Lesson

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Sciatica – Must Know Western Treatments

Physical Therapy

PT is usually the first treatment a doctor will prescribe for back pain and sciatica.  Passive treatments help to relax you and your body. They also prepare your body for therapeutic exercise, which is the active part of physical therapy.

Deep tissue massage is used as a form of manual therapy to decrease pain and improve the mobility of patients experiencing pain. This approach uses lumbar manipulation and/or mobilization techniques designed to help patients restore their functional movement. Stretching and light exercise are also used to help prevent re-injury of overused muscles, joints, and ligaments. According to physical therapies from New York City, musculoskeletal and bone injury recovery times can be anywhere from four to six weeks.

Therapeutic exercise programs are developed and tailored to the patient’s specific diagnosis. These long-term programs are designed to address pain and limitations and to increase the likelihood of future injury prevention.

Other Physical therapy treatments include hot and cold therapies. By using heat, the physical therapist seeks to get more blood to the target area because an increased blood flow brings more oxygen and nutrients to that area. For example, a heat pack placed on your piriformis muscle may help to reduce muscle spasms that could be causing your sciatica. Cold therapy slows circulation, helping to reduce inflammation, muscle spasms, and pain.

Spinal Decompression Therapy

Spinal decompression therapy is often used by physical therapists to help relieve back pain from constant pressure on the discs and spine. This treatment can be especially helpful in pain relief for individuals who cannot afford surgery and to take a lengthy amount of time to recover. This method of treatment, as it says, decompresses the spinal discs and facet joints by using traction, distraction, and body positioning.

This treatment may help relieve the excessive compression forces from daily activities that increases internal spinal disc pressure which can lead to spinal disc protrusion, herniation, and bulging of disc material.

In this reading, we mention two clinical studies and their conclusions:

“Eighty-six percent of ruptured intervertebral disc (RID) patients achieved ‘good’ (50- 89% improvement) to ‘excellent’ (90-100% improvement) results with decompression. Sciatica and back pain were relieved.” Of all the facet arthritis patients, 75% obtained ‘good’ to ‘excellent’ results with decompression.” This research study was an old one, dated in 1997, titled Decompression, Reduction, and Stabilization of the Lumbar Spine: A Cost-Effective Treatment for Lumbosacral Pain.

“Serial MRI of 20 patients treated with the decompression table shows in our study up to 90% reduction of sub ligamentous nucleus herniation in 10 of 14. Some rehydration occurs detected by T2 and proton density signal increase. Torn annulus repair is seen in all.” Title of the research study is Simple Pelvic Traction gives inconsistent relief to herniated lumbar disc sufferers.

“All but two of the patients in the study improved at least 30% or more in the first three weeks.” “Utilizing the outcome measures, this form of decompression reduces symptoms and improves activities of daily living.” This was from A Clinical Trial on Non-Surgical Spinal Decompression Using Vertebral Axial Distraction Delivered by a Computerized Traction Device, in 2004.

In opposition to some of these studies, in 2007 a literature review was published titled “Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?”. In this review, they sought to debate whether or not the research surrounding traction therapy was as effective as media advertising claims said them to be. According to their evaluation of numerous studies, they found that “only limited evidence is available to warrant the routine use of non-surgical spinal decompression, particularly when many other well investigated, less expensive alternatives are available”. Therefore, more rigorous research is needed to prove this treatment effective and reliable in relieving back pain associated with sciatica.

It is important to note that while this therapy may not be effective for some people, it may work for others. Pain management is not a cookie cutter for everyone and it is advisable to explain to your patient the various treatment options that they could try that may possibly relieve their pain. Being neutral to the treatment and explaining pros and cons of each treatment will also help in their decision-making process.

TENS (transcutaneous electrical nerve stimulation)

Transcutaneous Electrical Nerve Stimulation, TENS, is a machine that stimulates the muscles through variable (but safe) intensities of electrical current. This machine is able to modulate pulse width, frequency, and intensity. TENS helps reduce muscle spasms, and it may increase your body’s production of endorphins, your natural painkillers. The TENS equipment your physical therapist uses is larger than the “at-home” use machine. However, whether large or small, a TENS unit can be a helpful therapy.

Ultrasound

Ultrasound sends sound waves deep into your muscle tissues and creates a gentle heat that enhances circulation and helps to speed healing. Increased circulation helps to reduce muscle spasms, cramping, swelling, stiffness, and pain. In addition, ultrasound, used for low back pain and frozen shoulder, has started to become popular because of it’s use in speeding up the process of wound healing and the reduction of inflammation in soft tissue. Some research shows that this treatment is effective, while other studies indicate that it is not. The main mechanism by which ultrasound works is still somewhat unclear. One theory is that this treatment generates slight levels of heat, therefore increasing blood flow to the problem area, reducing swelling, muscle spasms, and pain.

Surgeries

Microdiscectomy

The most common operation that spine surgeons perform is called a microdiscectomy. Done for severe disc herniation, this relieves pressure on the affected nerve root. First, the ruptured disc is located using a CT scan or an MRI. This helps to plan for surgery. During surgery, the space between the affected vertebrae is entered through the back of the spine. To get there, a bit of bone from the bottom and top of the adjacent lamina often must be cut away. The lamina forms the arching walls that make up the back of the spinal canal. Using this widened entry, the surgeon searches for the nerve root that is under pressure. Once it is found, the nerve fiber is protected and gently teased to one side to allow access to the ruptured portion of the disc. Finally, the extended portion of disc tissue is removed using a special microscope (hence the name micro discectomy), leaving the remaining disc largely intact. Taking pressure off the nerve root helps stop the irritation and creates more room for the nerve.

Rates of recovery from surgery vary. Patients having routine disc surgery often go home the same day. Depending on age, general health and motivation, some return to their daily routines in a few weeks. Others can take three to six months to recover.

Partial removal of the disc can affect the spine’s ability to carry heavy loads. The remainder of the disc must adapt to make up for the missing part. The risk of another portion of the disc herniating is approximately 15 to 20 percent. Patients can expect significant improvement following surgery, but they may not have a 100 percent recovery.

Discectomy

Discectomies are considered a relatively safe procedure. But as with any surgery (including all of the ones listed in this reading), discectomy carries a risk of complications.

Potential complications include:

• Bleeding
• Infection
• Leaking spinal fluid
• Injury to blood vessels or nerves in and around the spine
• Injury to the protective layer surrounding the spine

If a patient undergoes a discectomy, they should be evaluated about the rigors of their occupation. For example, are they lifting, walking, or sitting a lot at their job? Depending the amount of physical activity they are required to do to perform their job, they should take time off to fully recover, which could range two to six weeks or more. Some physicians advise for eight weeks of leave to heal properly. Activities such as lifting, bending, stooping, twisting for four weeks after the surgery should be limited. In addition, the patient may need reduce the amount of time they spend sitting for four weeks post-surgery. Once the patient has healed properly, physical therapy is an excellent option to regain strength, mobility, and flexibility around the spine.

Spinal fusion

After many years of wear and tear, the spine’s vertebrae may no longer align properly. They are like a wobbly column of building blocks. One vertebra may slip forward on top of another, grinding back and forth, often putting pressure on nerve roots. Thanks to this, spinal fusion is the second most common procedure that spine surgeons perform. In this surgery, a section of the spine is immobilized to provide stability and pain relief. Usually, it is needed in the lower back. The surgeon places a bone graft along the spine segment to be fused.

The graft may come from the patient, an organ donor, or be made of a synthetic material. As it can take a year or two for the graft to fully integrate into nearby bone, metal alloy (often titanium) rods and screws form an internal splint to keep the vertebrae in place. Corrective wedges made of metal alloy or synthetic materials may be placed between two vertebrae to restore balance and supply more area for additional bone graft. Once the spine has fused, the rods and screws stay in place unless they cause irritation. Most people are comfortable after a month or two. However, it often takes six months to a year to really get back to normal.

Risks:

Spinal fusion is considered more invasive than micro-discectomy. This procedure often causes more structural issues with the discs above and below the surgery site because this disc has to compensate with the immobility of the fixed procedure area. It is important to note that failure to relieve lower back pain symptoms following the surgery is the most common risk. There is also a risk that the vertebrae may not fuse together following the surgery, called pseudarthrosis this happens 5% to 10% of spine fusion surgeries.

Pseudarthrosis refers to a “non-union” or false join, and is a bone fracture that has no chance of healing itself without intervention. In this case, the body perceives the fractured bones as different and separate, so it does not attempt to heal and unite them. In addition, a fusion involves extensive bone work, which can lead to more back pain and longer recovery. The lateral facet joints and transverse processes (specific parts of your vertebra, both located on the sides of each vertebra) are typically exposed during a fusion. This necessitates more muscle dissection (Highsmith, 2009).

Laminectomy:

Spinal stenosis results in a symmetric compression on the spinal nerves due to degeneration and overgrowth of the joints, ligaments, and bone spurs. Surgery to treat spinal stenosis often requires more extensive decompression than a simple micro-discectomy, so the surgeon may perform a Laminectomy, also known as spinal decompression surgery. This procedure involves removing the lamina that covers the spinal canal, and enlarging the spinal canal, allowing for the spinal cord and nerves to be untouched. The arthritic facet joints are also shaved down to provide more room for the exiting spinal nerves.

Compared to a Micro-discectomy, laminectomy patients typically experience an increased degree of post-operative discomfort due to the greater extent of muscle dissection and the larger skin incision. This is required to expose both sides of the spine, as opposed to a micro-discectomy that typically requires exposure of only one side. On average, patients are discharged from the hospital one to two days following surgery. Activities are limited to walking for the first several weeks following the operation. Physical therapy is often useful, initially involving stretching and range of motion exercises followed by endurance and strength training.

The procedure is performed under general anesthesia. A midline incision in the lower back is centered over the affected area.

Dissection through the back muscles provides access to the spine. The portion of the vertebra known as the lamina is removed, along with any thickened ligaments to release the nerves traveling down the center of the spinal canal. Individual nerves are released as they exit the spinal canal by shaving a portion of the degenerative facet joint. The soft tissues are then closed in multiple layers with absorbable sutures. Risks are return of back pain and infection at the surgical site.

Medications

Types of over-the-counter medications include:

• Analgesics: Pain-relieving medications drugs
• Non-steroidal Anti-inflammatory Drugs (NSAIDs): Medications that relieve both pain and inflammation
• Topical Medications: Creams, gels, ointments, patches, and sprays that relieve pain and inflammation through the skin
• Over-the-counter pain relievers can help with your back pain. Over-the-counter means you can buy them without a prescription. Most doctors recommend acetaminophen (such as Tylenol) first because it has fewer side effects than other drugs. It is important to advise patients that taking too much of over the counter drugs such as Tylenol can cause severe damage to the liver.

If a patient already has liver disease, they should be advised to check with their primary care doctor before the use of this medicine for pain management. Non-Steroidal Anti Inflammatory (NSAIDS), can be useful in treating pain if used with precaution. NSAIDs, some of which being ibuprofen and naproxen, can be purchased without a prescription. NSAIDs help reduce the swelling around the swollen disc or arthritis in the back. NSAIDs and acetaminophen in high doses, or when taken for a long time, can cause serious side effects. Advise your patient to be aware of the following side effects and to monitor how they are feeling on NSAIDS. Side effects include stomach pain, ulcers or bleeding, and liver or kidney damage.

Narcotic pain relievers

Narcotics, also called opioid pain relievers, are used only for pain that is severe and is not assisted by other types of painkillers. They work well for short-term relief. Do not use them for more than 3 to 4 weeks. These medicines are only rarely used to treat someone with chronic pain. Narcotics work by binding to receptors in the brain, which blocks the feeling of pain. These drugs can be abused and are addictive. They have been associated with accidental overdose and death. When used carefully and under a doctor’s direct care, they can be effective in reducing pain.

Examples of narcotics include:

• Codeine
• Fentanyl (Duragesic) — available as a patch
• Hydrocodone (Vicodin)
• Hydromorphone (Dilaudid)
• Morphine (MS Contin)
• Oxycodone (Oxycontin, Percocet, Percodan)
• Tramadol (Ultram)

Possible side effects of these drugs include:

• Drowsiness
• Impaired judgment
• Nausea or vomiting
• Constipation
• Itching

Skeletal Muscle Relaxers

Skeletal muscle relaxants are drugs that relax striated muscles (those that control the skeleton). They are a separate class of drugs from the muscle relaxant drugs used during intubations and surgery to reduce the need for anesthesia and facilitate intubation.

Muscle Relaxer Medications

• Cyclobenzaprine (Flexeril)
• Diazepam (valium)

Cyclobenzaprine may be used with physical therapy and rest to treat back pain or injury. It works by blocking pain sensations that are sent to the brain. It is important to note that this medication should not be given to an individual who has thyroid disorder, heart block, congestive heart failure, heart rhythm disorder, or if they have recently suffered a heart attack. All patients should be advised to talk to their primary care physician for an evaluation to use this drug.

Diazepam is not only used to treat muscle spasms but also anxiety disorders and alcohol withdrawal symptoms. It is in the class of drugs called benzodiazepines. In addition, it can also be used in conjunction with other medications to treat seizures. Side effects of diazepam include shakiness, blurred vision, anxiety, agitation, chills, confusion, cough, stomach pain, difficulty urinating, faintness, etc.

Purpose of Skeletal Muscle Relaxants

Skeletal muscle relaxants may be used for relief of spasticity in neuromuscular diseases, such as multiple sclerosis, as well as for spinal cord injury and stroke. They may also be used for pain relief in minor strain injuries and control of the muscle symptoms of tetanus. Dantrolene (Dantrium) has been used to prevent or treat malignant hyperthermia in surgery. All drugs in this class may cause sedation. Important to note that baclofen, when administered intrathecally, may cause severe central nervous system (CNS) depression with cardiovascular collapse and respiratory failure.

Course Directions

1. When you are finished reading the course & are ready to take the quiz, go to the bottom of this page & click the link underneath the Quizzes Section to begin the quiz.

2. After you complete the quiz with a passing score of 70% or higher, your certificate will be available to view & save for your records.

3. You have unlimited attempts to obtain a passing score on the quiz.

Helpful Tip 

In case you need to double check an answer while taking the quiz, you can keep this reading material page OPEN by taking your mouse, and right clicking the “Quiz” link.  Then, select the option to open to “Open Link in New Tab”.

This will open the quiz in a new tabbed window next to the reading material page.