Sciatica

Marc Darrow, MDMarc Darrow, MD

Of note: One fourth of patients who left their jobs because of  sciatica – were still unable to work two years later. Patients received surgery or conservative care including physical therapy.1

Radicular pain or “radiculopathy” (sometimes also referred to as a “”pinched nerve”) is often described by patients as a deep pain that travels down the leg. This pain is often accompanied by numbness or tingling, and muscle weakness in the limb.

The most common example of this type of problem is sciatica. This radiates down the leg along the sciatic nerve. Sciatica follows the path down the back of the thigh, into the calf and then into the foot via branches of the nerve.

Radicular pain may be caused by an injury to the spine. It may be from impact injuries that cause compression in the vertebrae, such as those in sports related injuries or motor vehicle accidents, i.e., disc herniation. Or it may be caused by a degenerative process discussed above such as stenosis or Degenerative Disc Disease.

It is essential to perform a physical examination in cases of referred pain to isolate the problem.

It may actually be a ligament injury that appears to be a nerve impingement and ligament trigger points may refer pain in a manner similar to radiculopathy.

This is why relying on an MRI as the sole diagnostic tool could lead to unnecessary surgery. An MRI may show a pre-existing condition that never caused pain. If surgery was performed to correct this condition and pain was actually generated by a ligament sprain, the surgery would fail.

A physical examination and conservative treatment will help determine if this is a ligament injury or a nerve problem.

It is important for the patient to know in cases of radiating pain that an MRI that indicates slippage of the vertebrae (Spondylolisthesis), an arthritic condition, or a bulging disc is NOT necessarily an indication that surgery is needed.

Sciatica Diagnosis MRI

We typically have patients come into our office with stacks of MRIs, CT Scans and x-rays to confirm the label of Degenerative Disc Disease placed on them by other medical professionals. For example, a woman once came into our office. She had in essence become the living, breathing “embodiment,” of the problem that showed up on her film. When she came in, all she could do was talk about her degenerative disc disease. This woman had pain in her groin and her back. When we told her we were going to examine her to determine if this was indeed her problem, she had a lot of difficulty comprehending that her pain may not come from her Degenerative Disc Disease at L-5, S-1 because she had already been diagnosed as needing surgery. There have been many studies and papers written on the accuracy or correctness of diagnosis based on an MRI reading.

We know from studies that half the people after a certain age show disc problems on film but they reported they had no pain.

So if someone has a diagnosis from an MRI the first thing we do is see if that is REALLY where the pain is coming from. To practice good medicine we need to rely on MRI, x-ray and CT scans. But we also need to use our hands to find out where the pain is coming from, being careful to gently press on the suspect area causing pain. When the physician’s touch elicits an intense pain spot, known as a trigger point or tender point, this may be a good area to do Prolotherapy.

1. Grøvle L, Haugen AJ, Keller A, Ntvig B, Brox JI, Grotle M. Prognostic factors for return to work in patients with sciatica. Spine J. 2013 Dec 1;13(12):1849-57. doi: 10.1016/j.spinee.2013.07.433. Epub 2013 Sep 21.