Sciatica and lumbar radiculopathy treatments

Ross Hauser, MD and Danielle Matias, PA-C

You have been diagnosed with sciatica and lumbar radiculopathy

You went to your doctor concerned about a burning pain and numbness sensation in your buttocks, legs, and feet. Often the pain will wake you up in the middle of the night. You may have grinding and popping in your back, even with little movement.

You decided to go to the doctor now because your own pain management plan of aspirin, anti-inflammatories, heat, ice, yoga, stretching, resting, and back braces have not helped. Your problems have probably gone on for some time and now your symptoms are getting worse as you begin to suffer from severe spasms in the lower leg and calf muscles.

After an examination, the doctor, physician’s assistant, or nurse practitioner may suspect sciatica symptoms and will be looking at the possibility of a herniated, slipped, bulging disc in the lumbar spine causing inflammation of the sciatic nerve or lumbar radiculopathy and need a sciatica treatment plan.

A friend may have also recommended a great chiropractor, who has centered your treatment on nerve impingement happening in your L4/L5 lumbar region. You were told that a few adjustments should relieve the pressure on the sciatic nerve bundle and your symptoms should be gone. For many, maybe like yourself, unfortunately, after a few adjustments, you did not respond well enough to call yourself healed or cured.

In this article, we will look at treatments and options for lumbar radiculopathy and sciatica.

Article Outline:

Part 1: Diagnosis

Part 2: Sciatica and lumbar radiculopathy treatment and pain management

Part 3: Failure of conservative care treatments

Part 4: Surgery

Part 5: Injections

Part 1: Diagnosis: “Sciatica (as) a clinical diagnosis is nonspecific.”

In the image above: The caption reads:

“Posterior seating of lumbar nerve roots” (A) Sagittal view (B) Axial view. Because of slouching the posterior ligament complex of the lower back becomes overstretched and injured which leads to shifts in the anatomy where the nerve roots (that ultimately go to the legs) end up posteriorly instead of centrally located (as depicted by the arrows). This leads to “sciatica” down the leg or “buttock pain” with sitting.

What is being suggested is that some sciatica may be caused by a spinal ligament injury, overstretching, and weakness. Ligament injury is rarely spoken of in diagnosis causes of sciatica. This may lead to why there is controversy in what is a correct diagnosis and if there should be any diagnosis of sciatica.

Researchers at the Logan University Health Centers-Integrative Clinics, in Chesterfield, Missouri wrote in the Journal of the American Association of Nurse Practitioners (1).

“Sciatica (as) a clinical diagnosis is nonspecific. A diagnosis of sciatica is typically used as a synonym for lumbosacral radiculopathy. However, the differential for combined low back and leg pain is broad, and the etiology (causes) can be one of several different conditions. The lifetime prevalence of sciatica ranges from 12.2% to 43%, and non-successful outcomes of treatment are prevalent.

Nurse practitioners and other primary care clinicians often have minimal training in the differential diagnosis of the complex causes of lower back and leg pain, and many lack adequate time per patient encounter to work up these conditions. Differentiating causes of low back and leg pain proves challenging, and inadequate or incomplete diagnoses result in suboptimal outcomes.”

Radiculopathy is a disease of the disc causing inflammation of the nerve. Sciatica is not a disease.

Sciatica is not a disease, Sciatica is a symptom of lumbar instability and radiculopathy. Radiculopathy is a disease of the disc causing inflammation of the nerve. If you are reading this article you have likely been diagnosed with sciatica and it has been described to you as an inflammation of the sciatica nerve caused by pressure from a bulging or herniated disc pressing down on the sciatic nerve. For this reason, a diagnosis of lumbar radiculopathy and sciatica are terms often used interchangeably.

If you are reading this article, you should not be at all surprised that research has called into question all of these “remedies,” as not being particularly effective for sciatica patients. If you are reading this article you may be near the point of exhausting all conservative care options and surgery may be indicated. You are likely researching the avoidance of having to make a choice between constant medication and spinal surgery. We see many patients who are not really sure what is wrong with them, or, they are diagnosed with a problem that they do not really understand. Such is the case with Piriformis syndrome.

Please see our article: Piriformis Syndrome and Sciatica Pain

Part 2: Treatment and Pain Management

Sciatica pain down leg

“Management of sciatica can be suboptimal and shows a large variation (of treatment) in clinical practice.”

How did you get here?

Most patients with sciatica and lumbar radiculopathy come in with a lot of problems that have been identified but no clear path to treatment.

A July 2020 paper written by Dr. Bart W. Koes of Erasmus University Medical Center was published in the British medical journal The Lancet (2) and discusses the challenges in understanding the diagnosis and treatment of sciatica:

“Sciatica is a condition involving considerable pain and disability. It is characterized by radiating pain in one leg with or without associated neurological deficits at physical examination. Most patients with sciatic symptoms receive conservative (non-surgical) care in a primary care setting, although patients with signs and symptoms indicative of possible cauda equina syndrome (urinary bladder dysfunction, weakness, or paralysis in the legs) need an urgent referral. A minority of patients (i.e., those with persisting symptoms despite conservative care) are considered for spinal (disc) surgery.

Management of sciatica can be suboptimal and shows a large variation in clinical practice. In general, we only have limited knowledge about the diagnosis of sciatica, the value of diagnostic interventions, the natural and clinical course of the disease, predictors of outcome, and the efficacy of most therapeutic interventions. Compared to the amount of research on non-specific low back pain, research activities focused on sciatica are scarce.”

Comparing how Neurologists treat you and how Anesthesiologists treat you for sciatica and lumbar radiculopathy symptoms.

Some patients will tell us that each time they visit a doctor, they “kind of” take the same path of treatment but the treatment program varies and is mainly focused on pain management then surgery. In an April 2021 study in the medical journal European Neurology (3) researchers in the Netherlands looked at how neurologists and anesthesiologists diagnose and treat people with sciatica in secondary care and evaluate their adherence to the newest treatment guidelines.

Here are the summary learning points:

Neurologists

Anesthesiologists

Preferences differ within and between patients and physicians, which adds to the practice variation. Lack of understanding between doctor and patient

Later, in November 2022, in the publication BMJ Open Quality (4) this line of research continued: “Dutch sciatica care is characterized by a cascade of decisions preceding surgery. Preferences differ within and between patients and physicians, which adds to the practice variation. To improve decision-making, physicians, and patients should invest not necessarily more in the exchange of options or preferences, but in making sure the other understands the rationale behind them.”

Lack of communication and understanding can indeed lead to poor treatment choices and outcomes. Let’s discuss some pain management techniques and therapies.

Conservative care options can help many lumbar radiculopathy patients

Chiropractic spinal manipulative therapy

A December 2022 study (5) led by the University Hospitals Cleveland Medical Center and the College of Chiropractic, Logan University compared outcomes between chiropractic spinal manipulative therapy (CSMT) and lumbar discectomy used for lumbar disc herniation and lumbosacral radiculopathy. The paper suggested that chiropractic spinal manipulative therapy (CSMT) for newly diagnosed lumbar disc herniation or lumbosacral radiculopathy would reduce the odds of needing lumbar discectomy over 1-year and 2-year follow-up compared with those receiving other care.

A June 2022 paper also led by University Hospitals Cleveland Medical Center was published in the BMJ Open. (6) found that in a study of over 9000 patients, those patients receiving chiropractic spinal manipulative therapy (CSMT) for newly diagnosed radicular low back pain (rLBP) had reduced odds of receiving a benzodiazepine prescription during follow-up.

Is it the nerves? Acupuncture for sciatica

The basic concept of traditional Chinese medicine in regard to acupuncture is that the body is in balance and harmony with its parts and if there is an imbalance, health problems begin. There is a lot of research to suggest that acupuncture can help back pain. How it helps is a matter of controversy. Let’s point out that people who have had successful treatment with acupuncture find no controversy at all. Many of the people we see at our center have tried acupuncture and did not achieve hoped-for results. Many studies report that acupuncture addresses neurological pain.

A June 2021 study in the Annals of Palliative Medicine (7) compared different types of acupuncture treatments including traditional manual acupuncture, electroacupuncture, and motion-style acupuncture (the patient exercises during acupuncture treatments). The researchers found that “acupuncture therapy achieved good therapeutic effects in the treatment of acute low back pain, especially motion style acupuncture therapy.”

They also concluded that the research they evaluated to come to this conclusion was “low quality” and that “the credibility of our conclusions is low.”

A May 2021 study (8) in the Journal of Clinical Medicine examined the role of acupuncture on nerve pain. The researchers here recorded: “None of the included studies reported consideration of or accommodations for neuropathic pain mechanisms in the acupuncture approach for sciatica. Additionally, the rationale for using acupuncture was inconsistent among studies.” The question surrounding acupuncture is what is it treating? Blood flow to muscles? Nerve pain?

“The most effective pain medication to treat patients with sciatica or radicular leg pain is unclear“

In the British Medical Journal,(9) researchers also found that pain medications were really not that helpful.  Paralleling the findings of the two studies above, the British researchers found that most sciatic-related pain resolves on its own, however, they cited supportive research that suggested 30% of people will continue to have it after one year.

The highlights of this study:

The effectiveness of NSAIDs for pain reduction for sciatica and lumbar radiculopathy was not significant.

Researchers in Sweden had a difficult time assessing the effectiveness of Non-Steroidal Anti-Inflammatory medications (NSAIDs). Writing in The Cochrane Database of Systematic Reviews (10) they could not make a clear recommendation for NSAIDs usage in sciatica patients.

“This updated systematic review including 10 trials evaluating the efficacy of NSAIDs versus placebo or other drugs in people with sciatica reports low- to very low-level evidence using the GRADE criteria (the GRADE criteria are exactly what it sounds to be: a grading system of evidence. In this case, low grades).

A November 2022 study (11) followed this line of research. Here doctors writing in the journal Cureus suggested from previous research findings that the use of NSAIDs in sciatica was not significantly more effective than the placebo in reducing pain or disability and some improvements resulting from NSAIDs were short-term (three weeks). Other research suggested an increased risk of adverse effects of NSAIDs compared to a placebo. Compared to the placebo, NSAIDs had 1.14 odds of adverse effects and there was no significant evidence of more NSAIDs effectiveness than the placebo. Most of these adverse effects reported were mild and included headache, abdominal pain, gastrointestinal problems, and dizziness. “Though some studies evaluated the effectiveness of NSAIDs in terms of pain relief, general improvement, and adverse effects, sciatica patients found no improvement in disability.”

Researchers in Australia at the University of Sydney wrote in the journal Drugs and Aging (12) of their questioning pharmacological management, including paracetamol (Tylenol),  in older patients with sciatica. “There is overall very limited information on the efficacy, safety, and tolerability of these medicines in older patients.”  A 2018 study agreed (13): Due to limited and heterogeneous evidence, it was difficult to draw firm and meaningful conclusions on changed risk for paracetamol safety in older people.

Glucocorticoid steroids, selective nerve root block, and nonsteroidal anti-inflammatory drugs (NSAIDs)

A July 2022 paper in the journal Medicine (14) comes to us from Israeli researchers. The researchers write that the purpose of their study “was to investigate the clinical symptomatology of discopathies (degenerative disc diseases) before and 7 days after treatment with one of the following: intravenous dexamethasone a Glucocorticoid steroid), selective nerve root block, and systemic treatment with different nonsteroidal anti-inflammatory drugs (NSAIDs).”

Also noting that some patients responded well to conservative radiculopathy treatment, they also acknowledge those who show no improvement and it is those people who may benefit from more invasive treatment options, such as intravenous corticosteroids, spinal injections, and surgical procedures.

In this study, 81 male and female patients aged 18 years and above who had radicular pain were assessed up to seven years after initial treatments.

The visual analog (pain) scale, straight leg raise test, and neurological deficits were assessed to evaluate the patients before and after receiving treatment. Visual analog scale scores and the ability to perform straight leg raise tests significantly improved after treatment with dexamethasone, selective nerve root block, and NSAIDs. However, clinical improvement was significantly better in both the dexamethasone and selective nerve root block groups than in the control group. Motor deficits improved significantly after dexamethasone treatment alone. Dexamethasone and selective nerve root block are useful and safe treatment options for treating patients with acute radicular pain.

The world of nerve blocks and spinal injections for sciatica and lumbar radiculopathy

It is very challenging to try to convince someone who has a lot of pain that their primary pain relief medication of treatment, an epidural steroid injection, may not be that helpful or, worse, that the injection itself can cause worsening of symptoms down the road. We do understand that some people have had great success with epidural steroid injections. Some people even had a few of them. These are the people we typically do not see in our office. We see the ones who had less than desired results or failure of the treatment. This is the group of patients this section of this article is for.

A January 2023 paper in the European Spine Journal (15) stated: “Clinical guidelines recommend epidural steroid injection (ESI) as a treatment option for severe disc-related sciatica, but there is considerable uncertainty about its effectiveness. Currently, we know very little about factors that might be associated with good or poor outcomes from ESI.”

Understanding Epidurals are sometimes referred to as epidural nerve blocks or epidural blocks for sciatica and lumbar radiculopathy

A very brief description of the goal of this injection is pain relief through a reduction of inflammation and swelling in the epidural space. The epidural space is an area of the spine that surrounds the spinal nerves and the spinal cord. So injecting into this space allows for access to the spinal nerves and the ability to send a small amount of anesthetic (painkiller) to numb the nerves and block pain signals between the spine and brain.

The injection can be given as:

Epidural corticosteroid injections and pain management: Epidural corticosteroid injections have no or little demonstrated benefit beyond the placebo effect for sciatica-like and lumbar radiculopathy symptoms.

Let’s start with an October 2020 study in the medical journal NeuroRehabilitation. (16) Here this review of the current published research and commentary on the effectiveness of epidural corticosteroid injection for lumbosacral radicular pain is discussed.

The learning points:

What does this mean to you? According to the study’s conclusion: “Epidural corticosteroid injection is slightly more effective than placebo for leg pain and disability at short-term follow-up. Clinicians and patients however should be informed of the small effect size of the treatment.” You may not get any or small relief from the epidural.

Concerns over short-term gain and long-term costs in the use of epidural steroid injection side-effects have been noted.

Epidural steroid injections ease the pain temporarily by reducing the size of stressed nerve roots. However, concerns over short-term gain and long-term costs in the use of epidural steroid injection side effects have been noted. Although many patients initially respond well to the injections, they still remain a temporary fix.

Research to 2023 on the effectiveness of corticosteroids.

The two papers cited above were written in 2015. More recent papers have cited these papers of offered similar findings. Let’s take this research to 2023.

Many patients do get relief from Epidural Steroid Injections

Chronic pain and chronic inflammation patients get lesser results in the short term.

A May 2019 study in the journal Medicina (20) reported on earlier research that suggested: “A longer duration of symptoms results in chronic inflammation, including fibrosis (scar tissue) and necrosis (cell death) of nerve root fibers. These results suggest that corticosteroids are less effective in chronic inflammation. In this study (the researchers added) hyaluronidase (hyaluronic acid) to steroids and lidocaine for injections, but the outcome was the same as in previous studies.”

A June 2020 study from the Department of Neurosurgery, Adana City Training Research Hospital in Turkey (21) found that transforaminal epidural steroid injection could help patients with radiculopathy from foraminal stenosis. However, it could not produce the same results in patients with central spinal stenosis and lumbar disc herniations.

Systemic corticosteroids appear to be slightly effective at improving short-term pain and function in people with radicular low back pain, not due to spinal stenosis, and might slightly improve long-term function. The effects of systemic corticosteroids in people with non-radicular low back pain are unclear and systemic corticosteroids are probably ineffective for spinal stenosis. A single dose or short course of systemic corticosteroids for low back pain does not appear to cause serious harm, but the evidence is limited.

Study: Doctors should not offer Epidural steroid injections in this way:

In May 2020, the journal Pain Medicine,(22) published a section of the journal titled: “Fact Finders for Patient Safety.” In this section came the findings of the Spine Intervention Society’s Patient Safety Committee. What were these findings? The identification of “Two Myths.”

Myths are busted you should not offer Epidural steroid injections in this way:

What was published as strong recommendations against these myths were: 

A January 2021 paper in the journal Anesthesia and Pain Medicine (23) added: “Common complications include: hypothalamic-pituitary-adrenal (HPA) axis suppression, adrenal insufficiency (most common symptoms are fatigue, nausea and darkening of the skin), iatrogenic Cushing’s syndrome, hyperglycemia, osteoporosis, and immunological or infectious diseases. Other less common complications include psychiatric problems and ocular (vision) ailments.”

Study: Doctors should offer Epidural steroid injections for the elderly in this way:

A July 2023 study in the journal Pain Physician (24) examined the effectiveness of transforaminal epidural steroid injections in 294 elderly patients with lumbar radiculopathy. Treatment success was defined as more than or equal to 50% reduction in pain scores at 6 months. Pain scores were assessed using the Numeric Rating Scale.  This study revealed that the patient would have the best success with the epidural if they had: a short duration of symptoms, if surgery was performed, a good immediate postoperative response, and a high neutrophilic granulocyte percentage (high inflammation).

Ultrasound-guided caudal epidural steroid injection vs. blind injection vs. Fluoroscopy-guided injection

Most recently a July 2021 paper in the Journal of Back and Musculoskeletal Rehabilitation (25) wrote: “Fluoroscopy-guided caudal epidural steroid injection (EDSI) is an option for conservative treatment of low back pain and sciatica; however, repeated exposure to radiation is a concern. With the blind technique, the needle misplacement rate is 30%; hence, ultrasound-guided caudal EDSI is a favored option.”

In this study:

Amidst all this research is still the common patient concern: The pain comes back when the steroid wears off

This article has a lot of research. Throughout this research, we also like to explain how this research translates into what your problems are today. In the research, we have doctors debating the various steroid methods of treating back pain, whether epidural, nerve blocks, etc. For patients with sciatica symptoms and bulging discs somewhere from L1 to S1, these injections can be very helpful. In some, these injections can make the pain go away for long periods of time. But for others we hear the common story and perhaps a story that is very familiar to you, the injections have “worn off.” So we have a patient that tells us how happy they were initially with their cortisone injections and how with physical therapy the pain they suffered from went away. But, then the injection wore off and now they were back where they started from, acute and chronic pain in their lower back shooting into their legs.

Part 3: Failure of conservative care treatments for sciatica and lumbar radiculopathy

Failure of conservative care treatments for sciatica and lumbar radiculopathy

A review of the treatments to see why you are now going to surgery for your sciatica

Doctors at the Arthritis Research UK Primary Care Centre at Keele University and the University of Nottingham in the United Kingdom attempted to categorize a patient’s one-year trajectory or treatment/improvement path with their sciatica-related pain. In part, this would help perplexed doctors understand their sciatica patients better.

The study was published in December 2018, in the journal Arthritis Care & Research. (26)

Four patient types were identified from 609 study participants with back and leg pain still in primary care.

What we see in this study is that 61% of the participants, after one year of follow-up, were getting better, so there is some degree of confidence that the traditional pathways of treatment, medication, rest, therapy, and stretching, are slowly but positively helping people manage their sciatica.

However, 39% of the study participants continued or persisted with moderate to severe pain after one year. If you are reading this article, you are likely in the 39% and you are now being recommended for surgery.

Difficult to treat sciatica and lumbar radiculopathy patients who get more drugs with no evidence that they are helpful. Researchers call these treatments “overused” and tell doctors they have “no use” for patients. Some of you get them prescribed anyway.

Once you progress past the ineffectiveness of aspirin or ibuprofen, you may be managed with stronger medications, these painkillers include oxycodone, antidepressants, and anticonvulsants.

Doctors writing in the Canadian Medical Association Journal wrote in July 2018 (27) that: “There is moderate- to high-quality evidence that anticonvulsants are ineffective for the treatment of low back pain or lumbar radicular pain. There is high-quality evidence that gabapentinoids (one of the classes of anticonvulsants including pregabalin (Lyrica) and gabapentin (Neurontin)) have a higher risk for adverse events.”

You can get a second opinion on that from another group of Canadian researchers writing in the journal Public Library of Science Medicine (PLOS). (28)

In the Journal of the American Medical Association (JAMA) December 8, 2018 issue (29), editors provided a 2018 update on “medical overuse,” which is medical treatments that have “no use,” and in fact are potentially harmful to patients. One of the top problems was the use of the drug pregabalin. To quote: “Pregabalin does not improve symptoms of sciatica but frequently has adverse effects (40% of patients experienced dizziness).” Yet the drug is still sometimes prescribed for sciatica nerve-related inflammation.

The above represents a surge in research in 2018, what happened since?

A January 2022 systematic review (30) of previously published research, including that cited above suggests: “clear evidence for lack of effectiveness of pregabalin and gabapentin for sciatica pain management. In view of this, its routine clinical use cannot be supported.”

Physical therapy for sciatica and lumbar radiculopathy. When it works when it will not.

A December 2022 study in the European Spine Journal (31) comes to us from The University of Oxford. In this study, the researchers examined the effectiveness of physical therapy interventions in people with sciatica. The researchers write: “Physiotherapy interventions are prescribed as first-line treatment for people with sciatica; however, their effectiveness remains controversial. In this study, the research team compared physical therapy with control interventions in the short-, medium- and long term.

This was a review study that reexamined the data of 2699 participants from 18 previously published trials. What the researchers found was no differences between physical therapy and control interventions in pain alleviation or improving disability. They concluded: “Based on currently available . . .there is inadequate evidence to make clinical recommendations on the effectiveness of physiotherapy interventions for people with clinically diagnosed sciatica.”

We generally recommend physical therapy for our patients including those with sciatica and lumbar radiculopathy. Many respond very favorably. Much of the research surrounding physical therapy for sciatica and lumbar radiculopathy considers the treatment controversial. Why? Because it is not clearly understood if the treatment helps. For some people, physical therapy will not help, yet. For physical therapy to work there must be resistance for the muscle to strengthen. If patients have weak spinal ligaments and tendons, those soft tissues that hold bone to bone and muscle to muscle, there may be little or not sufficient resistance for the muscles to strengthen. Simply, if the tendon is weak, the muscle cannot get its resistance by pulling against the bone. If the ligaments are weak, the vertebrae will be wandering out of place, slipping and herniating the disc and stretching the tendons. The stretched tendons may not be able to support the pull of the muscle to the bone. Below we describe our treatments to address this problem. Once the ligament and tendon damage is addressed, physical therapy for low back pain can be very effective.

Surgery

In the image’s caption are the technical aspects of the laminectomy and bilateral laminotomy procedures.

What are we seeing in the above image?

We want to again stress that many people have had very successful spinal surgeries. These are typically not the people that we see at our center. We see people with less-than-hoped-for results and continued pain after surgery.

Often we will see patients with a history of multiple spinal surgeries. Sometimes a few years apart, sometimes many years apart. The progression will usually go from a partial laminectomy to a full decompressive laminectomy.

Are you a difficult-to-treat patient? Trying to solve the refractory sciatica riddle.

Are you a difficult-to-treat patient? Are you a patient who doctors describe as having refractory sciatica, a difficult-to-treat problem that stubbornly refuses to respond to conventional treatments? Doctors have seen many patients respond to anti-inflammatories, physical therapy, and even cortisone, and epidural. This is why they stubbornly hold onto these conventional treatments as primary interventions following a sciatica determination. When these treatments do not help you, despite increasing doses or a trial and error medication plan that looks to see which one works best if any, your doctors may have become perplexed when you did not respond. This is when surgical discussion typically begins.

I had an MRI because of my lower back pain, and sciatica pain. My doctors tell me I have a herniated disc. A few doctors are telling me I need fusion surgery.

As you are reading this article it is very likely that you have now progressed to a surgical recommendation for a spinal fusion or other decompression procedures. Your story may sound like this:

I had an MRI because of my lower back pain, and sciatica pain. My doctors tell me I have a herniated disc. A few doctors are telling me I need fusion surgery. My MRI revealed Spondylolisthesis and instability at L5-S1. I am developing foraminal stenosis. This has been going on for years and recently the pain has become much worse. I have had PT, chiropractic adjustments, and pain, and anti-inflammatory medications recommended and prescribed. I am hesitant about the surgery because two different doctors had recommended two different fusion procedures. 

Minimally invasive spinal surgery procedures for lumbar radiculopathy and sciatica-like symptoms.

We have published a much broader article on this subject on this website: In that article we discuss

You can read the entire article here: Minimally invasive spinal surgery

The surgery works great unless it doesn’t

In August 2019, in the British Medical Journal BMJ Open,(33) doctors from University Hospitals Birmingham and the University of Birmingham in the United Kingdom wrote:

“Lumbar discectomy is a widely used surgical procedure internationally with the majority of patients experiencing significant benefit. However, approximately 20% of patients report suboptimal functional recovery and quality of life. The impact and meaning of the surgical experience from the patient’s perspective are not fully understood. Furthermore, there is limited evidence guiding postoperative management with significant clinical practice variation and it is unclear if current postoperative support is valued, beneficial, or meets patients’ needs and expectations.”

Microdiscectomy for sciatica pain are the reported outcomes correct?

A team of neurosurgeons in the Netherlands published a February 2022 study in the European Spine Journal (34) suggesting that favorable outcomes for microdiscectomy for sciatica may not have been that favorable. How? This is what the paper said:

“It remains unclear whether the long-term results of randomized control trials regarding the outcome of microdiscectomy for the lumbosacral radicular syndrome are generalizable.” In other words, are the results reported accurate for all patient types, or are they accurate for a specifically smaller group of patients? Are the good results for everyone or a select few?

To answer this question, 246 patients (average age 51 years old) who had a  single-level microdiscectomy for MRI disk-related lumbosacral radicular syndrome answered questionnaires about back pain, leg pain, function, disability, and recovery.

The researchers noted that in their 246 patients, the long-term results after microdiscectomy for lumbosacral radicular syndrome were less favorable than those obtained in randomized control trials, possibly caused by less strict patient selection than in randomized control trials. The findings emphasize that patients, who do not meet the same inclusion criteria for surgery as in randomized control trials, should be informed about the chances of a less favorable result.

In summary: This study was performed on patients at a high-volume spine center. At this center, more advanced cases of spinal degeneration were seen and operated on than those in the published randomized control trials. The more advanced spinal degeneration patients would likely not get the same results and as the published research may not have included advanced spinal degeneration patients in their outcomes, these patients should be told they would likely not have the same outcome.

The best conventional medicine has to offer for lumbar disc herniation and associated lumbar radiculopathy and sciatica are surgeries that do not work that well.

So your journey now has come to a surgical recommendation. Up until this time, you may have spent years looking for some type of relief for a problem that has become significantly worse and there seems to be little else for you to consider beyond getting the surgery. But you may have seen the commercials on TV and the ads on the internet for minimally invasive surgery. This has piqued your interest.

Let’s look at a March 2021 study published in the medical journal The Lancet Rheumatology (35) comparing surgical microdiscectomy versus transforaminal epidural steroid injection. Here doctors looked at the optimal invasive treatment for sciatica caused by herniated lumbar disc. To come to a recommendation the doctors compared transforaminal epidural steroid injection against surgical microdiscectomy. These treatments, among others, the doctors noted are and remain remains controversial.

The patients of this study had symptoms perhaps similar to those many of you reading this article may suffer from. They had MRI-confirmed non-emergency sciatica secondary to herniated lumbar disc with symptom duration between 6 weeks and 12 months and had leg pain that was not responsive to non-invasive management.

In a side-by-side comparison, the study’s authors noted:

Successful radiculopathy surgery is not always successful for low back pain and can cause more spinal instability

A January 2022 paper in the journal Medicine (36) examined the question as to whether discectomy improves low back pain as well as radiating pain in patients with lumbar herniated intervertebral disc. In this paper, the doctors wrote that “Most postoperative patients with herniated lumbar disc complained of lower leg radiating pain (LRP), referred buttock pain (RBP), and low back pain (LBP). When a discectomy is performed, improvement in lower leg radiating pain is observed due to spinal nerve irritation. However, long-term low back pain due to degenerative changes in the disc may occur postoperatively.”

What is being suggested is that the pain radiating into the legs from spinal nerve irritation can be helped by the discectomy, however, degenerative changes in the disc continue. This can be caused by the degenerative condition causing spinal instability.

Returning to the study the doctors continue: “Limited research has been reported on the short-term (within 1 year) improvement in low back pain after discectomy. This study aimed to evaluate the effectiveness of discectomy in reducing low back pain within 1 year postoperatively.”

Findings:

This according to the paper puts the surgeon in a decision-making process, “The surgical spine surgeons may prefer to remove the herniated disc aggressively to reduce recurrence or remove the herniated disc less aggressively to reduce back pain caused by degenerative changes. However, consequential degenerative changes in (disc) may still trigger low back pain, and limited discectomy may cause recurrent (disc) herniation.”

Changes in radiculopathy and lower back pain after lumbar decompression

A July 2023 study in the Journal of Neurosurgery (37) comes to us from King’s College Hospital, London. In this study, surgeons and specialists assessed outcomes of patients who had lumbar laminectomy or lumbar discectomy, for changes in their lower back pain after lumbar decompression.

Here is the summary of this research.

The study acknowledges that “lumbar spine decompression surgery, in the form of laminectomy or discectomy, is known to be effective in improving symptoms of radiculopathy and neurogenic claudication. However, it is less clear how it impacts coexisting low-back pain. . . The minimal clinically important difference (MCID) was defined as a 30% reduction in pain.”

Results:

Of the 25,349 patients, sixty-two percent of patients attained the minimal clinically important difference in back pain reduction, with 51% reporting a substantial improvement (more than a  50% reduction in pain). This improvement was observed six weeks post-surgery and patients maintained this pain reduction 2 years post-op. Patients with more back pain were more likely to attain the minimal clinically important difference compared with those with more radiculopathy leg pain. (63.6% vs. 60.1%).

Regardless of pain presentation, low-back pain improves in approximately 62% of patients who undergo lumbar decompressive surgery, with 51% experiencing substantial improvement.

Approximately 41% of patients on daily opioids before surgery remained on daily opioid usage one year after lumbar radiculopathy surgery.

In May 2020, Canadian surgeons, publishing in the Canadian Journal of Surgery (38) described the problems of extensive opioid use before surgery and the continued problem of opioid dependence after surgery.

When comparing epidural steroid injections to surgery, epidurals may be a better choice.

When surgeons are willing to trade effectiveness for fewer side effects and complications.

Let’s look at a study in the European Spine Journal (39) it was a “discrete choice experiment” concerning which surgeries surgeons preferred and why. What is a “discrete choice experiment?” It is a way researchers can find out what treatments a health care provider may favor without asking them directly “Which treatment do you prefer for your patients?” This choice of experiment is seen as valuable in assessing what a surgeon is willing to trade off in exchange for a better surgical outcome. In this case, are surgeons using less effective surgical techniques to avoid complications often seen in more effective but perhaps more risky techniques?

What the researchers found was: “Neurosurgeons consider the risk of complications as most important when a surgical technique is offered to treat sciatica, while the risk of recurrent disk herniation and effectiveness are also important factors. Neurosurgeons were prepared to trade off substantial amounts of effectiveness to achieve lower complication rates.”

Pain and disability paths in patients following lumbar discectomy surgery.

A July 2022 paper published in the journal Scientific Reports (40) collected data on patients to help surgeons understand pain and disability paths in patients following lumbar discectomy surgery. Patients of this study population presented chiefly with lumbar radiculopathy and underwent discectomy surgery.

The researchers noted patient outcome variables of interest. These included numeric rating scales for leg/back pain and modified Oswestry disability index scores at baseline, three, twelve, and 24 months post-operatively.

Data from 524 patients revealed these outcomes for:

While disability improved the most, persistent leg and back pain remained. The researchers noted a disconnect between function and residual pain that needed to be better explained. See the discussion below on ligaments.

What are we seeing in this image? Pain NOT coming from the spondylolisthesis at the L4-L5 level.

Complication from spinal surgery is often described as failed back surgery or failed back surgery syndrome. In most patients, the surgery failed to relieve their pain. In some patients, the surgery made the pain worse. Part of the problem is that the wrong areas of the spine are being operated on.

For those of you diagnosed with spondylolisthesis, this image should look familiar to you. Here we have a patient who was suffering from sciatica. They have an image that clearly shows spondylolisthesis at the L4-L5 level. But upon physical examination is was revealed that the pain was not coming from the spondylolisthesis but from the instability of the L5-S1 and the sacroiliac joint. This patient was treated with dextrose Prolotherapy injections.

What are we seeing in this image? Pain NOT coming from the spondylolisthesis at the L4-L5 level

New pain after radiculopathy surgery.

I had laminectomy and fusion in L5-S1 for sciatica that radiated down my left leg. Prior to the surgery, I had no pain on the right side. After the fusion, I had excruciating pain in both hips, both knees, and both legs. One year after the surgery x-ray showed mild osteoarthritis in the right hip but the most terrible pain was in the left hip which showed no osteoarthritis. The surgery caused some SI issues. I had two SI Injections but no relief at all, the pain was the same if not worse.

In February 2022 (41) doctors at the Orebro University School of Medical Sciences and Orebro University Hospital wrote in the European spine journal about patients who had no pre-surgical back pain and how they did after surgery for their lumbar radiculopathy-related leg pain. They then compared these results to patients who had back pain prior to surgery.

A July 2022 study (42) from Japan’s leading universities’ Departments of Orthopaedic Surgery evaluated the incidence, characteristics, and risk factors for clinical L5-S1 adjacent segment degeneration (ASD) after L5 floating (disc was removed) lumbar fusion.

What are we seeing in this image?

Many people have very successful fusion surgeries. Typically these are not the people that come to our clinic for continued back pain. We see those people who continue with new and chronic pain after back surgery. The caption to the image below is an AP (facing the front of the patient) X-ray of the pelvis showing previous surgical fusion. Lumbar fusion surgeries put pressure on adjacent joints. This particular patient now has severe bilateral sacroiliac pain. As one can see (arrows) the sacroiliac joints are right next to the area that was fused.

X-ray of the pelvis showing previous surgical fusion

Prolotherapy

Ross Hauser, MD discusses ligament damage as the possible cause of nerve compression and injury

A brief summary transcript is below:

The nerve stretches – sciatica, and radiculopathy can follow

Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction
We treat the whole low back area to include the sacroiliac or SI joint.

Summary and Learning Points of Prolotherapy to the low back

Comprehensive Prolotherapy for sciatic pain involves treating all of the affected areas, such as the sacroiliac ligament attachments and the lumbosacral area as necessary. Prolotherapy injections stimulate the body’s own natural healing process which is through inflammation. The inflammation causes the blood supply to dramatically increase in the injured areas, alerting the body to send reparative cells to the ligament site. Ligaments, such as the sacroiliac ligament are made of collagen. In this healing process, the body deposits new collagen. The sacroiliac ligament will then be strengthened and tightened as this new collagen matures. The sacroiliac joint which was unstable will then become strong and stabilized, and the symptoms will abate.

Diagnosing lumbar instability & treatment with Prolotherapy, PRP, cortisone, and nerve blocks

Ross Hauser, MD, and Danielle Matias, PA-C discuss the types of cases we see at Caring Medical Florida for low back pain and spinal instability.

Our research: Published research from Caring Medical

In addition to the in-house data analyzed from consecutive cervical and lumbar radiculopathy causes, Caring Medical published research in the Journal of Prolotherapy demonstrating the effectiveness of Prolotherapy for unresolved back pain.

In our research, we reported on 145 patients who experienced low back pain for an average of 58 months, who were treated on average with four sessions of dextrose (12.5%) Prolotherapy, quarterly, at a charity clinic.

The patients were contacted on average 12 months after their last Prolotherapy session. In these patients:

Results were similar in the patients who were told by at least one medical doctor that there was no other treatment option (55 patients) or that surgery was the only option (26 patients). (41)

The approach to back pain used in these studies was the foundation used in our clinic.

In our research, we reported on 145 patients who experienced low back pain an average of 58 months, who were treated on average with four sessions of dextrose (12.5%) Prolotherapy, quarterly, at a charity clinic. The patients were contacted on average 12 months after their last Prolotherapy session.In these patients: pain levels decreased from 5.6 to 2.7 (numerical rating scale NRS , 1-10 scale); 89% experienced more than 50% pain relief

In our research, we reported on 145 patients who experienced low back pain an average of 58 months, who were treated on average with four sessions of dextrose (12.5%) Prolotherapy, quarterly, at a charity clinic. The patients were contacted on average 12 months after their last Prolotherapy session. In these patients: pain levels decreased from 5.6 to 2.7 (numerical rating scale NRS, 1-10 scale); 89% experienced more than 50% pain relief

Back to Pseudo-Radiculopathy-Structural radiculopathy vs intermittent or transient radiculopathy-Realistic treatment options with Prolotherapy.

In utilizing Prolotherapy as a treatment, diagnosing lumbar radiculopathy as an intermittent transient pain, as mentioned above, requires a physical examination, manipulation, and palpitation of the suspect area. During the physical examination, we are looking for underlying ligament injury to the lumbar spine. When the ligaments become weaker and allow for more movement than normal the vertebrae then move excessively, and rotate, and the nerve can get pinched. This pinching causes extreme pain down the legs and feet. If the lumbar radiculopathy is intermittent, then this pain will be occasional or intermittent. Prolotherapy to the injured and weakened areas will stabilize the lumbar vertebrae. Intermittent radiculopathy generally responds very well to Prolotherapy. Three to six Prolotherapy sessions and the majority of these pains subside.

For the people who have true radiculopathy, the following is typically present:

What are we seeing in this image?

In this group of x-rays of Dr. Hauser’s spine, we see that Dr. Hauser has L5 lumbar instability. During extension, we can see that the L5 slides backward on the sacrum causing compression and severe sciatic pain. Dr. Hauser reported that Prolotherapy on this lower back resulted in significantly diminished sciatic pain

In this group of x-rays of Dr. Hauser's spine, we see that Dr. Hauser has L5 lumbar instability. During extension we can see that the L% slides backwards on the sacrum causing compression and severe sciatic pain. Dr. Hauser reported that Prolotherapy on this lower back resulted in significant diminished sciatic pain

In our office when a person with structural or true radiculopathy comes in, and we think we can help, we may offer nerve blocks with steroids along with the Prolotherapy. If the vertebrae are rotated and that is what is causing the problems of pinched or compressed nerves, and we are going to try to rotate it back with Prolotherapy, we may offer nerve blocks because Prolotherapy to work effectively will need time. Certainly a lot less time than surgical repair recovery. The person with true radiculopathy needs to decrease the inflammation of the disc material pressing on the nerve while Prolotherapy helps stabilize the herniated areas.

The key is time. When there is the presence of bone spurs and they are pinching on the nerves a person may be tempted to try decompressive laminectomy or other surgical procedures.

In the case of a true pinched nerve, most Prolotherapists will get the person some pain control while the Prolotherapy is working.

Obviously, the person gets Prolotherapy to the areas.

Four to six Prolotherapy sessions are sometimes needed. The above approach has been used at Caring Medical for years. It has kept a lot of people out of surgery.

In our experience, the above approach even with herniated discs is around 90% successful. Of course, we have a handful of cases that have needed surgical consultation and surgery. We are grateful the surgeons are there for backup. Even for an acute herniated disc, the surgeon is second-line therapy. For the person with pseudo- or true radiculopathy, the treatment of choice is Prolotherapy.

But what if it is not nerve pain? Another path to treatment – Prolotherapy and spinal ligament damage

Above we discuss nerve blocks, epidurals, medication for nerve pain, acupuncture, manipulation, and surgical options that center on the aspect of nerve pain. But what if your sciatica and lumbar radiculopathy is not nerve-pain related?

In the above research, we presented the typical paths of treatments patients may take in the treatment of their sciatica. Some of the treatments worked, some of the treatments provided some relief, and some of the treatments did not work at all. We will focus now on the treatments that did not work and why.

Maybe you did not have lumbar radiculopathy and the burning sensations in your hip and leg are not really sciatica. Many patients are diagnosed with “sciatica” when, in fact, their sciatic nerve is not getting pinched. How can this be?

The term sciatica is thrown around loosely and is often used for any pain traveling down the leg. In fact, some patients come in asking for sciatic nerve treatment. True sciatica is a nerve injury that causes extreme pain and is caused by the sciatic nerve being pinched due to a herniated disc, spondylolisthesis, or foraminal or lumbar stenosis commonly referred to as spinal narrowing.

However, many patients are diagnosed with “sciatica” when, in fact, their sciatic nerve is not getting pinched.

In our experience, many individuals who are diagnosed with sciatica or lumbar radiculopathy, are more likely to have a “pseudo” sciatica and a “pseudo” radiculopathy. This is a condition where radicular or sciatica pain comes and goes with changes in activity or changes in position, pinching the nerve intermittently.

Sciatica can be a ligament injury problem

In this video, Danielle R. Steilen-Matias, MMS, PA-C, describes the challenges of diagnosing true sciatica

Summary transcript and explanatory notes

Indications the symptoms are caused by a “pseudo sciatica” ligament injury rather than a nerve injury

It is important to note that many people have herniated disks or bone spurs that will show up on MRIs and other imaging tests but cause no symptoms. So a herniated disc according to MRI does not cause sciatica in all patients.

Sciatica may be due to ligament laxity in the sacroiliac joint, which can cause radiating pain down the side of the leg, as well as numbness, a symptom that has traditionally been attributed only to nerve injury.

Summary and contact us. Can we help you?

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your sciatica and lumbar radiculopathy challenges.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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