In this episode of Dr. Talks we host Dr. SK Rajan, a renowned neurosurgeon and spine surgeon based in Gurgaon, India. He is an ‘AO International’ Certified Spine Surgeon with 20 years of experience in surgical arena.

Dr. Rajan explains in detail following.

  • Overview of Sciatica Pain
  • Causes of Sciatica Pain
  • Sciatica Risk factors
  • Symptoms of Sciatica Pain
  • Treatment for Sciatica Pain
  • Prevention of Sciatica

#sciatica #sciaticapain #sciaticatreatment

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Transcript

Sciatica Nerve Pain: Causes, Symptoms, Prevention and Treatment

A talk with Dr. SK Rajan.

Speaker: Mr. Vivek
[0:00]

Hello, welcome to Dr. Talks. This is your host Vivek. Here we chat with the best doctors about diseases and conditions they treat. Our guest today is Dr. SK Rajan. Dr. Rajan is an associate chief neurosurgery and head neuro spine neurosurgery at Artemis hospital, Gurugram. He is an ‘AO International’ certified spine surgeon who brings with him over 20 years of experience in the surgical arena accumulated from a wide variety of institutions from around the globe. He was recently honored with the ‘Award of Excellence in Spine Surgery’ at the Global Healthcare Excellence Award at New Delhi for his contributions to the field of spine surgery.
Welcome Dr. Rajan.

Speaker: Dr.Rajan
[0:58]

Hello. Thank you for inviting me to Dr. Talks.

Speaker: Mr. Vivek
[1:02]

Doctor, I would first request you to share your background in medicine with us.

Speaker: Dr. Rajan
[1:07]

Yeah Vivek. I’m basically a neurosurgeon by training. I started my surgical training from PGI Chandigarh in the year 2000 after which I came to Delhi to do my specialization in neurosurgery. Following that, I went to the UK to do my higher training in spine surgery, and then to the US Cleveland Clinic spine institute, where I was exposed to the latest in terms of spine problems and their treatment. I also spent some time in Mumbai to further develop my skills in neurosurgery and spine surgery. This was followed by a faculty position at a Delhi central government hospital by the name of Safdurjang hospital where I worked as an Assistant Professor for over a period of about three years. Then I jumped into practice and I’ve been practicing since so it’s been over 20 years of surgical training and experience and currently I’m working as the head of neuro spine at Artemis hospital and Associate Director of Neurosurgery.

Speaker: Mr. Vivek
[2:11]

Dr. Today I wanted to discuss Sciatica Nerve Pain. Can you help us understand what Sciatica is?.

Speaker: Dr. Rajan
[2:20]

Sciatica basically refers to pain that radiates along the back of your thigh and down to your legs. It is a pain which radiates along the path of a nerve by the name of Sciatic nerve. Now this happens because either the nerve gets irritated or it gets compressed. Now this nerve is unique in the sense that it is the largest nerve in the body and is made up of a combination of a few nerves in the back. So this pain is often experienced by the patient as either shooting, sharp, stabbing kind of pain, which may be accompanied by some sort of numbness or tingling occasionally and is often seen on one side of the body. So this is basically an introduction of Sciatica.

Speaker: Mr. Vivek
[3:10]

What are the epidemiologic characteristics of Sciatica pain?

Speaker: Dr. Rajan
[3:15]

In general there doesn’t appear to be any predominance in the sense that Sciatica is something which will affect males and females equally. Most of these cases are seen in the age group between 20 and 60. And often the peak incidence is seen in the age group of about 40 years of age. In general, it is rare to find Sciatica in patients who are less than 20 years of age until unless they’ve experienced some kind of trauma. Also, one thing that we can observe in terms of epidemiological characteristics is that this seems to be common in patients who have professions where there is a lot of physical task involved in awkward positions, like weightlifting, machine operators, truck drivers.

Speaker: Mr. Vivek
[4:03]

What are the common causes of Sciatica?

Speaker: Dr. Rajan
[4:06]

It’s very important to understand that even though people commonly refer to Sciatica as if it’s a diagnosis, it’s not actually a diagnosis. It is basically a symptom, sort of a presentation. So it’s important for us to understand the possible causes of Sciatica, so that we can focus the treatment on addressing the root problem rather than just the pain. So, as I said earlier, Sciatica happens when the Sciatic nerves become pinched or get inflamed or irritated. Now, there are a number of causes why this nerve can get inflamed or compressed. The most common cause is we have seen that in over 90% of cases Sciatica happens because of a lumbar herniated disc. We mean that in the spine we have bones, which are separated by soft tissues called the discs. So sometimes these discs which are like a cushion, the covering ruptures and content will come out and cause compression on one of the nerves that forms the Sciatic nerve. So the compression that happens in such a case could either be a direct compression, which is a physical compression of the nerve, or it could be a chemical inflammation of the nerve. So this is the most common cause of Sciatica. Other than that, as we age our spine becomes narrow, and the space for the nerve becomes less and this is referred to as lumbar canal stenosis but this is also one of the common causes of Sciatica. As seen in the relatively elderly group of patients. This often causes pain which goes to both sides of both legs other than a single leg. Another cause of Sciatica is degeneration, which means that there is no stenosis as such, there is no herniated disc, but extra bone gets formed which causes impingement of the nerve and cause this pain and one of the causes for Sciatica is something known as spondylolisthesis spondylolisthesis. Now spondylolisthesis happens when there’s a small fracture in the back, and the bone slips on one on the other and this causes pinching of the nerve root. Then we also have some rare causes of Sciatica. There is a long list, but I will just focus on two of them, which often lead to a diagnostic dilemma where as doctors we feel that sometimes we miss the diagnosis. One of these is a sacroiliac sacroiliac joint dysfunction. Now we have these two joints on either side of your spine at the level of the hip, which can often get inflamed and give the impression of it being a Sciatica because the nerve crosses that joint, so it’s not really the nerve, which is the culprit level it’s the joint. A second is a piriformis syndrome. There’s muscle in the hip, which occasionally will trap nerve root and cause pain. Very rarely, one could have Sciatica because of tumor infection or some sort of fracture in the lumbar spine, where the nerve can get trapped and cause Sciatica.

Speaker: Mr. Vivek
[7:14]

What are Sciatica risk factors?

Speaker: Dr. Rajan
[7:18]

Sciatica is found to be common in certain types of occupations where there is a lot of physical strenuous activity of positions involved, as we had discussed like in truck operators, machine operators or truck drivers. So, in general apart from the occupation there are certain factors which do predispose people to developing Sciatica. One of them is obesity, which means that in case you’re overweight or morbidly obese the amount of load on your spine is excessive, and then that can cause the disc to herniate or it can cause the degeneration to take place faster. Also people who got a profession where they have a lot of prolonged sitting or you have a sedentary lifestyle. They also develop Sciatica because the support structures which are the bones, the muscles, they are the ones which become weak. There are also other medical conditions like Diabetes, Vitamin B12 deficiency and these kinds of conditions also predispose a person to Sciatica. A few modifiable risk factors include smoking, which we have seen to increase incidence of degeneration and also the poor work ergonomics in terms of how you sit in terms of how you work in terms of how you sleep, all those aspects can also expose you to developing Sciatica.

Speaker: Mr.Vivek
[8:47]

What are the symptoms that one should look out for?

Speaker: Dr. Rajan
[8:50]

So Sciatica basically refers to the pain as we had discussed which radiates from the back down to the back of your leg and reaches down up to your calves. This is the hallmark of Sciatica. So if you talk about symptoms, you will find that the patients feel the pain to be the most predominant symptom and it’s like a sharp shooting pain, excruciating pain, which feels like an electric shock. It becomes worse when coughing or sneezing or sometimes prolonged sitting. So as we had discussed, it’s often seen on one side so patients who find that there’s a pain going down the leg on one side of the body which is sharp, excruciating, this is what Sciatica will refer to. Now in some subset of patients you will also find that the patient will feel some tingling or numbness. So all these features, tingling, numbness, altered sensations, all these are features of a nerve pain. So apart from the pain itself you can also find these features. Another characteristic of Sciatica pain is that it often increases on changing posture or decreases on changing posture. So this fluctuation in changing posture is also tied to characteristics of Sciatica pain.

Speaker: Mr. Vivek
[10:06]

Doctor once you see a patient with Sciatica symptoms, how do you go about clinically diagnosing the patient?

Speaker: Dr. Rajan
[10:14]

It is basically a self diagnosable disease in the sense that it is a symptom and not the disease itself. You know anybody who has a pain which goes into the leg on one side with these characteristics is already diagnosed to have Sciatica. So we have to find out the underlying cause of Sciatica. So if you talk about diagnosing the cause of Sciatica, it’s important to understand that this is usually not possible without the patient being physically present in front of the doctor and without the help of a certain imaging and other modalities. So if you talk of a diagnosis, the doctor will make you lie down and try to lift your legs one by one. Now because the nerve is inflamed, often the leg raising will not be possible beyond a certain angle. So this is something which the doctor will mention as a straight leg raising test and any patient who doesn’t have an ability to lift his leg right up to 90 degrees will come under the category of sciatic. There will be further questions for diagnosis like whether there has been any history of trauma, lifting of weights, certain jerks and then the patient will be sent for the most important investigation which is MRI. But I would add here that many of the patients don’t need an MRI to begin with. We start with a symptomatic treatment understanding that 90% of Sciatica is because of disc collapse. So unless there are some warning signs, which we can discuss a little later, one can start the treatment right away without needing any major investigations but in a certain subset of patients whose pain is very severe or who had developed a limp or where the urine or stools problem become predominant or who develop numbness around their perennial area, those patients require an immediate MRI. So MRI is the modality of choice in diagnosing Sciatica and it is a lumbar spine which is covered in the MRI and in more than 90% of cases, you get answers from there.

Speaker: Mr. Vivek
[12:28]

Can you highlight certain red flags which a patient should look out for and immediately go for medical consultation?

Speaker: Dr. Rajan
[12:37]

Very good question. You know, by general experience in the population, a lot of patients find that their Sciatica will usually go off with time, it will often recover completely and that’s why we find that the seriousness of Sciatica is often ignored by general public because they have some cousins or relatives who has improved without even going to a doctor or just going to a physiotherapist or just doing some Ayurvedic treatment. So it’s important to understand that not all patients with Sciatica will recover on their own. And some may even go ahead and get complicated in case they don’t take timely medical attention. So, these are what you are referring to as red flags. So things like developing a pain converting to numbness in the affected leg is a red flag. Patient developing weakness means not because of pain, but because of a limp, painless difficulty in lifting the ankle, foot or knee. So, all these indicate that the nerve damage is severe. So which means we should not take it lightly and try some home remedies. Another aspect that one must keep in mind is that there is a possibility of a bladder or bowel dysfunction, which could manifest in the form of either constipation or inability to pass urine, decreased frequency of urination, poor emptying of the bladder, feeling of fullness even after going for the urine, numbness around the perianal and Peri urinal area. So all these are indications that the nerves are getting critically involved. So extremely important to meet your doctor immediately.

Speaker: Mr. Vivek
[14:24]

How’s Sciatica treated, I mean the treatment options you have when you have diagnosed a patient with Sciatica.

Speaker: Dr. Rajan
[14:33]

In the majority of the patients the Sciatica will resolve on its own with help of just a few precautions, some physiotherapy, some medications without the need for any kind of intervention. So the typical period of recovery is between four to six weeks. However, in some cases, we may find that the Sciatica gets prolonged for more than a few weeks. It is one of the normal things we see especially in patients who have advanced disease where they have injured the nerve in some way, either slipped in the washroom or had some kind of trauma, in those cases it may take slightly longer time but if you look at the treatment on the whole we divide it into two parts, one is non surgical treatment other is surgical treatment. Non surgical treatment will include a wide gamut of modalities such as precautions, physiotherapy, medications, some therapeutic injections, some alternative therapies, yoga but obviously, in certain restricted forms. So if you look at the treatment of Sciatica, we are basically taking support of three main modalities. One is precautions, which means you’re not allowed to bend at the waist, you’re not allowed to sit on the ground, you’re not allowed to squat, you’re not allowed to do gardening or play with pets or sit in a low sitting area or lift children all these can worsen the pain. So these have to give rest to the nerve. The second pillar of support is taking the right kind of medications, which will help to decrease the inflammation of the pain. And third is taking the support of physical therapists where sometimes they use modalities which penetrate deep into the spine to decrease inflammation of the nerve and sometimes they take help of exercises to stretch the muscles which are in spasm.

Speaker: Mr. Vivek
[16:34]

Are there any self help approaches which patients can follow themselves?

Speaker: Dr. Rajan
[16:39]

Yes, first, of course, as I said is the precautions itself, which means you’re not inducing any more injury to the nerve and therefore not increasing the pain other than that local therapies like heat or cold therapy are known to decrease the amount of pain in the back. So one could use ice packs to decrease inflammation. Some patients prefer to use heat pads for causing relief in their pain. In general it is ice packs which work better in acute inflammation but other than that in terms of self help one can also develop certain forms of exercises as a part of the routine as the pain decreases which will keep their muscles in tone. Some physical activities, aerobic activities 20 to 30 minutes or five times a week should be enough to keep your muscles in tone.

Speaker: Mr. Vivek
[17:36]

Doctor we talked about self help approaches, we talked about prevention in case the pain still persists. What are the options remaining in front of the patient and his or her doctor if the pain persists?

Speaker: Dr. Rajan
[17:50]

In a certain subset of patients you are right they may not improve on medications and physical therapy exercises. Now those subsets of patients will have inflammation which is out of proportion. In such a subset of patients, we find that the inflammation is very severe. Now, depending upon the MRI findings, we decide whether to go for some sort of therapeutic injections for Sciatica or whether to go for a surgical explanation. Now, patients who’ve got only inflammation of the nerve, where there is no physical compression of the nerve, these patients will often benefit from therapeutic injections into the spine to decrease inflammation and to deposit the medicine right there where the inflammation is taking place. And the other subset of patients who got actual physical compression of the nerve where they are not responding to medicines, sometimes you have to take the help of endoscopy go inside and remove the compression by surgical methods.

Speaker: Mr. Vivek
[18:51]

Can you elaborate more how a surgery is planned? What are the key elements of it and post recovery.

Speaker: Dr. Rajan
[19:01]

Surgery as I said is basically a mechanical procedure where we are going to remove the mechanical compression upon the nerve. Now that mechanical compression could either be a disc collapse or it could be an extra bone formation or it could be a small tumor. So these are basically causing mechanical compression of the nerve. So we use a scope which is often about one to one and a half centimeters of incision rather than the big long cut we used to see earlier. This is an incision, we put up a part through which we are able to take our instruments and remove this fragment. But this itself is about an hour and a half procedure and is often done in a daycare setting where the patient comes in the morning, gets admitted, undergoes the procedure and goes back home in the evening. However, in some patients because of either their comorbidities like diabetes or other things, we may need to keep them for another day to give them adequate antibiotics and then that subset of patients gets discharged the very next day or the middle of the day or the evening. Now in terms of recovery, we find that the pain which is because of compression of the nerve goes almost completely on the very next day because it’s a mechanical compression which you have removed, and the patient is able to walk within a few hours of the surgery in a pain free manner. In some patients who have come after long standing disease, the inflammatory part of the disease will take time to recover. In those patients we find that 80% of pain is gone, but 20% of pain takes slightly longer to go in terms of recovery to work. Often patients who are working from home or who have light duties are able to join back by the end of two weeks, and patients who’ve got the most tedious work are able to join by the end of three weeks.

Speaker: Mr. Vivek
[20:55]

What would you advise our audience to prevent Sciatica altogether? In terms of their lifestyle changes.

Speaker: Dr. Rajan
[21:03]

Now, it’s not always possible to prevent Sciatica, because some people may have some genetic predisposition or their profession predisposes them to developing Sciatica, we have already discussed the risk factors, but in general there are a few things one can do to decrease the risk of developing Sciatica. One of them is to exercise regularly as we had discussed because it is the muscles of our abdomen and the lower back which are important to keep us in good posture and alignment and also to prevent the impact to reach that disc level. So, if they exercise regularly, as we had discussed, the chances of developing Sciatica become quite less and second is to maintain right posture when you’re sitting give good back support use armrest where possible and also considered the single small rolled towel at the back of your back when you’re sitting in front of a system. Also important to understand is that there are certain aspects which will predispose you to developing Sciatica, such as smoking and those things should be avoided as far as possible because they weaken the bone and they weaken the disc. Smoking is known to be a very significant cause of delayed recovery or lack of recovery.

Speaker: Mr. Vivek
[22:22]

Doctor you mentioned smoking as a risk factor, it is really a revelation, because mostly we associate smoking with lung diseases or cancer but we fail to understand that it can even have an impact on our Sciatica nerves. Your inputs about Sciatica, and its pain were very informative. We learned about what is Sciatica, pain, its symptoms, risk factors, diagnosis, and available treatment options. Thank you for talking to us.

Speaker: Dr. Rajan
[22:52]

Thank you so much Vivek. It was my pleasure to be on Dr. Talks. I do look forward to more such discussions.

Speaker: Mr. Vivek
[22:59]

Dear listeners please spread awareness about Sciatica nerve pain by sharing Dr. Talks podcast with Dr. SK Rajan. You can visit www.drstories.com to hear and read interesting and informative talks and stories from our doctors. Cheers till we meet next time.

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