Is surgery really necessary in the treatment of sciatica?

By Dan Plev, Consultant Spinal Neurosurgeon, The London Clinic

Sciatica is a term used to describe a pain experienced in the nerves which leaves the lower back and passes through the buttocks and/or legs.  It can be felt as a dull ache, shooting pain or numbness and can occasionally cause weakness in the legs. 

Sciatica is often constant, unlike some pain which comes and goes. There’s no escape from it and this is why it causes misery.

In most cases the pain will subside with a bit of time because our body is able to heal itself.  However, when the pain doesn’t pass, there are a variety of treatment options. 

Treatments range from medication, manual therapy and exercise, to non-invasive IDD Therapy disc treatment.  When non-invasive treatment is not working, we may consider injections and in some cases surgery is the appropriate treatment route.

Causes of sciatica

There are a variety of causes of sciatica but usually the origin is the lower back.  Our spine is made of a stack of bones like cotton reels (vertebrae).  Between the vertebrae we have cushion-like discs or intervertebral discs which act as spongy shock absorbers as we move. 

The discs are also important because they create a gap between the solid vertebrae.  The gaps create space for the nerves to pass as they branch off from the spinal cord. 

There are two main issues which can affect the nerves:

  1. Disc problems:  The discs have a strong outer wall made of tough fibrous collagen (annulus fibrosus).  Inside the disc is a gel-like substance (nucleus pulposus) which has a high water content and provides shock absorbing properties. 

If the centre of the disc pushes out against, or even through, the disc wall it can touch or put pressure on the nerve.  This “bulging” or “herniated” disc can press on the nerve and or cause chemical irritation to the nerve leading to pain.

  • Narrowing between the vertebrae:  If the gap between the vertebrae in the lower back narrows, this can reduce the space for the nerve. When there is pressure on the nerve, this can result in sciatic pain. 

The reduction in the space between the vertebrae can be caused by a loss of disc height.            Over time our discs lose water.  Rather like a deflated bicycle tyre, if the disc loses water it can also lose height, thus narrowing the gap between the vertebrae.  This can pinch a nerve.

Alternatively, or as a result of the loss of disc height, the body can add more bone to a vertebra to strengthen it.  The disc carries a certain proportion of our bodily load.  If there is an issue with the disc and it takes less of the weight, then more load is placed on to our bones. 

In order to support the additional load, the body reinforces the vertebra by adding more bone.  That additional bone can lead to a loss of space for the nerves.  This additional bone is described as spinal stenosis.  With less space for the nerve they can again become “pinched” and the nerve pressure causes pain.

Treatment Options

A sudden onset on sciatica can be caused by a small disc bulge pressing on to a nerve.  In this circumstance, as the body moves, pressure changes may help to retract the bulge and thus relieve the pain.

Our discs are designed to support our weight and allow us to move freely.  They rely on movement to stay healthy and function as a unit with the muscles and ligaments. 

Weakness and stiffness in the soft tissues can mean that the disc and vertebrae are placed under increased load.  When that is combined with exposure to load for long periods, most commonly from poor posture and lengthy periods of sitting, it can put more strain the discs. 

Unfortunately, long periods of sitting usually go hand in hand with lower activity levels.  This is a cause of the weakness in the muscles and leaves them less able to take their share of the support.

Manual Therapy and Exercise

Manual therapists will use a range of stretching and mobilisation techniques to increase the flexibility of the soft tissues and alleviate the stiffness in the joint. Pain creates a vicious cycle where we can’t move but it is the movement which is so important for the cure!

The goal is to create some movement in the spine and to unload the disc and the joints.  Sometimes the soft tissues even become stuck together (adhesions) which prevents movement.  Part of the manual therapy and stretching will aim to address that.

For many, the word exercise conjures up memories of PE lessons and cross country running.  But as movement is restored and pain subsides, certain exercises, which anyone can do at home, are important.  These are designed to help to move the joints of the spine and hips, in particular.  Exercise keeps them active, strong and engaged so that they can support their share of load as we move. 

Combined with gentle walking these simple exercises help to keep our spines healthy and prevent further episodes of pain.

IDD Therapy Disc Treatment

IDD Therapy (Intervertebral Disc Decompression) is a non-surgical spinal decompression treatment.  When pain from a bulging or herniated disc persists and has not responded to manual therapy, therapists use IDD Therapy as a tool to help take pressure off targeted discs and to gently mobilise the spine. 

IDD Therapy is a mechanical tool which replaced old-style traction.  It uses computer-controlled pulling forces to open the space between the vertebrae to decompress the disc and gently mobilise the soft tissues and joints with some soft oscillation.  The goal is to relieve pain and help restore movement.

Patients lie on the Accu SPINA machine which delivers IDD Therapy.  They are connected to the machine using ergonomic harnesses and pulling forces are applied at specific angles to treat the affected spinal level. 

The IDD Therapy lasts for 25 minutes and patients remain completely relaxed throughout.  A series of treatments are given and the forces used are gradually built up as the body adapts to the changes. 

IDD Therapy is combined with some other modalities, such as heat, and is provided in combination with manual therapy and strengthening exercises as part of a programme of care.

Injections

There are different types of injection.  The most common injection given by doctors for sciatica is aimed at reducing inflammation. Inflammation is a natural process of healing.  However, after prolonged periods, the inflammation itself can become a problem and excessively irritate the nerves, thus causing pain. 

A steroid injection can be given which helps to neutralise the inflammation and relieve pain.  It is important to make the distinction – corticosteroids for pain relief in medicine are different from anabolic steroids which are performance-enhancing drugs.

Injections are usually given to create a pain-free window, whereas the other treatments described here address the causes of the problem.

Surgery for sciatica

Surgery is the preferred treatment for sciatica when either the pain is intolerable and has not responded to other non-invasive treatments or the pressure on the nerve is such that it is causing weakness, usually in the legs or in very extreme cases, a loss of bladder or bowel control (cauda equina).

If a disc in the spine has herniated, this is where the centre or nucleus of the disc has pushed out through the walls of the disc. 

Sometimes only a small amount of the nucleus has pressed through the wall, or it can be substantial.  Usually the body can reabsorb this disc material, however if it remains, it can become hard and leave patients in constant pain.

The most common surgery given is called a microdiscectomy.  This is where a small incision is made in the lower back and using surgical instruments, the piece of disc material is removed.  This surgery can be very effective in relieving leg pain.

If the space where the nerve lies is narrowed, other forms of “decompression” surgery can be used where small pieces of bone are removed to create space for the nerve or to remove bone which is pressing on it.

It is important to stress that long term pain relief is best achieved if the causes of the weakness are addressed.

Urgent surgery:  Where a patient is experiencing weakness in their legs this is a more serious proposition and usually surgery will be considered early.  Weakness or a loss of leg power can mean that the nerve is at risk of damage and thus relieving the pressure quickly is very important. Surgery is also usually given as a priority if there is a loss of bowel or bladder function.

Whilst surgeons and therapists see a lot of patients with back pain, in some ways sciatica is the condition which causes the most stress and anxiety. 

Surgery and invasive treatments are only necessary in a small percentage of cases.  The advances in conservative (non-invasive) care mean that most sciatica can be addressed without the need for surgery.  Clinicians work together to match the right option for the right condition. 

The final word on sciatica is that prevention is always better than cure.  Staying mobile, keeping active and avoiding prolonged sitting are key to looking after your back and keeping sciatica at bay.

ABOUT THE AUTHOR

Dan Plev is a Consultant Spinal Neurosurgeon and IDD Therapy provider at The London Clinic in Harley Street, London.

‘Intervertebral Differential Dynamics” orIDD Therapy is the fastest growing non-surgical spinal treatment for intervertebral discs with over 1,000 clinics worldwide and 34 clinics across the UK. Safe, gentle and non-invasive, IDD Therapy helps patients who need something more for their pain when manual therapy alone is insufficient to achieve lasting pain relief. http://iddtherapy.co.uk/

Facebook: IDD Therapy Europe

Twitter: https://twitter.com/iddtherapyeuro

Sciatica – Check if you have sciatica




 

Sciatica

Sciatica

Sciatica is when the sciatic nerve, which runs from your hips to your feet, is irritated. It usually gets better in 4 to 6 weeks but can last longer.

Check if you have sciatica

If you have sciatica, your:

bottom

backs of your legs

feet and toes

may feel:

painful – the pain may be stabbing, burning or shooting

tingling – like pins and needles

numb

weak

Your symptoms may be worse when moving, sneezing or coughing.

You may also have back pain, but this isn’t usually as bad as the pain in your bottom, legs or feet.




You probably don’t have sciatica if you only have back pain.

How you can ease the pain yourself

Sciatica usually gets better in 4 to 6 weeks but can sometimes last longer.

To help relieve your pain and speed up your recovery:

Do

carry on with your normal activities as much as possible

regular back stretches

start gentle exercise as soon as you can – anything that gets you moving can help

hold heat packs to the painful areas – you can buy these from pharmacies

ask your pharmacist about painkillers that can help

Don’t

sit or lie down for long periods – even if moving hurts, it’s not harmful and can help you get better faster

take paracetamol on its own – this doesn’t help with back pain or sciatica

use hot water bottles to ease the pain – you could scald yourself if your skin is numb




See a GP if the pain:

hasn’t improved after trying home treatments for a few weeks

is getting worse

is stopping you doing your normal activities

Go to A&E/ER  if you:

have sudden weakness in both legs

have numbness or tingling around and under your genitals or inner thighs

suddenly can’t pee, or can’t control when you pee or poo

These could be symptoms of a serious back problem that needs to be treated in hospital as soon as possible.

Treatments from a GP

Your GP may:

suggest exercises and stretches

prescribe painkillers that help with nerve pain like sciatica

They might also refer you for:

physiotherapy – including exercise advice and techniques like massage (manual therapy)

psychological support – to help you cope with the pain

Physiotherapy from the NHS may not be available everywhere and waiting times can be long. You can also get it privately.

 Injections and surgery for sciatica

How to stop sciatica coming back

To reduce the chances of getting sciatica again:

Do

stay active – take regular exercise

use a safe technique when lifting heavy objects

make sure you have a good posture when sitting and standing

sit correctly when using a computer

lose weight if you’re overweight

Don’t

  • smoke – smoking can increase your risk of getting sciatica

Causes of sciatica

Sciatica is due to something pressing or rubbing on the sciatic nerve.

Causes include:

slipped disc (the most common cause) – when a soft cushion of tissue between the bones in your spine pushes out

spinal stenosis – narrowing of the part of your spine where nerves pass through

spondylolisthesis – when one of the bones in your spine slips out of position

a back injury

Raising Awareness of Cauda Equina Syndrome

Raising Awareness of Cauda Equina Syndrome!

As some of our readers will know one of the objectives of Patient Talk is to raise awareness of the less well known medical conditions.

Today we would like to take a look at Cauda Equina Syndrome with this excellent infographic.

We have cover some of the territory in a previous blog post here on Sciatica.


Raising Awareness of Cauda Equina Syndrome

From Visually.

Sciatica! What are the signs, symptoms, causes and treatments of Sciatica?


Sciatica patient

Sciatica patient

Welcome to the latest of our informational blog posts about common medical conditions.  Today we turn our attention to Sciatica.

Sciatica can be defined as pain which is cause by damage or irritation of the sciatic nerves.  For an overarching look at nerve pain please have a look at our previous blog on neuropathic pain here https://patienttalk.org/?p=281. It is a useful resource as we have had over 100 people sharing their experiences so you can learn a lot.

The sciatic nerve is the longest in our body.  Starting at the pelvis and ending in both feet.

When the nerves are irritated typically the pain “radiates” from the back down the legs.  Pain levels will vary from mild to severe.  In some cases sciatica will clear up after a few days of its own accord but others may have a chronic (or long term) condition.  It is worth noting that sciatic pain does not often affect much of the back making it different from back pain.  You can find out more about the specifics of back pain here https://patienttalk.org/?p=389.

Sciatica can be caused by a number of things:-

a)  Slipped disc.  Also known as a herniated disc.  This occurs when a spinal disc cracks and the gel inside breaks through and puts pressure on the sciatic nerve.

b) Spinal stenosis.  This is the narrowing of the spinal nerve passages.  The nerves can be squashed by the bones or ligaments causing the sciatica.  Normally in older people.

c)    Tumours on the spine

d)  Infections

e)  Cauda equina syndrome.  This is very rare but occurs when there is pressure on the nerves at the end of the spinal column.

Treatments of sciatica depend on whether it is chronic or not.  If it is just short term then over the counter painkillers can be used alongside hot or cold packs.  Exercise is also recommended.  You may be interested in the following article about people who suffer from pain and need some new techniques for keeping fit.

For those with a longer term version of the condition a structured course with a physiotherapist is suggested.  In a very few cases surgery may be required.

Over to you.  What was your experience of sciatica?  Please feel free to share your story in the comments box below.  In particular we are interested to know what sort of treatments you received and how effective they were!

We really look forward to reading your stories.

Thanks very much in advance.