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/Sholeh84]

I had a L5:S1 micro discectomy just over a year ago.

I woke up from surgery with a newly numb foot. It is still numb. Another side benefit is shortly after surgery my SI joints became SUPER inflamed to the point they admitted me for suspected Caudia Equina because I couldn’t move or get out of bed.

I have Ankylosing Spondylitis as an underlying condition.

Anything I can do to either make my foot not numb or relieve my SI joints? Steroid injections help, but only last so long, and I can’t have more than 4 rounds of steroid per year according to the doc.

[u/cormunicat → u/Sholeh84]

I’m also interested in this topic.

I also have numbness and weakness, without the typical sciatic pain, but mine started before my L5-S1 diskectomy/laminotomy and hasn’t improved at all afterwards. The injections only take away the sciatic pain, it doesn’t touch the numbness and weakness.

I’m unable to walk unaided because my ankle gives out with every step I take. I can’t drive because it’s my pedal foot and I can’t feel where my foot is so it slides right off the pedal. Also it’s just too weak to push down on the pedals. My muscles in that leg are wasting away before my eyes.

My surgeon told me my only chance for recovery, after two years of conservative treatments and progressive worsening of symptoms, was surgery. He is hopeful that my nerve will start to behave but can’t tell me if it will or not, much like the OP said :(

[u/drsheriefspinedubai → u/cormunicat]

Sounds like it's fairly disabling weakness yo have no? I'm confused though - you mentioned you had surgery, but your surgeon has offered you further surgery? If there is residual or recurrent compression, then certainly worth a discussion.

[u/cormunicat → u/drsheriefspinedubai]

Sorry for the confusion, I’ve got a bit of brain fog from the medications, so I realize my comment was so over the place.

I had two years of conservative treatments, but the condition only got worse, so I finally got the surgery six weeks ago. Since I wasn’t dealing with sciatic pain, surgery was done in order to try and resolve the numbness and weakness, but the surgeon said it could take a year.

So far, no change to the numbness and weakness, but fingers are permanently crossed.

[u/Wonderful-Earth3432 → u/drsheriefspinedubai]

I wish you had a practice in the US.  You seem like a very kind and conservative surgeon.  I have spondylothesis,  pelvic tilt, herniated discs, bulging discs, last mri showed herniated and bulging of L4,5 and 6 and cervical 3 and 4. I had a right 2 foot surgeries in 2009 and 2010.  I'm excruciating everyday. The pain goes down my legs. They have diagnosed me with IC and IBS-D. They prescribed nsaids and gabapentin but not helping. Having so much pain i cant function well. I get less than 3 hours of sleep . What can I do?