Sciatica - The Cause and the Cure

spinal stenosis

What it is

Sciatica is the name people give to a pain in the buttock, leg or foot brought on as a direct result of some form of irritation to the sciatic nerve. The sciatic nerve is the longest nerve in the body. It runs all the way from the lower back splitting at the base of the spine and terminating in the foot.

The discs which cushion the vertebrae in the lower back become progressively thinner and harder as we get older. This stresses the lower back and often causes a variety of lower back pain disorders, including sciatica.

Sciatica is usually caused by a prolapsed or 'slipped' disc bulging and pressing on to a nerve. It doesn't usually cause permanent nerve damage since the spinal cord is not present in the lower part of the spine and a prolapsed or herniated disc in this area does not pose a risk of paralysis.

The cause

The most common cause of sciatica is a prolapsed (slipped) disc, pinched nerves or some form of arthritis. It usually starts with back pain which sometimes improves only to be followed by hamstring or calf pain. It may also include numbness in the toes depending on which branch of the sciatic nerve is irritated.

Piriformis syndrome is a condition in which the piriformis muscle irritates the sciatic nerve. The piriformis muscle is a small muscle behind the gluteus maximus. Piriformis syndrome is most common among women, runners and walkers.

Spinal stenosis is the name given to the narrowing of the nerve channel (vertebral canal) of the spine. This narrowing causes compression of either the spinal cord within the vertebral canal, or the nerve roots that exit the spinal cord. People with spinal stenosis experience sciatic pain symptoms in the legs and feet. It usually results from degenerative arthritis causing a narrowing of the spaces in the vertebral canal. Manual workers are more prone to developing symptoms of spinal stenosis but it seldom affects people under 30 years of age - unless it is due to traumatic injury to the vertebrae.

The spine is made up of a series of connected bones called "vertebrae." Spondylolisthesis or isthmic spondylolisthesis occurs when a cracked vertebra slips over the vertebra below it. Poor posture and curvature of the back or weak abdominal muscles can contribute to this slippage, which can press on the nerve. The presence of this spondylolysis usually does not represent a dangerous condition in the adult and most treatments concentrate on pain relief and increasing the patient's ability to function.

The Cure

Some cases of sciatica which result from inflammation get better with time and heal themselves perhaps within six weeks to three months.

Recent studies have shown that bed rest is not necessarily the best way to treat sciatica. It is better to remain active, starting off with some gentle stretching and exercise. Swimming is particularly useful, as it is not a weight bearing exercise. The good news is that herniated spinal discs usually do heal on their own, given time.

There are many different treatments for sciatica and it is important to discuss these with your health practitioner. Accurate diagnosis to determine the exact cause of sciatic pain is also equally important. The most conclusive diagnosis is usually gained by a having an MRI scan. However having said that skilled medical practitioners, and I include Osteopaths and Chiropractors, are often able to determine the suspected cause by carrying out a physical examination

Stretching and exercising are a must if you really want to progress along the road to rehabilitation and if you are in extreme pain this is probably the last thing you will contemplate doing.

Since getting mobile and becoming flexible is extremely important you might require some pain management to help you get going. For mild cases of sciatica your doctor may start off by recommending non prescription medications like aspirin, ibuprofen, or naproxen, known as non steroidal anti-inflammatory drugs, or NSAIDs. A downside of these drugs is that they may cause stomach upsets or bleeding.

If your pain is not relieved by analgesics or NSAIDs, your doctor might prescribe narcotic analgesics (such as codeine) for a short time. Side effects of these include nausea, constipation, dizziness and drowsiness, and continued use may result in dependency.

Sciatic pain is usually nerve related and responds well to treatment with low doses of tricyclic anti-depressant drugs like amitriptyline, dothiepin, nortriptyline, lofepramine, desipramine, clomipramine or imipramine combined with acupuncture or the use of TENs machines. The low dosage of the tricyclic drug acts by closing "a pain gate" blocking the message to the brain.

Other medications like Corticosteroids taken orally or by injection are sometimes prescribed for more severe back and leg pain because of their very powerful anti-inflammatory effect. Corticosteroids also have side effects and the pros and cons of taking them should be fully discussed with your doctor.

In extreme cases spinal injections of corticosteroid into the epidural space (the area around the spinal nerves) or facet joint (between vertebrae) may be given. This is usually carried out by a specialist with follow up injections at a later date.

Other treatments to manage sciatica include traction; manipulation by a skilled osteopath, physio therapist or chiropractor; Chemonucleolysis (injection of a special enzyme into the disk).

There is a fairly new procedure called IDET which stands for Iintro Discal Electrothermy). When a disc is herniated the water content of the inflamed disc causes it to bulge and press against the nerve. IDET dries up the disc very quickly, in less than 20 minutes, a process which might take weeks or months if left to dry up naturally

As a last resort you may consider surgery to remove fragments of the prolapsed disc are then removed.

As I mentioned earlier it is important to stay active and continue with an exercise and stretching program. Especially do exercises to develop your back and stomach muscles. This will help stabilize your spine and support your body.

It is also important to maintain a reasonable body weight, ensure you have a good posture, sleep on a mattress that is neither too soft nor too hard, be careful when bending or lifting heavy weights.

This information in this article should not be used to diagnose, treat, or prevent any disease. You should always consult with your health care professional especially relating to the suitability of supplements or drugs and on all health matters that may require diagnosis or medical attention. If you suffer from progressive weakness in the leg or bladder or bowel incontinence this constitutes a medical emergency and you should seek immediate medical attention - you may have cauda equina syndrome a serious condition due to compression of the nerve roots in the lower end of the spinal canal.

Taking Out the Pain With Cervical Spine Surgery

spinal stenosis

Cervical spine surgery will get rid of that pain, that numbness, that tingle which is accompanied by a weakness that even writing is impossible. However, before going further, it is best to know what the surgery is for.

When talking about the spinal column, there is that area just at the nape of the neck where the head is directly attached and where the head can pivot. Those small bones are called the cervical vertebrae. These encase the very root of the spinal column, meaning, anything untoward happens to those bones will not only directly affect the head and neck area, but the entire body. This is the mother source so to speak. So if there is anything that can cause damage to it, if it is severe enough, a cervical spine surgery will have to be performed.

The succeeding vertebrae control the areas in the body lower than the cervical. The thoracic from the trunk down, the lumbar from the waist down and the sacral, from the pelvic down. Whatever may cause damage, be it a herniation or arthritis, if the condition worsens to the point where the patient is immobilized then a cervical spine surgery would be called for.

Usually, when there are symptoms that point to a spinal problem, the obvious treatments would involve pain and inflammation medications, just like those in bulging disc treatment. However, if all fails, the cervical spine surgery can be performed which may entail invasion with a scalpel. Now in the past, the invasion was massive and the treatment was worse than the condition itself, now there are newer techniques which call for lesser invasion with minimal blood loss and less recovery time.

Arthritis, trauma to the spine as well as others can cause damage to the vertebrae and sometimes the damage will press on the bundle of nerves which are the central pathways to the brain and out. There are obvious risks involved in any surgery and the least of which can be loss of voice. Also, infection as well as blood loss can also happen. However, this is true for any type of surgery, be it a minor or a major one.

Taking risks with a cervical spine surgery is actually less of a risk when it comes to eventual paralysis, and weighing the pros and cons can reveal that the pros outweigh the risks and will lead to a cure rather than just a relief from the symptoms.

Sciatica Stretches

spinal stenosis

Sciatica stretches can consist of exercises to loosen muscles in the buttock area that can cause sciatic nerve compression and/or mimic the symptoms of it, they may be used to reduce disc bulging in the lumbar spine, or they may be used for the purpose of relieving soft tissue adhesions around the nerve. All of these approaches have their benefits, but using certain stretches improperly can make things worse rather than better.

Stretching of the muscles that can produce sciatica symptoms is most often directed at the piriformis. This muscle in the lower buttock has different orientations relative to the sciatic nerve in different people. The nerve may run over the muscle, under the muscle, or even go through the middle of it. In cases where it runs under or through the piriformis, abnormal tightness of the muscle can compress the sciatic nerve and cause pain and other symptoms.

There are a few variations of stretching for the piriformis muscle. In all cases, the mechanics of the stretch require flexion and inward rotation of the hip joint. The basic idea is to bend the leg, pulling the knee towards the chest and across towards the opposite shoulder.

Another group of sciatica stretches are commonly referred to as McKenzie exercises, named after physical therapist, Robin McKenzie. The most often used of these exercises involve extension or backward bending of the lumbar spine. Spinal extension is used with the intention of squeezing bulging disc material forward and away from nerve branches that form the larger sciatic.

Finally, there are actual sciatic nerve stretches. That is, the purpose is to actually place tension on the sciatic nerve to eliminate various soft tissue adhesions and allow the nerve to be more mobile. This approach is sometimes called "nerve flossing". The technique involves stretching the symptomatic leg, alternately bending and straightening it. While this can be helpful in long-standing cases of sciatica, it can cause considerable irritation of the sciatic nerve and may make symptoms worse. For this reason, this type of stretching for the sciatic nerve should really only be done by those experienced with its use and/or under the supervision of a health care provider.

All of the types of stretching exercises for sciatica symptoms can be very helpful. In fact, for many sufferers with this type of pain, their symptoms can be effectively alleviated and prevented with the appropriate use of sciatica stretches.

Will Spine Surgery Get Rid of All My Back Pain?

spinal stenosis

In the world of back surgery, there are what are called "home run" procedures and then there are sometimes "strike outs".

It can be extremely difficult to eliminate all of a person's pain at times. Surgery for leg pain from a herniated disc is a very successful operation for eliminating the leg pain, but not back pain. The same is typical for surgery for spinal stenosis. A laminectomy is a very good operation for leg pain, but does not help much with leg pain. In fact, a typical complication in 50% of patients after a laminectomy is resultant back stiffness and pain.

Surgery for a degenerative disc, however, is a different story. Studies looking at artificial disc replacement versus spinal fusions for degenerative disc disease showed that even with successful outcomes, 50% of patients still required narcotic pain medication for their back pain. That should be considered somewhere between a strike out and a home run, we'll call it a ground rule double.

If a surgery is of considerable magnitude, such as an adult degenerative scoliosis operation, complication rates approach 70%. Success rates are usually over 75%, but looking at the complication profile the decision for surgery needs to be made very carefully. Has the patient tried physical therapy? What about chiropractic treatment, pain management injections like facet injections, spinal decompression therapy, pain medications? Older individuals do not have the physiologic reserve as teens having scoliosis surgery.

Getting rid of all pain with adult degenerative scoliosis surgery is next to impossible. Anything over 50% should be considered a success and over 75% - Home Run.

It is actually possible after spine surgery to end up in more pain than where you started. Reasons for this may include the right surgery being done for the wrong reason, technical complication causing more pain, failure of the body to heal such as a non-fusion occurring, or a medical complication. Also, after a successful spine surgery one may end up later with an adjacent level problem such as with a fusion where the stresses go up or down and can cause problems.

The bottom line here is that spine surgery success rates vary widely. Prior to deciding on elective spine surgery, conservative treatment should be considered including pain management, spinal decompression, physical therapy, chiropractor treatment, spinal injections, etc. You may regret not trying those if the outcome is less than a Home Run.

Why Should You Consider Lumbar Spine Surgery?

spinal stenosis

In many cases of lower back pain, unless conservative treatment options didn't give good results, if there is critical traumatic injury, and if the patient exhibits signs of accelerating neurological problems such as loss of bladder and bowel control and leg weakness, lumbar spine surgery will not be suggested. Abnormal spine curvatures such as scoliosis would also involve surgery if the marked lateral deviation of the spine brings about serious pain and other signs.

The surgical approach to spine surgery would be based upon the site of the damaged area to permit for greater visualization and operative reach. For example, if the patient is suffering from spinal stenosis, the lamina and foramen will have to be treated which is why doctors will make use of the anterior lumber surgery together with anterior fusion.

When it involves minimally invasive lumbar spine surgery, the more critical is the surgical approach since only a tiny cut is made. As an instance, as a way to decompress the spinal canal and/or the nerve roots properly, the anterior endoscopic method is undertaken to the cervical spine. Some of these procedures are assisted by video for better visualization.

For folks who wish to know more about the topic, there are many internet sites that will show how a certain surgical treatment is conducted through the many surgery video clips accessible.

Two questions that are on the minds of most patients when it concerns lumbar spine surgery are...

1. 
   Are there any ramifications that may arise on or after the surgery?


2. 
   How quickly will I get better?

The dangers of bleeding, infection, dural tears and nerve root injury are common in both major and minor lumbar spine surgeries though these arise less in endoscopic surgeries.

The major benefit of minimally invasive lumbar spine surgery is the rapid recovery time. An hour after surgery, most patients are released from the Recuperation Room. It also doesn't call for lengthy bed rest. After just two weeks of rest, a patient can already begin working and after six weeks, they can resume with their everyday routine without any restrictions. Obviously, it will take a lot more time to get better from a major surgical operation.

Ultimately, however, the determination of the type of lumbar spine surgery to be undertaken would be reliant upon the area affected and the physician's selection of surgical method.

Types of Spine Surgery

spinal stenosis

Spine surgery is not as serious of an option for back and leg pain anymore. Today's minimally invasive techniques can make as small of an incision as a half inch, with recovery time practically overnight as opposed to some of the procedures offered in the past. A physician can decide whether a minimally invasive spine surgery is appropriate after diagnosing the situation and determining whether or not there is a high potential for success. There are several procedures available for different conditions, and some that are now under study. With lower back pain as the most common reason for people over the age of 60 to have surgery, these techniques offer plenty of relief.

Spinal Fusion

Spinal fusion can address scoliosis, spinal degeneration and instability caused by injury or aging. Conducted through small incisions to the back with an endoscope (a tube with a camera running into the site) and high-tech tools that perform the surgery, the surgeon can see the procedure on a television monitor with great clarity. The fusion itself occurs when the physician inserts bone tissue between the bones to help it grow - or fuse - together. Screws or a tiny "bone cage" can also be placed in between the bones to encourage quick growth. This attachment of the two vertebrae together prevents future movement that in the past was causing pain.

Kyphoplasty

Bone fractures in the spine can come from a variety of causes, including osteoporosis, hyperthyroidism, or cancer and its treatments including chemotherapy and radiation therapy. Kyphoplasty was developed to provide stability to crushed or fractured vertebrae. During the spine surgery, a small incision is made in the back and an endoscope is inserted next to the injured bone. A modified "balloon" is inserted through the tube with fluoroscopy lighting the way and using X-ray images, the surgeon inflates the balloon at the point of the vertebrae and creates a cavity. The balloon is removed and a cement-like substance is injected there where it hardens quickly. Patients typically feel relief immediately or within a couple of days.

X-Stop Spacer

When people suffer from lumbar spinal stenosis - which is the narrowing of the passageways of the vertebrae where the spinal cord and nerve roots pass - they will have pain in the buttocks, groin and either leg. When the individual is bending over or sitting down, the back bones release the pressure on the nerves and offer relief. This compression can be duplicated by placing an implant, a spacer, between the two bones that are pressing together, and sustained relief is offered. This procedure is a welcome addition to the 1.2 million Americans suffering from spinal stenosis.

Investigational ISS

The Superion Interspinous Spacer is an investigational technique very similar to the X-Stop Spacer, in that a device is placed between two vertebrae and acts as a support column to release the compression of the spinal cord and nerve roots. As of this writing, the procedure is still under study in locations across the US, and is expected to receive FDA approval by 2014.

With Americans spending around $50 billion each year on back pain alone, the time has come for spinal surgeries to be less invasive, with a quicker recovery time, at less cost.

Treat Back Pain Through Spinal Stabilization

spinal stenosis

Have you injured your back, gone through rehabilitation but still experience stiffness, weakness, or chronic back pain which limit you from participating in the activities you once enjoyed doing?

Many rehabilitation programs address acute stages of the injury, to decrease swelling and pain in the injured area and to restore range of motion but they fail to provide a proper treatment program to prevent further injury and to improve any remaining symptoms like chronic pain, muscle stiffness, weakness in the mid section and the lower extremities, muscle imbalances, bad posture, and weakness and instability experienced when trying to perform certain activities that require core stability like skiing, shoveling snow, lifting, moving and carrying heavier objects etc., other traditional treatments like manual therapy, spinal manipulation and EMS relieve the symptoms but do not treat the cause.

The core or mid section of a person (below the pelvis up to the nipples) is the very foundation for virtually any activity that requires standing upright and performing a movement. The muscles of the core work together to stabilize the spine, protect it from injury and to coordinate and execute movements. The deeper muscles like the multifidus, quadratus lumborum and transverse abdominis primarily function to stabilize the spine and give it structural integrity to prevent injury during movement. The more superficial muscles like the abdominals, spinal erectors, obliques, iliopsoas and gluteals function more to initiate and execute movements of the limbs and trunk (although they can also function as stabilizers when contracting isometrically).

If the deep stabilizer muscles are weak then the spine is unstable and susceptible to injury. Once an injury occurs these muscles become even weaker because they are the closest to the site of injury and this makes the spine even more unstable and more susceptible to injury. The larger more superficial muscles have to work harder to compensate for the lack of stability. This causes a muscle imbalance: some muscles become tight and some muscles become weak.

If there is any structural abnormality such as a deformed spine, scar tissue, muscle imbalance, or compression of the vertebrae then a client's functional capacity (the ability to perform certain activities) will be significantly affected and there will be residual symptoms such as chronic back pain, stiffness, and weakness. You may not be able to restore the spine to its previous uninjured condition but you can strengthen the stabilizer muscles to give the spine more stability which reduces compression and shear forces, protects against further injury and unburdens the more superficial muscles thus restoring balance to the system. Strengthening these stabilizer muscles should improve the residual symptoms because weak stabilizer muscles are the broken links in the chain and are essential for keeping a healthy back.

To illustrate this with an example, a client of mine herniated a disc 10 years ago shoveling snow. He underwent traditional rehabilitation but continued to suffer from low back pain, weakness in the core and lower extremities, as well as stiff muscles in the lower back. His lower back posture was flat with little lordosis (spinal curvature) and he had a limited ability to hyperextend. He made regular visits to his chiropractor for traditional treatments such as adjustments, interference current and soft tissue work. This offered some relief but the relief was temporary and his symptoms persisted. He also engaged in a rigorous stretching regiment because his lower back was always tight but this also failed to provide proper relief. I tried my best to strengthen his core using various traditional exercises that target the superficial muscle like the abdominals, spinal erectors and the obliques. Although he did make some progress in functional strength (i.e being able to push pull and carry) his symptoms persisted.

Another client of mine also herniated a disc although not as severely (only a slight bulge) and he developed chronic pain on the left side of his hip which spread to his lower back. When I did an assessment on him I discovered that he had lower crossed syndrome (a common muscle imbalance).

Each person's symptoms, the cause of those symptoms, and any currently present structural abnormalities depend on several factors like site of injury, nature of injury, posture, preexisting muscle imbalance, weight and age. These factors interact in complex ways to produce symptoms and structural abnormalities that are unique to each person. For example a person with a posterior lumbar disc herniation can either have lordosis (a hyper-extended spine) or a flat back with minimal lumbar extension (as in the case of my first example). The etiology of any musculoskeletal disorder is very complex because it is dependent on many factors. However, whatever the cause is, chronic back pain can be significantly reduced and re-injury can be prevented by a properly designed spinal stabilization program because spinal instability is at the root.

Dr. Phil Jelinowski DO., CSCS., MES