Is It Sciatica or Something Else? A Neurosurgeon Breaks It Down

Shooting pain down the leg is one of those symptoms that is easy to explain away. A pulled muscle. A long day on your feet. Just getting older. But according to Arthur L. Jenkins III, M.D., board-certified neurosurgeon, founder of Jenkins NeuroSpine and a complex spine specialist, that dismissal can cost people months of unnecessary pain and delay treatment that could make a real difference.

Sciatica is widely misunderstood, frequently misattributed and surprisingly common, yet the path from symptom to diagnosis to relief is one that many patients navigate without the right information. Jenkins is here to change that. From the specific nerve distributions that distinguish true sciatica from a muscle problem, to the everyday habits most people never connect to spine health, to the moment you should absolutely stop waiting it out and call a doctor, his answers cut through the noise with the kind of clinical clarity that patients actually need.

So many people dismiss shooting leg pain as a muscle problem or just part of getting older. What are the signs that what someone is feeling is actually sciatica and not something else?

Arthur L. Jenkins III, M.D.: Sciatica is pain radiating down the leg, typically in the sciatic nerve distribution, but is generally used to describe any nerve pain in a specific distribution in the leg consistent with one or more nerve dermatomes or areas of innervation. These specific dermatomes run down the inside of the thigh (L2), the front of the thigh (L3), the outside of the leg, and then wrapping around the outside of the knee, across the front of the leg, into the inside of the ankle (L4), the outside of the leg, the outside of the calf, to the top of the foot (L5), or running down the back of the leg (S1).

While these may be irritated peripherally in the leg itself, they can also be irritated proximally in the spine before it even leaves the spinal canal, or immediately after it leaves the spinal canal, but before it gets into the leg itself. Other signs to watch for are a combination of pain, weakness, or numbness in the same distribution as the pain.

What are the most common everyday habits or lifestyle factors that contribute to sciatica that patients are usually surprised to hear about?

ALJ: Smoking contributes to degeneration of the spine. Osteoporosis leads to collapse of different parts of the spine and may accelerate degenerative changes that can also pinch the spine. Other postural issues include sitting for too long, looking down for too long, bad posture or combining multiple movements at the same time without adequately engaging the core. One of the worst combination movements is what we call the BLT: bending, lifting and twisting all at once. If you’re going to lift, bend or twist, make sure you tighten your abdominal muscles to better support your spine.

At what point should someone stop waiting it out and see a doctor about their sciatica symptoms?

ALJ: The decision as to when to see a doctor is typically nuanced when pain is the only symptom. If there is weakness and pain at the same time, or numbness and pain at the same time, that’s when you should absolutely speak with your doctor. If you’ve tried stretching, strengthening or exercise without improvement, it’s also time to seek medical advice.

For mild pain, I typically recommend talking to a doctor after six to 12 weeks. If pain is moderate or comes and goes but continues beyond a week or two, it's worth checking in sooner. Any new, severe pain that lasts for several hours should prompt a call to your doctor. If symptoms are accompanied by leg swelling, chest pain, dizziness, nausea, changes in consciousness or other neurological symptoms, seek emergency medical care immediately.

When the pain is getting worse over time, limits your ability to move or do normal activities, requires more than Tylenol to manage, has lasted six weeks without improvement, or is consistently triggered by bending, lifting, twisting, standing or walking for long periods, it’s time to be evaluated.

When a patient comes in with sciatica, what does the treatment journey typically look like, and how often does it actually require surgery?

ALJ: Sciatic pain is not just a part of getting older, although it becomes more common with age. If it’s truly nerve-related pain, we can usually identify the cause and recommend treatment. When a patient comes in, we start with a thorough history, including what brought on the pain, what makes it better or worse, and their overall medical history. We also perform a physical examination and may order imaging such as X-rays, MRIs or CT scans.

Once we’ve identified the cause, we discuss the appropriate treatment plan. About 90% of uncomplicated disc herniations causing sciatica improve without surgery through physical therapy, stretching and activity modification. However, if sciatica is caused by another spinal condition, such as Bertolotti syndrome, spondylolisthesis or a fracture, surgery may be more likely. If conservative treatment has been given enough time (typically six weeks for severe pain, three months for moderate pain or six months for mild pain) and symptoms still haven’t improved, surgery may offer the best chance for relief.

For someone dealing with sciatica right now, what is the one thing they can do today to start managing their symptoms while they figure out next steps?

ALJ: The best thing someone with sciatica can do is start a pain diary and make a plan for treatment. Keeping track of when the pain occurs, what triggers it and what relieves it can help identify patterns. The most important step is getting an accurate diagnosis from a spine or pain specialist so the underlying cause can be treated. From there, work with your physician and stick with the recommended treatment plan.