First things first; What causes sciatica? Inflammation with a side of compression!
We discussed in the previous blogs how disc herniations can sometimes lead to pain and the role of inflammation, rather than just compression.
To summarize a little, if you have pain (that can also be explained as pins and needles, sharp shooting, lancinating, shocking, or electric-like) down the leg that is associated with an irritated nerve in the low back, that is called lumbar radicular pain. If you have numbness or a loss of strength because of the same irritated nerve, that’s called lumbar radiculopathy. But they can often happen together, hence sciatica is a term casually used to describe either radicular pain or both of these conditions together.
In this blog, we’ll try to understand the treatment options available for symptoms arising from nerve root irritation/sciatica and the effectiveness of surgery.
It is not sciatica every time!
In general, an estimated 5%-10% of patients with low back pain have sciatica, whereas the reported lifetime prevalence of low back pain ranges from 49% to 70%. The annual prevalence of disc-related sciatica in the general population is estimated at 2.2%.
Additionally, sciatica is a symptom rather than a specific diagnosis, which is a result of not only compression but also inflammation around the nerve root. Many clinicians use sciatica for ANY pain arising from the low back and radiating down the leg. The majority of the time, this painful sensation is referred pain from the lower back and is neither related to disc herniation nor does it result from nerve-root compression.
Sciatica is mainly a result of a herniated disc, fortunately, the vice versa is not true.
In 90% of cases, sciatica is caused by a herniated disc with nerve-root compression, but lumbar canal or foraminal stenosis and (less often) tumors or cysts are other possible causes. Hence an MRI holds value in ruling out cases where symptoms may be caused by underlying pathology (infections, malignancies) other than DH.
But, do not fear disc herniations in the absence of symptoms discussed below, or wait!? Do not fear them at all! Because they resolve pretty quickly on their own.
About 66% of the disc herniations (slip disc), un-slip, as it never happened. And of course, there is evidence to support that sciatica can improve without the resolution of the discs (win-win).
Symptoms of nerve root irritation include:
Pain down the leg is worse than back pain
Pain radiating to foot or toes
Symptoms of burning, tingling, numbness, and paraesthesia down the leg
Muscle weakness
Reflex changes
Leg pain when coughing, sneezing, and taking deep breaths
The word “nerve” can sound scary, but it’s like any other condition
In general, the clinical course of acute sciatica is considered to be favorable, probably because of the favorable natural course of sciatica. Most cases of sciatica will resolve on their own, with no special treatment, within 3–6 weeks. Most people will not have the problem again, or maybe only once or twice again.
A recent study found 75% of people were better, mostly or completely recovered at 12 weeks but only 20% were pain-free at one year.
There are numerous treatment options readily available for sciatica, each with its own pros and cons, ranging from bed rest, lumbar belts, spinal manipulation, acupuncture, exercises, corticosteroid injections, and surgery. Importantly, as we already know each person’s pain is unique to them which might reflect their own age, gender, experiences, beliefs, comorbid conditions, etc, likewise, treatment for every individual would vary accounting for all the individual factors and what works best for them.
No complete bed rest!
Diving a little deeper into the treatments available and their usefulness, something still avidly advised is bed rest. Although it's not shown to be harmful there is nothing to gain from it holding a risk of unnecessarily losing muscle mass, pain self-efficacy, and could potentially be one of the factors driving an acute low-back pain episode into a chronic one.
Relative rest and activity modifications in terms of how and how much you are doing something can be reconsidered, however complete rest must be avoided.
Leave the needles, belts, chairs, and posture gurus behind
Additionally, no evidence supports the use of acupuncture, spinal manipulation, and corsets in cases of sciatica.
A little food for thought in regards to corsets, use of corsets indirectly decreases movement in that area, leads to heightened attention towards the region, and because of their standard shape, they hold the tendency to not work for everyone, all of this collectively can again contribute to worsening of the condition or as a hindrance in the path of improvement.
Furthermore, there is no evidence to support that one specific posture can cure or cause sciatica, likewise with ergonomically designed chairs, if they feel comfortable, use them. Still, they are not essential and hence you don’t need to spend a hefty amount of money on them. The best thing to do is sit in a way you feel most comfortable and move often.
Pills and injectables
According to this Cochrane review, the effectiveness of NSAIDs (diclofenac, combiflam) for patients with sciatica has not been established, even when compared to a placebo. Likewise, No evidence supports the efficacy of muscle relaxants for radicular pain.
However, in cases of severe pain episodes, a little effect is better than nothing, these medications can be used to attain some temporary relief. Although if they produce no significant positive effect for you or if you have been taking them for a long duration, it’s a good idea to drop them, considering their side effects and risks.
For extraordinarily severe sciatica, corticosteroid injection can be considered an option (with caution) because of its anti-inflammatory effect.
A recent review that included a more significant number of trials concluded that there was no evidence of positive short-term effects of epidural corticosteroids other than pain and that the long-term effects were unknown. Therefore, epidural corticosteroid injections could be recommended as a means of reducing pain in the short term although no long-term effects can be expected.
Importantly, giving more than three injections does not seem to confer additional effects and is not recommended
Surgery is not a permanent cure
All the evidence around surgery narrows down to a common conclusion that lumbar discectomy to remove the offending herniated disc material is marginally better in the short term in regards to pain and disability, but eventually, you will end up on the same track as someone who opted for conservative care.
It makes more sense to lean on the side of surgery when sciatica has been most painful, persistent, and resistant to continued conservative treatment. The need for surgery is mainly limited to patients in clear discogenic (the presence of a disc herniation on your MRI doesn’t necessarily mean it has to be painful) sciatica when rapid pain relief is a priority.
It is also important to note that if symptoms persist for 6 months or more, surgery may be ineffective.
In the first 6–8 weeks, there is consensus that treatment of sciatica should be conservative. Absolute indications for urgent surgical treatment are progressive and significant lower limb weakness, altered bladder function, or cauda equina syndrome.
Most of all substantial improvements in symptoms appear within four to six months, with time to complete recovery spanning 24 to 36 months in most patients. So if you don’t see improvement in your symptoms in the first couple of weeks, don’t panic!
In this very recent meta-analysis, the authors of the study concluded, “ Very low to low certainty evidence suggests that discectomy was superior to non-surgical treatment or epidural steroid injections in reducing leg pain and disability in people with sciatica with a surgical indication, but the benefits declined over time. Discectomy might be an option for people with sciatica who feel that the rapid relief offered by discectomy outweighs the risks and costs associated with surgery.”
“sciatica is a heterogeneous condition and no routine clinical measures can consistently predict outcome”
A paper by Peul et al (2007) and a systematic review by Fernandez et al suggest that surgery might provide better short-term relief and faster recovery; but on average long-term outcomes between surgery and conservative management are similar, therefore conservative treatment should be preferred in most cases considering that surgery doesn’t guarantee a permanent fix, comes with its personal and social burdens, providing similar outcomes in one year as conservative treatment.
The best way to go is a shared decision-making process, by way of information sharing, knowledge, and good relationships in making the difficult decision regarding the best management approach for sciatica.
Get Moving
Exercise is one of the many things included in conservative care along with education, medications, and a focus on lifestyle factors like sleep, diet, stress, and comorbidities.
In favor of some good old exercise, keep it simple, the best thing to do is to stay as active as possible working our way along with pain and then trying to gradually move beyond it.
There is moderate quality evidence that structured exercises for sciatica have the same effect as advice to stay active in the long term. Exercise focusing on core strengthening, training specific muscles, or muscle activation tends to have no additional benefit so just focus on moving in any way you can and like. Additionally, you can get a professional to help you along the road to recovery.
The benefits of exercise go beyond just strengthening, having an effect on confidence, self-efficacy, mood, and a host of added benefits like decreased inflammation, better tolerance, better blood flow, better pain relief, and can’t forget, it comes at an overall lower cost and risks than surgery.
In conclusion:
Don’t worry about the radiograph.
Surgery is not a necessity, nor a permanent fix. It’s only reasonable to consider it when you have dried out all other options and if you think a slightly faster recovery along with some pain relief in the short term could be worth it.
It is important to make the decision of surgery driven by weighing the pros and cons, rather than fear and panic.
Stay away from complete bed rest for long and doctors who recommend you to do so.
Get the basics right: sleep, diet, stress, and regular movement.
Get moving, however much you can, even if it is as much as 10 steps thrice a day.
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Disclaimer: This blog is for educational purposes only.
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