Sciatica

What sciatica actually is

Sciatica is a symptom, not a diagnosis. It names where pain travels — from the low back through the buttock and down the back of the leg, along the path of the sciatic nerve, the largest nerve in the body. The clinical term is lumbar radiculopathy (sciatica): irritation or compression of a nerve root at the point where it leaves the lower spine. Something is pressing on that root, or inflaming it. Most often it is a herniated disc that has pushed into the nerve's space. It can also be a canal narrowed by arthritis — lumbar stenosis — or a vertebra that has slipped forward, spondylolisthesis, crowding the opening the nerve passes through. The word "sciatica" tells you the pattern of the pain. It does not tell you the cause — and treatment follows the cause, which is why the evaluation matters more than the label.

Symptoms

Sciatica pain is typically sharp, electric, or burning, and it travels — from the buttock down the back of the thigh and calf, sometimes into the foot. It usually affects one leg. Numbness, tingling, or weakness can travel with it, and the exact pattern is a clue: pain and numbness into the top of the foot and big toe point to one nerve root; symptoms into the calf, heel, and outer foot point to another. Sitting, bending, coughing, and sneezing often intensify it, because each raises pressure on the irritated root. Plain back pain, by contrast, tends to stay in the back or buttock and ache rather than shoot. Pain that stops at the knee is less likely to be a nerve root problem at all — one reason the pattern deserves a careful look before it is treated.

Diagnosis

Diagnosis begins with the history and examination, not the MRI. Where the pain travels, what provokes it, and whether strength, reflexes, and sensation are normal for each nerve root narrow the possibilities before any image is opened. Nerve-tension maneuvers — gently stretching the nerve to see whether they reproduce the leg pain — support a root source. The hips and circulation are examined as well, because hip arthritis and poor circulation can each imitate sciatica. MRI is used when symptoms persist, weakness is present, or a procedure is being planned, and it is read level by level against the examination: a finding only matters if it sits at the level your symptoms name. Imaging shows anatomy; the examination shows which anatomy is misbehaving.

What your first visit covers

A first visit for sciatica is a mapping exercise. You will be asked where exactly the pain goes, what makes it better or worse, and how it is trending — improving, plateaued, or worsening. Strength, sensation, and reflexes are tested root by root, your walking is observed, and your images are reviewed with you so you can see the level involved. Most patients leave with a named cause, a conservative plan, and clear criteria for what would change that plan. The visit is not complete until the level is identified with confidence — every later decision, from therapy to surgery, depends on treating the right one.

Treatment options

Most sciatica is treated conservatively first, and most episodes improve substantially within 6 to 12 weeks. The plan is built around staying as active as the pain allows — prolonged bed rest slows recovery — along with physical therapy that calms the irritated nerve and rebuilds comfortable movement, and medication for pain and inflammation when appropriate. As the inflammation around the root settles, the pain usually retreats up the leg and fades. If an injection is being considered to calm the nerve or help confirm the level, Dr. Choi refers to pain management colleagues for injections rather than performing them himself. What matters is the trajectory: steady improvement supports patience; a plateau or worsening prompts a second look.

When surgery is considered

Surgery earns its place when leg pain, numbness, or weakness persists or progresses despite good conservative care — or when weakness is advancing and waiting risks losing function. The operation is matched to the cause: a microdiscectomy removes the disc fragment pressing on the root, while a narrowed canal is treated by decompressing it. Done for the right level and the right reason, surgery for sciatica is aimed at the leg pain — it is considerably more reliable for the radiating pain than for back pain alone, and that distinction is part of an honest conversation before anyone schedules an operation.

When a second opinion can help

A second opinion is worth seeking when the proposed operation and your symptoms do not line up — surgery suggested at a level that does not explain your leg pain pattern, for example. It is also reasonable when fusion has been proposed for a straightforward nerve compression with no instability, when surgery was recommended before a fair trial of conservative care, or when symptoms persist after an earlier operation. A second set of judgment calls — before anything irreversible.

When to seek care promptly

One pattern is an emergency. New loss of bladder or bowel control, numbness in the saddle region — where you would sit on a bicycle seat — or weakness progressing in both legs can signal cauda equina syndrome, compression of the bundle of nerves at the end of the spinal cord. That needs same-day, emergency evaluation; hours matter. Rapidly worsening weakness in one leg, such as a new foot drop — trouble lifting the front of the foot — should also be assessed promptly, not watched.

Related care

Lumbar radiculopathy · Lumbar disc herniation · Lumbar stenosis · Microdiscectomy · Second opinions

From Back Talk

Related reading: Sciatica: Leg Pain From Your Back