Melanie Cole, MS (Host): Welcome to Flourish, a Prisma Health Podcast. I'm Melanie Cole. And today, we are learning about sciatica. Joining me is Dr. Taylor Girolamo. She's a neurosurgeon with Prisma Health. Dr. Girolamo, thank you so much for joining us today. We hear this term sciatica bandied about, and nobody's quite sure what it is. Can you tell us what that term sciatica means and what causes that type of nerve pain?

Dr. Taylor Girolamo: Yes, absolutely. So like you said, sciatica is a general term that gets used a lot to describe shooting pains that come from the spine and travel down the leg. Typically, sciatic nerve pain occurs when the sciatic nerve, which is one of the longest and thickest nerves in the body, becomes compressed or inflamed or irritated. This can be due to pressure or pinching on the nerve from the spine by conditions such as a bulging or herniated disc, or from narrowing in the spine from bony overgrowth and degeneration of the discs and ligaments over time, a condition that we call lumbar stenosis.

The nerve can also be pinched or inflamed by pressure from the surrounding muscles and soft tissues of the glutes and the leg as it passes through the leg to its destination in the feet and toes. And so, it's really a pretty broad condition and pretty broad range of causes that can cause the sciatic nerve pain that people describe.

Melanie Cole, MS: Are there different types of sciatica? You just mentioned a few reasons, whether it's, you know, that piriformis muscle, everything in the glutes pressing or that stenosis that you mentioned. Are there different types, categories, ways that you categorize sciatica?

Dr. Taylor Girolamo: Yes, there are. The different types of sciatica can be determined by the source of the pressure on the nerve, such as from the muscles or from the spine, how long it's been going on, and also whether one or both legs are affected by the pain. Sciatica most commonly affects one leg or the other, but involvement of both legs could indicate significant pinching of the nerves within the spinal canal.

Acute sciatica is a term we use to describe new pain that's been going on for six weeks or less. This is most commonly treated with conservative measures such as activity modification, physical therapy, and medications, and it usually does get better and resolve with these measures. Chronic sciatica is a pain that's been going on for three months or more, is refractory to those initial conservative attempts, and requires more dedicated evaluation.

Melanie Cole, MS: So then, who is most likely to struggle with sciatic nerve pain? And I have to say, Doctor, as an exercise physiologist who's worked with people for so many years with this, but then got it myself one time, I feel that you can't really appreciate the pain, the really true pain of back problems like this unless you have experienced them. It is just wild how it feels. So, who is at risk for this kind of thing?

Dr. Taylor Girolamo: Yeah. So, there are several risk factors that can increase the likelihood of experiencing this sciatic nerve pain. Disc herniations are most common in the 30 to 50-year age range, while the advanced degeneration and arthritis in the spine is most commonly seen after age 60. People that have jobs that involve prolonged sitting or heavy lifting and twisting of the spine can also have increase in the overall strain that their low back experiences over time.

And other medical conditions such as diabetes, obesity, and even pregnancy can increase your chances of experiencing pain from the sciatic nerve.

Melanie Cole, MS: Why would it be worse at bedtime? It would seem that when you get to go to sleep, that's when it would feel better

Dr. Taylor Girolamo: When we lie down to go to sleep, the pressure is taken off of our spine from gravity and the weight of carrying just our body upright, and disc herniations may swell and add pressure to the nerves, which is something that we wouldn't otherwise experience during the daytime. Sleeping position can also play a role. So, lying flat or side sleeping, especially with the legs straight, puts additional pressure and tension on the normal lumbar curvature and on the sciatic nerve. Also, attempting to quiet our minds in preparation for sleep can make us more aware of our body's internal pain signals, making nighttime particularly uncomfortable for patients experiencing sciatic nerve pain.

Melanie Cole, MS: So, Doctor, once you've determined that this is what's going on, tell us about some of the common remedies and treatments, but start with the conservative measures first. You mentioned a few of them before. If someone comes to you, expand a little what the first thing that you're gonna do with them is, and then we can move on to some more interventional modalities.

Dr. Taylor Girolamo: Absolutely. So, a lot of times, the first line of folks that are being seen for these conditions are a patient's primary care provider. And especially in that acute phase, treatment for the sciatic nerve pain is centered on that conservative non-surgical care. So, this includes interventions such as activity modification, gentle stretching, walking, physical therapy, heat and ice application, and core strengthening exercises.

While it may be tempting to stay in bed and avoid all activity when you're experiencing this pain, it can actually worsen the overall condition and your mobility. And so it's best to remain as active as possible. Over-the-counter medicines like ibuprofen and Aleve can provide some relief, and then medical providers can also assist with prescriptions for medications such as muscle relaxers, neuropathic pain medications like gabapentin or Lyrica, and even courses of steroids when those are deemed appropriate.

Now, when the pain is resistant to these measures, further evaluation is warranted with imaging such as X-rays and MRI, and possibly a referral to a spine specialist based on those imaging results. And based on those results, additional interventions like steroid injections targeted to specific nerves or surgery may be recommended to address the source of the pain.

And the surgery can involve anything from something we call a microdiscectomy, where a disc herniation that's pinching the nerve is removed, or something like a laminectomy, where if it's from general more circumferential compression of the nerves by arthritis and thickened ligaments, it allows us to decompress the nerves more fully in order to relieve that compression and that pressure

Melanie Cole, MS: So, there's so many more tools in your toolbox now in your armamentarium of options for patients that are suffering from sciatica. And thank you for telling us about some injections and some of the surgical options out there. Is there any way to reverse the causes of the pain or to undo it? And you said you want people to keep active. Are there things such as weight loss or physical therapy, really activity that can undo or reverse this? Or is this something that's going to plague them?

Dr. Taylor Girolamo: No, absolutely. The initial conservative steps that we've discussed can help reduce the load on the spine and improve the inflammation around the nerves, and things like weight loss and physical therapy techniques can help correct posture and spinal load-carrying causes of the sciatic nerve pain. Even small disc herniations can be reabsorbed by the body over time. Larger disc herniations or significant degenerative causes in the spine may require surgery to correct, but even these can be corrected with a carefully selected approach.

Melanie Cole, MS: So if it doesn't resolve on its own, does it sometimes resolve on its own, Doctor?

Dr. Taylor Girolamo: Yes, absolutely. About 80% to 90% of those non-surgical sciatica cases can resolve with the conservative measures that we've discussed here.

Melanie Cole, MS: And if someone is waiting for it to resolve on its own, how long should they wait to see if it doesn't? And what happens if they don't go and get help for it?

Dr. Taylor Girolamo: So, I would usually say that these initial conservative measures should really be attempted for the first, like, four to eight weeks, while you're still in that acute sciatica window. But definitely, as we span into the three months or longer, that's when that additional intervention is really warranted.

Severe compression of a nerve without a proper treatment could lead to symptoms such as weakness, worsening or permanent numbness, loss of sensation in the groin area, or loss of bowel and bladder control. And these are a group of symptoms that we call red flag symptoms, and they should be evaluated by a provider immediately. And if you're unable to get an urgent appointment with someone, we recommend that you go to the emergency room to be evaluated for any of those red flag symptoms.

Melanie Cole, MS: Do you have any final thoughts that you'd like to leave listeners with about sciatica? the red flags you just mentioned, but the symptoms they might experience that would send them to the doctor in the first place, that groin pain that you mentioned, all of those sorts of things, can you summarize for us and give us your best advice for someone that is suffering this type of pain?

Dr. Taylor Girolamo: Sciatica is certainly something that can be, life-changing, debilitating for someone that's experiencing this pain. And so anyone that's experiencing this, whether it's new and acute after something that happened here recently or something that you've been experiencing for a long time, I would really encourage you to get in with either your primary care doctor or a referral to a specialist so that we can truly get to the bottom of what could be causing the pain that you're having, because there are definitely options that run the spectrum, as we've discussed, of conservative measures up to and including surgery for people that do have spinal conditions and degenerative changes that are causing the pressure on the nerves. And so, there is hope and there is relief, and we just wanna make sure that we are here as a tool to you to help you reach that level of function that you want to get back to.

Melanie Cole, MS: Thank you so much for joining us and sharing your incredible expertise for something that so many people suffer from and really, as you said, can affect the quality of life. So, thank you so much again. And to hear more podcasts from our experts and to learn more, please visit our website at prismahealth.org/podcast.

I'm Melanie Cole. And we'd like to invite our audience to download, subscribe, rate, and review Flourish from Prisma Health on Apple Podcasts, Spotify, iHeart, and Pandora. Thanks so much for listening to Flourish from Prisma Health.