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Sciatica (Pinched Nerve)

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What is sciatica?

Sciatica is pain that travels from the lower back or buttock into the leg, caused by irritation or compression of a nerve root in the lower spine. It is a symptom rather than a diagnosis in its own right and is commonly associated with lumbar radiculopathy.

Sciatica specifically refers to pain from irritation of the nerve roots that form the sciatic nerve. The sciatic nerve runs from the lower spine through the buttock and down the leg, which is why the pain often follows that path. Most often the problem is at the nerve root in the spine, where something such as a herniated disc presses on it, rather than in the nerve further down the leg. Sciatica is less common than ordinary low back pain, and in most people it settles over time.

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What does sciatica feel like?

The typical picture is pain that starts in the lower back or buttock and travels down one leg, often below the knee and sometimes as far as the foot. It can be sharp, burning, or like an electric shock, and it is often accompanied by pins and needles, numbness, or weakness in the leg or foot. It is usually felt on one side, and it is often worse with sitting, bending, coughing, or sneezing. Some people find they shorten their stride or limp, either to avoid the pain or because of genuine weakness in the leg or foot. Sciatica does not usually cause visible swelling in the leg; leg pain with genuine swelling points elsewhere and should be checked, because other causes of swelling need ruling out.

Some symptoms need urgent medical attention rather than watchful waiting: loss of bladder or bowel control, numbness around the groin or inner thighs, or leg weakness that is getting worse, such as a foot that begins to drag. These can signal cauda equina syndrome or a significant nerve injury, which is a medical emergency.

What causes sciatica?

Because sciatica is a symptom, the useful question is what is compressing the nerve. The common causes are:

  • A herniated (slipped) disc pressing on a nerve root. This is the most frequent cause, usually at the two lowest levels of the lumbar spine (L4/L5 and L5/S1).
  • Degenerative disc disease and the bone changes that come with age, which can narrow the space around the nerve.
  • Spinal stenosis, a narrowing of the spinal canal.
  • Spondylolisthesis, where one vertebra slips forward on the one below.
  • Less often, irritation from muscles in the buttock, or the sacroiliac joint, can mimic sciatica without a pinched nerve root.

How is sciatica diagnosed?

Diagnosis begins with your history and a physical examination, including tests that stretch the nerve (such as raising the straight leg) and checks of reflexes, strength, and sensation, which help identify which nerve root is involved. An MRI can then show whether a disc or another structure is pressing on that nerve, and at which level. As with other spine conditions, imaging must be read alongside symptoms, because disc bulges are common on the scans of people who have no pain.

How long does sciatica last?

Sciatica is usually described by how long it has lasted, which is a more useful guide than any grade, because it shapes what to do next.

Acute (the first six weeks): sciatica is often at its most intense early on and then begins to settle. The great majority of cases improve in this window without surgery.

Subacute (six to twelve weeks): pain that is easing can be given more time, while pain that is not settling is usually the point at which imaging and further options are considered.

Chronic (beyond three months): a smaller group have pain that persists. This does not make surgery inevitable, but it is where a clear look at the cause matters most.

Timing guides urgency in the other direction too: severe or worsening weakness, or any loss of bladder or bowel control, is never something to wait out, whatever the timeframe.

How is sciatica treated?

Most sciatica improves without surgery. Studies of its natural course show that acute symptoms settle in the majority of people regardless of the treatment used, and that a herniated disc often shrinks on its own over time, so the first approach is almost always conservative.

1. Conservative care (first line). Staying active within comfortable limits (prolonged bed rest is no longer recommended), simple pain relief and anti-inflammatory medication where appropriate, and physiotherapy. Most people improve over weeks to a couple of months, and conservative care alone leads to substantial improvement for the large majority.

2. Injections. An epidural steroid injection can calm a badly inflamed nerve and help settle a flare, although the benefit is variable and often temporary.

3. Surgery. Surgery is considered when severe leg pain does not settle after a reasonable period of conservative care, usually six to twelve weeks, or sooner if there is a red flag such as progressive weakness or any loss of bladder or bowel control. Removing the fragment of disc pressing on the nerve relieves leg pain faster than continuing with conservative care; over the longer term, the difference between the two narrows.

What are the surgery options for sciatica?

When sciatica needs surgery, the choice depends on why the nerve is compressed and on the state of the disc underneath.

1. Endoscopic Microdiscectomy

The usual first operation. Through a small, often keyhole or endoscopic, incision, the surgeon removes the fragment of herniated disc pressing on the nerve, which relieves the leg pain. It treats the compression rather than any underlying degeneration, and because it removes disc material, the disc can herniate again: studies put re-herniation at roughly 7 to 18 percent within two years, with most of those going on to need a further operation.

2. Artificial Disc Replacement (ADR)

This becomes relevant where the disc underneath is also worn or collapsing, or where sciatica keeps returning after a microdiscectomy. Replacing the disc rebuilds the height and preserves movement at that level, rather than repeating a microdiscectomy procedure that previously failed.

3. Spinal Fusion

Reserved for cases with significant instability or advanced degeneration, where a motion-preserving option is not suitable.
In every case, the aim is to match the procedure to the cause rather than to fit every patient to the same operation.

A patient's story: recurring sciatica after a microdiscectomy

Poppy came to us after an L5/S1 microdiscectomy in Australia had failed to hold. About a year after that operation, her symptoms returned. She and her husband were travelling the world aboard their sailing yacht, and she wanted to get back to that life without resorting to a spinal fusion.

Rather than repeat a procedure that had not lasted, she was assessed for a motion-preserving option and travelled to Germany for an L5/S1 artificial disc replacement with Dr. Illerhaus at the ONZ centre. Twelve months on, she sent us photos from an unmistakably active recovery: cycling in the Greek Islands, kayak fishing in Malta, playing tennis in Sicily, and climbing the mast of her yacht.

What we see at Spine Connection

Many of the sciatica patients who reach us have already worked through conservative care, and some have had a microdiscectomy that did not hold, or have been told a fusion is the only option left. Our focus is to look at what is actually driving the nerve compression, and whether a motion-preserving option fits, before any fusion is considered.

Frequently Asked Questions

Not quite. A pinched nerve is any nerve under compression, anywhere in the body. Sciatica is one specific pattern: pain travelling from the lower back or buttock down the leg because a nerve root is compressed or irritated where it leaves the lower spine. So sciatica is caused by a pinched nerve, but not every pinched nerve is sciatica. The medical term for it is lumbar radiculopathy.

Sciatica follows the nerve’s path: it starts in the lower back or buttock and travels down one leg, often below the knee, and it is frequently accompanied by pins and needles, numbness, or weakness. It is usually one-sided and often worse with sitting, bending, coughing or sneezing. Pain that stays local to the back, without travelling down the leg, points elsewhere.

The most common cause is a herniated disc pressing on a nerve root in the lower spine, usually at L4/L5 or L5/S1. The sciatic nerve is formed from several of those roots and runs through the buttock and down the back of the leg, which is why compression at the spine is felt in the buttock. Less often, muscles in the buttock or the sacroiliac joint can produce a similar pattern without a pinched nerve root.

Yes. Pain can make you shorten your stride or shift weight off the affected side. More importantly, sciatica can cause genuine weakness in the leg or foot, and a foot that begins to drag or catch is a different matter from limping to avoid pain. Weakness that is getting worse should be assessed promptly rather than waited out.

Sciatica itself does not usually cause visible swelling in the leg. If you have leg pain with genuine swelling, that combination points away from a simple pinched nerve and should be checked, because other causes of leg swelling need ruling out. Nerve pain more typically produces burning, shooting pain, pins and needles, or numbness.

Most sciatica settles. The pain is often at its most intense in the first six weeks and then begins to ease, and the great majority improve in that window without surgery. Pain that is still not settling between six and twelve weeks is usually the point at which imaging and further options are considered. A smaller group have symptoms beyond three months.

Surgery is considered when severe leg pain has not settled after a reasonable period of conservative care, usually six to twelve weeks, or sooner if there is progressive weakness. Removing the fragment of disc pressing on the nerve relieves leg pain faster than continuing conservative care, though over the longer term the difference between the two narrows. Some symptoms are urgent: any loss of bladder or bowel control, or numbness around the groin, needs immediate care.

Been told you need surgery for your sciatica?

If your sciatica is not settling, or a microdiscectomy has not held, or you have been told a fusion is the only option, it is worth seeking a second opinion before you commit. Our specialists in Germany and Thailand can review your imaging and tell you honestly whether time and conservative care are still on your side, whether a motion-preserving option fits, or whether it does not.

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Sources

  1. Pojskic M, et al. Lumbar disc herniation: epidemiology, clinical and radiologic diagnosis. WFNS Spine Committee recommendations. World Neurosurgery: X, 2024. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10982570/)
  2. Zhong M, et al. Incidence of spontaneous resorption of lumbar disc herniation: a meta-analysis. Pain Physician, 2017. (https://pubmed.ncbi.nlm.nih.gov/28072796/)
  3. Comparison of treatments for lumbar disc herniation: systematic review with network meta-analysis. (Acute sciatica settles in most patients regardless of treatment; surgery relieves pain faster with the difference narrowing over time; re-herniation in about 7 to 18 percent within two years.) (https://pmc.ncbi.nlm.nih.gov/articles/PMC6408089/)
  4. Hammed A, et al. Surgical vs. Conservative Management of Chronic Sciatica (>3 Months) Due to Lumbar Disc Herniation: Systematic Review and Meta-Analysis. Cureus, 2024. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11145364/)
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