Treatment of Sciatica

by | Aug 25, 2018

Many patients come to my office telling me that they have sciatica or a pinched nerve in their neck or back. The first thing I would like to clear up is that sciatica is a symptom and not a diagnosis. Most people correctly think of sciatica as pain which is running down their leg. However, any doctor who tells the patient he has sciatica is using the term incorrectly. Sciatica is a symptom of some spinal problem, but it does not explain the cause of the condition.

Cervical and lumbar radiculopathy is the more clinical term used to describe symptoms running down a patient’s arm or a leg. Patients are very commonly told that they have a pinched nerve. Sometimes this is true but at other times it may not be true. Again a appropriate pain management work up following a systematic approach is necessary to determine the true ideology.

As with all conditions,  a comprehensive work up is the only way of determining the true cause of the condition. This includes a comprehensive history and physical examination, MRI studies, and possibly EMG electromyography & NCV (nerve conduction velocity) Studies. These studies test for muscle and nerve and nerve abnormalities.

Symptoms of a true radiculopathy follow known pathways down the arm (cervical), trunk (thoracic) and legs lumbar).  This diagram shows the true anatomical distribution of nerves in the body. For example, abnormalities of nerves C2-C4 cause pain in the occiput which may present as headaches.  Nerves C5-C8 innervate the arms, T2-L1 the chest, trunk, abdomen and pelvis, L2-S1 the legs, and abnormalities of nerves S2-S5 can produce pain in the groin and perineum.

People who read my blog know that I consider interventional therapies as an incredibly important part of the overall diagnostic and therapeutic work up of any pain producing condition.  Ridiculopathies are no different. The true test to confirm this condition is with a transforaminal epidural injection (aka selective nerve root block). Only one or two nerves should be tested at a time, and should be retested for validity.

One last term which I want to discuss is referred pain.  Referred pain is pain which spreads or shoots away from the structure causing the pain, but does not follow a true radicular pattern.  This can cause symptoms in an arm or leg that mimics sciatica, but isn’t.  Any spinal condition unrelated to a pinch nerve can cause  referred pain. This can include facet joint arthropathy, sacroiliitis, vertebral body abnormalities, and many others.  If a selective nerve root injection is not beneficial, then these other etiologies need to be evaluated.

Lastly, I want to briefly discuss treatment.  Treatment for a ridiculopathy would depend on the cause of the condition. The spinal nerves exit the spinal canal through the neuroforamen. This can become narrowed due to abnormalities of the intravertebral discs, hypertrophy of the facet joints, or collapse of the vertebral bodies.  Therefore, the one we need to, respectively, alleviate intradiscal pressure, remove part of the facet joint, or expand the bony aspect of the foramen.  As always, my approach if you utilize minimally invasive and state of the art modalities to alleviate the condition.

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