Sciatica and lumbar radiculopathy treatments
Ross Hauser, MD, Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Florida
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
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 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 began to suffer from severe spasms in the lower leg and calf muscles.
At the doctor’s, after an examination, the doctor, or 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.
How did you get here?
Researchers at the Logan University Health Centers-Integrative Clinics, in Chesterfield, Missouri wrote in the Journal of the American Association of Nurse Practitioners (1) a possible explanation of why you are here at this point of non-effective treatments:
“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 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.”
Sciatica is not a disease, Sciatica is a symptom of Lumbar Instability
Ross Hauser, MD discuss ligament damage as the possible cause of nerve compression and injury
A brief summary transcript is below:
- Most nerve injuries, such as cervical or lumbar radiculopathy, spinal cord problems, neuritis, neuralgia, that can cause neurological symptoms, can find their origins in ligament weakness in the spine that causes spinal instability and a “pressing,” on the nerves.
- The sciatic nerve for instance runs through the lower spine and journeys down into the buttock, down the back of the thigh and leg, and then into the foot. All along its path the sciatic nerve runs very close to and it attached to the movement of the bone.
The nerve stretches – sciatica, radiculopathy can follow
- IF THE JOINT IS UNSTABLE
- In an unstable joint, such as lumbar vertebrae facet joints, the SI joint, the hip, the movement of the bones becomes hypermobile and the nerve stretches to stay within proximity to the bone. If the nerve stretches by only 5 – 6 %, vital nerve impulses (messages) can be blocked. If the nerve is strecthed by 12% all nerve impulses can be blocked and function is lost.
- In the same unstable situation the bones can press on the nerves that causes the burning, severe, radiating pain, the tingling and numby feeling.
- If you have a nerve problem that no one can seem to understand, there may be an underlying nerve injury from joint, SI joint, or spine instability.
Sciatica is not a disease, Sciatica is a symptom of Lumbar Instability and Radiculopathy. Radiculopathy is a disease of the disc causing inflammation on 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.
- Your doctor may recommend a pain relief plan and tell you about an epidural injection or nerve block for sciatica nerve pain, pain-killers, NSAIDs anti-inflammatory therapy or corticosteroids.
- Your doctor will likely issue warnings to you about the realistic expectations of pain relief you may achieve and what type of herniated disc sciatica recovery time you may expect.
- Recommendations to reduce physical activity is generally made, heavy lifting is to be avoided. Hamstring stretches and abdominal strengthening or low back exercises may be encouraged to strengthen the spine. A physical therapy plan may be encouraged.
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.
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 the problem that stubbornly refuses to respond to conventional treatments? Doctors have seen many patients respond to anti-inflammatories, physical therapy, 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.
Difficult to treat patients 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 (2) that: “There is moderate- to high-quality evidence that anticonvulsants are ineffective for 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 wring in the journal Public Library of Science Medicine (PLOS).(3)
- “Existing evidence on the use of gabapentinoids in chronic low back pain is limited and demonstrates significant risk of adverse effects without any demonstrated benefit. Given the lack of efficacy, risks, and costs associated, the use of gabapentinoids for chronic low back pain merits caution.”
In the Journal of the American Medical Association (JAMA) December 8, 2018 issue (4), editors provided a 2018 update of “medical overuse,” which is medical treatments that have “no use,” and in fact are potential 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 most effective pain medication to treat patients with sciatica or radicular leg pain is unclear“
In the British Medical Journal,(5) 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 after one year.
The highlights of this study:
- “The most effective pain medication to treat patients with sciatica or radicular leg pain is unclear“
- “Medications used for the treatment of sciatica can have considerable side effects.”
- Acute sciatica will usually clear within two weeks, and about three-quarters of patients reported any improvement within 12 weeks.
- Thirty percent of patients will report persistent and disabling symptoms after one year.
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 (6) 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 is exactly what is sounds to be a grading system of evidence. In this case low grades).
- The efficacy of NSAIDs for pain reduction was not significant.
- NSAIDs were better than placebo.
- While the trials included in the analysis were not powered to detect potential rare side effects, we found an increased risk for side effects in the short-term NSAIDs use.
- As NSAIDs are frequently prescribed, the risk-benefit ratio of prescribing the drug needs to be considered.
Researchers in Australia at the University of Sydney wrote in the journal Drugs and Aging (7) 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.”
Epidural corticosteroid injections and pain management: Epidural corticosteroid injections have no demonstrated benefit beyond the placebo effect
Epidural steroid injections ease pain temporarily by reducing the size of stressed nerve roots. However, concerns over short-term gain 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.
- 2014: In the French medical journal Prescrire international (Prescribe), (8) this editorial appeared in late 2014: “Sciatica and epidural corticosteroid injections.”
- According to trials conducted in hundreds of patients with sciatica, epidural corticosteroid injections have no demonstrated efficacy beyond the placebo effect, either in the short term or the long term. However, they expose patients to a risk of sometimes serious neurological adverse effects.
- However, some patients do get relief from Epidural Steroid Injections. In a November 2017 study in the journal World Neurosurgery, (9) doctors in Switzerland wanted to see how long that pain relief lasted.
- Fifty-seven patients who underwent a transforaminal epidural steroid injection for sciatica secondary to a lumbar disc herniation were followed for 24 months.
- Leg and back pain, health-related quality of life were measured using various scoring systems. Patients who underwent a second injection or surgery were defined as treatment failures (nonresponders).
- At 24 months, 31 (54.4%) patients were responders, and 26 (45.6%) were nonresponders.
- Further, research in the Journal of the American Medical Association, JAMA said that oral steroids as compared to placebo, offered minor improvement in function but did not improve pain conditions.(10)
- A June 2020 study from the Department of Neurosurgery, Adana City Training Research Hospital in Turkey (11) did find 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.
A review of the treatments to see why you are now going to surgery
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, December 2018, in the journal Arthritis Care & Research.(12)
Four patient types were identified from 609 study participants with back and leg pain still in primary care.
- Patients with improving mild pain (58%) where the pain is associated and seemingly from back pain problems
- Persistent moderate pain (26%) where the pain is associated and seemingly from back pain problems
- Persistent severe pain (13%) where the pain is associated and seemingly from back pain problems
- Improving severe pain (3%) where it is unclear where the original pain was coming from. See below for a discussion on spinal ligaments.
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, stretching, is 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 to a surgery.
Doctors writing in the Swiss Medical Review (Revue médicale suisse) suggest not even waiting a year, if these treatments are not working, better to decide on surgery sooner:
“(If symptoms worsen) under conservative treatment or if pain is poorly controlled by well-conducted conservative treatment performed during four to six months, surgery is then recommended.(13)
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 to 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.
Minimally invasive spinal surgery procedures
We have published a much broader article on this subject on this website: In that article we discuss
- Is Minimally invasive spine surgery really less complicated, less risky, less painful? Toronto Western Hospital, University of Toronto surgeons questions this.
- Is Minimally invasive spine surgery less complicated, less risky, less painful? New York University Langone Medical Center Study questions this.
- Is Minimally invasive spine surgery less complicated, less risky, less painful? A study in the British Journal of Neurosurgery questions this.
You can read the entire article here: Minimally invasive spinal surgery
- Writing in the European Journal of Pain, doctors found that some patients with sciatica still experience pain and disability 5 years after surgery. They wrote in their conclusion “Although surgery is followed by a rapid decrease in pain and disability by 3 months, patients still experience mild to moderate pain and disability 5 years after surgery. “(14)
The surgery works great, unless it doesn’t.
In August 2019, in the British Medical Journal BMJ Open,(15) 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 patients’ 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.”
You may conclude that the surgery works great unless it does not and then there is a problem of what to do with these patients.
Approximately 41% of patients on daily opioids before surgery remained on daily opioid usage one year after surgery.
In May 2020, Canadian surgeons, publishing in the Canadian Journal of Surgery (16) described the problems of extensive opioid use before surgery and the continued problem of opioid dependence after surgery.
- Significantly more patients using opioids had a chief complaint of back pain or radiculopathy than neurogenic claudication (inflammation or compression of the nerves emerging from the spinal cord.)
- Significantly more were under 65 years of age than aged 65 years or older
- Approximately 41% of patients on daily opioids at baseline remained so at 1 year after surgery.
Another path to treatment – Prolotherapy and spinal ligament damage
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, 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
- We commonly get patients that call in complaining of sciatica or they’ve been diagnosed with sciatica and they want to know what their treatment options are. What is interesting is that when some of these people come into the office and we evaluate them, they may not even have true sciatica.
- Some patients do have sciatica, but others may have referral pain patterns, this is not sciatica, but the symptoms are easily confused with sciatica. This would be pain running down the leg that are coming from injured and weakened ligaments around the hip or low back.
- True sciatica effects the sciatic nerve which may cause pain in the low back or even into the buttock area. Some people may have sciatica that causes pain sensations all the way down the back of their leg. But other people may have different pain patterns. These are pains that may wrap around the side of the thigh or go straight down their thigh or impact the inner part of their groin. A really good physical examination and evaluation can help us determine if it’s a true sciatica case or if the pain is actually coming more from injured tissue in the low back or the hip
- What we often find in patients that have a true sciatica often suffer from low back injuries or hip injuries or in some cases both.
- Prolotherapy injections to those injured structured and recreating stability in the low back that Elvis on and or the head can actually get the pressure off the sciatic nerve and was all that condition
Indications the symptoms are caused by a “pseudo sciatica” ligament injury rather than nerve injury
- You can sit in a chair and raise your leg straight out in front of you without reproducing your pain.
- Your low back pain is greater than your leg pain. Leg pain is 25% or less of the pain.
- The pain isn’t to the point of causing you to sweat.
- No numbness in your leg or foot.
- You experience numbness, but can touch the area and have a sensation of touch there. This is a referral sensation, generally from a ligament injury, not a nerve injury.
It is important to note that many people have herniated disks or bone spurs that will show up on MRI’s and other imaging tests but cause no symptoms. So a herniated disc according to MRI does not cause sciatica in all patients.
- The sciatica complaint very possibly is a simple ligament problem in the sacroiliac joint. For the majority of people who experience pain radiating down the leg, even in cases where numbness is present, the cause of the problem is not a pinched nerve but sacroiliac ligament weakness.
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.
The Spinal ligament repair injection treatment option Prolotherapy
In this video Danielle R. Steilen-Matias, MMS, PA-C ., explains and demonstrates a Prolotherapy treatment into the lumbar spine.
Video Summary and Learning Points
- Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
- Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate repair of the ligament attachment to the bone. This will help restore stability and alleviate nerve compression.
- We treat the whole low back area to include the sacroiliac or SI joint. I am treating the sacroiliac area to make sure that I get the ligament insertions and attachments of the SI joint in the low back.
- I’ve marked with a black crayon all down the midline of this patient’s back and then I have a horizontal line drawn where her pain stops.
- It’s important to note that this particular patient is actually not sedated in any way so even though it is a lot of shots and a lot of injections through the skin which can be painful, patients tend to tolerate it really well the whole procedure goes relatively quickly
- At 2:20 I’m just making sure that I get the sacroiliac or SI ligaments as well as the iliolumbar ligament to help strengthen the low back.
- After treatment we want the patient to take it easy for about 4 days.
- Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.
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
Our research: Published research from Caring Medical and Rehabilitation Services
In addition to the in-house data analyzed from consecutive cervical and lumbar radiculopathy cases, 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 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
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).(15)
The approach to back pain used in these studies was the foundation used in our clinics today.
Back to Pseudo-Radiculopathy-Structural radiculopathy vs intermittent or transient radiculopathy-Realistic treatment options with Prolotherapy
- Testing for Radiculopathy: An EMG or nerve conduction study seeks to determine if the nerves are getting pinched. If the nerve is getting pinched then we have to figure out is it a structural radiculopathy (constant pain) or is it a radiculopathy that’s intermittent (pain and numbness comes and goes).
In utilizing Prolotherapy as a treatment, diagnosing lumbar radiculopathy as an intermittent of 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, 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 a true radiculopathy the following is typically present:
- Crippling pain.
- The MRI shows an acute herniated disc
- The MRI finding is consistent with the person’s symptoms and exams
- The EMG collaborates the MRI
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 is 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 a true radiculopathy needs to decrease the inflammation of the disc material pressing on the nerve while the 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 try decompressive laminectomy or other surgical procedure.
In the case of a true pinched nerve, most Prolotherapists will get the person some pain control while the Prolotherapy is working.
- A nerve block can be performed where the disc is herniated.
- Sometimes an epidural is done, but we like putting the medication directly where the problem is located.
- The person is also prescribed muscle relaxers and rarely oral steroids. These steps are only immediate-level treatments.
- Simultaneously, Prolotherapy works on the long-term cure. Yes, the steroids may block some of the Prolotherapy effect, but the person needs immediate pain relief.
- A medication to help sleep is also warranted sometimes.
Obviously, the person gets Prolotherapy to the areas.
- The person is seen in follow-up in one week. At this time if they still have a lot of pain, then another steroid injection is given to the painful area.
- At the two-week point, sometimes another Prolotherapy session is done.
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 our handful of cases that have needed surgical consultation and surgery. We are grateful the surgeons are there for back-up. Even for an acute herniated disc, the surgeon is second-line therapy, or the person with a pseudo- or true radiculopathy the treatment of choice is Prolotherapy.
Do you have a question about Prolotherapy Sciatica and lumbar radiculopathy treatments or need help?
Get help and Information from our Caring Medical staff
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