Sciatica News and Treatment
Do You Have Suggestions For “Sciatica”?
By Lewis G. Maharam, MD, FACSM
Hi,
I am registered for the P.F. Chang’s Rock ‘n’ Roll Arizona Half Marathon on Jan. 16 and have had a very challenging bout of sciatica for months. After physical therapy, acupuncture, chiropractic and traditional medicine helps, I remain stifled in training with longer distance efforts at walk, run. I was not a true athlete to start and this is a real disappointment to me. Do you have any suggestions? Recommendations from your knowledge, expertise? I do not really want to pull out, but I am afraid that my performance will be impaired radically.
Thank you for your reply to this appeal.
Roseanne K.
Dear Roseanne:
Your letter was forwarded to me as Medical Director of all the Rock ‘n’ Roll Marathons. I’m sorry to hear of your issues.
I hear this same question all the time in my practice of sports medicine in NYC! Runners are the most sophisticated medical consumers I know, but they’re still getting — and buying — one of the big, bogus diagnoses of all time: “sciatica.” It’s bogus because it somehow makes you feel good without actually revealing a thing about what’s wrong. Sciatica is a symptom, not a diagnosis!
Why, then, do some physicians simply stick “sciatica” onto so many athletes like a diagnostic Post-it, give them a couple of generic exercises, and send them away? Because, frankly, a lot of back patients don’t get better. They return repeatedly with the same complaint, and the doctor eventually begins to wonder whether they even want to recover, overlooking the fact that it could be the treatment that’s not hitting the target. A more refined answer takes time and effort, whereas a “sciatica” diagnosis is an easy way of sending the patient away happy. (Plus, “sciatica” is a reimbursable diagnosis code.)
That tingling or painful sensation going down your leg could be caused by any number of things happening to any number of nerves way “upstream.” Degenerative disk disease, which we all get as we age, can let a vertebra settle onto a nerve and irritate or pinch it. A facet joint at the back of a vertebra can get out of alignment. A strained back muscle might go into spasm and painfully squeeze a nearby nerve or nerve sheathe. Even running with a leg-length discrepancy, the most common back pain culprit among my patients, can cause “sciatica”.
The list goes on and on, but fortunately these are not unfathomable mysteries. They can, and will, be found by someone determined to get to the bottom of a patient’s back pain because we now have the diagnostic tools to do that. And each cause has a specific treatment.
If “sciatica” is as far as you can get with your physician, consult someone else. You don’t want a Post-it — you want a probe. I’m sorry I can’t tell you that “you can run” without the real diagnosis. Please write back when you do get that real diagnosis, and let us know how things turned out. Good luck.
Enjoy the ride.
Dr. Lewis G. Maharam is the world’s premier running physician. He is medical director of Competitor Group’s Rock ‘n’ Roll Marathon series and The Leukemia & Lymphoma Society’s Team in Training program. He also serves as Chairman of the Board of Governors, International Marathon Medical Directors Association. Dr. Maharam’s column can be followed in Competitor Magazine and on his Facebook page: Running Doc
Any questions you may want answered by Dr. Maharam in future columns should be written in the comments below. Feel free to add your comments about your experience with the above situation as well. Dialogue is great and we look forward to expanding that in the comments section of this blog.
What to do about sciatica pain
Sciatica is an often-used term in the medical field and many of you reading this will have experienced that awful leg pain caused by a ‘pinched’ nerve in the lower back. Sciatica refers to the pain that radiates down the back of your leg along the path of the sciatic nerve. The sciatic nerve is the largest nerve in the body and originates from the spinal nerves of the lower five vertebrae in the spine.
As you go down each vertebrae of your spine from your neck to your tailbone, there are nerves that branch off the spinal cord and then exit your spine between each vertebrae. There are 31 matching pairs of spinal nerves supplying the left and right side of your body. Irritation of a spinal nerve at any level can have a number of consequences including: numbness, tingling, pins and needles, weakness and pain. When the nerves in the lower back area are irritated, sciatica is often the result.
Nerves are one of the most sensitive tissues in our body and they require a large amount of continuous blood flow to them to maintain health. All of our nerves added together account for only two per cent of our total body mass, however nerves use approximately 20 per cent of our blood flow, a full 10 times the amount you might expect. Because of this high demand for blood if there is any disruption of blood flow to the nerves as they exit the spine, the end result is very often pain.
Compression or inflammation of a spinal nerve is typically caused by either a bulging disc (disc herniation), or by compression from the deep spinal muscles. A disc rupture or herniation occurs when the tough, outer ring of the disc breaks open or cracks, allowing the inner fluid material to push outwards causing the disc to bulge. This bulging causes an inflammatory reaction that often leads to irritation of the nerve, resulting in pain. In the majority of the cases the disc bulge does not actually press on the nerve, however the resulting inflammation causes protective muscle tightening and joint stiffness to occur. Very often it is this resultant tightening of the muscles and spinal joints that prevents blood flow from ‘washing’ out the inflammation around the nerves. If this stiffness can be reversed, the body is in many cases able to heal itself and the sciatica pain goes away.
Although the pain from sciatica often comes on suddenly, the reality is that in most cases it is the result of years of accumulated micro-traumas to the spine. The stress and micro-traumas created by the constant motion of our spine and by poor postures, leads to ‘wear and tear’ on our discs, spinal joints and ligaments. Labour jobs and traumas such as motor vehicle accidents can also create early wearing down of the spine.
Treatment of sciatica focuses on improving the blood flow to the nerves by increasing the flexibility of the spine as well as releasing the deep muscle tension in the low back that often creates extra pressure on the exiting nerves. As soon as the mobility improves in the spine, the next step is often to strengthen the core muscles of the abdomen and lower back in order to prevent recurrence. Most cases of sciatica can be treated and do not require surgery. If you are suffering from sciatica type pain, consult your physiotherapist or medical doctor as it usually can be treated and shouldn’t be something you have to live with.
Check-up: Lumbar epidural steroid injections
With a recent diagnosis of sciatica, my GP referred me on to a specialist. She has recommendedan epidural steroid injection into my back. Can you explain what this is?
Sciatic pain is usually caused by irritation or compression of one or more spinal nerve roots in the lumbar spine. Although this can cause pain in the buttocks and down the leg, the problem is actually in the back.
For sciatic pain, an epidural steroid injection will be injected into the lumbar (lower back) area. A mixture of a dilute local anaesthetic and a long-acting steroid is injected into the epidural space that surrounds the spinal cord and nerve roots.
The aim of the treatment is to help reduce inflammation in that area.
What does the procedure involve?
Before the procedure, a small cannula will be placed in the back of your hand, through which a short-acting sedative will be given. This will make you feel relaxed. You may also be given oxygen during the procedure.
Lying, curled on your side, local anaesthetic will be used to numb the skin at the injection site and to numb the space between the lumbar vertebrae. An epidural needle is then passed through the skin into the epidural space with the aid of an X-ray image.
The anaesthetic and steroid mixture is injected slowly into the epidural space and you may feel a build-up of pressure in your back while this is done.
For a couple of hours after the injection, you will be positioned on your side, with the affected side down, to encourage the epidural medication solution to reach the affected area.
Most people can be discharged – with supervision – after a number of hours, or when all vital signs are stable.
What about side effects?
Soreness and bruising at the injection site, which typically settles after a few days, is common after epidural injection.
Less common side effects can include bleeding and haemorrhage into the epidural space or infection leading to an epidural abscess.
The spinal cord and nerves may be damaged by the needle, while puncture of the dural membrane can occur if the epidural needle is put in too far. Severe allergic reaction can develop due to the injection solution.
Epileptic seizures may occur and, in rare cases, numbness in the whole body can happen due to the local anaesthetic entering the spinal fluid.