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minimally-invasive treatment for sciatica

Posted by elliott on 3/22/05 at 14:54 (171781)

A lot of people on heelspurs seem to suffer from sciatica, maybe in part due to their foot troubles. After more than 5 years of suffering from sciatica, I am now pain-free, and wanted to share what specific treatment worked for me.

The sciatica started on my right side in '99, two months after a bad surgery on my right foot. It progressed to the point where I really couldn't sit long in a chair. I spent a good chunk of my day at work kneeling on the floor. I tried PT to no avail, and yoga which helped but wasn't a cure. I got an MRI that showed a bulging disc corresponding to the course of the sciatic pain. Due to the horror stories--too many to ignore--I didn't want surgery, nor a blind epidural shot that usually misses and hits something it's not supposed to.

Years passed, until an acquaintance told me about a friend of his that got cured without real surgery. The treatment was called epiduroscopy, an outpatient procedure where a teensy incision is made to just break through the skin (it requires just one stitch to close), and then a teensy scope is placed in the lower back. A rod inside it can poke and prod a bit in case there's some scar tissue to be scraped away. But the main thing done is to squirt enzymes, anti-inflammatories, and steroids down the various nerve roots as needed based on observation. Do a search on google using a few terms like epiduroscopy spine, and you'll get hits. Here is a really great description, including photos (just click on the first link, Epiduroscopy A Review):

http://www.smj.org.uk/0804/epidural.htm

I had this procedure done and my sciatic pain was cut in half instantly. I think I took off just one day of work. They often repeat the procedure one or two more times several weeks later (it's broken up into separate treatments because you can't overload the body with too much steroids--do that and you'll be forced to break Hank Aaron's home run record :-)), but my insurance wouldn't cover any more such procedures, and the doc, based on what he saw, wasn't sure it would help for my case despite my positive response.

Several more years passed, and in the meantime I contracted sciatica on my left side too, with bulging discs showing up there too on a new MRI (with dye--hey, where's wendyn?). Surgery was really out at this point even if I wanted it--they can't cut your whole back out. Then, last year, a friend told me his sciatica was cured by a somewhat different treatment, x-ray fluoroscopy. Here's a brief description:

http://www.spineuniverse.com/displayarticle.php/article389.html

This is done in the doc's office; you get the shot and go back to work. An x-ray device is used for accurate placement of the steroid shot. When they start injecting, they can see on the screen whether the dye runs where it's supposed to; if not, they just re-angle the needle slightly and try again, and then they know they got it in the right place. Wait 2-7 days to see the reaction. Depending on what they do, the shot may be called different names, e.g., intradiscal nerve root shot, a facet block, a trigger point injection, or whatever, but the key is they're all x-ray guided. We started with my right side. On the first visit, the doc followed the MRI as to where to place the shots, and I got no relief at all. At the next appt a few weeks later, I showed him where my pain was, and he targeted the rest of his shots there. Shortly after the 4-th visit, I was completely pain-free on my right side. After one additional visit and just one shot, I was completely pain-free on my left side. Turns out it was the SI joints bilaterally, where the nerve courses through. It's a big joint so it can take several shots to hit it and get it all.

I'm now about 5 months out and holding. I wish I would've heard of these treatments earlier so I wouldn't have suffered for so long, but in retrospect I'm glad I waited it out and didn't risk back surgery.

Even if you're pain-free, it still pays to take care of yourself. Due to yoga, which I took up after onset of symptoms, my back is now stronger and more flexible than it's ever been, and I feel this may be helping prevent a recurrence.

Epiduroscopy has the advantage of seeing directly what's going on. X-ray fluoroscopy has the advantage of being even more minimally invasive, which is why I recommend trying the X-ray thing first--it also is very helpful as a diagnostic tool for where to direct further attention (e.g., if you do or don't get at least temporary relief in a certain area).

The provider offering the treatment will typically be an anaesthesiologist by training who does nothing but this all day, and likely will be listed under pain mgmt in your insurance manual. He typically will require an MRI report before treating.

These treatments aren't that new--about 15 years old, but many primary physicians and amazingly even some neurosurgeons have never heard of it. But that is changing rapidly, they are growing in use, and fast becoming the standard first line of treatment after rest and PT for sciatica and other nerve impingements that do not require emergency intervention. Published success rates are typically in the 50-90% range, but whatever they are, there is little downside, as the risks are close to non-existent in the hands of someone who knows what he's doing, and it leaves your back completely intact. I do feel the skill of the provider contributes to the success rate, so try and find someone good.

X-ray fluoroscopy and epiduroscopy may not be for everyone, but they're definitely worth looking into. They worked for me.

elliott

Re: minimally-invasive treatment for sciatica

marie on 3/22/05 at 15:06 (171782)

Great post elliott. I'm glad to hear you're doing well.

I have saved your links.

marie

Re: Dye, Elliott

wendyn on 3/22/05 at 20:41 (171796)

Hey - I'm around once in a while Elliott. Nice to be missed (?) by you.

I am very glad that you're doing so well. My piriformus/sciatica has been back with a vengeance since I spent too long one night sitting on a hard chair. I have to fly next weekend and I'm dreading the hours sitting down.

For those of you who have suffered from it, you have my deepest, deepest sympathy. Not from the bottom of my heart, but from the bottom of my bum (which is even deeper down than my heart).

I will keep all of this in mind if the physio doesn't work out and if the MRI shows it may help.

:)
;)

(couldn't resist)

Re: minimally-invasive treatment for sciatica

Ralph on 3/22/05 at 21:48 (171801)

Thanks for the post Elliott. I am beginning to have a problem with sciatica for the first time since my P.F. started. I had some low back problems before, but the sciatic nerve wasn't involved. Now like you I'm beginning to have problems sitting. In fact I saw my orthopedic surgeon yesterday.

I had a complete work up done a while back. MRI with that dye and some nerve testing. This time he is sending me for physical therapy and mentioned that there were others things to try prior to any surgery. Maybe he was talking about the same treatment. If not I'll certainly tell him about it.

For an orthopedic surgeon he is not really big on doing surgery right away so I'm lucky in that respect. He is also very personable which I consider unusual for orthopedic surgeons. Before I did anything I'd want a couple of good opinions especially for orthopedic back people.

In any case I will print your post and keep it for reference. I greatly appreciate the information you provided.

Re: minimally-invasive treatment for sciatica

John H on 3/23/05 at 09:53 (171819)

Ralph I have had low back problems for some 25 years including low back surgery. The surgery repaired my leg pain for the most part but still left me with pain in the low back. For most back problems sitting and driving is about the worst thing you can do. I would suspect if PT does not help they will eventually get around the a standard protocol of (1) 3 epidurals (2) facet injuections (3) radio frequency lesioning (4) discogram. All involve needles. I have been this route twice with no good results other than the discogram did help in diagnosing the problem. The discogram is primarly a diagnostic tool. Have they given you a confirmed diagnosis such as degenerative disc disease, bulging disc, spinal stenosis, etc? A problem such a s bulging disc can be managed with PT and the disc can actually pull back. Having leg pain is almost a plus as it helpa narrow down the problem and confines it to nerve entrapment or pressure. For those who need a new disc the FDA recently approved the artifical disc which has been in wide use in Europe for many years. Using this disc cuts down considerably on recovery and the disc is not rigid and allows the back to function like it was intended. It also does not increase the stress on disc above it nearly as much as a fusion. Take a look at the web site http://www.texasback.com They are one of the foremost back institutes in the world. Lots of good information here I have never really found a med that would do much for back pain although I have never got into the heavy duty narcotics. You also might take a look at
http://www.medtronics.com They will send you a free pain VCR and tell you a little about the devices they use that are implanted in the back to control pain. Will be glad to answer any questions.

Re: minimally-invasive treatment for sciatica

Ralph on 3/23/05 at 12:47 (171835)

Question for anyone
Since my back started acting up I'm wondering if it's possible that my P.F. pain can be caused by my back problem. Could I have referred pain into the arch area which is being diagnosed as P.F. but is actually because a root nerve is being pinched?

I didn't think about this until Elliott brought up sciatica. My lower back pain has expanded to include pain when I sit. Didn't even occur to me to ask the doctor if they could be related.

Re: minimally-invasive treatment for sciatica

Julie on 3/23/05 at 14:17 (171838)

They can be related, Ralph. Which came first, the foot pain or the back pain? If the former, even a small alteration of your gait to accommodate your pain would have knock-on effects further up: knee, hip, and lower back pain are often the consequence of heel pain.

If the back pain started first, then the possibility that it has caused your PF ought to be considered. The sciatic nerve is the longest nerve in the body; it supplies the entire back of the leg, with branches that end in the foot.

Sitting is the worst position for sciatica (and most back pain). Difficult to avoid if standing and walking are a problem! Check your chairs, and check how you are sitting, and if you are working at a desk, make sure the relationships of desk height, chair height, work height, screen height, etc, are all adjusted to produce maximum ease and minimum strain on spine, eyes, shoulders, hands, etc.
.
.

Re: minimally-invasive treatment for sciatica

john h on 3/23/05 at 18:54 (171846)

Having researched this for some years Ralph my conclusion is that is a very remote possibility. Most of the time it is just what it appears: PF

Re: On the ball

wendyn on 3/23/05 at 21:46 (171858)

I sit only on a 'fit-ball' now at work and at home on the computer. I actually roll the ball down the hall to meetings. It really really helps my sciatica - and hey, maybe I'll get some extra core strength in as well!

I highly suggest giving it a try.

Re: minimally-invasive treatment for sciatica

Julie on 3/24/05 at 01:02 (171864)

John, it may well appaear to be, and feel like, 'just what it appears, PF', but it still has an underlying cause, and as you know, there are many possibilities. One of them is pain emanating from the sciatic nerve, and however rare a possibility it is, it is a possibility. Pain from a compromised sciatic nerve although most usually referred to hip, thigh, and groin, can be referred further down the lower extremity. It may not be happening in Ralph's case, but if no identifiable cause has yet been found it's worth exploring the possibility.

My podiatrist was of the opinion that many more cases of PF stem from sciatic nerve impingement than is recognised or acknowledged.
.

Re: On the ball

Julie on 3/24/05 at 01:21 (171866)

Wendy, I would LOVE to see you rolling down the hall to your meetings!

I've recently learned a great stretch for the piriformis muscle: I'll email it to you once I've written out some sensible instructions (if I can).
.

Re: On the ball

elliott on 3/24/05 at 09:17 (171876)

The ball didn't work for me, I think due to my back crunching up when sinking into it. (I kept asking the fitness center I go to if they had that thing properly inflated. Alas, they did.) The best kinds of chairs for me are those with a firm flat base covered by just a little cushioning so as to remove the hardness. The new fancy chairs don't work for me either. I found an old one in the used section of a furniture store that's the best so far. I don't really need to use chairbacks: I'm so used to sitting with good posture (concave curve in the lower back) after being forced into it.

If it's really a tight muscle rather than a bulging disc, aside from all the hamstring stretches, here's two good pirformis stretches:

1. A PT showed me this one. Lie on a table (dining room table works fine) close to one edge, with the affected leg being the further away from the edge. Bend the affected leg to 90 degrees, hold it at the inner knee notch with the opposite hand and gently pull it over your body, knee positioned at around where your hip is, so it kind of just hangs a bit over the edge of the table. Your back is going to come up a bit, but try and keep it as flat on the table as you can. Holding the underside of the other side of the table with your other hand helps a lot with this. You will feel the stretch in your piriformis. Do it gently several times a day, holding it for 30 seconds or so. Slowly increase the amount of the stretch as you get more flexible. Done this way, it has the advantage of being able to take the stretch below body level, something you can't do on the floor. My PT said you do this for a month, and if you still have sciatic pain, it ain't cause of the piriformis.

2. Lie on the floor on your back. Let the sole of the foot of your good leg rest on the ground, so knee is raised up. Put the ankle of the affected leg up on your other knee, just like how gentlemen sit at a meeting (they lie on the floor? :-)), so the inner side of the affected knee is facing almost skyward. Then gently push the knee of the affected leg in the direction of the floor. You will feel the stretch.

Re: minimally-invasive treatment for sciatica

elliott on 3/24/05 at 09:21 (171877)

Thanks for the wishes.

Well, my back is doing well. But a lot of other body parts aren't worth bragging about right now. :-)

Re: On the ball

wendyn on 3/24/05 at 23:13 (171923)

That's too bad that the ball didn't work out Elliott. Thanks for the stretches. I will take a good look at them and give them a try.