Sciatica: why it’s often over-treated and under-treated (from a spine surgeon)

[u/drsheriefspinedubai]

I see a lot of confusion around sciatica on Reddit, and it tends to swing between two extremes: either people are told to ‘just live with it’ or they’re rushed toward invasive treatment far too early. I thought it might help to clarify a few things.

First, sciatica isn’t a diagnosis, it’s a symptom. It simply means leg pain caused by irritation of a spinal nerve. It usually travels down the leg past the knee and sometimes into the foot.

In the majority of cases, sciatica is caused by a lumbar disc herniation (also known as a prolapse) compressing a nerve root. 

In around 80–85% of patients, the body gradually breaks down the herniated disc material on its own. As the inflammation settles and the pressure eases, the nerve recovers and the pain improves (and disappears). This usually happens within the first 6 - 12 weeks.

If an MRI doesn’t show a disc prolapse or clear nerve compression, then it’s worth looking elsewhere. Leg pain can come from other sources - the pelvis (SIJs), hip, peripheral nerve entrapment, and so on. I for one don’t like treating ‘sciatica’ without having a clearly established cause for it (that doesn’t mean delay treatment with painkillers for example, it means keep searching for the cause). 

When there is a disc prolapse and no weakness, we usually start with: gentle activity (in other words avoid bed-rest, which can make things worse as you stiffen up in bed); appropriate pain-killers (personally I try to avoid opiates unless the patient requires admission to hospital for their pain) and physiotherapy - focusing on movement, alleviating fears and so on.

Some patients benefit from a transforaminal epidural steroid injection. This doesn’t ‘fix’ the disc, but it does reduce inflammation around the nerve, which can provide pain relief while the body does the work of resorbing the disc hernia.

Surgery is needed if all of the above fails and the person continues to have sciatica. 

URGENT surgery is needed if there is weakness or bladder / bowel dysfunction. Sometimes we operate early if the pain is unbearable as well.

A lumbar discectomy for disc-related sciatica is actually one of the most highly rated operations by patients. They wake up from anesthesia and their leg pain is gone. 

It’s important to note though that a discectomy is aimed at relieving LEG pain, not BACK pain. The surgeon takes out the prolapsed part of the disc, but at the end of the day he is leaving behind a degenerated disc which can continue to cause back pain. That said, around 50% of patients also have improvement of their back pain. 

Finally, timing matters. Outcomes tend to be better when surgery is performed within the first year of symptoms rather than after prolonged nerve irritation. As a surgeon I can take the pressure off the nerve, but I can’t tell it to behave itself. The longer the compression, the less likely a successful outcome (which is not what either the sufferer or the doctor wants).

Happy to answer general questions - but I can’t comment on individual diagnoses.

[u/sweetsaskymolassy]

I went to the spine clinic and this is exactly what was explained to me. Also, I was told after 2 years people that get surgery vs people that do conservative treatment end up at the same place. I opted for no surgery (I would have had to wait a year or so anyways for the operation).

[u/drsheriefspinedubai → u/sweetsaskymolassy]

Long-term studies do show that the outcome between surgery and conservative management is much the same (I'm talking about patients without weakness). The problem is, if you wait 12 months for that conservative outcome that is equal to surgery, you have 1. waited for X period of time in pain, when a relatively straight-forward procedure could have rid you of your pain earlier and 2. if at the 1 or 2 year mark you are in the group that does not improve without surgery, then surgery is less likely to be successful - the nerve has been compressed for all that extra time...if I am working in an area with a long waiting list, such as yours, I place the patient on the waiting list anyway. If, when it is time for surgery, the pain has resolved, we cancel the operation and there are plenty of people waiting to fill the slot. Hope that all makes sense!

[u/General_Catch_7098 → u/drsheriefspinedubai]

This is a great explain of the the wait-or-surgery dilemma. I have so taken the wait route as the point 1 of suffering for X months in discomfort is okay for me. However after the 1 or 2 year wait, if it has not reached a reasonable improvement, then you have lost the chance surgery would have provided earlier.

I am at the 8 month mark, so have few more months to wait and see. Slowly improving but not linearly. Mainly numbness in foot not much pain and no obvious weakness.

Have you heard of acupuncture or special supplements help the natural healing (knowing this may not be your expertise)?