In this episode of PodMD, neurosurgeon Dr Jeremy Russell will be discussing the topic of Sciatica, including what Sciatica is, treatment of the condition, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Neurosurgeon, Dr Jeremy Russell.
Dr Russell’s speciality involves expertise in cerebrovascular surgery, skull base neurosurgery and spinal surgery.
Today, we’ll be discussing the topic of Sciatica.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Jeremy, thanks for talking with us on Pod MD today.
Jeremy: Thank you for having me
The topic of today’s discussion is on sciatica. Jeremy, can you describe for our listeners what sciatica is?
Jeremy: So, sciatica, we’re talking about pain through the leg predominantly, it’s the lay term is sciatica. It’s actually got nothing to do with a psychotic nerve. I’d leave, but nonetheless, everyone refers to it as that. So it’s probably easier to keep it that way. it’s truly called radicular pain, and more often than not, it’s associated with back pain and it can also be referred to anywhere from the lower back into the hip, into the groin, into the buttock region, et cetera. And that’s all the referred component of the pain, which isn’t the true radicular pain. The radicular pain is the pain that shoots the whole way down the leg typically, or it depends really on, which nerve is involved as to where the pain will go.
And it’s pretty reproducible. So, there is a saying, L one to the groin, L three to the knee L five to the foot. so in the inguinal region is L one. I don’t think I’ve ever seen it. That’s more referred pain typically, and that can be discogenic in nature or from the facet. alternatively you’ve also gotta think of things like hip disease or, tendonitis or other, you know, sports exercise type stuff. L two goes to the medial mid thigh, again, rare as hen’s teeth. I think I might’ve seen at once, L three goes from the hip across the antr medial leg into the knee sometimes a little bit just beyond, and that is pretty common. L four is a little bit more lateral and goes into the bony shin, but not as far as the ankle L five runs down the back of the thigh, the posterolateral calf, the dors of the foot, and typically into the first and second toes into the top of the big toe.
And [inaudible] radiates the whole way down the back of the leg. So post your thigh, post your, a calf through the heel, into the sole of the foot, and more typically the outside of the foot to involve the fourth or fifth and fourth toes, but on the inferior aspect. And they’re pretty reliable as to the indicator as to which nerve is involved. I find it really critical that you nail this with the patient. You have to be really, really, prescriptive, and if they don’t answer it, how you want, you really have to push or force it out of them because 90% of the diagnosis is made in listening rather than anything subsequent. then the, the radicular pain is typically classified as a sharp electric shock or stabbing pain that radiates the whole way down the leg. Typically from the hip region down to the foot, rather than from the foot up, occasionally people do describe it that way.
And often there is associated a paresthesia or a tingling and nbness in the same distribution. so that, that’s what we, more, more commonly see. it is more often than not an acute on chronic thing. So most people who’ve got a history of some degree of back issues, longstanding, and they tend to fluctuate more often the nights, just back pain, lower back pain, and that’s due to a bulging disc or a bit of a worn out facet, et cetera. But that obviously is a marker for degenerative changes in the region. And if that then, worsens and ultimately puts pressure on one of the nerves, then that’s when you get the psycho. okay. I think that’s probably enough for that one.
How would a patient initially present with sciatica?
Jeremy: So more often than not, there is an associated back pain, but by no means is that necessary. Some people have no back pain at all and just present with a pure radicular leg pain. and as I said, it’s the quality of the pain. So it’s a neuropathic pain, so it’s not an arthritic, pain, which is generally described as, you know, an aching throbbing type pain. It’s more of a, well, it’s a nerve pain. So, it’s more electric shock, quality, sharp shooting, stabbing. They’re more the words that patients use. So it’s in trying to differentiate a neuropathic pain rather than an inflammatory pain, for example. and often it is precipitated by putting weight on the area. So standing, especially lifting, bending, and twisting, poor sitting posture. So when you sit down and everyone’s guilty of this year, normally sit down initially with quite a good posture, but almost inevitably slp forward so that the biomechanics in your spine, it puts more pressure on the front of the disc when you do that and pushes the disk backwards.
And that’s where the pathology is. So slping typically exacerbates the pain, and I mean, patients don’t generally volunteer this, but if you ask them to have you sit up and really push your pelvis forward and have a good seating posture that often improves, or maybe even alleviate the pain, and then lying down often helps, but not always, if they have a really large disc, or if they ruptured the disc and have what’s called a sequestr, which means that you actually, part of the internal, nucleus, that’s called the disc prolapses out and floats free in the canal. And it can be exactly excruciating when people come into ed. They can’t see it, they can’t stand up, but people come into the rooms, they lie down in the middle of the consulting floor. They’re wailing, they’re moaning that it can be really nasty, nasty pain.
Are there any warning signs or red flags a GP can look out for?
Jeremy: They end up with radiculopathy or a society, per se. it’s more keeping an open mind to other things that can be really dangerous. so the most common one and most fear, one is something called quarter Aquinas syndrome. And that’s where you have a very large disc prolapse that occupies the entirety of the central canal and puts compression on all the nerves within the canal. Now, the motor and sensory nerves, I E you know, the ones that have said [inaudible] are fairly robust, you, you certainly can have weakness with them. And, and a foot drop is a not uncommon presentation, but the more feared complication is the lower sacral nerve. So it’s two, three and four, supply sphincter and bladder function. And they are far less tolerant of compression. And patients often present with, inability to void, or even sometimes incontinence, but generally speaking, it’s more inability to avoid, enhanced pain, from a distended bladder.
Or sometimes it actually can be painless if they’ve really damaged the nerves. and also sometimes, incontinence of bow. But again, that’s less common. if they really have a bad one, they have complete flatulence or sorry, complete, it’s a, it was called patchoulis their anal sphincter ceases to work and that’s not retain anything. so that’s called recliner. I think all doctors are aware of it. That is a true spinal emergency. The longer the patient goes from onset of symptoms to us fixing it, which is a surgery to decompress the area, the less likely they have of ever regaining that function. that’s an example. If I have a patient come in and I get the registrar, call me at three in the morning, I come in at four in the morning to do that operation. so it’s not, when you wait on, what, certainly I wouldn’t want someone to wait on me.
Typically. It said you need to look within 48 hours, but I would tend to just get out of bed and fix it immediately. So that’s probably the main one that most people are concerned about. Another red flag is infection. so obviously, fevers, typically it’s more localized back pain rather than the leg pain, although you can have the leg pain, but they would generally complain of the back pain issues. and it’s been increasing in, in time. Obviously then you’ve got to consider things like immunocompromise, if they’re diabetic or on chemotherapy or more immunosuppressants, I guess these days, the elderly, the more susceptible, IV drug users, et cetera. or those kinds of things should at least run through your mind if only to exclude them. And then finally cancer. So metastasis to the spine is very, very common.
, typically it’s within the vertebral body, but then that predisposes to vulnerable body collapse. and again, it’s more of a back pain thing. So the lbar region or the thoracic region of the spine is the most common for this then lbar and cervical. but if they do get a collapse, they’ll have a sudden onset of pain. Often though they’ve had a niggling lead-up of pain, but the sudden onset when the bone collapses, because it’s a pathological fracture. And then depending upon the degree of collapse and neural compromise that they may or may not have, accompany neurological deficit, et cetera. so they’re really the main ones, that need to be thought of, in this setting, but by far and away, 99% of the time, it’s just going to be simple degenerative disc disease with compression on a singular or a couple of nerves.
What is treatment/management like for sciatica?
Jeremy: Sure, so conservative management is always, ideal where possible, so things that are not amenable to that, are any of the nasty, so quarter recliner, infection and malignancy is obviously not a conservative condition. similarly, if they’ve got a true foot drop, so if I say I was walking fine this morning, and I, now can’t lift my foot up and I’m dragging on the ground, that is not a conservative management that is let us know immediately, and I’ll take them to theater again that day, unless it’s a common peroneal nerve or other cause obviously. but for the vast majority, who’ve got, you know, mild, moderate pain, it’s , avoiding stressors, such as heavy lifting. And I would typically say no more than two kilograms for the first couple of weeks. So really they’re not lifting much at all, avoid bending and twisting where we’re able to a degree you still need to do it.
, sometimes for more elderly people that I recommend them getting a pair of the pickup sticks. So it’s like a little grippy handle with a long stick. and then, a cloth at the end of it to prevent bending over as much as possible. then the next step is typically medication. So simple paracetamol won’t do much, anti-inflammatories will help to a degree, but to be Frank that if it’s a proper sidecar, it’s not going to touch the sides. generally it’s a neuroleptic agent. now the most common one I get C being prescribed is pregabalin or Lyrica. I’ll use this little space to plug that I can’t stand Lyrica. it has a host of side effects, a really bad side effect profile, I should say. it’s a fixie is nowhere as good and that’s born out in multiple trials.
It is associated with significant weight gain, which is almost always a major pre-existing factor for spinal patients. there are significant mental health issues. A lot of people have severe reactions to it. Hmm. And it just doesn’t work as well as good old fashioned amitriptyline. So the studies bear this out time and time again, it’s cheaper. It works more often. It has a lower side effect profile. so I spend a lot of time swapping people from Lyrica to amitriptyline. Now it doesn’t always work for some people, Lyrica is better, but majority of the time I would start with amitriptyline at 12 and a half milligrams at night. I generally get them on that for two weeks because the side effect profile generally is dry eyes, dry mouth constipation, some lethargy, and a bit of a foggy head. And the key is to start slowly and go up.
If you hit them with a high dose at the start, they’ll just come straight off it. So at 12 and a half milligrams at night for two weeks and increase it to 25 milligrams, you must warn them that it doesn’t work immediately. It often takes a few days or a couple of weeks to work. So if they notice after five days or it hasn’t done anything to give a time, I generally say, if it hasn’t had any effect by a month, then you can stop it. There’s no point being on it and then trialing other medications. Then Lyrica is reasonable. Gabapentin works quite well. if the patient has a coexisting anxiety or depression, which is not uncommon, duloxetine is really good. typically starting at 30, going up to 60 milligrams, and then the other ones, there’s a, there’s a host of them, but that should take care of the vast majority.
, there’s been recent changes in the pain guidelines. So opiates are now I think, a six line medication. I think we’ve all been made cognizant of that more recently with a lot of the media, conversation, but really that should be the last case scenario and very rarely prescribed in my opinion. I’m a bit skeptical of physiotherapy in the immediate setting. I think it definitely has a course further down the track, but I think they’re better to get over their pain to a degree, short courses, so steroids, so prednisone alone, 50 milligrams for five or seven days then drop it down to 25 milligrams for again, five or seven days and stop. I pretty routinely offer a proton pp inhibitor, in conjunction with that. Cause it can upset the tmy obviously, and lifestyle modification as described, at this point in time.
And this is any of the prior red flags. I bother ordering a scan unless there’s overt weakness. 80% of people will fix themselves in 12 months. So that was the sport trial in the eighties. so, they did a trial looking at conservative management versus surgical management. And at 12 months, 80% of people, got better. Now they’re a bit more miserable at the start. so it doesn’t work for everyone, but certainly that’s the figure that I quite people, if it’s persisting, then you can try nerve root injections to be Frank. They have no long-term efficacy. I’ve stopped doing them. If I am happy that I know which nerve is involved, they will work. It’s typically anywhere from four hours to maybe a week, if you’re lucky, occasionally you’ll get the unicorn that goes longer. and again, there’s a lot of literature to back that up.
So I’ve largely stopped doing that. It’s more in the case where I’m not sure if it’s, so by this point, you’ve now got an MRI there’s compression of multiple nerves, and I’m trying to tease out which nerve it is so that I can plan a minimal operation. and then the nerve root injections can be very helpful if you’re not sure. Is it an L four? Is it an L five? I would then order an injection on the nerve that I think is the most likely culprit to gauge their response to that. If they say, Oh, you know, even for six hours, I doc my pain was great, disappeared back to back to normal and it came back. That’s absolutely what you want because now I know it tells five, if they sit on the other hand, did nothing and then it’s probably all four and then sometimes they’ll go, well, yeah, 30, 40% better versus still had a fair amount of pain here.
Then, it can be both nerves. And in which case, then I tailor my operation to address both nerves, not the singular. So I’m always looking for a way to minimize, the surgery, if we do get to that. And that really is a conservative management, I would suggest six weeks is very reasonable. rarely will I operate on someone under the six week timeframe in less. They’re one of those patients who literally can’t get out of the hospital because they’re in such extreme pain or they have significant neurological deficits such as, you know, partial foot drop or a complete foot drop, et cetera.
What imaging should be done?
Jeremy: Sure. So, if conservative management looks like it’s not going to work, or you have concerns about the other red flags, then an MRI is the scan of choice to be Frank. A CT is in my opinion, a waste of time. I never will manage someone on a CT. And in fact, if you come to see me in the rooms for this, my secretaries will organize that MRI of the lbar spine before you even see me. so although it’s cheaper and easier, long-term, I think it’s a waste of time. so you’re better off just going for a simple lbar MRI and that involves usual T1 and two sagittal and axial slices. And that shows the soft tissue anatomy in exquisite detail. If it, if it’s a decent MRI and most of the, at least the larger companies do very good jobs, that really is the only imaging that you need.
, ultrasound has no part to play. I’ve already touched on CT, nerve conduction studies, et cetera. I reserve more for unusual cases where I’m concerned that it is not emanating from the lbar region, and that will be after an MRI and a, and the MRI does not show any neural compression. And then, you know, you may be thinking about a common peroneal nerve dysfunction, or is there a nerve tor schwannoma, et cetera, et cetera. So that’s where nerve conduction studies come in. but really are the MRIs, the basis of the investigations.
When should a GP refer?
Jeremy: So typically following fail, conservative management. So either as stated previously, and I’ll always have back to this, if you, if you have any red flags that you’re worried about and just to reiterate, so that’s quarter Aquinas, concern of spinal infection or malignancy, or a significant neurological deficit, which is typically a foot drop, then they should be referred immediately. and to be Frank that’s, I’m happy to get a phone call back day with, with the patient in front of you or they should, if you can’t, if you don’t have a particular neurosurgeon, that, you know, a spinal surgeon, I should say, sorry, then I’d be referring those patients to the ed. that will be, only, you know, 5% or less of patients for the majority conservative management with the modalities that we’ve described. if they’re getting to the six week Mark and they’re really not improving, then that’s an indication I think to refer, if they’re starting to gradually improve, then it really comes down to the patient.
I call this lifestyle disease at that point. you’re not going to die from it. You not going to lose function, but you know, having constant pain is pretty miserable existence. So if things look like they’re going in the right direction and they’re happy to see how they go, then they don’t need to refer. But alternatively, if things are escalating, you know, if at week four, they’re worse than week three and again, worse at week five, then maybe you don’t need to wait the whole six weeks. You can sort of see where the trajectory is going. but then somewhere between the six and eight week Mark, if it’s really not improving and they’re just treading water, then I think referral to a spinal surgeon is reasonable. Still at that point, we’re not necessarily going to jp in and operate, but I think having that expert opinion to more than anything, assure that there is nothing nasty going on, is important.
And what is management like?
Jeremy: So, yes, and we deemed them, an operative candidate. Again, it really depends on the pathology more often than not. The surgery is just a simple micro diskectomy. It’s a very straightforward operation. It’s the most common operation we do. so briefly speaking, it’s a general anesthetic about a three centimeter cup, go down, expose the relevant area, drill away a little bit of bone, and then just remove the disc or the bone that’s compressing the nerve. It generally takes me 30 to 40 minutes to do the procedure. Most patients are in hospital only for one night. They go home the next day, they wake up, pain-free greater than 90% of the time in the leg I’m talking. So this doesn’t necessarily address back pain. I always make sure patients are aware of that. so really the key is selecting your patients well, and that, you know, that’s true of all surgery, but in a well select the patient where their symptoms fit a nerve, let’s say it goes to the big toe hotel five, they’ve got some Dorsey, flection weakness, a Fort, the MRI shows a nice L four five disc.
, you know, all the, it all lines up. Then I’d be saying that person you’ve got a greater than 90% chance of waking up pain-free and having an excellent response. so once they go home, I would generally ask them to catch up with their GP and approximately a week’s time to check the wound. I think most surgeons would do internal stitching, nothing typically would need to be removed. It would be unusual nowadays to be using staples or even, , interrupted searches. It’s more to make sure that the wound is healing nicely. It’s not leaking, no signs of infection. They’re reminded a bit of redness around the wound is entirely normal. That’s inflammation. It’s not necessarily infection. and if, if a GP is concerned of infection, if they’re happy managing it with flucloxacillin or whatever the case may be, that’s fine.
, or even keflex. But ultimately if you’ve got any concerns, we’ve just operated on this person, we’re incbent to look after them. so never hesitate to call. I’d much prefer to know about it and say, that’s fine. I’m not worried. And often in that setting, I just ask you to ask the GP to take a photo and text it to me. and obviously, you know, if they’re a febrile and their bloods are okay, then generally I say, don’t treat. But ultimately if you’ve got concerns, give us a call, happy to sort it out. That’s my job. and thereafter, I generally recommend consider rest for a while, at least four weeks, limited lifting no more than again, two kilograms for the first six weeks. And I review the patient typically at the six week Mark. And if all is going well, then I would generally refer for physiotherapy to work on core strengthening and the, get the back extensor muscles back in tone. And then things such as Pilates, yoga, et cetera, are really good exercises. I know it’s all sort of trendy these days, but they do work for core and flexibility. And from there on, it really depends upon the patient’s occupation, how physical it is as to how quickly I’ll get them back into it, et cetera.
Thank you for your time here today in the PodMD studio. To s up for us, could you please identify the three key take home messages from today’s podcast on sciatica?
Sure. So sided pain is a neuropathic pain shooting down the leg into a various distribution, depending upon the nerve. conservative management is generally indicated, but please always remember to think of, the red flags being caught or Aquinas syndrome infection or cancer. if there’s no significant neurology, then conservative management is indicated with a variety of rest and medication. And typically if they’re not getting there by six weeks or they’re incapacitated by the pain, then a referral will be appropriate at that point. and whether or not surgery, et cetera is required, ultimately we will decide.
Thanks for your time and the insights you’ve provided.
Jeremy: Thank you very much for having me.