What is meant by sciatica?
Sciatica means pain originating from the back and radiating down to the lower limbs. This pain is generally caused by bending forwards, lifting weights, coughing, sneezing, straining at stools, etc. This is the classical form of sciatica. This type of pain is generally seen in younger and middle-aged individuals. There is another form of leg pain, termed ‘neurogenic claudication’. This refers to pain, discomfort or heaviness classically noticed in the calf region or sometimes in and around the buttocks, on walking for some distance or standing for some time. This kind of pain may or may not be associated with any kind of low back pain. It is classically noticed in middle-aged and older population, who may unknowingly and incorrectly attribute this pain to age-related weakness!!!!
What are the causes of sciatica?
Sciatica and neurogenic claudication can be caused by causes within the spinal canal and outside the same. Causes within the spinal canal include slipped disc, bone overgrowth, slippage of one bone over the adjacent one or rarely, due to some kind of growth within the spinal canal.
What is a slipped disc? Our spine is made up of a number of bones called vertebrae stacked one on top of another. A disc is a soft, gel-like structure present between two adjacent vertebrae. Normally, these discs act like ‘shock-absorbers’ and also allow some movement between the two adjacent vertebrae, giving the spine its flexibility. When this disc slips beyond its normal confines, it can compress the spinal cord or its nerve roots located close by and lead to problems.
Why does the disc slip out? Over the years, the disc develops small microscopic tears, which may unite together over a period of time such that with some trivial injury or some innocuous activity, the disc may slip out of its normal confines. As a part of the normal aging process, the spine may develop some extra bone growth, leading to compression of the adjacent spinal cord or its nerve roots leading to pain.
Why is the pain noticed in the leg, when the disc has actually slipped out in the spine? When you press the switch at home, the tube-light that is located away from the switch, goes on; on a similar rationale, whenever there is compression of the nerve root in the spinal canal, the pain is noticed elsewhere! It is because our brain is conditioned to perceive sensations in a particular way!
Also, considering the same example for comparison, if the tube-light does not go on after pressing the switch, there could be something wrong with the switch, the intervening wires or the tube-light itself! So, any compression or problem affecting the nerves after they leave the spinal canal can also lead to sciatica. The most common condition that can affect the nerves after they leave the spinal canal is ‘peripheral neuropathy’, a condition wherein the nerves are ‘weakened’ secondary to diabetes, chronic alcoholism, smoking, other forms of tobacco consumption, nutritional deficiencies and other rare causes. A common complaint in patients with peripheral neuropathy is the presence of pain even at rest; pain of a burning nature or numbness in ‘glove and stocking’ distribution i.e. over the hands, just beyond the wrist joints and over the lower limbs, just beyond the knee joints. Additionally, as regards neurogenic claudication, compromise of the blood vessels that supply the legs can also lead to leg pain.
How does the doctor diagnose the exact cause of sciatica?
An accurate history is the most important diagnostic tool. The way the pain started and progressed; specific aggravating and relieving factors of pain; distribution of pain over your body, associated complaints such as weakness or numbness over the lower limbs will be a guide to short listing the possible causes of your low back pain and sciatica. A very important history relates to difficulty in controlling or passing urine.
A detailed clinical examination involving assessment of spinal motion, assessment of your neurology and certain special tests will allow to further narrow down the causes to 2-3 most probable ones.
Though this process of history-taking and clinical examination may appear boring and long-drawn, it is the most crucial part towards prescribing the correct treatment to you. So, it is essential to cooperate with your doctor throughout this entire procedure, which gives more information to the doctor regarding your ailment than any other investigation on earth.
How does the doctor investigate for sciatica?
On the first visit, if your problem is short-lived and there are no major signs or symptoms, you may not need any further investigation. However, if your problem has been present for some time, or if there is some history of trauma, fever, any other major illness, or any notable findings on clinical examination related to neurological dysfunction; you are likely to require some further investigations.
Commonly, plain x-rays of the spine may be ordered with or without some basic blood investigations such as hemoglobin, erythrocyte sedimentation rate [ESR], CRP, RA test, serum calcium, phosphorus and alkaline phosphatase.
Based on these tests, or sometimes, in the presence of some very significant signs or symptoms, you may be asked to undergo MRI scanning. Plain x-rays demonstrate bony features; while MRI demonstrates the spinal cord, its nerve roots, the intervertebral disc between the two bones of the spine. Both these tests are complimentary in nature; doing one does not necessarily mean that the other one is not needed.
In some cases such as peripheral neuropathy, additional investigation in the form of EMG-NCV test, to assess the function of each of the various nerves in your limbs may be required.
Rarely, a Color Doppler examination of the lower limb blood vessels may be asked for.
Is there any nonsurgical treatment for sciatica?
The treatment would depend on the duration of your problem, presence of similar episode in the past, neurological function, response to previous nonoperative treatment and lastly, the subjective severity of your pain. Various nonoperative means of treatment include bed rest, painkillers, muscle relaxants, various modalities such as heat and electrical stimulation, activity restrictions, etc.
During the acute period of sciatica, complete bed rest is helpful. If you sprain one ankle, you can hop on the other one and still continue to walk. But you have only one spine!! So, the only way to give rest to it is to go to bed! Among all the positions; sleeping, sitting, standing and walking, the load on the spine is least in the sleeping position. How should you sleep? You should sleep on your side, either right or left, whichever is comfortable, with a pillow in between your legs. What kind of bed should you sleep on? A cotton mattress is ideal! No need to sleep on hard beds, nor do you need to fall for any kind of so-called “spine-friendly” expensive mattresses sold out in the market! This bed rest should be for a period of 2-3 days. During this period, you should eat, drink and sleep in the bed. Only sponge bath is allowed. Ideally, you should not get up even to visit the washroom; you should use a bedpan or urine-pot. However, if this is too much of an inconvenience, you may be allowed to get up to use the washroom alone. How long should you take bed rest? If the pain has to respond to bed rest, it will do so within 2-3 days; continuing beyond this much time only further weakens your spinal muscles without really decreasing your pain; in other words, beyond 2-3 days, complete bed rest will do more harm than good to your back.
Painkillers will be prescribed to allow a smoother and easier return to normal function. You would generally be prescribed these on a shorter term or on a longer-term tapering program so as to guard against possible over dependence on these agents, as these are associated with significant side effects if used excessively in the long term. These side effects may range from hyperacidity, gastric ulcer, kidney damage, bleeding disorders, constipation, addiction, etc. In addition, based on individual merit, you may also be prescribed muscle relaxants so as to relax and soothe your back muscles. This is so because whenever you have neck or back pain, your muscles tend to go into spasm [sustained contraction] and hence, lead to pain. It is essential to break this spasm with a muscle relaxant so as to give effective pain relief.
Physiotherapy modalities may be used. This consists broadly of passive and active physiotherapy. During acute pain, generally, only passive physiotherapy would be used. This would be in the form of heat in various forms or electrical stimulation in various forms. Since complete bed rest has a more scientific role in relieving your back pain, in the acute phase of your back pain, it would not be recommended for you to travel every day from home to the hospital for purposes of physiotherapy; unless of course, if you are admitted into the hospital for complete bed rest! In this case, you could get the additional benefit of physiotherapy modalities such as SWD [short-wave diathermy], TENS [transcutaneous electrical nerve stimulation] and IFT [interference therapy]. After pain relief, you would be prescribed active physiotherapy i.e., spinal exercises. Based on whether you have pure sciatica or neurogenic claudication, your exercise protocol would be decided by the doctor.
Though complete bed rest would be prescribed only for 2-3 days, you would need to have some activity restrictions to help your spine get back into shape and stay that way!! You would not be allowed to bend forwards; sit on the floor; lift weights; use the Indian type of commode [toilet-chairs are available on rental basis as well as on sale in many medical shops]; travel [particularly not on 2 and 3 wheelers]; and smoke. These restrictions would be generally enforced for a minimum period of about one month. Smoking would be forbidden lifelong!
When is surgery essential?
Surgery would be indicated when there is no pain relief despite symptomatic treatment as mentioned above or, when there is significant neurological deficit or, repeated episodes of sciatica so as to get a permanent solution to the problem.
What is the nature of surgery?
Microdiscectomy is the usual surgery for sciatica. This is a surgery performed through the microscope so as to make this a relatively safer procedure. Is it a major surgery? We were told that we should not get a spine surgery done as it can lead to loss of control of urination and defecation! Or, in other words, what are the risks involved? Everything in life carries some inherent risk associated with it. The option for surgery would be offered only if the benefits of surgery significantly outweigh the risks. Rather than asking as to what are the risks of going in for surgery, it would be more prudent to ask as to what are the risks and benefits of getting the surgery done as compared to not getting the surgery done? Spine surgery has had a lot of advances in the past decade or two; there are better imaging facilities like MRI, better surgical instruments, surgical microscope to aid vision in the surgery, computer navigation system to further increase the safety level of surgery, better training and information in an overall sense making spine surgery no longer the taboo that it once was! So, if you have a problem that genuinely requires surgery, there is no point in tying yourself down to the bed for days or months on end; because ultimately life is mobility and mobility is life! Discuss the details of your surgery and its attendant risks with your doctor to quell any fears and to clear any and every doubt of yours! If you so desire, your doctor can even arrange to give you references of patients who have undergone similar surgeries. Can we not replace the disc back into its place; in other words, won’t it be harmful to remove the disc? The disc that has slipped out can no longer carry out its normal function; rather, it is causing harm to the body rather than doing anything good! So, trying to replace the disc back into its position is not a viable option. If the disk is badly damaged and if the back pain is more severe than the leg pain, then there remains the option of replacing the damaged disk with an artificial disk.
How is the postoperative recovery and rehabilitation?
Generally, you would be admitted one day prior to the day of surgery. You would be advised to stay starving after the dinner the previous night. Surgery would generally be carried out the next day morning. After the surgery, on the 2nd day, you would be made to walk with a lumbosacral belt. You would be discharged after 3-4 days. Sutures [stitches] would be removed generally on the 10th day following the surgery. By this time, you would be walking around and essentially be independent in doing activities of daily life. You would be allowed to take bath 48 hours after the suture removal. For 3-4 weeks, you would be allowed restricted mobilization within the house. During this period, you would be encouraged to increase your activities by weekly increments. 1 month later, you would be started on spinal strengthening exercises. 3 months later, you would be started on spinal stretching exercises. For 3 months at least, you would not be allowed to bend forwards, lift up weights, travel on 2-wheelers/ auto rickshaws/ jeeps, sit on the floor, or use Indian type of toilet commode. You would have to use the lumbosacral belt for a month at all times other than lying down and while taking bath. Continuing to wear the belt beyond one month after surgery would only weaken your muscles and it is hence, recommended to wean yourself off the same thereafter. Towards this end, you would have to take off the belt for 2 hours in the day time in the first week [after having completed one month following the surgery], for 4 hours in the day time in the second week, for 6 hours in the third week and so on. You would not be allowed to smoke for lifelong!
Will I be able to return back to work after the surgery?
Though you would be up and about, walking about within the first ten days following the surgery, you would be allowed only limited mobilization within the house in the first one month following surgery. Thereafter, if you are having a sedentary light job, then you may be allowed to resume work, provided you do not have to travel for a prolonged time on some bumpy road(s). If you were having some job that required some moderate labor, you would be allowed to resume work about three months after surgery. If you were involved in heavy manual labor, it would be wiser to seek some permanent job modification in these situations. Staying off work for more than three months post-surgery is not recommended at all.
What about newer surgical techniques such as laser discectomy, endoscopic discectomy, disc replacement, etc.?
Microscope allows for the use of both eyes while working, giving binocular vision and thereby, good depth perception that is very essential for the safe performance of these surgeries. This binocular vision is lacking in endoscopic discectomy. Percutaneous laser discectomy has not been proven to be scientifically superior to microdiscectomy. Long-term scientific studies regarding the efficacy of endoscopic and percutaneous laser discectomy techniques have failed to show any significant advantage over conventional techniques. Disc replacement is a promising new technology that helps replace the damaged disk with a new artificial disk that simulates the normal disk. This surgery is generally offered to patients who have significant back pain with or without leg pain. Generally, patients with sedentary lifestyle are best suited to this type of treatment. It is a better and more physiological surgical solution rather than the more prevalent option of inserting screws and rods to fix the spine and lose spinal mobility thereby. Several scientific studies have been published reporting the safety and efficacy of disk replacement.