Low Back Pain and Sciatica

The sciatic nerve is a nerve that begins in the lower back and travels through the buttock and into the leg and then into the foot. It is the longest and widest nerve in the human body. The sciatic nerve is made up of five lumbosacral nerve roots, L4, L5, S1, S2, and S3.

When a nerve is inflamed, irritated, compressed, or ischemic, etc., it generates symptoms (pain, numbness, tingling, hypersensitivity, burning, achiness, etc.) and/or functional disturbances (weakness, atrophy, etc.).

Technically, the sciatic nerve is a nerve. When a nerve causes symptoms, the technical term is neuritis or neuropathy. Therefore, technically, signs and symptoms attributed to the sciatic nerve are called sciatic neuritis or sciatic neuropathy. However, most people and most health care providers simply refer to it as sciatica.

As noted, the sciatic nerve is made from five nerve roots. When any of these nerve roots are inflamed, irritated, compressed, or ischemic, etc., it will generate the signs and/or symptoms of sciatica. However, nerve root problems have their unique terminology: radiculitis and radiculopathy.

Putting this together:

• • A nerve root cause of sciatica is called sciatic radiculitis or sciatic radiculopathy.
  • A peripheral nerve (beyond the nerve root) cause of sciatica is called sciatic neuritis or sciatic neuropathy.

The lumbar spine nerve roots exit from behind the intervertebral disk in a hole called the intervertebral foramen. This anatomic arrangement gives three of the nerve roots that make up the sciatic nerve a particular vulnerability:

• • The L4 nerve root, vulnerable between L3-L4.
  • The L5 nerve root, vulnerable between L4-L5.
  • The S1 nerve root, vulnerable between L5-S1.

Their vulnerability is usually linked to the integrity of the intervertebral disk. As seen here, a variety of intervertebral disk pathology narrows the nerve root hole, the intervertebral foramen. This decreases the margin of safety for the nerve root, increasing opportunities for irritation, inflammation, compression, etc.

Any irritation, inflammation, or compression of these nerve roots increases the signs and symptoms of sciatic radiculitis/radiculopathy. The primary complaint is leg pain, and especially leg pain that extends below the knee.

There is no doubt that the primary reason that patients go to chiropractors is for the management of low back pain (63%) (1). Chiropractic care for low back pain is very effective, has high levels of patient satisfaction, confers long-term clinical benefits, and is exceptionally safe (1, 2, 3, 4, 5, 6).

In randomized clinical trials comparing chiropractic spinal manipulation to prescription pain medicines for chronic low back and neck pain, chiropractic manipulation was significantly more effective, registered no significant side effects, and displayed stable long-term clinical benefits (at the one-year follow-up assessment) (5, 6).

When low back pain patients present with leg pain, the common lay person assessment is that of sciatica. But because of the anatomy, most health care providers initially assume the cause is discogenic; a discogenic radiculopathy resulting in sciatica.

It has been documented for decades that the primary anatomic tissue source for low back pain is the intervertebral disk (7, 8). Since the intervertebral disk is also the primary cause of radicular sciatica, it is not surprising that many with low back also have leg pain.

Also, for decades, publications have noted that spinal manipulation is not only effective in the management of low back pain, but also effective for discogenic radicular sciatica. Examples include:

In 1954, an article was published in the Instructional Course Lectures of the American Academy of Orthopedic Surgeons, titled (9):

Conservative Treatment of Intervertebral Disk Lesions

The author states:

“From what is known about the pathology of lumbar disk lesions, it would seem that the ideal form of conservative treatment would theoretically be a manipulative closed reduction of the displaced disk material.”

“Many forms of manipulation are carried out by orthopaedic surgeons and by cultists and this form of treatment will probably always be a controversial one.”

In 1969, a study was published in the British Medical Journal, titled (10):

Reduction of Lumbar Disc Prolapse by Manipulation

The patients in this study presented with an acute onset of low back and buttock pain that did not respond to rest. Diagnostic epidurography showed a clinically relevant small disc protrusion, along with antalgia and positive lumbar spine nerve stretch tests. These patients were then treated with rotation manipulations of the lumbar spine, accompanied with a thrust maneuver. The manipulations were repeated until abnormal symptoms and signs had disappeared. Following the manipulations there was resolution of signs, symptoms, antalgia, and reduction in the size of the protrusions. The authors note:

“Rotation manipulations apply torsion stress throughout the lumbar spine. If the posterior longitudinal ligament and the annulus fibrosus are intact, some of this torsion force would tend to exert a centripetal force, reducing prolapsed or bulging disc material.” 

“The results of this study suggest that small disc protrusions were present in patients presenting with lumbago and that the protrusions were diminished in size when their symptoms had been relieved by manipulations.”

These authors conclude: “it seems likely that the reduction effect [of the disc protrusion] is due to the manipulating thrust used.”

Another 1969 study was published in the Australian Journal of Physiotherapy, titled (11):

Low Back Pain and Pain Resulting from Lumbar Spine Conditions:
A Comparison of Treatment Results

The author compared the effectiveness of heat/massage/exercise to spinal manipulation in the treatment of 184 patients that were grouped according to the presentation of back and leg pain. The further the sciatic pain radiated down the leg, the greater the benefit of spinal manipulation.

This study was reviewed by Augustus A. White, MD, and Manohar M. Panjabi, PhD, in their 1990 book, Clinical Biomechanics of the Spine (12). Their comments include:

“A well-designed, well executed, and well-analyzed study.”

In the group with central low back pain only, “the results were acceptable in 83% for both treatments. However, they were achieved with spinal manipulation using about one-half the number of treatments that were needed for heat, massage, and exercise.”

In the group with pain radiating into the buttock, “the results were slightly better with manipulation, and again they were achieved with about half as many treatments.”

In the groups with pain radiation to the knee and/or to the foot, “the manipulation therapy was statistically significantly better,” and in the group with pain radiating to the foot, “the manipulative therapy is significantly better.”

“This study certainly supports the efficacy of spinal manipulative therapy in comparison with heat, massage, and exercise. The results (80–95% satisfactory) are impressive in comparison with any form of therapy.”

In 1977, the third edition of Orthopaedics, Principles and Their Applications was published. This reference book includes a section pertaining to the protruded disc, titled (13):

Treatment of Intervertebral Disc Herniation with Manipulation

“Some orthopaedic surgeons practice manipulation in an effort at repositioning the disc.  This treatment is regarded as controversial and a form of quackery by many men.  However, the author has attempted the maneuver in patients who did not respond to bed rest and were regarded as candidates for surgery.  Occasionally, the results were dramatic.”

In 1987, a study was published in the journal Clinical Orthopedics and Related Research, titled (14):

Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation

This study involved 517 patients with protruded lumbar discs and clinically relevant signs and symptoms. Their outcomes were quite good, with 84% achieving a successful outcome and only 9% not responding. Only 14% suffered a reoccurrence of symptoms at intervals ranging from two months to twelve years. These authors state:

“Manipulation of the spine can be effective treatment for lumbar disc protrusions.”

“Most protruded discs may be manipulated. When the diagnosis is in doubt, gentle force should be used at first as a trial in order to gain the confidence of the patient.”

“During manipulation a snap may accompany rotation. Subjectively it has dramatic influence on both patient and operator and is thought to be a sign of relief.”

“Gapping of the disc on bending and rotation may create a condition favorable for the possible reentry of the protruded disc into the intervertebral cavity, or the rotary manipulation may cause the protruded disc to shift away from pressing on the nerve root.”

In 1989, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (15):

Lumbar Intervertebral Disc Herniation:
Treatment by Rotational Manipulation

The authors state:

“It is emphasized that manipulation has been shown to be an effective treatment for some patients with lumbar disc herniation. While complications of this form of treatment have been reported in the literature, such incidents are rare.”

In 1993, a “Review of the Literature” was published in the Journal of Manipulative and Physiological Therapeutics, titled (16):

Side Posture Manipulation for Lumbar Intervertebral Disk Herniation

These authors state:

“The treatment of lumbar disk herniation by side posture manipulation is not new and has been advocated by both chiropractors and medical manipulators.”

“The treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective.”

In 1995, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (17):

A Series of Consecutive Cases of Low Back Pain
with Radiating Leg Pain Treated by Chiropractors

The authors retrospectively reviewed the outcomes of 59 consecutive patients complaining of low back and radiating leg pain, and were clinically diagnosed as having a lumbar spine disk herniation. Ninety percent of these patients reported improvement of their complaint after chiropractic manipulation. The authors concluded:

“Based on our results, we postulate that a course of non-  operative treatment including manipulation may be effective and safe for the treatment of back and radiating leg pain.”

In 2006, a study was published in The Spine Journal, titled (18):

Chiropractic Manipulation in the Treatment of
Acute Back Pain and Sciatica with Disc Protrusion:
A Randomized Double-blind Clinical Trial of
Active and Simulated Spinal Manipulations

The purpose of this study was to assess the short- and long-term effects of spinal manipulations on acute back pain and sciatica with disc protrusion. It involved 102 patients. The manipulations or simulated manipulations were done 5 days per week by experienced chiropractors for up to a maximum of 20 patient visits, “using a rapid thrust technique.” Re-evaluations were done at 15, 30, 45, 90, and 180 days. The authors note:

“Active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion.”

“At the end of follow-up a significant difference was present between active and simulated manipulations in the percentage of cases becoming pain-free.”

“Patients receiving active manipulations enjoyed significantly greater relief of local and radiating acute LBP, spent fewer days with moderate-to-severe pain, and consumed fewer drugs for the control of pain.”

“No adverse events were reported.”  

The authors concluded that chiropractic spinal “manipulations may relieve acute back pain and sciatica with disc protrusion.”

In 2014, a study was published in the Annals of Internal Medicine, titled (19):

Spinal Manipulation and Home Exercise with
Advice for Subacute and Chronic Back-Related Leg Pain

This study included 192 patients who were suffering from back-related leg pain for least 4 weeks. The authors concluded:

“For leg pain, spinal manipulative therapy plus home exercise and advice had a clinically important advantage over home exercise and advice (difference, 10 percentage points) at 12 weeks.”

“Spinal manipulative therapy with home exercise and advice improved self-reported pain and function outcomes more than exercise and advice alone at 12 weeks.”

“Spinal manipulative therapy combined with home exercise and advice can improve short-term outcomes in patients with back-   related leg pain.”

“For patients with subacute and chronic back-related leg pain, spinal manipulative therapy in addition to home exercise and advice is a safe and effective conservative treatment approach, resulting in better short-term outcomes than home exercise and advice alone.”

Another 2014 study was published in the Journal of Manipulative and Physiological Therapeutics and titled (20):

Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low-Amplitude, Spinal Manipulative Therapy

The purpose of this study was to document outcomes of patients with confirmed, symptomatic lumbar disc herniations and sciatica that were treated with chiropractic side posture high-velocity, low-amplitude, spinal manipulation to the level of the disc herniation. The authors make the following statements:

“The proportion of patients reporting clinically relevant improvement in this current study is surprisingly good, with nearly 70% of patients improved as early as 2 weeks after the start of treatment. By 3 months, this figure was up to 90.5% and then stabilized at 6 months and 1 year.”

“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.”

“Even the chronic patients in this study, with the mean duration of their symptoms being over 450 days, reported significant improvement, although this takes slightly longer.”

“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low-   amplitude side posture spinal manipulative therapy reported clinically relevant ‘improvement’ with no serious adverse events.”

“Spinal Manipulative therapy is a very safe and cost-effective option for treating symptomatic lumbar disc herniation.”

In 2016, an article was published in the New England Journal of Medicine, titled (21):

Herniated Lumbar Intervertebral Disk

The authors note that approximately 85% of patients with sciatica have a herniated intervertebral disk. Hence, sciatica is the single most important presenting symptom of discogenic radiculopathy/sciatica. The authors clearly acknowledge that chiropractic manipulation is acceptable conservative care for patients with low back pain and sciatica, stating:

“CT or MRI is necessary only in a patient whose condition has not improved over 4 to 6 weeks with conservative treatment.”

“The use of CT or MRI should be discouraged unless the symptoms do not decrease over 4 to 6 weeks” of conservative treatment.

Six weeks of conservative therapy is generally recommended in patients with herniated lumbar disks, in the absence of a major neurological deficit.

In the absence of severe neurologic deficits, discogenic sciatica patients should have conservative treatment for 6 weeks before agreeing to more invasive approaches.

A randomized trial of chiropractic manipulation for subacute or chronic back related leg pain “showed that manipulation was more effective than home exercise with respect to pain relief at 12 weeks.”

“A randomized trial involving patients who had acute sciatica with MRI-confirmed disk protrusion showed that at 6 months, significantly more patients who underwent chiropractic manipulation had an absence of pain than did those who underwent sham manipulations (55% vs. 20%).”

In 2020, a study was published in the journal Annals of Internal Medicine, titled (22):

Physical Therapy Referral from Primary Care
for Acute Back Pain With Sciatica
A Randomized Controlled Trial

The authors of this study note that most “sciatica is attributable to lumbar disk disorders,” and that “sciatica is estimated to occur in about 30% of low back pain episodes.” 

This study involved 220 subjects with an acute onset of low back pain and sciatica. Half were given usual care (drugs and a single education session), and have were referred for 6-8 early sessions of exercise with mechanical manual therapy. The manual therapy consisted of mobilization or high-velocity thrust manipulation of the lumbar spine.

Reassessments for pain, disability, function, and patient satisfaction were completed at 4 weeks, 6 months, and 12 months.

The authors found that referral for early mechanical-based treatment was more effective in reducing disability than usual care alone for low back pain and sciatica. They note:

The early treatment “group showed greater improvement in disability and back pain intensity across all follow-up times.” 

“Patients receiving [early mechanical treatment] were more likely to rate their treatment as successful at 4 weeks and 1 year.”

Early treatment “hastened functional improvement, indicating that [early mechanical treatment] can be offered to patients as first-line nonpharmacologic care.”

Early [mechanical] treatment “for recent-onset low back pain and sciatica resulted in greater improvement in disability and secondary outcomes than usual care across the 1-year follow-up.”

This study indicates that this “drug-wait-and-see” approach is flawed and that the best outcomes for acute low back pain with sciatica use early mechanical-based care. The use of early mechanical-based care resulted in the greatest improvements in pain, disability and patient satisfaction at 1 month, 6 months, and 1 year. This is clearly a physical therapy study, but the therapists used similar interventions that are used in chiropractic, including high-velocity-low amplitude manipulation (manual therapy), exercise, and traction.

The Bottom Line

Low back pain with sciatica is always important because it may be caused by discogenic compressive neuropathology, a problem that may require surgical decompression. However, the studies presented here indicate that early spinal manipulation is often successful at resolving both the low back and leg pain. Providers should be mindful of progressing neurological signs/symptoms and “red flags” should be watched for. The majority of such patients will experience successful outcomes within six weeks of conservative care.

References

1. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
2. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
3. Meade TW, Dyer S, Browne W, Townsend J, Frank OA; Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment; British Medical Journal; June 2, 1990; Vol. 300; pp. 1431-1437.
4. The Lancet; Chiropractors and Low Back Pain; July 28, 1990, p. 220.
5. Giles LGF; Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.
6. Muller R, Giles LGF; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005; Vol. 28; No. 1; pp. 3-11.
7. Mooney V; Where Is the Pain Coming From?; October 1987; Spine; Vol. 12; No. 8; pp. 754-759.
8. Kuslich S, Ulstrom C, Michael C; The Tissue Origin of Low Back Pain and Sciatica: A Report of Pain Response to Tissue Stimulation During Operations on the Lumbar Spine Using Local Anesthesia; Orthopedic Clinics of North America; Vol. 22; No. 2; April 1991; pp.181-187.
9. Ramsey RH; Conservative Treatment of Intervertebral Disk Lesions; American Academy of Orthopedic Surgeons, Instructional Course Lectures; Volume 11, 1954; pp. 118-120.
10. Mathews JA and Yates DAH; Reduction of Lumbar Disc Prolapse by Manipulation; British Medical Journal; September 20, 1969; No. 3, 696-697.
11. Edwards BC; Low back pain and pain resulting from lumbar spine conditions: a comparison of treatment results; Australian Journal of Physiotherapy; Vol. 15; No. 104, 1969.
12. White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second edition, JB Lippincott Company; 1990.
13. Turek S; Orthopaedics, Principles and Their Applications; JB Lippincott Company; 1977; page 1335.
14. Kuo PP and Loh ZC; Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation; Clinical Orthopedics and Related Research; No. 215; February 1987; pp. 47-55.
15. Quon JA, Cassidy JD, O’Connor SM, Kirkaldy-Willis WH; Lumbar intervertebral disc herniation: treatment by rotational manipulation; Journal of Manipulative and Physiological Therapeutics; 1989 Jun;12(3):220-227.
16. Cassidy JD, Thiel HW, Kirkaldy-Willis WH; Side posture manipulation for lumbar intervertebral disk herniation; Journal of Manipulative and Physiological Therapeutics; February 1993; Vol. 16; No. 2; pp. 96-103.
17. Stern PJ, Côté P, Cassidy JD; A series of consecutive cases of low back pain with radiating leg pain treated by chiropractors; Journal of Manipulative and Physiological Therapeutics; Jul-Aug 1995; Vol. 18; No. 6; pp. 335-342.
18. Santilli V, Beghi E, Finucci S; Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: A randomized double-blind clinical trial of active and simulated spinal manipulations; The Spine Journal; March-April 2006; Vol. 6; No. 2; pp. 131–137.
19. Bronfort G, Hondras M, Schulz CA, Evans RL, Long CR, PhD; Grimm R; Spinal Manipulation and Home Exercise With Advice for Subacute and Chronic Back-Related Leg Pain; A Trial With Adaptive Allocation; Annals of Internal Medicine; September 16, 2014; Vol. 161; No. 6; pp. 381-391.
20. Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK; Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow-Up; Journal of Manipulative and Physiological Therapeutics; March/April 2014; Vol. 37; No. 3; pp. 155-163.
21. Deyo R, Mirza S; Herniated Lumbar Intervertebral Disk; New England Journal of Medicine; May 5, 2016; Vol. 374; No. 18; pp. 1763-1772.
22. Fritz JM, Lane E, McFadden M, Brennan G, Magel JS, Thackeray A, Minick K, Meier W, Greene T; Physical Therapy Referral from Primary Care for Acute Back Pain with Sciatica A Randomized Controlled Trial; Annals of Internal Medicine; October 6, 2020 [epub].

“Authored by Dan Murphy, D.C.. Published by ChiroTrust^® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”

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