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Understanding Sciatica: Causes, Treatment Options, and Prognosis

by Pain Doc | May 10, 2024 | Chronic Pain, Sciatica

Introduction:

Sciatica is an often debilitating condition that typically appears after age 60 in those affected, characterized by dysthesias: abnormal sensations that can include shooting pain, numbness and tingling radiating (traveling) along the path of the sciatic nerve, the largest diameter nerve in the body, which runs from the lower back, between the deep hip rotator muscles, and down the back of each leg. This condition can significantly impair one’s quality of life, affecting mobility, work, and daily activities. In this post, I’ll delve into the main details of sciatica, exploring its causes, pathology, treatment options ranging from conservative approaches to surgical interventions, and the prognosis associated with each.

Understanding the Pathology of Sciatica:

Sciatica typically arises from compression or irritation of the sciatic nerve roots, also called the cauda equina, most commonly at the lumbar spine level. The sciatic nerve is composed of nerve roots originating from the lumbar and sacral spine (L4-S3). When these nerve roots are compressed or inflamed, they can give rise to the characteristic symptoms of sciatica, including pain, numbness, tingling, and weakness along the nerve’s distribution. The sciatic nerve is comprised of both motor and sensory fibers, but since the sensory fibers are larger in diameter they are more susceptible to mechanical pressure; hence, irritation of the nerves results in mostly sensory dysfunction and less of motor function (leg muscle strength and coordination).

Common Causes of Sciatica

Herniated Disc: One of the leading causes of sciatica is a herniated disc, also known as a slipped or ruptured disc. Intervertebral discs act as cushions between the vertebrae of the spine, providing support and flexibility. When a disc herniates, its inner gel-like material protrudes through the tough outer layer, exerting pressure on nearby nerve roots, including those of the sciatic nerve.
Spinal Stenosis: Spinal stenosis refers to the narrowing of the spinal canal: the passageway formed from the stacking of the spinal vertebrae, which are solid in the front and have a ringed rear portion that when stacked form the canal in which the spinal cord resides. Narrowing can occur due to age-related degenerative changes, such as the formation of bone spurs and thickening of ligaments. The bone spurs and buckled ligaments encroach the canal, narrowing it. This narrowing can compress the spinal cord and nerve roots, or cause them to rub against them during movements especially back extension, leading to sciatic symptoms.
Piriformis Syndrome: The piriformis muscle, located in the buttocks region, plays a crucial role in hip rotation. In some individuals, the sciatic nerve may pass through or under the piriformis muscle, making it susceptible to compression or irritation. This condition, known as piriformis syndrome, can mimic the symptoms of sciatica. The muscles scissor the nerve if they get spasmed, which can produce sciatica symptoms.
Spondylolisthesis: Spondylolisthesis occurs when a vertebra slips out of alignment anteriorly, often due to degenerative changes or trauma (fractured pars). This misalignment offsets the foramen at that level, usually at L4’L5 effectively scissoring the nerve roots and producing sciatica symptoms.
Degenerative Disc Disease: With age, the intervertebral discs undergo wear and tear, leading to degenerative changes such as disc dehydration, loss of disc height, and the formation of bone spurs. These changes can contribute to nerve root compression and the development of sciatica.

Treatment Options for Sciatica:

The management of sciatica aims to alleviate pain, reduce inflammation, improve mobility, and address the underlying cause of the condition. Treatment options may vary depending on the severity of symptoms, the underlying pathology, and individual patient factors.

Conservative Management: Conservative approaches are often the first line of treatment for sciatica and may include:

Pain Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and analgesics can help alleviate pain and reduce inflammation.
Physical Therapy: Targeted exercises, stretches, and manual techniques can improve spinal flexibility, strengthen supporting muscles, and alleviate pressure on the sciatic nerve.
Heat and Cold Therapy: Applying heat or cold packs to the affected area can help reduce pain and inflammation.
Epidural Steroid Injections: Corticosteroids injected into the epidural space can provide temporary relief by reducing inflammation around the affected nerve roots.

Surgical Intervention: If conservative measures fail to provide adequate relief or if there is evidence of progressive neurological deficit, surgical intervention may be considered. Surgical options for sciatica include:

Discectomy: In cases of herniated discs causing nerve compression, a discectomy may be performed to remove the protruding disc material and relieve pressure on the affected nerve roots.
Laminectomy: This procedure involves removing a portion of the vertebral bone (lamina) to alleviate pressure on the spinal cord and nerve roots, particularly in cases of spinal stenosis.
Spinal Fusion: Spinal fusion surgery may be recommended to stabilize the spine and prevent further slippage of vertebrae in cases of spondylolisthesis or severe degenerative disc disease.

Alternative Therapies: Some individuals may find relief from sciatica symptoms through alternative therapies, although evidence supporting their efficacy may vary. These may include:

Acupuncture: The insertion of fine needles into specific points on the body may help reduce pain and improve nerve function.
Chiropractic Care: Spinal manipulation techniques performed by trained chiropractors may help alleviate pressure on the sciatic nerve and improve spinal alignment. Combining chiropractic with a stretching and exercise routine is even better.
Mechanical Traction: Some chiropractic and physical therapy clinics have special tables that can stretch the spine using an electric motor. This may increase space between the vertebrae, retract buckled ligaments and provide temporary relief.
Yoga and Pilates: These forms of exercise focus on strengthening core muscles, improving flexibility, and promoting relaxation, which can be beneficial for individuals with sciatica.
Low Level Laser (LLLT): Lasering the area of the sciatic nerve may alleviate symptoms. LLLT, also known as cold laser (non-thermal) helps by providing deep penetrating light to the nerve tissue. Photons from laser light enter the sciatic nerve and can modulate pain producing biochemical pathways.

Prognosis:

The prognosis for sciatica depends on various factors, including the underlying cause, the severity of symptoms, and the effectiveness of treatment. In many cases, sciatica resolves with conservative measures within a few weeks to months. However, some individuals may experience chronic or recurrent symptoms that require ongoing management. Over time, the neurons in the irritated nerve roots lose some of their ability to conduct sensory signals, and the symptoms tend to be less acute.

Surgical intervention can provide significant relief for those with severe or persistent symptoms, but it also carries risks and requires careful consideration of potential benefits versus potential complications. With advances in surgical techniques and rehabilitation protocols, the outcomes of surgical treatment for sciatica have improved, with many patients experiencing long-term symptom relief and improved function.

Ultimately, the prognosis for sciatica is influenced by factors such as the individual’s overall health, adherence to treatment recommendations, and the presence of any underlying medical conditions. Early intervention, comprehensive management strategies, and a multidisciplinary approach involving healthcare providers from various specialties can optimize outcomes and improve the quality of life for individuals affected by sciatica.

Conclusion:

Sciatica is a complex condition with diverse causes, ranging from herniated discs to spinal stenosis and piriformis syndrome. Understanding the underlying pathology is crucial for guiding appropriate treatment interventions, which may include conservative measures, surgical intervention, and alternative therapies. With timely and comprehensive management, the prognosis for sciatica can be favorable, enabling individuals to regain function and resume their daily activities with minimal pain and discomfort.

Two Modalities to Heal Low Back Pain in Half the Time

by Pain Doc | Oct 20, 2021 | Low Back Pain, Pulsed EMF, Red light therapy, Self Treatment

Hey, I know there are millions of pages on the internet on how to fix low back pain. It can be a dizzying experience searching through them. It’s information overload.

I began blogging on this site around 2010, but actually have been writing articles on things like exercises for low back pain, neck pain, sprains and strains and so forth, since about 1994 when the internet was in its infancy. Fast forward 28 years, and now there are tons of articles and videos online, including mine. Much of the online content for treating low back pain is good: well-written, easy to understand and follow, and backed by evidence. Others are mediocre; just a re-hash of old-school approaches to treating back pain (rest, ice, no heavy lifting, etc.).

If you know me, when it comes to teaching others how to self-treat pain, I like to write fresh, interesting and innovative content. I figure that there are more than enough good videos on stretching and exercising for low back pain. What I like to do is explain the etiology of pain and propose interventions to prevent that pain from developing or getting worse.

If you have acute (recent onset) low back pain, research shows that in most cases, it will go away on its own if you just take it easy for a couple of days. Sure, icing, applying hot packs and no heavy lifting are obviously recommended to prevent re-aggravating the condition. The problem is that most people can’t afford to wait that long, and don’t like being in pain. They have a job, they have responsibilities to other people, and, they want to have fun and do the things they want to do.

For these individuals, there are a couple of home therapies I recommend, to shorten the healing time.

When you have low back pain, muscles and ligaments in and around your spine are generating pain. Something was disrupted mechanically, and inflammation is going on – blood vessels are releasing histamine and heparin and the inflammatory cascade is active—heat, redness, swelling, pain. The inflammatory chemicals irritate sensory nerves, causing some of the pain; as well as the pressure from the swelling. The nerves themselves may be over-firing; generating a level of pain that is not really proportional to the amount of tissue injury.

So with that, my go-to home therapy is a combination of Pulsed EMF and Red Light. Pulsed EMF is an externally-applied, pulsed electromagnetic field. The field, which is similar in frequency to the body’s own natural EM fields, passes through your body and essentially energizes the membranes of cells.

Cell membranes let things in and out of the cell, especially synthesized proteins, nutrients, oxygen, and waste products. They do this via active and passive transport, which both rely on membrane potential—a weak voltage created by negatively charged ions on the outside of the cell, and positive ions on the inside. Like how a battery’s voltage can power a light bulb, a cell’s weak voltage along its membrane powers the exchange of molecules in and out of the cell.

When cells (in this case muscle, bone, nerve, blood vessel cells) are physically damaged or weakened, this exchange is hampered and the tissues are slow to recover and return to a normal, non-pain state. Pulsed EMF lends a boost to this energy, helping cells become more robust in their healing and recovery activities.

Red Light therapy also can energize weak cells, but via photobiomodulation. Cells absorb red light in the 660-720 nanometer wavelength (electromagnetic energy), due to their molecular composition. Photons strike the nucleus, mitochondria and membrane, which changes the oxidative state of the cell. When this happens, it triggers cell signaling pathways related to metabolism and energy production. The cells increase their ATP output, which gives them more energy to repair damaged sites and synthesize needed repair proteins.

Pulsed EMF devices for home use are very easy to operate. Usually, it’s a matter of just pressing the power button, and sometimes a Mode button and Timer button. One of the better models is the BioBalance. You can order it with a full body mat, or a pad. Simply find a comfortable place in your home such as your sofa; place the mat on it, and lie down so that your low back is directly over the mat. No need to remove clothing; the pulsed EMF field passes right through. Do it 3x day for 20-30 minutes/ day to help your body heal and recover.

Another option is the OMI full body PEMF mat. It is lower power than the BioWave, but sometimes that works just as well, as the EM fields are very subtle. You don’t want fields that are too strong. Remember, your body already produces weak magnetic fields; you just want to complement them with a boost of comparable energy.

Red Light therapy is also a great investment in your health. I recommend getting a red light LED wrap, or LED panel. The wrap is a flexible pad embedded with red light LEDs emitting red light and infrared light (660, 820 nm). The red light diodes create photobiomodulation while the infrared diodes provide deep penetrating heat to dilate blood vessels and increase oxygen delivery to cells.

Red Light panels come in different sizes. The small ones are popular for treating facial skin conditions and beautification. The larger panels are better for treating pain. You can mount or hang the panel on the wall, and position yourself so that you are exposed to the red light (usually requires standing up).

In summary, if you are prone to getting lower back pain or have chronic pain issues, Pulsed EMF and Red Light Therapy are two, powerful and safe modalities that can be used at home for self-treatment and are easy to operate. Best of all, they have a long history of medical research to support their use in treating pain and healing injury. It does require a modest investment, but what is more important to your health and well-being? Without this, nothing else matters.

Simple But Powerful Posture Correction Exercise You Should Do Daily

by Pain Doc | Jun 27, 2014 | Uncategorized

The underlying theme of this blog is that by making strategic changes in your daily routine, you can save yourself a lot of pain and dysfunction now and later on in your life. And it’s my desire to share with you some of these simple changes.

Isn’t this a simpler and smarter way to live, rather than being indifferent or oblivious to the fact that your body slowly loses its resiliency as you age, and not taking appropriate, protective measures? If you perform regularly scheduled maintenance to your car, it will last a lot longer than if you do not. The same goes for your body, but the stakes are a lot higher.

One Popular Reason Why People Develop Pain

The problem I see is that most people forget that when you are in your 20s and 30s you can get away with things like prolonged sitting, staying out late and eating unhealthy things like burgers and fries frequently. At that age your human growth hormone is still giving you that fountain of youth energy and your musculoskeletal system, especially your joints, is still in good working order.

However, through your 40s-60s, your job and/or family responsibilities increase and you have less time for yourself, and you think you can take the same abuse that you took in your earlier years. This is where problems start to manifest.

You see, health problems such as degenerative disc disease take years to develop. Take an x-ray or MRI of your neck or low back, and all those nasty osteophytes, thinning discs and crooked spines you see didn’t start yesterday. They started perhaps ten or more years prior.

So, you are either in a situation where you can do lifestyle modifications to reduce the chances of disorders like this from affecting your health and quality of life; or, you already have the disorder, but need to find ways to stop it from progressing and/or reduce its impact on your health and quality of life.

You see, as long as you are alive, your cells have the capacity to regenerate or transform. Depending on the current state of your health and therefore your body’s recuperative capacity, it could take a long time or a relatively shorter time to see results.

For example, if you are overweight; a smoker and drinker and have a negative impression of life, those serve as extra barriers to healing. Get rid of them, and you’ve got a better chance.

A Simple Exercise to Do Daily if You Sit a Lot

Back to those “lifestyle modification” tips that can help you avoid a life of pain.

Here is today’s example, an exercise called Wall Angels. If you find yourself having a slouched upper back, rounded lower back and forward lunging neck, you’ve got to try these. When done regularly, they can help restore and maintain good posture.

Posture affects your spine, joints, muscles, breathing, energy levels and sometimes even mindset. It is critical to have good posture if you expect to achieve optimal health in your life.

Give it a try; all you need is an empty wall with no obstructions:

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Pain With No Apparent Cause

by Pain Doc | Jul 2, 2012 | Uncategorized

It’s strange, but you would think that for someone experiencing neck, back, shoulder or any other type of musculoskeletal pain in his body, he would know exactly when it started, and how.

But surprisingly, this is not the case for a majority of patients I have seen over the years. Most cases of pain I see are idiopathic; meaning, “with no apparent cause (at least in the eyes of the patient).”

A typical history of such a patient goes something like this:

Me: “Ok Sue, I understand you are experiencing pain in your upper back, right side. When did it start, and how, to your knowledge?”

Patient: “At least the past five or so years. I don’t know what started it; it just seemed to have appeared gradually. It is good some days, then bad, and lately it has been getting worse, so I decided to get it checked.”

At this point, I continue with the history by asking questions related to the patient’s occupational, social/recreational, and past medical history. Usually there is something in the history that can be linked to the complaint, like a past car accident, a particular sports activity during college, or something about the physical requirements of her occupation. But in some cases, there still is nothing in the history that can explain the pain.

But where there is a problem, there is an answer. It’s just that sometimes the answer requires some smart detective work.

If you suffer from pain that can’t seem to be traced to a specific cause, realize that musculoskeletal pain, aside from systemic related disorders such as rheumatoid arthritis, lupus, bone disease, and others, develops from some kind of mechanical breakdown in the musculoskeletal system. It can be something obvious like a hard fall that injures and misaligns a joint; something seemingly innocuous like sleeping on your right side for most of your adult life; or something very subtle, like a subluxated heel bone that does its damage via a drip effect.

So, your best bet is to find a practitioner who is very experienced in human biomechanics. Chiropractors or physical therapists such as Craig Liebenson, DC who emphasize body kinematics and targeted exercise rehabilitation will typically have a keen eye for abnormal or dysfunctional movement. The course of treatment will involve identifying and acknowledging the problem; aggressive rehabilitative exercise regimen, and lifestyle modifications. Manual therapies may be employed, such as spinal manipulation; and orthotics may be required, at least during the initial phase of treatment.

This applies to conditions including unilateral hip or knee pain, TMJ pain, neck pain with right or left rotation, rib or sternum pain, and many others. Oftentimes the condition is secondary to a primary cause, so the doctor should not jump to conclusions and direct all treatment to the site of pain. A thorough investigation and inspection is required.

Prolotherapy: A Controversial Remedy for Muscle and Ligament Pain

by Pain Doc | May 28, 2011 | Uncategorized

Prolotherapy, short for proliferation therapy is a controversial technique that involves a series of injections of an inactive irritant substance into a painful joint, or area where ligaments or tendons insert into bone. The injected substance can be dextrose, phenol, saline solution, glycerol, lidocaine, or even cod liver oil extract. Prolotherapy injections are intended to artificially initiate the natural healing process by causing an influx of fibroblasts that synthesize collagen at the injection site, leading to the formation of new ligament and tendon tissue.

Some of the signs that might benefit from prolotherapy include:

Joint laxity, such as in the shoulder, that does not resolve with standard treatment
Distinct tender points at tendons or ligaments as they attach to the bones
Unresolved, intermittent swelling or fullness involving a joint or muscle
Popping, clicking, grinding, or catching sensations in joints
Temporary benefit from chiropractic manipulation or manual mobilization
Aching or burning pain that is referred into an upper or lower extremity
Recurrent headache, face pain, jaw pain, ear pain
Chest wall pain with tenderness along the rib attachments on the spine or along the sternum
Spine pain that does not respond to surgery, or where there is no definitive diagnosis despite X-rays, MRIs and other tests.

So why is prolotherapy considered “controversial?” Because, according to the federal government (Health Care Financing Administration) there is currently no strong, compelling study that proves prolotherapy can cure cases of soft tissue pain. A “strong” study is one that has at least several hundred test subjects; has a control group (who get a placebo, or fake treatment) and is done in a “double-blind” methodology where the test subject and the administering doctor do not know if the injection is a prolotherapy agent (only a third member of the research study knows). However, there are numerous studies in the literature using smaller test populations (less than a hundred) that support prolotherapy as an effective treatment for pain.

A 2005 study entitled A systematic review of prolotherapy for chronic musculoskeletal pain (Clin J Sport Med. 2005 Sep;15(5):376-80) analyzed major studies on prolotherapy and reached the following conclusion:

Two RCTs (randomized controlled trials) on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy
Two RCTs on low back pain reported significant improvements in pain and disability compared with control subjects, whereas 2 did not. All studies had significant methodological limitations.

There is a research project at the University of Wisconsin involving prolotherapy to treat knee osteoarthritis that is due to publish its results soon.

So, if you have chronic musculoskeletal / joint pain, especially related to trauma, that has not resolved with cortisone injections, chiropractic, physical therapy, personal training, surgery, and time, prolotherapy may be worth investigating. The good thing about it is that it is generally safe.