Sciatica is a common cause of back and leg pain. It typically occurs when a nerve root in the lower spine becomes irritated or compressed, producing pain that may travel from the lower back or buttock into the thigh, calf, or foot.
While many cases improve with conservative treatment, persistent or severe symptoms require proper diagnosis to determine whether the patient needs medication, physiotherapy, injections, or surgery.
What Is Sciatica?
Sciatica is not a diagnosis by itself. It describes a pattern of symptoms caused by irritation or compression of the lumbosacral nerve roots, most commonly L4, L5, or S1.
Typical symptoms include:
- Sharp, burning, or electric-shock-like pain
- Pain radiating from the buttock into the leg
- Numbness or tingling
- Weakness in the leg or foot
- Pain aggravated by coughing, sneezing, or straining
Sciatica may affect one or both legs, although unilateral symptoms are more common.
What Causes Sciatica?
The most common causes include:
Cause
Typical mechanism
Lumbar disc herniation
Disc material compresses a nerve root
Lumbar canal stenosis
Narrowing reduces space for neural structures
Foraminal stenosis
Narrowing of the nerve-root exit canal
Spondylolisthesis
Vertebral displacement may cause nerve compression
Degenerative changes
Arthritic changes can contribute to narrowing
Less common causes
Tumours, infection, fracture and other conditions
A careful evaluation is important because not every patient with leg pain has sciatica.
My Approach to a Patient With Sciatica
As a spine surgeon specialising in minimally invasive and endoscopic spine surgery in Mumbai, my approach begins with one fundamental question:
Is the patient’s leg pain actually coming from a compressed spinal nerve—and if so, what is causing the compression?
1. Detailed History
I first determine the exact pattern of pain.
Important questions include:
- Where did the pain begin?
- Does it travel below the knee?
- Which part of the leg and foot is affected?
- Is there numbness or tingling?
- Is there weakness?
- Is pain worse while sitting, standing, walking, bending, or coughing?
- How long have symptoms been present?
- Has the patient tried medicines or physiotherapy?
- Has there been previous spine surgery?
The distribution of pain and neurological symptoms can provide important clues about the affected nerve root.
2. Look for Red Flags
Not every patient with back and leg pain should be treated as routine sciatica.
Urgent assessment is required when symptoms suggest conditions such as:
- Progressive or severe neurological weakness
- New bladder or bowel dysfunction
- Saddle-area numbness
- Fever with severe back pain
- History suggesting infection
- Significant trauma
- Suspected tumour or pathological fracture
These situations may require urgent imaging and treatment.
3. Neurological Examination
A neurological examination helps localise the affected nerve root.
I assess:
- Motor power
- Sensory changes
- Deep tendon reflexes
- Gait
- Straight-leg-raise and other tension signs
- Heel and toe walking
- Relevant hip and sacroiliac joint findings
For example, weakness of ankle dorsiflexion or great-toe extension may suggest L5 nerve-root involvement, while plantar-flexion weakness may point toward S1 involvement.
4. Imaging When Indicated
MRI is particularly useful when symptoms are persistent, severe, associated with neurological deficits, or when surgery is being considered.
MRI can demonstrate:
- Disc herniation
- Nerve-root compression
- Foraminal stenosis
- Central or lateral recess stenosis
- Degenerative changes
- Other less common causes of nerve compression
However, an MRI abnormality does not automatically mean that surgery is required.
The imaging finding must correlate with the patient’s symptoms and examination.
Treatment of Sciatica
Treatment depends on the severity, duration, neurological findings, cause, and functional impact.
Conservative Treatment
Many patients improve without surgery.
Depending on the individual patient, treatment may include:
- Activity modification
- Appropriate analgesic or anti-inflammatory medication
- Neuropathic pain medication when indicated
- Physiotherapy
- Core and mobility exercises
- Education regarding posture and activity
- Weight management where appropriate
Prolonged bed rest is generally not the goal. Maintaining safe activity is usually preferable when medically appropriate.
Epidural or Selective Nerve-Root Injections
For selected patients with persistent radicular pain, image-guided epidural or selective nerve-root injections may be considered.
These injections can sometimes provide temporary pain relief and may also help confirm the symptomatic nerve root.
They are not a substitute for surgery when there is progressive neurological deterioration or another urgent surgical indication.
When Does Sciatica Need Surgery?
Surgery is considered when the benefits are expected to outweigh the risks.
Common situations include:
1. Progressive neurological deficit
Increasing weakness requires prompt assessment.
2. Persistent disabling radicular pain
When severe leg pain continues despite appropriate conservative management and correlates with nerve compression on imaging, surgery may be considered.
3. Cauda equina syndrome
This is a surgical emergency requiring urgent evaluation.
4. Significant structural nerve compression
A disc prolapse, foraminal stenosis, lateral recess stenosis, or other pathology may require decompression when it clearly correlates with symptoms.
Endoscopic Spine Surgery for Sciatica
For appropriately selected patients, full-endoscopic spine surgery can provide a minimally invasive method of decompressing the affected nerve.
Depending on the location and pathology, an endoscopic procedure may be performed through a transforaminal or interlaminar approach.
Potential advantages of appropriately performed endoscopic surgery include:
- Small incision
- Limited soft-tissue disruption
- Direct visualization of the compressed nerve
- Potentially faster mobilisation
- Short hospital stay in selected cases
- Possibility of performing some procedures under local or regional anaesthesia
However, endoscopic surgery is not automatically the best operation for every patient. The approach should be selected according to the level, location, pathology, anatomy and surgeon expertise.
A Simple Decision Framework
Leg pain → Confirm radicular pattern → Neurological examination → Identify red flags → MRI when indicated → Correlate MRI with symptoms → Conservative treatment when appropriate → Injection/advanced pain management when indicated → Surgery when persistent disabling symptoms or neurological indications warrant decompression.
The most important principle is:
Treat the patient, not the MRI.
Can Sciatica Be Prevented?
Not every episode can be prevented, particularly when disc degeneration or structural disease is involved.
However, maintaining a healthy body weight, regular physical activity, good muscular conditioning, avoiding tobacco, and using appropriate lifting techniques may contribute to overall spinal health.
When Should You See a Spine Specialist?
Consider specialist assessment if:
- Leg pain persists despite initial treatment
- Pain significantly interferes with walking or sleep
- There is progressive weakness
- Numbness is increasing
- Symptoms repeatedly recur
- MRI shows significant nerve compression
- You are being advised to undergo spine surgery and want another opinion
Meet Dr. Om Patil – SpineWala®
Dr. Om Patil (SpineWala®) is an Orthopaedic Spine Surgeon in Mumbai specialising in minimally invasive and endoscopic spine surgery.
His clinical practice focuses on the evaluation and treatment of conditions including sciatica, lumbar disc herniation, lumbar canal stenosis and other degenerative spine disorders, with an emphasis on selecting the least invasive appropriate treatment for each patient.
Sciatica is a symptom, not a single disease. The key to successful treatment is identifying the exact cause of nerve irritation or compression and matching treatment to the patient’s clinical findings.
Most importantly, not every patient with sciatica needs surgery—and not every patient who needs surgery should wait indefinitely.
An accurate diagnosis, appropriate timing, and the right surgical or non-surgical approach can make a significant difference to recovery.
Dr. Om Patil | SpineWala®
Orthopaedic Spine Surgeon | Minimally Invasive & Endoscopic Spine Surgery | Mumbai
Your Back in Action
Spine Surgeons Notes 
Leave a comment