Search for tag: "sciatica"

Interviewer: Before considering surgery for back pain, there could be other options you might want to consider first. Dr. Andrew Joyce is a physical medicine and rehabilitation specialist, focuses on non-surgical treatment of various muscle and spine issues. So here's a scenario. A patient has been told by another provider that their back pain might benefit from surgery. They come to you for a second opinion or just wanting to know if there's something that they can do before surgery. First question is there?

Dr. Joyce: Definitely. In the vast majority of cases, there's something that we can offer to at least try to ameliorate the pain before jumping to surgery. There's a variety of treatments that we look at, whether it be medications, therapies, modalities, or procedures to go and help manage people's pain.

Interviewer: And does that happen often that you end up talking to a patient that has been told surgery is what is going to help with their back pain and have not been told about some of these other options?

Dr. Joyce: Yes. I would say, you know, we're fortunate here at the university because most of the way our referrals are sent in, they get sent to us first to evaluate for non-operative treatments before we decide whether or not the patient would really benefit from surgery. But in the community, that's not always the case. And so it's not uncommon for patients to have back pain or pain originating from their back and sciatica, who see another provider who offers them surgery, and then come to us for a second opinion to see what else we can do.

Interviewer: Let's talk about some of the options that somebody might take. Where do you start that conversation?

Dr. Joyce: The first thing we do is we try to get a comprehensive physical and history from the patient. And what we're looking for is to try to identify what the exact source of the pain is. And so we'll review with you, you know, the history of your pain, where exactly is it located, we'll take a look at imaging, and we'll look at different other medical conditions which may factor into our decision. And then once we've looked at all of that, we'll discuss the different options that we can use for different procedures. And so it varies depending a little bit on which diagnosis we think you have.

Interviewer: And I think a lot of times patients think these non-surgical options tend to be like some sort of like a cortisone injection or something like that, which is definitely an option, but there are other options as well. So walk me through some of those options and how they might apply to a patient.

Dr. Joyce: So the most common injection and the ones that people call, you know, cortisone injections are basically steroid injections. And what matters is not necessarily that you're injecting steroid, it matters where you're injecting the steroids. So we use these steroid injections in various parts of the body depending on where we think your pain is coming from. So if you're having pain that's caused by a herniated disc pressing on a nerve, well then we would do an epidural steroid injection, where we place steroid in and around the epidural space to bathe that nerve and calm down any inflammation and irritation that's happening to the nerve. On the other hand, if you're having pain that we think is coming from your sacroiliac joint, which is a large joint at the base of the spine, then we would inject the steroid into the sacroiliac joint and use that to calm down inflammation and irritation to the area.

Interviewer: And then other than the injections, what are some of the other options that you can offer a patient and what situation with those apply?

Dr. Joyce: Some of the more common things when people have arthritis related pain in their back, we do a series of procedures where we do test blocks to help determine if the arthritis is truly the source of the pain. And those are called medial branch blocks. And if patients do feel substantially better after those test blocks, then there's another procedure called radiofrequency ablation, where we actually burn those little tiny branches of nerves that go to the joints and help relieve the pain. And those can actually be very durable. They can often last anywhere from six months to a year and a half, at which point we can repeat it and get similar pain relief.

Interviewer: And then I've also heard of electrical stimulation. Is that another option?

Dr. Joyce: Yeah, and this is kind of an emerging technology. Spinal cord stimulation itself has actually existed for over 50 years. But in the past 10 to 15 years, there's been huge advances in the technology that we can use for it. Now this is almost never a first line treatment that we use. But for people who are having severe pain in their back and aren't getting better, we can use electricity to kind of help modulate the pain signals. And so that involves putting electrical leads either in the epidural space behind the spinal cord or even more superficially, around nerves in the low back to help block the pain signals.

Interviewer: And then does the type of treatment that we've talked about, we've talked about injections, we've talked about the burning the nerves, we've talked about the electrical stimulation, does that really, really depend on the type of pain somebody has? Or are those options suitable for all types of pain and you just kind of cycle through one after another? I mean, is there some sort of a procedure you like to go through?

Dr. Joyce: No. Yeah, it definitely depends on the type of pain and where the source of the pain is. So, you know, if your pain is coming from purely the arthritis in your back and I do an epidural steroid injection, I'm not expecting you to get substantial relief of that pain. So it really depends on where the pain is. And where this becomes more complicated is when patients have more than one thing going on, right? It's not uncommon for patients to have arthritis in their back, that then causes some pressure on a nerve. And so they have more than one thing going on. And so then, in those cases, we will use more than one of these types of procedures to help with their pain. But really, it depends on what the source of their pain is.

Interviewer: And I'm kind of getting the feeling that back pain can be kind of a complicated thing. I mean, it sounds like you have to know what's causing it and then what treatments are the most effective for that type of pain, depending on what kind of pain, what's causing it, the location. How often just kind of after a couple of visits do patients find relief, versus you've kind of got to look a little bit further in the cases where patients might have multiple things going on?

Dr. Joyce: It depends on the patient. I would say, you know, for many of our more acute patients, so patients who have had pain for between 6 and 12 weeks, those patients tend to, on average, do a lot better, because they haven't had the pain for quite so long and oftentimes it's less complex. But certainly, when it gets more complicated, sometimes it does take a little bit of trial and error and some searching. And sometimes these injections can actually be helpful, both therapeutically to help people with their pain, but also diagnostically to help us determine the exact source of pain and help us get a better treatment program put together.

Interviewer: Kind of a mystery that you have to unravel in that case.

Dr. Joyce: Exactly.

Interviewer: Yeah. And then at what point would you even recommend somebody for surgery?

Dr. Joyce: Most common reasons that I will have someone be seen by surgery is back pain or neck pain going down their arms or their legs, with associated numbness, tingling, and in particular weakness. When people are having symptoms that are causing, you know, objective findings on our examination when they're objectively weak, that's when surgery is most indicated. And that's oftentimes when I will send them to surgeons earlier rather than later because we don't want patients to be left with any sort of neurological problems long term. And surgery is the only way to decompress nerves and help prevent that from happening.

Interviewer: Is weakness generally always a sign you're going to be sending somebody to surgery or not always?

Dr. Joyce: So it depends a little bit on having objective weakness, but also on the pattern of weakness. So we know certain nerves in the body go to certain muscles. And so we'd expect that if a nerve is being compressed and causing weakness, it would affect those muscles that it innervates. And so what we look for is to try to see if the pattern of weakness matches the nerve being pinched. And if that's the case, then surgery might be necessary.

Interviewer: And again, it just really sounds like coming to a specialist like you is really just a great step just to make sure.

Dr. Joyce: Yeah. I think at that point, if there's any concern that you might have weakness, or you're having neurological findings and you're not sure what to do, definitely seeing a specialist, like us, I think makes a lot of sense.

Interviewer: What you described, you know, choosing the right place for an injection, the type of injection you want to use sounds really, really complicated. What do you recommend a patient look for in a provider that's doing that type of work?

Dr. Joyce: You want to make sure that the person who is doing your injection has done hundreds of these types of injections and is well versed with it before you go in with them.

Interviewer: Whether that be through a fellowship that they did, that extra year after medical school specializing in this, or they've done numerous procedures over the length of their career.

Dr. Joyce: Agreed. Yeah.

Dr. Miller: Sciatica. What is it? What do you do about it? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Ryan Spiker. He's an orthopedic surgeon and a spine specialist, and we're going to talk a little bit about sciatica. What is sciatica? What does that mean, Ryan?

Dr. Spiker: Sciatica is a pain that originates in the back but shoots down the legs, often just one of the two legs, often down the back of the leg and can go all the way to the foot.

Dr. Miller: What does that feel like? Is it a dull pain, shooting, electric . . . I mean, what would a person feel if they had sciatica?

Dr. Spiker: For most people it's kind of an electrical type sensation, a sharp pain that kind of shoots down the leg in a pretty clear distinct path that connects from the back all the way down into the leg.

Dr. Miller: Who gets sciatica? Would it only be somebody that has a traumatic injury or can it just happen?

Dr. Spiker: Sciatica is most common from degenerative conditions which are nontraumatic conditions where people are out working in the yard doing their normal activities and suddenly will feel this sharp pain. It can come from a disk herniation.

Dr. Miller: What's that? What is a disk herniation? We always hear about disk herniation, but what really is that?

Dr. Spiker: Yeah, that's a great question. So disk herniations are very common and fortunately they usually don't pinch nerves, but when they do, when a disk herniates from its normal position and pushes toward the nerve, it can cause nerve pain and that nerve pain can be described as sciatica.

Dr. Miller: So the disk is, it seems to me, to be kind of a shock absorber between the bones or vertebrae in the spine. Is that what that is?

Dr. Spiker: Correct, so the disk is between the two bones in the spine in each segment, and so our spine is full of different bones with discs in between and if that disk has damage to it, which can be traumatic but most likely is degenerative and most commonly seen in patients as they get older, they can start to rupture and have some of the material from inside the disk push out.

Dr. Miller: How do you describe the nerves traveling out of the spine? Do they travel out between the disks and the bones? What does that look like?

Dr. Spiker: Yes, between the bones are the disks and then between each level there's a nerve that will exit, so between each level of the spine there's a unique nerve that will exit and that nerve can be pinched from the disk.

Dr. Miller: Are there certain levels of the spine that are more susceptible to sciatica, or not sciatica but disk herniation that would cause a compression of the nerve?

Dr. Spiker: Yes, the lower spine, the lumbar spine is by far the most common, and even within the lumbar spine it's usually the bottom, the lowest part of the spine, in the L4, L5, S1, the very bottom part of the spine is the most common area, and that leads to compression of the nerve roots which shoot down the back of the leg and that's where we most commonly hear the symptoms of sciatica being, shooting down the back leg.

Dr. Miller: You mentioned that this is due to a degenerative condition so would we more likely see sciatica in someone who is older or younger, or what?

Dr. Spiker: It depends on the cause. With disk herniation sometimes we do see that in younger patients, even in their 20s, 30s, 40s. Other causes where arthritis or kind of slow processes are causing nerve compression, we see that in older patients or what we think of as lumbar spinal stenosis which is kind of more generic stenosis than just from a disk, and we'll see that in older patients. We see the symptoms of sciatica in all age ranges but different causes.

Dr. Miller: Sciatica is usually described as a pain, but can there be weakness associated with it?

Dr. Spiker: Absolutely, and that's something that is often missed by patients. When they initially describe their symptoms they'll have weakness in their leg without significant pain and it's unclear why, and it can come from nerve compression either in the lumbar spine or elsewhere.

Dr. Miller: So let's say a patient is out shoveling snow and all of a sudden they have this pain radiating down the side of their leg. It's pretty intense. What should they do?

Dr. Spiker: So first things first, taking a little bit of rest for a few days and if the symptoms aren't severe often they'll improve on their own. If it's persistent, getting worse day to day or associated with severe weakness or changes in their bowel or bladder function then they need to see someone immediately there in the emergency room or in clinic to get x-rays and get evaluated to see if there is significant nerve damage.

Dr. Miller: When you say rest, you mean they should just get in bed and lie in bed for a few days?

Dr. Spiker: Not necessarily lying in bed. As long as they're able we encourage people to be up and walking and moving as early as possible, but minimizing lifting, twisting, bending. The physical function is a little bit less aggressive in those first few days.

Dr. Miller: I think going to bed and just lying down used to be the old treatment, and it was found that people got pretty weak over time pretty quickly if they did that, so it got to the point of stay as active as you can as much as you can tolerate the discomfort.

Dr. Spiker: Absolutely, absolutely.

Dr. Miller: So should patients take any kind of medication for sciatica while they're waiting for it to naturally heal?

Dr. Spiker: If they can tolerate anti-inflammatories, it doesn't have any contraindications with their other diagnoses or medications, it's a great first-line treatment to calm down the inflammation and often helps with the symptoms and allows them to be functional, allow them to walk and move and heal on their own. There are other medications but that's probably the first step, and then getting into physical therapy as soon as possible to really get as much as we can out of our own bodies before we move on to more aggressive treatments.

Dr. Miller: More aggressive treatments would be . . .

Dr. Spiker: It includes injections, a steroid injection can help calm some of that inflammation, and in rare cases sometimes people do need surgery.

Dr. Miller: How many people who have sciatica eventually go on to surgery? It's not that many.

Dr. Spiker: Correct, it's a small percentage and it's hard to know because so much sciatica resolves before people even come to a physician, but even in people who come to see a spine surgeon like myself, it's by far the minority who end up needing spine surgery

Dr. Miller: That's really good news. So I think the bottom line for the listeners would be that if you have sciatica, it suddenly develops, to plan on waiting it out for a week or two because things generally progressively improve and to use nonsteroidal anti-inflammatories like ibuprofen, Naprosyn or aspirin to treat it, and then if it's not getting better to seek care from your primary care physician or perhaps even a physiatrist. Would that be right?

Dr. Spiker: Absolutely.

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updated: March 12, 2019
originally published: June 21, 2016

Dr. Miller: What is spinal stenosis? Could you have that as a problem? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists with Dr. Tom Miller" is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Ryan Spiker. He's an Orthopedic Surgeon and a Professor of Orthopedics here at the University of Utah. Ryan, what is spinal stenosis and who gets that?

Dr. Spiker: It's a great question. Spinal stenosis is very common, especially as we age. So in the elderly population, what happens is you get some reason for compression of the nerves in the low back. This is often from arthritis, degenerative changes, and slowly that compression can lead to pinching of the nerves in the low back, which leads to weakness and pain in the legs.

Dr. Miller: So the anatomy is . . . tell me about that. The spinal cord goes down through the vertebrae, which are the bones of the spine and they travel through a tunnel. And what happens? That tunnel becomes narrow, is that what happens?

Ryan. Absolutely. So at the bottom of the spinal cord, there are still nerve roots and all those nerve roots end up innervating our legs, providing sensation and strength to our legs. And in that bottom part of the spine, just above the pelvis, it's common for arthritis to lead to hypertrophy or thickening of the ligaments, thickening of the disk and then compression of those nerve roots. And that compression leads to the pain that often shoots down into the legs.

Dr. Miller: So is spinal stenosis then a condition that someone who is a farmer or a laborer would get more commonly than somebody who was maybe working at a desk, or does it matter?

Dr. Spiker: So it does matter. There's some effect of environment so what we do. Sitting is actually very bad for our backs and so that can be a risk factor in and of itself.

Dr. Miller: So a clerk or a professional who's sitting a lot might be at greater risk than even somebody who is out working all day?

Dr. Spiker: Absolutely. Depending on the type of the work and there are also some genetic risk factors that we've studied here at the U that have been shown to impact how often family members will get spinal stenosis.

Dr. Miller: Well, tell me a little bit about what the symptoms are.

Dr. Spiker: The most common symptoms are pain or weakness or heaviness of the legs and it's usually worse when people are standing up and walking and improved when they bend forward. So if they're using a shopping cart or if they're using a walker, it feels much better. But again, it's worse when they attempt to stand up straight or extend their back.

Dr. Miller: What kind of pain is it? Is it a burning pain in both legs generally, if they're walking more than a block, I mean if it's severe?

Dr. Spiker: Often, people will describe some burning sensation. Commonly, it's a heaviness. It's a feeling that their legs are disconnected from their body. It can be a sharp pain that shoots down the spine. There's some variation with nerve pain, but invariably, it's worse with walking and usually goes down the back of the legs and can go all the way down into the feet.

Dr. Miller: What age groups are most susceptible to spinal stenosis?

Dr. Spiker: So, for most patients, it's as they get older so usually in patients that are 50 or 60 or above. Certainly, there are causes of spinal stenosis such as fractures or really large disc herniations that can occur in a younger population, but the vast majority of patients are a little older.

Dr. Miller: In a previous talk, we talked about sciatica and how that's caused by disc herniations mostly. Would spinal stenosis be more common or less common than disc herniation-related sciatica?

Dr. Spiker: So similar in different groups. So at a national level, certainly more common to have spinal stenosis than disc herniations that would cause somebody to see a spine surgeon like me. Most spinal stenosis patients will have some progression over time or continue to have symptoms, whereas most patients with disc herniations will get better on their own and this won't require to come in to see a spine surgeon.

Dr. Miller: So tell me about the therapies, treatments, for spinal stenosis. Obviously, it depends on the severity of the problem.

Dr. Spiker: Absolutely. So our first line treatments are anti-inflammatory medications, non-steroidal anti-inflammatories.

Dr. Miller: Ibuprofen, naproxen, aspirin, things like that.

Dr. Spiker: Exactly. They help calm down some of the inflammation from the area of compression. And then getting people into physical therapy to help strengthen their core, take some of the stress off the bones and the nerves of the back.

Dr. Miller: Would you say that physical therapy is kind of an underused and underappreciated modality?

Dr. Spiker: Absolutely, absolutely. And often, I would say 60, 70, 80% of patients that I see in my clinic have not yet undergone physical therapy and anti-inflammatories. And sometimes, these simple interventions can really change the quality of their life.

Dr. Miller: How long would it take before someone would know if physical therapy was actually working?

Dr. Spiker: It's a great point that it does take time so often the first few weeks can be frustrating because it's difficult and it can cause some pain, but usually, within six to eight weeks, people start to see the fruits of their labor.

Dr. Miller: In your experience, when then do you start talking about a surgical solution to the problem?

Dr. Spiker: So surgery is always the last option, it's never the first option. And fortunately, we can usually get people better with the anti-inflammatories, the physical therapy, some nerve medications, neuromodulatory medications like gabapentin, sometimes even injections. If all of these fail and the symptoms are progressive and really causing a change in their quality of life, that's when we talk about surgery.

Dr. Miller: And surgical outcomes, how well does it work?

Dr. Spiker: So surgical outcomes are excellent in well-selected patients. So in patients that have gone through the right preoperative therapies and interventions, it ends up about 80-85% of people are much better after surgery than they were before.

Dr. Miller: That's a great outcome.

Dr. Spiker: Yes.

Dr. Miller: And over time, does that hold?

Dr. Spiker: It does. So we have great data up to about eight years now showing that people have continued benefit with surgical intervention for at least eight years and we certainly think longer.

Dr. Miller: Well, thanks, Ryan. So for our audience, basically surgery is the last option, but it has an excellent outcome. But prior to surgery you want to think about a good trial of physical therapy and the use of over-the-counter non-steroidals like ibuprofen and naproxen just to try to control the pain while you're testing physical therapy and working with your therapist.

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