Sciatica is a pain in the back and leg. It usually comes from a herniated lumbar intervertebral disc pinching a lumbar nerve root.
The disc is a cushion to reduce the pressure on the spine. When the spine is under extreme stress, such as when a person bends forward and lifts heavy box, the disc is squeezed out its confinement and into the epidural space.
The epidural space is a narrow space inside of the spinal canal where the spinal cord and nerve root reside. The herniated disc is thus an alien, foreign object in this epidural space where it does not really belong. The herniated disc would take up space and push upon the nerve root and spinal cord. This cause both mechanical and chemical pain. This pain is called lumbar radicular pain.
Because the nerve root carries pain sensation from the lower leg and the foot, pain of these pinched lumbar nerve root feels like shooting pain to the foot or toes.
62 year young lady radiating back and thigh pain to her left front knee.
MRI: L2/3 degenerative disc disease and large herniated disc.
Diagnosis: lumbar radiculopathy and pinched nerve.
Treatment: lumbar epidural steroid injection.
66 year young man 3 month of back pain shooting to left leg after lifting furniture.
He has positive left straight leg raise test.
MRI: L4/5 degenerative disc disease and very large herniated disc causing stenosis.
Diagnosis: lumbar sciatica and pinched nerve.
Treatment: lumbar epidural steroid injection. Surgical consult.
42 year young man 3 days history of acute lower back pain with radiating sharp pain from his back to his left thigh and knee but not beyond. Cough and sneeze are unbearably painful. No position is comfortable. He can barely stand.
High dose steroid taper did not help.
He reported sharp pain with his elevated.
Diagnosis: sciatica, likely from a herniated disc.
Treatment: lumbar epidural steroid injection relieved his pain.
62 year young lady chronic back pain shooting to her right leg and right toes recurred 3 years after initial treatment.
She has right lower back pain but negative straight leg raise test.
MRI: showed advanced L4/5 degenerative disc disease and bilateral foraminal stenosis and impinged nerve root.
Diagnosis: lumbar sciatica and pinched nerve.
Treatment: Steroid pack and lumbar epidural steroid injection.
61 year young lady with 3 months of back and right leg shooting pain when she stands or walks. The pain is severe and did not respond to pain meds or bed-rest. Cough or sneeze or bending forward did not make it worse.
She had lower back pain but Negative straight leg raise test.
MRI showed bulging discs and degenerative changes.
Diagnosis: Lumbar degenerative discs disease and radiculopathy.
Treatment: total pain relief with epidural steroid injection.
64 year young man 3 months history of left back and shooting left leg pain to his left foot. The pain is worse with standing and walking. Cough or sneeze did not worsen the pain. Bending forward did not make the pain worse.
He has left lower lumbar spine pain with pressure on examination.
X ray showed lumbar spinal degeneration and facet arthritis and disc disease worse at L4, L5 levels.
Diagnosis: As above and lumbar radiculopathy.
Treatment: lumbar epidural steroid injection with immediate pain relief.
39 year young lady with 1 year of left lower back pain shooting to her left foot. It is worse with bending forward and cough.
MRI showed a herniated disc at L5/S1 level.
Diagnosis: herniated disc, lumbar radiculopathy.
Treatment: lumbar epidural steroid injection with pain relief.
41 year young lady 6 months of right back pain shooting to her right thigh and right knee.
The pain does not improve with physical therapy.
MRI: L1-3 area bulging discs with lumbar stenosis.
Diagnosis: lumbar degenerative disease, lumbar radiculopathy.
Treatment: Lumbar epidural injection helped the pain >90%.
44 year young thin lady developed a right back and leg shooting pain . It is worse with coughing, laughing, sneeze or bending forward.
She has strong right leg straight leg raise test.
MRI: large L4/5, L5/S1 herniated discs with stenosis.
Diagnosis: as above
Treatment: right side transforaminal epidural steroid injection. Significant pain relief after two sets of injection. Pain is down to 1-2/10 from 10/10.
56 year young man developed a sudden lower back pain with shooting pain to his left buttock and thigh to his knee while exercising. The pain was excoriating. He could barely move, sit or stand. Cough or sneeze made the pain much worse. He went to ER and was given pain meds. Denies weakness, numbness, incontinency.
4 days later, the leg pain resolved.
1 month later, the back pain remains.
Signs: lower back pain with tenderness and positive straight leg test for both legs.
L-X ray: degenerative disc and arthritis.
MRI: L4/5, l5/1 herniated disc with stenosis, worse at L5/S1.
Diagnosis: sciatica; lumbar radiculopathy
Management: Prednisone taper helped; epidural steroid injection deferred; Surgery consult made.
80 year young man 3 months severe left lower back pain shoots to his left buttock and left front and anterior thigh to his left knee and medial calf. Cough and sneeze make it worse.
Signs: left leg straight leg raise test positive
MRI: old back surgery at L4, and L5. New herniated disc at left L3 and pinched a nerve.
Diagnosis: pinched nerve root- left L3.
Management: Selective nerve root block at Left L3 relieved pain
44 year young lady radiating and shooting right lower back and leg pain to her toes for many years. The pain is severe at times. The pain is worse with house chore and lifting heavy objects. She denies weakness or numbness.
She had lower back spinal tenderness but negative straight leg raise test.
MRI showed lumbar degenerative disc disease.
Management: lumbar epidural steroid injection, physical therapy, weight loss.
41 year young lady 20+ year history of right lower back pain shooting t her right buttock, thigh, calf and ankle and foot. The pain comes and goes. it is worse with lifting, cough, sneeze, laugh, etc. It is better with rest. She denies weakness or numbness.
She had positive right leg straight leg raise test.
MRI showed L4/5, and L5/S1 herniated disc with narrowed spinal canal at these levels.
Diagnosis: Lumbar generative disc disease, lumbar radiculopathy.
Management: Avoid weight lifting; physical therapy; lumbar epidural steroid injection; None worked. Surgery consult referred.
43 year young man right back and leg shooting pain for 6 months. Cough sneeze, laughing, bending forward tying shoe laces, defecation all hurts. Lying flat, lumbar decompression makes the pain better.
He has a positive right straight leg raise test.
Lumbar spine MRI showed evidence for a small synovial cyst at right L4/5 facet joint.
Treatment: lumbar epidural steroid injection with total pain relief.
80 year young lady many years of left lower back pain shooting to left posterior thigh, foot, toes with tingling sensation. She had back surgery ~2 years ago without significant change of her pain. Cough or sneeze does not make it worse. House chore or yard work makes it much worse- she can not cook or wash no more. She failed narcotics.
She has lower back pain on examination with negative straight leg raise test.
Treatment: consider caudal epidural steroid injection; if not effective then spinal cord stimulator (good for neuropathic pain) can be tried.
48 year young man one month of sudden onset acute right lower back pain shooting down the right leg to right big toe. The pain is severe enough for him to visite ER twice within 10 days. Cough, sneeze, standing, walking, bending forward, and laughing all cause severe pain.
He had strong positive right leg straight leg raise test but no weakness, numbness, incontinence.
MRI showed right L4/5 moderate size disc herniation.
Treat: right lumbar trans-foraminal epidural steroid injection at L4, L5 levels twice, 10 days apart.
He went back to work.
56 year young man with 4 month of left lower back pain with shooting pain to his left buttock, left posterior thigh, left posterior-lateral calf to his left foot bottom. Cough sneeze does not make it worse. Nothing makes it better.
Examination: negative straight leg raise test for both legs.
He has lower back pain and tenderness on examination.
He has numbness in his left lower leg and foot.
Red: Pain range
Lumbar spine MRI showed left side herniated disc at L4/5, L5/S1 level.
He received lumbar epidural steroid injection and referred to Neurosurgery.
50 year young man chronic left back and leg shooting pain for many years. Cough sneeze or bending forward or even walking can make the pain worse.
Left straight leg raise test is positive.
Lumbar MRI showed degenerative disc disease and lumbar stenosis and lumbar spondylolisthesis at L4/5 level.
Diagnosis: lumbar radiculopathy; lumbar stenosis
Management: Lumbar epidural steroid injection eased his pain over the past two years.
80 year young man one year of shooting pain from his back to his left front leg, knee, shin and foot. The pain is worse with standing and better with sitting or lying flat.
He has positive straight leg raise test on the left.
HIs MRI showed left L3 herniated disc with lateral recess stenosis.
Diagnosis: lumbar radiculopathy; degenerative disc disease
Management: Lumbar transforaminal epidural steroid injection.
Outcome: Immediate pain relief.