Sciatica – Lots Learned, Lots to Learn

~ By Dr. Ken Cohen, MD, FACP, Chief Medical Director,New West Physicians ~

As we enter the Spring season replete with home improvement projects and lots of heavy lifting, the subject of low back pain and sciatica drifts to mind. What we do know about sciatica:

  • It is one of the most common ailments in our society, eventually affecting up to 40% of people.
  • It is related to irritation of the sciatic nerves, usually as the nerves exit the spine in the lower back.
  • The usual symptoms are lower back pain on one side or the other which radiates down the leg. This will sometimes travel all the way to the toes and can be very severe. It can also be associated with numbness and muscle weakness in the distribution of the nerves that are affected.
  • The lumbar discs are the cushions that separate the vertebrae, and the usual cause of sciatica is a lumbar disc herniation. This occurs when the disc protrudes or breaks off and applies pressure to the sciatic nerves.

What we know pretty much ends there.

One would think with such a common condition that the treatments would be well worked out. The case is quite the contrary. It seems that regardless of how sciatica is treated, be it physical therapy, chiropractic therapy, medications, acupuncture, epidural cortisone injections, or surgery, the long term outcomes are about the same. This means that one year after the onset of symptoms, patients treated with each of the above modalities all have the same degree of recovery. A fascinating new study adds to our uncertainty of this condition.

This study looked at patients who were treated with surgical or non-surgical approaches and had repeated MRI scans of the lower back after one year. 84% of these patients had recovered by this time. Of those who had completely recovered, 35% still had their disc herniation as visible on an MRI, and of those who did not recover, 33% still had their disc herniation visible on the MRI. In other words, the patients who still had their disc herniation were exactly as likely to have made a full recovery as the patients who did not still have their disc herniation. Additionally, there was clear evidence of the disc pressing on the sciatic nerves in 24% of those that had recovered and 26% of those who had not. In other words, no differences in either case, whether patients had surgery or not!

This information raises two critical points:

  1. The MRI scan – Both physicians and patients alike tend to look at the MRI scan as the definitive means to understand what is going on in cases of sciatica. The above information suggests that this is clearly not the case, and that decisions about surgery should rarely be based just on the appearance of the MRI. In fact, MRI’s will often lead to surgery – an incorrect direction when we base it solely on the MRI. The above study however, shows us how we can be misled by the MRI, and that we are better off relying on symptoms and the physical examination than we are on the MRI. In most cases of straightforward sciatica, MRI is not even needed.
  2. Although it is true that in some cases the pain and weakness are so severe that cortisone injections and surgery are the only means to symptom relief, nonetheless the research supports the goal of trying to”hang in there” until recovery can take place. This can sometimes take six months or longer, but on average, the likelihood of recovery is as good without surgery as it is with surgery.

Suffering through sciatica can be a trying experience. Your primary care physician can help you explore the best approaches to your care, as well as help you decide when more invasive and expensive imaging and surgical procedures might be worth considering.


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