsening Pain with Movement:

• Certain movements or positions can worsen sciatic pain. For example, bending forward, lifting heavy objects, or sitting for extended periods may aggravate symptoms.
• Identifying Aggravating Factors: Individuals with sciatica may find it helpful to pay attention to activities or postures that worsen their pain. Identifying and avoiding these aggravating factors can contribute to better pain management. Additionally, maintaining good posture and incorporating gentle exercises may help alleviate discomfort associated with movement.

V. Diagnostic Tools and Tests

• The diagnostic process for sciatica can be complicated for a number of reasons. Sciatica does not have a single cause and can be broadly defined as a set of symptoms rather than a concrete diagnosis. Therefore, great care must be taken to assess the patient’s symptoms in full, and take their complete medical history. An individual’s professions or their underlying conditions may provide good clues regarding the cause.

A. Medical History

• Your physician may you ask you the following questions
  how severe is the pain?;
  have you experienced any loss of strength in the affected area?;
  are you able to sense and feel your leg and foot?;
  how long have you been feeling the pain?;
  what exact pathway has the pain taken to travel through your body?;
  whether coughing, rest, or movement exacerbate the pain?;
  and how has this affected your daily activities?

B. Physical Tests

• Your physician may also conduct any or all of the following physical tests, which check for the mechanical compression or irritation of the sciatic nerve.

Clinical Test	Purpose	Procedure
Straight Leg Raise Test	To assess mechanical compression or irritation of nerve roots, especially the sciatic nerve.	The patient lies supine, and one leg is raised while keeping the knee straight. A positive test is indicated if the patient experiences pain along the sciatic nerve pathway.
Femoral Nerve Test	To evaluate the femoral nerve for compression or irritation.	The patient lies prone, and the therapist stabilizes the pelvis. The affected leg is flexed at the knee to its end range. Pain or discomfort during this maneuver may suggest femoral nerve involvement.
Slump Test	To provoke pain and assess neural tension in the spinal cord and peripheral nerves.	The patient is seated with hands behind their back for a neutral spine. They slump forward at the thoracic and lumbar spine. If no pain is felt, various neck and knee movements are performed to reproduce or alleviate symptoms. A positive test indicates pain reproduction.
Neurological Deficit Signs	– Muscle Weakness: Reduction in muscle strength associated with the affected nerve root. – Absence of Tendon Reflexes: Diminished or absent reflexes indicating nerve dysfunction. – Sensory Deficit: Altered or loss of sensation in the dermatomal distribution.	These signs are indicative of nerve dysfunction and can be assessed through clinical examination, including strength testing, reflex assessment, and sensory examination.

• Imaging tests such as the MRI may be used in exceptional circumstances. MRI is only recommended if the patient experiences loss of sensation and reflexes, and muscle weakness, has a history of trauma (injury), or has not been relieved of their symptoms for a prolonged period despite conservative care. If you believe your condition aligns with these criteria, you can discuss the possibility of an MRI with your doctor.

VI. Seeking Professional Diagnosis:

Sciatica can present with a variety of symptoms, and seeking professional diagnosis is crucial for several reasons:

• Healthcare professionals, such as orthopedic doctors, neurologists, or physical therapists, have the expertise to accurately diagnose sciatica.
• Professionals can conduct a thorough evaluation, including medical history, physical examinations, and, if necessary, imaging studies like MRI or X-rays.
• Once diagnosed, healthcare professionals can develop personalized treatment plans based on the specific characteristics of the individual’s sciatic pain. This may include a combination of medications, physical therapy, exercises, and lifestyle modifications.
• Certain underlying conditions leading to sciatica may require specific interventions or medical management to prevent complications. Professional guidance ensures that any potential complications are addressed promptly and effectively.
• Regular follow-ups with healthcare professionals allow for the monitoring of progress and adjustments to the treatment plan if necessary. This ongoing care ensures optimal recovery and helps prevent the recurrence of symptoms.

If you are experiencing any of the following symptoms, immediately seek medical attention.

Red Flag	Possible Diagnoses
Major trauma prior to onset	Vertebral bone fracture and displacement, traumatic nerve injury
Known cancer, particularly involving pelvic organs	Compression of nerves in the cauda equina or pelvis by metastasis or primary tumor
Known infection	Abscess with compression of spinal or sciatic nerves
Unremitting pain	Compression of nerves in the cauda equina or pelvis by metastasis or primary tumor
Worsening of pain at night when sleeping	Tumor of the cauda equine particularly a schwannoma
Pain in both legs when walking	Spinal stenosis
Weakness in one or both legs	Disk herniation, spinal stenosis, bone displacement, tumor of cauda equina
Bowel and bladder dysfunction	Midline disk herniation, spinal stenosis, bone displacement, tumor of cauda equina
Saddle anesthesia (numbness in a saddle distribution)	Midline disk herniation, spinal stenosis, bone displacement, tumor of cauda equina

VIII. Conclusion

Sciatica manifests through distinct symptoms such as radiating pain from the lower back down the leg, tingling, numbness, and muscle weakness. Additionally, individuals may experience shooting pains or electric shock-like sensations, worsened by certain movements. It’s crucial not to self-diagnose or self-treat. Seeking professional help ensures an accurate diagnosis, comprehensive evaluation, and personalized treatment plans. Healthcare professionals can monitor progress and prevent complications, emphasizing the importance of timely and expert intervention for effective management of sciatic symptoms.