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Sciatica: How is it diagnosed and treated? Is an X-ray necessary? Physiotherapist explains!

Derek Yeung, a registered physiotherapist from Miracle Prehab & Sports Clinic, will introduce sciatica in this article and discuss the related methods of examination, diagnosis, and treatment.
Author Bowtie Team
Date 2023-07-25
Updated on 2023-09-12
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What is sciatica?Why do we experience sciatica?70 to 80% of people experience lower back pain at least once in their lives.Understanding the main purposes of X-rays, MRI, and CT scansSince insurance covers it, why not get the scans?Surgery is not a cure-all solutionIs it effective to seek a physical therapist for sciatica?

What is sciatica?

Derek: Sciatica can be considered one of the most common pain problems among urban dwellers. In fact, like knee pain or finger pain, sciatica is just a description of pain in a specific area of the body and is not an official diagnostic term. In general, if you have lower back pain accompanied by symptoms such as leg pain or numbness, it can be described as sciatica.

Sciatica does not necessarily mean there is a problem with the sciatic nerve. As long as the pain involves the distribution area of the sciatic nerve (from the lower back through the buttocks to the back of the thigh), it can be called sciatica. There are many causes that can lead to this type of pain, which need to be determined through examination.

 

Why do we experience sciatica?

Derek: There are several common causes of the back and leg pain known as sciatica, including:

1. Herniated discs, degenerative discs, or bone spurs.

These conditions can compress the nerve root and cause pain.

2. Compression of the sciatic nerve.

Tightness in the piriformis muscle in the buttocks can compress the sciatic nerve and cause pain.

3. Spinal cord compression pain.

Bone spurs caused by degeneration of the lumbar spine can narrow the spinal canal, leading to compression of the spinal cord inside the canal and resulting in symptoms such as pain, numbness, and muscle weakness.

4. Referred pain caused by muscle problems.

Tight muscles in the lower back and buttocks can sometimes cause pain in other parts of the leg.

5. Referred pain from the lumbar spine or pelvic joint.

Limited mobility (stiffness) or excessive mobility (instability) in these joints can cause referred pain to the buttocks and legs.

In addition to the above causes, in very rare cases, sciatica can be caused by other medical or surgical problems, such as tumors, bacterial infections, or other visceral problems.

 

70 to 80% of people experience lower back pain at least once in their lives.

Do you need to have an X-ray, MRI, or CT scan to determine if you have sciatica?

Not necessarily. For individuals with symptoms of sciatica or lower back pain, it is not necessary to rush into getting an X-ray. Various studies have shown that 70 to 80% of people experience lower back pain at least once in their lives, and the majority of them naturally recover.

Therefore, Derek would recommend that individuals with lower back pain not overly worry and try allowing their bodies some time for self-repair. However, if the condition persists or shows signs of worsening, seeking professional advice is advisable.

Understanding the main purposes of X-rays, MRI, and CT scans

Many people believe that X-rays or other radiological imaging tests (such as MRI or CT scans) can help diagnose the cause of sciatica or lower back pain, and therefore, they actively request their doctors to arrange these tests.

However, in clinical practice, doctors or physical therapists can generally identify the cause through understanding the patient’s medical history, conducting a physical examination, and performing dynamic tests. These clinical assessments are usually sufficient to determine the cause and guide future treatment.

Spinal X-rays are typically used to rule out serious skeletal problems such as fractures or joint misalignment or dislocation. If, after a clinical examination, the doctor considers that the possibility of a fracture is unlikely and there are no “red flag” symptoms such as cancer, sudden weight loss, fever, infection, loss of bowel or bladder control, or abnormal deep tendon reflexes in the patient’s history or examination, then getting an X-ray in the early stages of lower back pain may not be appropriate.

As for MRI, it can indeed effectively assist doctors in diagnosing more severe soft tissue issues, such as infections, tumors, inflammation, herniated discs, compressed nerves, or ligament tears.

However, as per routine procedures, doctors should have already conducted a detailed examination and made a clinical diagnosis before undergoing an MRI. The purpose of an MRI is usually to confirm the location and size of the lesion, facilitate surgical planning, or when the problem has been persistent or is more unique, to exclude the possibility of rare conditions. Therefore, MRI is generally not suitable for initial diagnosis.

The American Academy of Family Physicians recommends that unless the doctor suspects an emergency medical condition during the examination that requires radiological imaging to assist in diagnosis or exclusion of related symptoms for surgery or other emergency treatments, most patients with lower back pain usually do not need to rush into X-rays or MRI scans within the first six weeks.

Since insurance covers it, why not get the scans?

“I have insurance coverage, so doctor, please write me a referral for the scans!” I have heard many cases making this request, but personally, I do not recommend unnecessary radiological imaging tests. In recent years, numerous studies have indicated that excessive radiological imaging tests may not only waste patients’ time and money but also delay their treatment and even cause harm.

Firstly, the radiation dose from spinal X-rays is several tens of times higher than a typical chest X-ray, and CT scans can be over a thousand times higher. Although generally safe for the human body, there are still situations where it may cause harm. Therefore, unless the doctor deems it clinically necessary, I do not recommend patients actively requesting X-rays or CT scans.

Secondly, unnecessary radiological imaging tests occasionally unexpectedly reveal some “issues.” Sometimes, patients may experience unnecessary anxiety due to these incidental findings, or they may mistakenly attribute the cause of their pain to the “newly discovered” findings. If combined with suboptimal clinical examinations, it is possible to delay the identification of the true cause of the pain, thereby prolonging the patient’s suffering.

Surgery is not a cure-all solution

Many patients with lower back pain often undergo diagnosis and plan for surgery. However, there have been reports indicating that many back pain patients may undergo surgery for benign issues that would not have been discovered or required treatment otherwise, and unfortunately, their original back pain does not improve after the surgery.

Furthermore, a foreign study found that patients who underwent an MRI within the first month of experiencing lower back pain were eight times more likely to undergo back surgery compared to those who did not have an MRI. The medical expenses for patients who had an MRI and surgery were also five times higher than those without an MRI. The study also found that patients who had an MRI and surgery did not recover faster than those without an MRI and surgery.

Finally, I emphasize that I do not oppose any necessary radiological diagnosis and surgery. However, it is recommended that before making a decision, patients should ask their doctors or therapists about the necessity and risks involved.

Is it effective to seek a physical therapist for sciatica?

Patients with sciatica generally experience significant improvement after undergoing physical therapy.

Before providing treatment, physical therapists typically conduct detailed interviews and examinations, including specific tests to help differentiate the patient’s condition. Based on the patient’s situation, they tailor a series of targeted treatments.

Physical therapy for sciatica often includes manual therapy, myofascial release techniques, and a range of therapeutic exercises. Additionally, acupuncture, electrotherapy, ultrasound, and heat therapy are used to alleviate pain and discomfort caused by muscle tension.

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