Sciatica is easy to misunderstand. Many people think of sciatica as excruciating pain that starts in the buttock or hip and travels down the back of the leg. Others assume the problem must be somewhere in the hip or that they somehow injured the large sciatic nerve itself. Neither is quite right. “Sciatica actually has nothing to do with the sciatic nerve [in the leg],” said Dr. Jesse Stem, an orthopedic spine surgeon with Vero Orthopaedics. “Sciatica is the medical term for nerve pain that you feel in your hip and leg, but it comes from [nerve irritation] … in your low back.” That distinction is important because the source of the pain and the place where it is felt can be two very different locations. The lower back contains several nerves that travel into the legs. When one of those nerves becomes irritated or compressed, the resulting pain can be felt far from the actual problem. Dr. Stem compares it to the phenomenon of referred pain that can occur during a heart attack, when a person may feel pain in the jaw or arm – even though the heart is the source. “Our body is wired in such a way that when you have an irritated nerve in your low back, that nerve does travel down the leg,” he said. “So when it’s irritated, you’ll feel pain distant from an area where the actual problem is.” And that pain doesn’t necessarily follow the classic path people associate with sciatica. “There are several nerves that travel into the leg,” Dr. Stem said, “and depending on which one is irritated, symptoms may be felt down the front, side or back of the leg. The sensation can also be quite different from ordinary muscle pain.” Nerve pain may feel like burning, cramping, tingling or numbness. Some patients describe it as though their leg has “fallen asleep.” The most common culprit isn’t necessarily an accident or dramatic injury. More often, it is simply the result of aging and wear and tear. Arthritis in the lower spine can produce bone spurs and calcium deposits that crowd or irritate a nerve. Discs can also become problematic as they gradually degenerate and weaken over time, sometimes shifting or bulging enough to put pressure on a nearby nerve. That is another misconception about sciatica: A person doesn’t necessarily have to remember doing anything to cause it. “There are a lot of times when people think that a disc problem comes from an injury,” Dr. Stem said. “But similarly, the most common thing that causes discs to misbehave is just degeneration.” And while the pain can be severe, the good news is that sciatica is often a temporary problem. In fact, most people won't need surgery. Dr. Stem said approximately eight out of 10 people with sciatica will be significantly better within about six weeks. Give it another six weeks and approximately nine out of 10 people will have improved. Research on acute sciatica has similarly found that about 90 percent of patients with lumbar disc-related sciatica begin improving within six weeks and generally resolve within about 12 weeks with conservative care. That doesn’t mean patients have to simply suffer through those weeks. Treatment may include medications to reduce inflammation and pain, physical therapy, targeted exercises and, in some cases, an epidural steroid injection. The goal is to allow the irritated nerve to calm down while maintaining as much safe activity as possible. “We want people to continue to move,” Dr. Stem said. “We kind of think of movement as life, but it might be protected movement.” Physical therapy can be particularly useful because patients can learn stretches and exercises designed to relieve the nerve and reduce irritation. Dr. Stem recommends working with a physical therapist for several visits to make sure the exercises are being performed correctly before continuing them at home. One of the most common mistakes Dr. Stem sees is patients having a few bad days followed by a good day and immediately returning to everything they were doing before the flare-up. Instead, he encourages patients to ease back into normal activities and continue the stretches and exercises that helped them recover. “If you got better with physical therapy, I tell them their ‘apple a day’ is to continue to do your home stretches and exercises,” he said. Other approaches, including chiropractic care, acupuncture and certain light-based therapies, may also provide relief for some patients. Perhaps the biggest mistake, however, is assuming that every ache running down a leg is sciatica. A pulled muscle, hip problem and irritated spinal nerve can produce overlapping symptoms, making self-diagnosis unreliable. A medical evaluation can help determine whether the symptoms are actually coming from the lower back or from another structure. If imaging is needed, an MRI can provide a detailed look at the discs, nerves, bones, ligaments and other structures surrounding the spine. Imaging isn’t necessarily required at the beginning of an uncomplicated episode, however; guidelines generally recommend considering it when symptoms persist despite a period of conservative treatment or when warning signs suggest a more serious problem. For most people, time, movement and appropriate treatment will allow that irritated nerve to settle down. But there are circumstances when waiting it out isn’t appropriate. Changes in bowel or bladder control can indicate that nerves controlling those functions are being affected and require urgent evaluation. Significant neurological weakness is another warning sign. Dr. Stem specifically mentioned foot drop, when a person is unable to lift the front of the foot normally despite trying, as a situation in which surgery may need to be considered more promptly to prevent permanent nerve damage. When surgery is necessary, the main objective is simply to take the pressure off the nerve. If a disc is compressing it, the surgeon may remove the portion causing the pressure. If bone spurs or calcium deposits are responsible, those may be carefully removed instead. But for the vast majority of people experiencing a painful episode of sciatica, the story doesn’t end in an operating room. It ends with an irritated nerve calming down, movement gradually returning to normal and, ideally, a few exercises becoming part of the daily routine. Dr. Jesse Stem received his medical degree at West Virginia University School of Medicine, and completed his orthopedic surgery residence at Georgia Baptist/Atlanta Medical Center in Atlanta. He then completed his Kenton D. Leatherman Spine Fellowship at the University of Louisville. He practices at Vero Orthopaedics at 3955 Indian River Blvd. Call 772-569-9460 to schedule an appointment.