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 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.
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.
- You have been diagnosed with sciatica and lumbar radiculopathy.
- I had an MRI because of my lower back pain, sciatica pain. My doctors tell me I have a herniated disc. A few doctors are telling me I need fusion surgery.
- Exaggerated Lumbar Lordosis. spinal curvature, sciatica and lumbar radiculopathy.
- “Management of sciatica can be suboptimal and shows a large variation (of treatment) in clinical practice.”
- “Sciatica (as) a clinical diagnosis is nonspecific.”
- Comparing how Neurologists treat you and how Anesthesiologists treat you for sciatica and lumbar radiculopathy symptoms.
- Are you a difficult-to-treat patient? Trying to solve the refractory sciatica riddle.
- 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.
- Sciatica is not a disease, Sciatica is a symptom of Lumbar Instability.
- Radiculopathy is a disease of the disc causing inflammation on the nerve.
- “The most effective pain medication to treat patients with sciatica or radicular leg pain is unclear.”
- The effectiveness of NSAIDs for pain reduction for sciatica and lumbar radiculopathy was not significant.
- The world of nerve blocks and spinal injections for sciatica and lumbar radiculopathy.
- 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.
- Concerns over short-term gain long-term costs in the use of epidural steroid injection side-effects have been noted.
- Study: you should not offer Epidural steroid injections in this way.
- Ultrasound-guided caudal epidural steroid injection vs blind injection vs. Fluoroscopy-guided injection.
- Amidst all this research is still the common patient concern: The pain comes back when the steroid wear offs.
- A review of the treatments to see why you are now going to surgery for your sciatica.
- There is no way to predict which patients who “must-have” lumbar spinal surgery for sciatica and lumbar radiculopathy will benefit from the “must-have surgery.”
- 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.
- Conservative care options can help many lumbar radiculopathy patients.
- Minimally invasive spinal surgery procedures for lumbar radiculopathy and sciatica-like symptoms.
- The surgery works great unless it doesn’t.
- 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 lumbar radiculopathy surgery.
- When surgeons are willing to trade effectiveness for less side-effect and complication.
- Pain and disability paths in patients following lumbar discectomy surgery.
- What are we seeing in this image? Pain NOT coming from the spondylolisthesis at the L4-L5 level.
- Is it the nerves? Acupuncture for sciatica.
- But what if it is not nerve pain? Another path to treatment – Prolotherapy and spinal ligament damage.
- Sciatica can be a ligament injury problem.
- Indications the symptoms are caused by a “pseudo sciatica” ligament injury rather than nerve injury.
- Back to Pseudo-Radiculopathy-Structural radiculopathy vs intermittent or transientradiculopathy – Realistic treatment options with Prolotherapy.
I had an MRI because of my lower back pain, 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, 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, pain and anti-inflammatory medications recommended and prescribed. I am hesitant on the surgery because two different doctors had recommended two different fusion procedures.
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 is having severe bilateral sacroiliac pain. As one can see (arrows) the sacroiliac joints are right next to the area that was fused.
Exaggerated Lumbar Lordosis. spinal curvature, sciatica and lumbar radiculopathy
A story we hear goes something like this. It is a case where there is confusion surrounding the spinal curve in the lower back. Exaggerated Lordosis is the spine curving inward as if it is trying to come out the front of you.
The person’s MRI reveals that there is a mild disc bulge at L3-L4 which is compressing the thecal sac the outer covering of the spinal cord. But there is no indication that bone spurs are present. The spinal canal is severely narrowed at L4-S1. The L4 nerve root is impacted. There is no (protective) Cerebral Spinal Fluid around the nerve roots. (Signifying a fluid backup or drainage problem around the spinal cord). There is severe spinal stenosis from L4-S1. MRI and x-ray show exaggerated Lordosis.
What are we seeing in the image below?
We just described a situation where a person had exaggerated lumbar lordosis. Their spine was pushing out towards the front. In this image, we see that the lumbar spine pushing forward has a detrimental effect all the way towards the head.
“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 similar stories to the one just described. A lot of problems 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 (1) 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.”
“Sciatica (as) a clinical diagnosis is nonspecific.”
In the image below: 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 by 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.
Researchers at the Logan University Health Centers-Integrative Clinics, in Chesterfield, Missouri wrote in the Journal of the American Association of Nurse Practitioners (2) 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 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.”
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 diagnose their sciatica patients primarily using magnetic resonance imaging (89%).
- Selective diagnostic nerve blocks are considered useful by 81% of neurologists.
- Neurologists primarily treat patients with pain medication, and 40% of Neurologists think epidural steroid injections are effective in 40-60% of injected patients.
- Twenty-nine percent of neurologists refer patients to a neurosurgeon after 4 months.
- Conclusion: Neurologists treat sciatica patients initially with pain medication and physiotherapy, followed by epidural steroid injections and referral for surgery.
- Anesthesiologists consider a selective diagnostic nerve root block to have a higher diagnostic value than (MRI) mapping.
- The most reported side effect of epidural injections is an exacerbation of pain (82%).
- Pulsed radiofrequency is applied in 9-11% of acute cases.
- Conclusion: Anesthesiologists treat sciatica patients with one or more steroid injections or may perform a selective nerve root block
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, 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 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 (4) 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). (5)
- “Existing evidence on the use of gabapentinoids in chronic low back pain is limited and demonstrates the 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 (6), editors provided a 2018 update of “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.
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 is 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 become 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 stretched 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 cause the burning, severe, radiating pain, tingling, and numb 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.
Radiculopathy is a disease of the disc causing inflammation on the nerve.
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, painkillers, 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 are 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.
“The most effective pain medication to treat patients with sciatica or radicular leg pain is unclear“
In the British Medical Journal,(7) 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 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.
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 (8) 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).
- 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 (9) 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.”
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 the less than desired results or failure of the treatment. This is the group of patients this section of this article is for.
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 spine and brain.
The injection can be given as:
- interlaminar epidural injections (which delivers the injection over a wider area of the back),
- transforaminal epidural injections, (more targeted to a specific nerve – some call this an epidural nerve block or epidural block injection),
- and caudal techniques (delivery into the extreme lumbar spine).
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. (10) 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:
- Epidural corticosteroid injection had a small effect on leg pain at immediate and short-term follow-up for lumbosacral radicular pain
- Epidural corticosteroid injection had a small effect on disability at short-term and intermediate follow-up.
- Adverse or side-effects noted were not different between corticosteroid and placebo injections.
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 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 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), (11) 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, (12) 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. (13)
- A June 2020 study from the Department of Neurosurgery, Adana City Training Research Hospital in Turkey (14) 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.
Study: you should not offer Epidural steroid injections in this way:
In May 2020, the journal Pain Medicine,(15) 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.”
- Myth #1: Epidural steroid injections can be repeated without concern regarding the duration of time between injections.
- Myth #2: A “series” of epidural steroid injections are sometimes required regardless of the clinical response to a single epidural steroid injection.
Myths are busted you should not offer Epidural steroid injections in this way:
What was published as “fact,” was:
- After an epidural steroid injection, a period of up to 14 days may be needed to assess the clinical response.
- Systemic effects on the hypothalamic-pituitary-adrenal (HPA) axis may last three weeks or longer. (These are the well-known side effects of epidurals, they include Cushing’s syndrome where a fatty hump may develop between the shoulders, a rounded face (moon face), and pink or purple stretch marks.)
- These factors must be considered when determining if or when another Epidural steroid injection is indicated.
- There is no evidence to support the routine performance of a “series” of repeat injections without regard to the clinical response.”
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 (16) 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:
- One hundred and ten patients with low back pain and sciatica who were unresponsive to conservative treatment were included.
- Ultrasound-guided caudal EDSI was administered at first treatment, three weeks later, and six weeks later.
- Visual Analog Scale (pain) score was recorded at first treatment, two, four, 12, and 24 weeks.
- Visual Analog Scale (pain) score was significantly reduced at two, four, 12, and 24 weeks.
- At two weeks after injection, 20% of patients displayed more than 50% pain reduction.
- At four weeks after injection, 26% of patients displayed more than 50% pain reduction.
- At 12 weeks after injection, 74% of patients displayed more than 50% pain reduction.
Amidst all this research is still the common patient concern: The pain comes back when the steroid wear offs
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 the patient with sciatica symptoms and bulging discs somewhere from L1-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 low back shooting into their legs.
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, December 2018, in the journal Arthritis Care & Research. (17)
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, we’re 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 for 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 the pain is poorly controlled by the well-conducted conservative treatment performed during four to six months, surgery is then recommended. (18)
There is no way to predict which patients who “must-have” lumbar spinal surgery for sciatica and lumbar radiculopathy will benefit from the “must-have surgery.”
We will often see a patient who will tell us they have a large bulging disc. They have already had several cortisone injections and now several doctors are recommending surgery because the MRI shows a large or massive bulging disc. These people are in our office because they have been able to manage their large bulging discs, many without the need for painkillers. One thing that concerns them is that they will need painkillers to help them through the post-surgical recovery.
But is the “must-have surgery” really a “must-have surgery?”
In October 2020 a study was published in the Global Spine Journal (19). It is the result of research from the Harvard Medical School. The researchers of this study examined whether the size of a lumbar disc herniation could predict which patients would need surgery within two years after obtaining an initial magnetic resonance imaging (MRI) scan. The thinking or hypothesis of these researchers was that the size of the herniation would not matter, that the portion of the disc that occupied a larger percentage of the spinal canal would not predict which patients would fail non-surgical conservative care lumbar back pain management.
In other words, the description of the herniated disc that we hear from some patients that they have a “large,” “massive,” bulging disc that must have surgery, may in fact not need surgery based on the fact that surgery or conservative care options, the outcome may be the same. Let’s get back to this study:
- In this study, the patients had received a diagnosis of primary lumbar radicular pain, had MRI showing a disc herniation, and underwent at least 6 weeks of nonoperative management.
- Patients experiencing symptoms suggesting cauda equina syndrome and those with progressive motor neurological deficits were excluded from analysis, as were patients exhibiting “hard” disc herniations (infiltration of bone spurs).
- A total of 368 patients
- 14 patients (3.8%) had L3-L4 herniations,
- 185 patients had L4-L5 herniation (50.3%),
- 169 patients had L5-S1 herniations (45.9%).
- Overall, 336 (91.3%) patients did not undergo surgery within 1 year of the lumbar disc herniation diagnosis.
- Patients who did not receive surgery had an average herniation size that occupied 31.2% of the canal, whereas patients who received surgery had disc herniations that occupied 31.5% of the canal on average. (The size of the herniation was virtually the same).
Conclusions: The percentage of the spinal canal occupied by a herniated disc does not predict which patients will fail nonoperative treatment and require surgery within 2 years after undergoing a lumbar spine MRI scan.
A July 2022 study (28) 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.
- 306 patients who received L5 floating lumbar fusion were included in this study.
- Clinical L5-S1 Adjacent segment degeneration was defined as newly developed radiculopathy in relation to the L5-S1 segment.
- Clinical L5-S1 Adjacent segment degeneration occurred in 17 patients (5.6%).
- On average L5-S1 Adjacent segment degeneration developed 13 months after the primary surgery. Among these patients, 10 (58.8%) presented with clinical L5-S1 Adjacent segment degeneration within 12 months.
- Reoperation was performed in three patients (1.0%).
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.
What are we seeing in this image?
We want to again stress that many people have very successful spinal surgeries. These are typically not the people that we see at our center. We see the 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.
In the image’s caption are the technical aspects of the laminectomy and bilateral laminotomy procedures.
- In the laminectomy, the lamina and the spinal process are removed. The ligamentum flavum and the supraspinous ligament are removed.
- In laminoplasty, a trough or “open door” is drilled into the lamina to allow more room for the spinal cord. This is a decompression: surgery.
Conservative care options can help many lumbar radiculopathy patients
A July 2022 paper in the journal Medicine (29) 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.
- 32 patients received intravenous dexamethasone,
- 24 patients received selective nerve root block, and
- 25 received various NSAIDs as the control group.
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 test 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.
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
- 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. “(20)
The surgery works great unless it doesn’t
In August 2019, in the British Medical Journal BMJ Open,(21) 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.
In our article Alternatives to Epidural Steroid Injections, we describe situations, probably very similar to yours where the patient wanted to do everything they could to delay or Many people delay or prolong the need for spinal surgery. One option is the use of epidural steroid injections. For some of you, there may be frustration and confusion as you may have already had epidural steroid injections. The confusion and frustration of course are that you are someone who had already failed to have their symptoms managed with epidural steroid injections, that is why you are being recommended to have spinal surgery. Now that you are waiting for surgery you are being told to have more epidurals, only now with stronger and more frequent doses as a means to “hold you over” with pain management until you get the surgery. Of course, you may have been also recommended to have more painkillers as well.
Let’s look at a March 2021 study published in the medical journal The Lancet Rheumatology (22). 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:
- The surgical group had a little better response than the transforaminal epidural steroid injection group.
- Some patients in the surgical group had serious adverse events. The transforaminal epidural steroid injection group had none.
- Assessing both factors, cost, side-effects, and other factors suggest that transforaminal epidural steroid injection should be considered before the surgical decompression.
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 (23) 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.
When comparing epidural steroid injection to surgery, epidural may be a better choice.
When surgeons are willing to trade effectiveness for less side-effect and complication
Let’s look at a study in the European Spine Journal (24) 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 the 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 (30) 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:
- Leg pain improvement (excellent = 18.4%, good = 55.4%, poor = 26.3%)
- Disability improvement (excellent = 59.7%, fair = 35.6%, poor = 4.7%)
- Back pain improvement (excellent = 13.0%, good = 56.4%, poor = 30.6%).
While disability improved the most, persistent leg and back pain remained. The resear54chers 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.
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 (25) 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 “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 (26) 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?
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, 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 is coming from injured and weakened ligaments around the hip or low back.
- True sciatica affects 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 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 or pelvis can actually get the pressure off the sciatic nerve.
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 MRIs 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.
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
- 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.
- We treat the whole low back area to include the sacroiliac or SI joint. In the photo above, the patient’s sacroiliac area is being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
- Why the black crayon lines? This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
- 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.
Diagnosing lumbar instability & treatment with Prolotherapy, PRP, cortisone, 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 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). (27)
The approach to back pain used in these studies was the foundation used in our clinic.
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 structural radiculopathy (constant pain) or if it is radiculopathy that’s intermittent (pain and numbness comes and goes).
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, 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:
- 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
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 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.
- 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 has also been prescribed muscle relaxers and rarely oral steroids. These steps are only immediate-level treatments.
- Simultaneously, Prolotherapy works on long-term restoration/stabilization. Yes, the steroids may block some of the initial Prolotherapy effects, 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 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 a pseudo- or true radiculopathy, the treatment of choice is Prolotherapy.
Summary and contact us. Can we help you?
We hope you found this article informative and 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
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated on July 25, 2022