Sciatica and lumbar radiculopathy treatments

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C., Brian Hutcheson, DC

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.

How did you get here?

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 urgent referral. A minority of patients (ie, those with persisting symptoms despite conservative care) are considered for spinal (disc) surgery.

Management of sciatica can be suboptimal and shows 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 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.”

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 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 is attached to the movement of the bone.

The nerve stretches – sciatica, radiculopathy can follow

    • 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 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 cause 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.

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 (3) 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 writing in the journal Public Library of Science Medicine (PLOS).(4)

  • “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 (5), 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.

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

In the British Medical Journal,(6) 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 (7they 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 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 (8of 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

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 injection. 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, sometimes referred to as epidural nerve blocks or epidural blocks.

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

Let’s start with an October 2020 study in the medical journal Neuro Rehabilitation.(9) 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 epiduiral.

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

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)(10) 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(11) 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.(12)
  • A June 2020 study from the Department of Neurosurgery, Adana City Training Research Hospital in Turkey (13) 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,(14) 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:

  • Fact:
    • 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.”

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.(15)

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.(16)

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.

Degenerative processes may result in foraminal stenosis development over time that can result in lumbar radiculopathy, even after a successful surgery. The narrowing of the intervertebral foramina is illustrated to the right.

Degenerative processes may result in foraminal stenosis development over time that can result in lumbar radiculopathy, even after a successful surgery. The narrowing of the intervertebral foramina is illustrated to the right.

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. “(17)

The surgery works great, unless it doesn’t

In August 2019, in the British Medical Journal BMJ Open,(18) 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 (19) 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 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 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 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 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.

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

Our research: Published research from Caring Medical

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).(20)

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

  • 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 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 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 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 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 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 back-up. 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.

Do you have a question about Prolotherapy for Sciatica and lumbar radiculopathy treatments, or need help?
Get help and information from our Caring Medical staff

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This article was updated on January 17, 2021

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