Can Sciatica Be Caused By Varicose Veins?

The most common presentation of sciatica is pain radiating down the back of the leg.  Internists and pain management physicians manage sciatic discomfort using a combination of anti-inflammatories, corticosteroids, physical therapy and surgery.  In advanced cases, compression of nerve roots can require lumbar decompression surgery.  But, can sciatica be caused by varicose veins? In a word—yes!   And it’s important to consider this before considering more extensive interventions like back surgery.  However, to see a vein specialist, you may have to advocate for yourself.  Few patients or even physicians are aware of the potential relationship between sciatic leg pain and varicose veins.  And yet, having an evaluation for vein disease in the presence of sciatica may be the right solution.  

In this brief article, we will review the association between vein disease and the sciatic nerve.  Additionally, we will describe our experience evaluating and successfully treating sciatic pain with minimally-invasive treatments for varicose veins. 

What Is Sciatica

Sciatica is nerve pain is often secondary to  an injury or irritation to the sciatic nerve, which originates in your buttock region.

Most commonly, it is related to a herniated disk in the lower back that compresses the nerve.  Pain can be felt in the back and radiate down the back of the leg on the side of compression.

The level of pain is variable from a mild ache to a sharp, burning pain that can impair quality of life and disrupt work.   Disability can be common with severe sciatic pain that can be felt like intermittent bolts of electricity down the leg.  

Additional symptoms can include numbness, tingling or muscle weakness in the leg or foot.

What Are Sciatic Nerve Varices

Sciatic nerve varices are an atypical presentation of varicose veins.   The varices appear on the back of the leg, below the knee and often laterally.  In some cases, visible signs of vein disease  (i.e spider veins or varicose veins) can be minimal or even absent.  With disease, sciatic pain can sometimes be reproduced with finger pressure on the visible leg veins near the crease of the knee (figure 1).

Figure 1: Sciatic Veins (adapted from labropoulos et al)

Sciatic nerve varices will follow the course of the nerve (see figure 2).  In this figure, Ricci et al. show the varices coursing near the saphenous fibular nerve superficially.  At the popliteal crease, the veins run in close contact with the common fibular nerve and further into the sciatic nerve.

Figure 2: Sciatic Nerve Varices 

Sciatic nerve veins are part of normal anatomy to all of us.  However, with disease, these veins can dilate and demonstrate reflux like any other varicose vein.  

Diagnosis of Sciatic Nerve Varices

If the physical exam suggests vein disease, a venous reflux ultrasound can help confirm the diagnosis.

Sciatic varicosities demonstrate typical features of varicose veins on ultrasound:

1. Dilation and tortuosity in relationship with the nerves
2. Extended reflux indicating poor venous flow
3. Additional features may include demonstration of a incompetent small saphenous vein (SSV) or its thigh extension communicating with the sciatic varices.  
4. Sciatic vein deep vein thrombosis should also be excluded

Therapy for Sciatic Nerve Varicose Veins

Successful treatment for sciatic varices depends on an accurate diagnosis.  Importantly, the treatment choices are non-surgical.  The therapy choice must be tailored correctly to the underlying cause.  An accurate diagnosis is facilitated by a detailed ultrasound that highlights relevant venous structures including the small saphenous vein, posterior accessory saphenous veins, and associated thigh extensions.

For saphenous veins, radiofrequency or laser vein ablation work well to relieve the increased venous pressure and correct symptoms from sciatic varices.

In the absence of saphenous disease, sclerotherapy should be considered.  However, it’s important to limit the concentration and volume of injection to reduce the risk of causing inflammation around the nerve.  Foam sclerotherapy is preferred to better target the sciatic nerve varices.  Visible veins can also be treated with mico-phlebectomy however one must be careful not to disrupt the superficial, lateral saphenous fibular nerve.

In our experience, most patients were found to have a thigh extension with reflux depicted on a thorough ultrasound examination.  Treatment with venous ablation improved symptoms without any additional treatment. 

Who Should Have A Vein Screening with Sciatic Pain

1. Patients with persisting pain despite anti-inflammatories, corticosteroids or pain treatment
2. Patients with visible signs of vein disease (spider veins or varicose veins) on the back of the thighs or lateral calves
3. Patients with unremarkable workups for sciatic pain including CT or MRI demonstrating no evidence of nerve compression
4. Patients with persisting sciatic pain after back surgery 

If you are experiencing sciatic leg pain and would like to be screened for vein disease, please call our office at 609-257-2095 or complete an evaluation form here.

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