Sciatica

Doh(nut)! Pain!


It’s not such a stretch of the imagination for early Germans to attribute the misery of sudden, sharp, radiating leg pain to a witch’s shot (Hexenschuss) or for the ancient Brits to curse the pain inflicted by the elf’s arrow. But enlightened, modern-day practitioners like to stretch the imagination by attributing much of back-butt-and-beyond pain to leaked jelly donuts. Simply googling “back pain jelly donut” will leave us with the impression that we’re kept erect by a stack of strawberry jelly donuts and any change in posture can potentially leave us a tortured, albeit, delicious mess. 


Causes of lumbosacral radiculopathy: jelly donuts and beyond

The leaked jelly donut analogy may help provide a visual for bulging disc, but lumbosacral radiculopathy (commonly referred to as “sciatica”) can be caused by anything that pisses off those sensitive spinal nerve roots. Lumbar disc herniation pressing on the nerve root and narrowing of the spaces from which the nerves exit the spinal canal are the most common causes of irritation to the spinal nerve roots. Infection, inflammation, tumor, and vascular disease can also irritate the nerve roots, but they are relatively uncommon. 


So is the pain caused by a witch’s shot, elf’s arrow, or leaked jelly donut?

Statistically, it’s likely a bulging disc (leaked jelly donut). A thorough clinical history and physical exam can help narrow down, if not identify the culprit for the misery. In most cases, imaging may not be necessary as symptoms are self limited. Urgent medical evaluation with visualization via magnetic resonance imaging is warranted if there is:

  • Worsening pain

  • Pain, numbness, or weakness in one or both legs

  • Loss of or altered sensation in the legs, buttocks, inner thighs, back of legs, or feet

  • Problems with bladder or bowel function

  • Sexual dysfunction that come on suddenly

  • Persistent pain for 12 weeks from onset of symptoms despite conservative management

  • History of, or suspicion of cancer or infection

  • History of trauma


What to do about that pain in the back, butt, and beyond?

It depends. For most spinal nerve compression cases, conservative management with NSAIDs, acetaminophen, nerve pain medications, and in severe cases,opiates aim to control pain and maintain function. Non-drug interventions, such as physical therapy, acupuncture, chiropractic manipulation are commonly used, although data supporting these modalities is equivocal. Epidural steroid injections may provide short term pain relief in some patients. Surgery is typically reserved for refractory cases or severe and progressive neurologic symptoms.