My husband has been diagnosed with sciatica. Is there a relationship with arthritis? Because he also has osteoarthritis in the knees, hands, and hips as well as the back. Physical therapy does not seem to work. Many of my friends swear by chiropractors. My husband is also a heart patient who has had six bypasses, a valve replacement, and wears a pacemaker. Would any of these conditions limit what the therapist can accomplish or recommend? — Anastasia, Illinois

I will address your specific questions about your husband's situation after I give general information on sciatica, an important and common problem.

The sciatic nerve is the biggest and longest nerve of the body, originating from lumbar nerve roots in the lower spine, coursing under buttock muscles and down the back of the thigh and leg. Sciatica is the irritation and inflammation of the sciatic nerve, which has several causes. Sciatica tends to happen in our later years, 50 plus, and these are the years when osteoarthritis (OA) occurs. You are correct — some causes of sciatica are related to OA. These are:

  • Narrowing of the canal inside the lumbar spine (spinal stenosis)
  • Disc herniation or prolapse
  • Slippage of vertebra in the lumbar spine (spondylolisthesis)
  • Piriformis syndrome (a buttock muscle problem)
  • Injury of the lumbar spine or the sciatic nerve
  • Tumor in the lumbar spinal canal or the sciatic nerve
  • At times no obvious cause can be found

Spinal stenosis tends to occur in the later years. Within the spine, in the back of the vertebrae, is the spinal canal. In it is found the spinal cord -- the continuation of the brain — until about the second lumbar vertebra. After this point the spinal canal contains the nerve roots that originate in the spinal cord. The nerve roots exit the spinal canal and combine to form a plexus (a braid of nerves so to speak), from which the actual nerves to the extremities are formed. The nerve roots of the lumbar spine form the lumbar plexus, from which the sciatic nerve originates.

Osteoarthritis can involve the spine in several ways. In the lumbar spine, osteophytes (bone spurs) may form at the vertebrae, at the facet joints on each side of the spine, and even inside the spinal canal. The last two kinds of osteophytes can cause narrowing (spinal stenosis), press on the nerve roots, and cause sciatica.

The discs are structures between the bones of the spine (vertebrae), known in medical lingo as "intervertebral discs." They act like cushions and provide greater mobility to the spine. The outer portion of the disc is made of firm connective tissue, and the center is soft like a gel. With age, starting at about 25 to 30 years, cracks may form in the firm portion of the disc (the annulus fibrosus), that, with a sudden or forceful spine motion may allow the soft center (nucleus pulposus) to push through the crack. This is called a disc herniation or prolapse.

Depending on what tissue the prolapsed disc is pressing, there may be pain if it presses on ligaments, or pain, numbness, tingling and/or muscle weakness if it presses on nerve roots.

Disc herniation tends to occur in younger persons. It often gets better with brief rest and back and abdominal exercises, but sometimes requires surgical removal of the herniated part. The surgery can be done through small incisions (arthroscopically), so that the recovery time is shorter than with traditional surgery.

Spondylolisthesis literally means "vertebral slippage" and can happen at any age. It may be caused by a defect in the back of the vertebral bone or by hairline fractures that create instability in that area of the spine. With added stress (injury, excessive weight gain), one vertebra slips over the other and can press on nerve roots.

Piriformis is a muscle of the buttock that lies over the sciatic nerve. Any irritation, inflammation, or injury to the piriformis, from prolonged sitting, running, walking, or falls, can affect the sciatic nerve and cause sciatica. If only the piriformis muscle is affected (piriformis syndrome), the pain starts in the buttock and runs on the back of the thigh, but does not go beyond the knee.

Injuries and tumors of the lumbar spine, the sciatic nerve, and its vicinity can cause sciatica, too.

The general principles of sciatica treatment are topical cold compresses or heat (whichever works). Usually in the acute phase of symptoms cold compresses on the affected buttock for ten to 15 minutes, three to four times a day seem to work best. Gel packs can be placed in the refrigerator and used wrapped in a soft towel, or a bag of frozen peas, wrapped in the same way. Heat (warm compresses) may be preferred by some patients, especially if used a couple of days after the initial acute episode. Simple over-the-counter painkillers -- analgesics like acetaminophen (Tylenol), or nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil or Aleve -— may be used, as long as steps are taken to protect the stomach with the last two. Taking these medications with food or antacids or with certain prescription drugs (omeprazole, lansoprazole, esomeprazol, etc.) can protect the stomach.

If the above do not bring control of pain, certain prescription drugs may be tried: tramadol, codeine derivatives (opiates), and others. If a narcotic drug is used (codeine, hydrocodone, etc.), care should be taken to ensure regular bowel movements. All opiates cause constipation, which should be prevented by drinking plenty of water, eating salads, fruits and vegetables, and fiber (cereal, dark bread, psyllium).

Regular activity, walking, and physical therapy with a home program of stretching and strengthening of affected muscles is very important, as is good posture.

If the above fail, injections of steroid (cortisone-like medicine) in certain areas of the spine (epidural or facet joint injections, under X-ray or CAT scan) or near the piriformis muscle, may help.

In the case of persistent or worsening symptoms after injection with spinal stenosis, especially if combined with spondylolisthesis, surgery may be the only remaining option. Laminectomy with fusion is preferred. With spinal stenosis alone, laminectomy may be sufficient. After surgery, physical therapy is essential for the patient's recovery.

The National Institutes of Health consider acupuncture effective for several types of pain including low back pain from sciatica. One should choose a licensed, experienced acupuncturist if exploring this option. Chiropractic manipulation is rated as an effective treatment by the Agency for Healthcare Research and Quality. I am not well informed about chiropractic methods, but, if this choice is considered, the chiropractor should be chosen carefully as with any other health professional, on the basis of license, certification, if applicable, and reputation.

As for your husband's case with heart disease, bypass surgery, valve replacement, and a pacemaker, non-surgical treatments, including the steroid injections, can be done with care. I believe acupuncture and gentle manipulation could be done too. You obviously have to inform all health care personnel about your husband's history and may even want to provide copies of his medical records.

If surgery were necessary, the cardiologist who treats your husband should evaluate him in terms of anesthesia and surgery risks.