Injuries Unpacked #14: Sciatica & Lower Back

Sciatica is radiating pain that follows a dermatomal distribution (specific area of the skin supplied by a specific nerve) down the leg1. By name this would suggest the sciatic nerve is involved, but colloquially the term “sciatica” is used to encompass any nerve that produces this uncomfortable shooting/lightning/radiating/tingling pain1. The two important things to realise are sciatica is a symptom (like pain or numbness) NOT a diagnosis, and secondly there are other causes of nerve pain or “referred pain” (pain felt in one area but caused by another)1.

In 90% of cases, sciatica is caused by a disc herniation pushing on a nerve root causing it to be compressed1, leading to irritation and symptom reproduction2. The diagnosis of a disc herniation causing your symptoms can be made by a Physiotherapist after a careful history-taking and objective examination.

And there it is.

 The boogeyman of injuries, the kryptonite of your spine, the poorly paired wine with your dinner, the pathology whom should not be named!

The herniated disc

Before you start checking under your bed, researching wine pairings or have any premonitions to watch Harry Potter let me tell you why disc herniations are not the serial-killer you think they are, but more akin to a casual shoplifter or loud but harmless in-law.

Our intervertebral discs (IVD’s for short) slowly develop small clefts by age 3 and accumulate as we age and certain cells in our discs will break down and rebuild themselves slowly5. A herniation will happen at a spot along the disc that is particularly weak (due to cell break down/large number of clefts)5. As the disc herniates, it will initiate an inflammatory cascade that is CRITICAL in the reabsorption of the disc5.

Yes, reabsorb.

If the herniation happens to be upon a nerve the inevitable inflammatory process will irritate the nerve it’s on and cause your symptoms5, your sciatica. The inflammatory process is normal in disc herniations and not an enemy. Consult your GP about advice pertaining to taking anti-inflammatories as part of your pain management.

Modifiable Risk Factors put you more or less at risk of disc herniations: A high bodyweight5, stressful or physically demanding job (specifically repetitive bending over/upright + twisting + manual labour)5, 6, driving motor vehicles for prolonged times7 and smoking5, 7 are all going to put you at an increased risk of herniations.

But if they fix themselves, why change my lifestyle?

Because this is not a system you want overwhelmed.

To illustrate this point, pretend you have just seen a pipe leaking water through a small hole. You laugh at the sheer ease of the task; you grab some trusty duct tape and slap it on. Then another leak appears and you carry out the same task…..simple!

Then a larger hole bursts; duct tape won’t cut it so being rational you jam your foot in it. Then another part bursts just out of your reach – you throw your hat at it in an ill-conceived attempt to somehow miraculously plug the hole – it somehow works. But now another has burst 2 feet from you, and another, and another! Eventually the whole pipe bursts and some angry water buffets you.

See where I’m going? If you encumber the body’s ability to heal itself, the end result is recurrent disc herniations that likely will not reabsorb. So, what can you do?

Physiotherapy – People with sciatica who undertook a Physiotherapy functional restorative programme achieved significant scores in work satisfaction, change in symptoms, improved disability scores9. 70-90% of people will improve overtime with conservative management10. In a randomised control trial 6 patients reported temporary increase in symptoms with physio (6%) with 5 reporting symptom dissipation in 1 hour and 1 participant reporting symptoms lasting 1 day9.

Surgery – If that water pipe has burst, it may be too late and surgery may be your best option. Recommended after a course of Physiotherapy/conservative management11 the goal is to remove disc material compressing a nerve to reduce irritation11 called a discectomy. These do come with the complications11 including reoperation rates of around 13.4% within 5 years12.

Injections – Significant pain relief (>50% of severity) in 74% of patients within 1 year13 in those that receive injections (anaesthetic with or without steroids), with complication rates of around 11%14. It won’t fix anything structural pertaining to the underlying cause, but it will likely reduce symptoms13.

If you can afford me one last metaphor: You’re playing Jenga. You make a bit of a silly move and the tower is left wobbling early in the game, your adversary laughs and affords you the choice to undo your mistake.

So, do you?:

  1. Push it back into place, restoring the structural integrity of the tower as much as you can prolonging your game of Jenga?
  2. Cut the piece out at risk of some stability to the tower?
  3. Look away and pretend the piece protruding doesn’t exist?

I’ll leave that for you to decide!

References

Valat, J.P., Genevay, S., Marty, M., Rozenberg, S. and Koes, B., 2010. Sciatica. Best Practice & Research Clinical Rheumatology24(2), pp.241-252.

Konstantinou, K. and Dunn, K.M., 2008. Sciatica: review of epidemiological studies and prevalence estimates. Spine33(22), pp.2464-2472.

www.welcomebackclinic.com. (n.d.). Disc Herniation and Sciatica – Welcome Back Clinic – MRI and Pain Management Centre. [online] Available at: https://www.welcomebackclinic.com/blog/Disc-Herniation-and-Sciatica.htm [Accessed 25 Oct. 2020].

www.stlukes-stl.com. (n.d.). Sciatica Multimedia Encyclopedia Health Information St. Luke’s Hospital. [online] Available at: https://www.stlukes-stl.com/health-content/health-ency-multimedia/1/000686.htm [Accessed 25 Oct. 2020].

Schroeder, G.D., Guyre, C.A. and Vaccaro, A.R., 2016, March. The epidemiology and pathophysiology of lumbar disc herniations. In Seminars in Spine Surgery (Vol. 28, No. 1, pp. 2-7). WB Saunders.

Zhang, Y.G., Sun, Z., Zhang, Z., Liu, J. and Guo, X., 2009. Risk factors for lumbar intervertebral disc herniation in Chinese population: a case-control study. Spine34(25), pp.E918-E922.

Heliövaara, M., 1989. Risk factors for low back pain and sciatica. Annals of medicine21(4), pp.257-264.

www.cartoonstock.com. (n.d.). Water Pipe Cartoons and Comics – funny pictures from CartoonStock. [online] Available at: https://www.cartoonstock.com/directory/w/water_pipe.asp [Accessed 25 Oct. 2020].

Hahne, A.J., Ford, J.J., Hinman, R.S., Taylor, N.F., Surkitt, L.D., Walters, A.G. and Mcmeeken, J.M., 2011. Outcomes and adverse events from physiotherapy functional restoration for lumbar disc herniation with associated radiculopathy. Disability and rehabilitation33(17-18), pp.1537-1547.

Saal, J.A., 1996. ▪ Natural History and Nonoperative Treatment of Lumbar Disc Herniation. Spine21(24S), pp.2S-9S.

Kamper, S.J., Ostelo, R.W., Rubinstein, S.M., Nellensteijn, J.M., Peul, W.C., Arts, M.P. and van Tulder, M.W., 2014. Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis. European Spine Journal23(5), pp.1021-1043.

Kim, C.H., Chung, C.K., Park, C.S., Choi, B., Kim, M.J. and Park, B.J., 2013. Reoperation rate after surgery for lumbar herniated intervertebral disc disease: nationwide cohort study. Spine38(7), pp.581-590.

Manchikanti, L., Singh, V., Falco, F.J., Cash, K.A. and Pampati, V., 2010. Evaluation of the effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: A randomized, double-blind, controlled trial. Pain physician13(4), pp.343-355.

Karaman, H., Kavak, G.Ö., Tüfek, A. and Yldrm, Z.B., 2011. The complications of transforaminal lumbar epidural steroid injections. Spine36(13), pp.E819-E824.

Chen, T. (2017). Why love is like Jenga. (online) Medium. Available at: https://medium.com/collect-moments-not-things/love-is-like-jenga-f9686ede207a 25 Oct. 2020].