Welcome to Hicksville Physical Therapy’s patient resource about Piriformis Syndrome and Sciatica.
Any pain that begins in the area of the buttocks and proceeds down the leg is often referred to as sciatica. Of all the causes of sciatica, the most common is spinal nerve irritation near the lumbar region of the spine. Occasionally, this irritation of nerves can occur away from the immediate region and instead be down the leg. Another possible cause of sciatica is what’s known as piriformis syndrome. While this syndrome can indeed be painful, seldom does it present any danger and/or require surgical intervention. The good news is that afflicted individuals can ease pain and properly manage their condition with a few easy steps and even physical therapy.
The following information will help you learn:
Consisting of 24 spinal bones known as vertebrae, the spine utilizes these vertebrae, as they are stacked on one another, to create what is known as the spinal column. The spinal column not only helps to give shape to the body but allows humans upright support.
The rear portions of the spine form together to create a bony ring. When vertebrae are stacked naturally, these bony rings come together to make the spinal canal. As previously mentioned, the spinal canal encompasses nerves that make up the spinal cord throughout the length of the spine. Similarly to how the brain is protected by the skull, the spinal cord is protected by the vertebrae.
Contrary to popular belief, the spinal cord stops at the second lumbar vertebra in the lower back. Beyond this, the remaining nerves encased in the spinal canal extend down to the legs and pelvic organs. This bundle of nerves is known in Latin as cauda equina, which translates to “horse’s tail.”
Functioning as a sort of shock absorber, intervertebral discs, which are in between each vertebra, protect the spine from the constant strain of gravity. Additionally, they help to protect against activities such as running, lifting, and jumping, which can put heavy stress on the spine.
An intervertebral disc is composed of individual components call the nucleus and the annulus. The nucleus, or the center, is springy. It gives the discs their ability to absorb stress. This center is held in place by a series of strong ligaments rings that surround it, otherwise known as the annulus.
Typically, the spinal canal has plenty of room for nerves to function freely at around 17 to 18 millimeters. For comparison, this is just slightly smaller than an American penny. Spinal stenosis begins to occur when the spinal canal reduces in size to 12 millimeters. Once its size is restricted even more to 10 millimeters or less, severe symptoms associated with lumbar spinal stenosis begin to occur.
Apart from this, additional reasons symptoms may appear include:
Congenital Stenosis: Individuals who are born with a narrower spinal canal can suffer from spinal stenosis. Afflicted individuals may not have any issues early on in life, but wear and tear of the spine as an individual ages, or even a minor injury, can ultimately lead to spinal stenosis.
Degeneration of the Spine: As the most common reason of spinal stenosis, degeneration caused by general age can lead to a wide range of issues in the lumbar region. Conditions that can cause the spinal canal to shrink and reduce the space available to nerves include collapsed intervertebral discs, bone spurs, and thickening of the ligaments that hold the vertebrae together.
View animation of degeneration:
Instability of the Spine: Simply put, spinal instability can lead to spinal stenosis. This means that the bones that make up the spine have more maneuverability than they typically have. This instability can be caused if ligaments in the area have been torn or severely stretched due to an injury or if a disease loosens the connective tissues. Regardless of the reason, this instability can certainly lead to spinal stenosis.
Herniation of a disk: When an intervertebral disc in the lumbar region of the back ruptures (herniates), spinal stenosis can occur. When functioning properly, the disks are able to absorb force properly as well as manage the overall pull of gravity. However, if the pressure becomes too great due to an injury or other circumstance, the nucleus can rupture through the outer annulus and make its way out of the disk. This process is referred to as a disk herniation. If the disk happens to herniate backwards, it can put stress against the spinal canal, leading to spinal stenosis.
As the main cause of spinal stenosis is degeneration, spinal stenosis tends to develop over a number of years, most often late in life. When degeneration is the cause, symptoms will seldom develop rapidly. A traumatic injury or herniated disk has the potential to cause almost immediate symptoms.
Individuals who suffer from stenosis do not always experience back pain but will have extreme pain and weakness in one or both legs simultaneously. Individuals describe the situations as if their legs are going to give out at any moment.
As mentioned, symptoms mainly affect the legs. Pressure on spinal nerves can lead to a sensation of pins and needles in the skin where nerves travel. Reflexes will slow down. Some individuals have reported leg cramps, while others have reported a sensation like water trickling down their legs.
Symptoms can change, or be alleviated, with an adjustment of the lower back. When bending forwards, the spinal canal widens, leading to an easing of symptoms. This form of relief can come from both sitting down and curling up in bed. Reaching, standing, and walking can narrow the spinal canal and lead to a return of symptoms and pain.
How will my medical professional diagnose me?
Diagnosis starts with a physical examination and a completed history of your medical records by our team here at Hicksville Physical Therapy. Our team will ask questions regarding any symptoms as well as how your daily life is affected. Detailed questioning will include overall pain, feelings of numbness or weakness, and whether or not the symptoms are made better by standing or sitting. This line of questions will allow us to more accurately make a diagnosis.
During the physical examination, our licensed medical professional will have you perform various movements to determine what causes pain and what does not. Things such as muscle strength, reflexes, and skin sensation will be tested as well. Additional tests may be performed as necessary.
Some individuals may be referred to another medical professional for further evaluation. Once your evaluation is complete, our team of physical therapists at Hicksville Physical Therapy will provide you with treatment options that will not only help speed your healing process but will allow you to return to an active lifestyle.
Unless your symptoms are severe or are progressing rapidly, spinal stenosis is traditionally addressed via non-surgical treatment options. Up to 50% of individuals suffering from mild to moderate lumbar spinal stenosis can manage their condition via non-surgical treatment. Paralysis and neurologic decline are rare in this group.
Upon beginning physical therapy with us here at Hicksville Physical Therapy, our team may advise ways to immobilize the spine for short periods of time to help reduce pain and inflammation. Individuals may find that sleeping while curled up or lying down with the knees up will provide a relief of symptoms, as the spinal canal is more widely opened during these times.
Our team may recommend a lumbar support belt or corset, although their benefits may not be prevalent in every patient. Lumbosacral corsets have not been proven to provide long-term benefits; however, they have been shown to provide temporary relief of symptoms so long as the piece is being worn. The provided support can limit not only the amount of pressure the spine is receiving but extra movement as well. However, the negative is that a corset can lead to potential weakening of the back and abdominal muscles. Some medical professionals will recommend a rigid spinal brace that will hold the spine in a slightly flexed position. Whatever is chosen, when worn as prescribed, will generally be limited to one to two weeks.
Our team at Hicksville Physical Therapy may also recommend using traction. Traction is often used to treat stenosis as it stretches the lower back, relieving pressure on the spinal nerves. Treatments that are more hands-on, such as massaging and soft-tissue mobilization, may be used in the beginning to help you move with less pain and greater ease.
Our team of physical therapists here at Hicksville Physical Therapy will also help guide patients on a specialized program designed to help widen the spinal canal and relieve nerve pressure. After evaluating a patient, we can provide stretches and exercises to help ease symptoms.
We also want to help improve the overall strength of abdominal and lower back muscles. Our team will create a program that will not only help you regain movement, but it will also help you regain strength, function, and endurance. Our physical therapists may also suggest various aerobic and strengthening exercises. The strengthening exercises will focus on enhancing both the strength and control of the muscles in the back and the abdomen. The aerobic exercises will be used to improve the health of both the heart and the lungs as well as increase overall endurance in the spinal muscles. Exercising on a stationary bike will not only help to provide good aerobic exercise but will allow the spine to bend slightly forward to alleviate stress.
Our therapists may also perform an evaluation on your workstation or your activity routine in order to suggest changes to your lifestyle so that future problems may be avoided. Although recovery time can vary from person to person, most of our patients are seen at least twice a week for up to two months. In severe cases, individuals may require additional time.
If surgery is required, afterwards, surgeons may require patients to still undergo physical therapy. Patients that have undergone a fusion surgery generally have to wait for two to three months before beginning physical therapy. Although recovery time varies between individuals, physical therapy will likely need to be attended for six to eight weeks will a full recovery time taking up to six months.
When beginning your physical therapy program, our team may use treatments such as heat or ice, massages, and electrical stimulation to help ease pain. Our team will also provide you with information on how to move safely while placing the least amount of strain on your back.
As you progress in your rehabilitation, our team will provide you with increasingly difficult exercises to challenge you. Our ultimate goal is to help you safely improve both your strength and function. As time continues, we will focus on returning you to an active lifestyle while providing guidance on how to safely go about these activities. Ideally, you will be able to resume your life as normal.
Once your recovery has progressed significantly, your visits with Hicksville Physical Therapy will end. Just remember that we will continue to be a source of information as you go about your exercises at home.
Your physician may first order X-rays to pinpoint the cause of your discomfort. X-rays can show if the problems are from changes in the bones of the spine. The images can show if degeneration has caused the space between the vertebrae to collapse. X-rays may also reveal any bone spurs sticking into the spinal canal.
The best way to see the effects and extent of lumbar spinal stenosis is with a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the spinal canal and whether the nerves inside are being squeezed. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require dye or a needle.
Computed tomography (a CT scan) may be ordered for those patients who can’t have an MRI for some reason, when the results of the MRI are unclear, or symptoms don’t match the MRI findings. The CT scan is a detailed X-ray that lets your doctor see slices of bone tissue. The image can show any bone spurs that may be sticking into the spinal column and taking up space around the spinal nerves.
When there is a concern about neurologic problems, doctors may recommend electrodiagnostic tests of the nerves that go to the legs and feet. An electromyogram (EMG) checks whether the motor pathway of a nerve is working correctly. Motor impulses travel down the nerve and work to energize muscles.
Doctors may also order a somatosensory evoked potential (SSEP) test to locate more precisely where the spinal nerves are being squeezed. The SSEP is used to measure nerve sensations. These sensory impulses travel up the nerve, informing the body about sensations such as pain, temperature, and touch. The function of a nerve is recorded by an electrode placed over the skin in the area where the nerve travels.
Not all causes of spinal stenosis are from degenerative conditions. Doctors use blood tests to determine whether symptoms are coming from other conditions, such as arthritis or infection.
Some patients are given an epidural steroid injection (ESI). The spinal cord is covered by a material called dura. The space between the dura and the spinal column is called the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet joints. This can reduce swelling and give the nerves more room inside the spinal canal.
Research shows that a single steroid injection offers only short-term relief. Multiple injections can produce long-term, lasting pain relief. Epidural injections should be given using contrast-enhanced fluoroscopy. Fluoroscopy is an imaging technique used by the surgeon to guide the needle to the right spot during the procedure. This type of imaging improves the accuracy of medication delivery.
Doctors sometimes prescribe medication for patients with spinal stenosis. Patients may be prescribed anti-inflammatory medication such as nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin. These medications can cause side effects in the kidneys and gastrointestinal tract. Also, because most stenosis patients are elderly, doctors closely monitor patients who are using these medications to avoid complications.
Narcotic drugs, such as codeine or morphine, are generally not prescribed for stenosis patients. They are addictive when used too much or improperly. Muscle relaxants are occasionally used to calm muscles in spasm.
Symptoms of stenosis can lead to mood changes. As a result, doctors sometimes prescribe anti-depressant medication, called tricyclics. Tricyclics help steady peoples’ moods, and some tricyclics even improve sleep by helping the body make an important hormone called serotonin. These medications also seem to calm back pain by affecting the membranes around pain nerves.
If stenosis symptoms have been mild and are not progressing, surgery is not often recommended. However, some individuals may benefit from using a device known as the X-STOP. The X-STOP is a titanium implant that is placed into the spinous processes of the vertebrae in the lumbar region via a small incision in the skin. As it is fitted, the X-STOP stays in place without needing to be attached to any bones or ligaments.
The X-STOP keeps the space in between your spinous processes open, meaning that bending forward to alleviate symptoms is no longer required. Once the X-STOP is in place, patients can stand without any nerves being compressed. This is all done via outpatient surgery using local anesthesia. The procedure is minimally invasive with no soft tissue or bone being removed in the process.
For those suffering from severe symptoms, surgery may be recommended. While there are most often signs of building pressure on the spinal nerves, decompression surgery may be needed as soon as a diagnosis has been made. This form of surgery is done by removing bone and/or soft tissue around the nerves to help alleviate pressure. Medical professionals often make this decision by looking for symptoms such as muscle weakness in the legs, constant pain, and bladder and bowel issues.
When pressure is applied to the spinal nerves, an individual may have issues with their bladder and bowel control. This is a serious situation. If this pressure isn’t relieved, it can lead to issues of permanent bladder and bowel paralysis. With this being said, surgery is almost always recommended to alleviate the nerve pressure.
The primary procedure utilized to treat spinal stenosis is known as a lumbar laminectomy. Some individuals may also require a fusion surgery following the lumbar laminectomy if any sort of instability in the spine is present.
Forming a covering layer around the bony ring of the spinal column, the lamina helps make a roof-like structure over the back of the spinal canal. When the spinal canal nerves are being squeezed, a lumbar laminectomy removes the entire lamina to help alleviate pressure. This type of surgery is what is primarily used for lumbar spinal stenosis.
Posterior Lumbar Fusion
This form of surgery may be required after a lumbar laminectomy. The procedure is often done when a spinal segment has become unstable.
A fusion takes at least two bones and turns them into one solid one. This prevents the joints and bones from moving allowing for stability. During a posterior lumbar fusion, the medical professional places small grafts of bone on the back of the spine where the instability is occurring. A large number of medical professionals will also place metal plates and screws in order to prevent the individual bones from moving. This plate will also help to protect the bone graft, allowing it to heal more quickly and efficiently.