Identifying ligament weakness and resulting spinal instability as a cause of sciatica.
In a 2016 study published in the journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders, Ross Hauser, MD and team noted that in approximately 90% of patients, low back pain is a structural problem typically originating from overuse, straining, lifting, or bending that results in ligament sprains, muscle pulls, or disk herniation.
The popular understanding of back pain is disk herniation as a frequent cause, but to a much greater extent, ligament injury forms the underlying basis. Ligaments hold the disk in place, and with ligament weakness, the disk is more likely to herniate.
The source of low back and buttock pain as related to the sacroiliac (SI) joint is present in as many as 15%–30% of back pain patients and perhaps up to 40% in patients who have had a previous lumbar fusion.
SI joint dysfunction may also produce pain similar to a herniated lumbar disk along the same sciatic nerve distribution. Low back pain patients who remain symptomatic despite tailored physiotherapy are believed to possess deficient ligament strength in the posterior elements of the SI joint, resulting in insufficient stability to permit effective muscle recruiting strategies.Experimental studies have found prolotherapy effective in stimulating the production of collagen fibers, thus strengthening ligaments.(1)
Identifying Prolotherapy injections as a non-surgical treatment for sciatica
Comprehensive Prolotherapy is a simple injection technique that introduces dextrose and other substances into the the areas of the spinal ligaments. These injections are given into the sacroiliac ligament attachments and the lumbosacral area as necessary. Prolotherapy injections stimulate the body’s own natural healing process which is through inflammation. The inflammation causes the blood supply to dramatically increase in the injured areas, alerting the body to send reparative cells to the ligament site. Ligaments, such as the sacroiliac ligament are made of collagen. In this healing process, the body deposits new collagen. The sacroiliac ligament will then be strengthened and tightened as this new collagen matures. The sacroiliac joint which was unstable, will then become strong and stabilized, and the symptoms will abate.
You have been diagnosed with sciatica -Surgical and conservative care evaluations.
A person will begin the journey to a sciatica diagnosis with a trip to his/her doctor for complaints about leg pain and/or severe knee pain and a burning, numbness sensation in your legs from hip to toe.
The doctor at this point may suspect sciatica symptoms and will be looking at the possibility of a herniated, slipped, bulging disc and need a sciatica treatment plan.
Recommendations to reduce physical activity is generally made, heavy lifting is to be avoided. Hamstring stretches and abdominal strengthening or low back exercises may be encouraged to strengthen the spine. A physical therapy plan may be encouraged.
Your doctor may recommend a pain relief plan and tell you about an epidural injection or nerve block for sciatica nerve pain, pain-killers, NSAIDs anti-inflammatory therapy or corticosteroids. Your doctor will likely issue warnings to you about the realistic expectations of pain relief you may achieve and what type of herniated disc sciatica recovery time you may expect.
Research has called into question all of these “remedies,” as effective for sciatica patients.
Pain medications and pain management: The most effective pain medication to treat patients with sciatica or radicular leg pain is unclear
- October 2017, a team of Brazilian researchers writing in the British Medical journal highlight their reaserch this way:
- “The most effective pain medication to treat patients with sciatica or radicular leg pain is unclear”
- “Medications used for the treatment of sciatica can have considerable side effects.”
- Acute sciatica will usually clear within two weeks, and about three quarters of patients reported any improvement within 12 weeks. Thirty percent of patients will report persistent and disabling symptoms after one year.(1)
- Researchers in Sweden concluded in the The Cochrane database of systematic reviews: “The efficacy of NSAIDs for pain reduction was not significant. . . we found an increased risk for side effects in the short-term NSAIDs use. As NSAIDs are frequently prescribed, the risk-benefit ratio of prescribing the drug needs to be considered”(2)
- Researchers in Australia at the University of Sydney wrote in the journal Drugs and Aging of their questioning pharmacological management, including paracetamol (Tylenol), in older patients with sciatica. “There is overall very limited information on the efficacy, safety, and tolerability of these medicines in older patients.”(3)
Epidural corticosteroid injections and pain management : Epidural corticosteroid injections have no demonstrated efficacy beyond the placebo effect
- 2014: In the French medical journal Prescrire international (Prescribe), this editorial appeared in late 2014: Sciatica and epidural corticosteroid injections:
- According to trials conducted in hundreds of patients with sciatica, epidural corticosteroid injections have no demonstrated efficacy beyond the placebo effect, either in the short term or the long term. However, they expose patients to a risk of sometimes serious neurological adverse effects.(4)
- However some patients do get relief from Epidural Steroid Injections. In a November 2017 study in the journal World Neurosurgery, doctors in Switzerland wanted to see how long that pain relief lasted.
- Fifty-seven patients who underwent a transforaminal epidural steroid injection for sciatica secondary to a lumbar disc herniation were followed for 24 months.
- Leg and back pain, health-related quality of life were measured using various scoring systems. Patients who underwent a second injection or surgery were defined as treatment failures (nonresponders).
- At 24 months, 31 (54.4%) patients were responders, and 26 (45.6%) were nonresponders.
Most patients with a symptomatic lumbar disc herniation who opt for a second injection or surgery do so within the first 6 months. Reliable prediction of the long-term treatment response based on short-term pain relief is not possible.(5)
Diagnosing Sciatica and leg pain. Long-term problems can begin with a confusing diagnosis
The term sciatica is thrown around loosely and is often used for any pain traveling down the leg. In fact some patients come in asking for sciatic nerve treatment.
True sciatica is a nerve injury that causes extreme pain and is caused by the sciatic nerve being pinched due to a herniated disc, spondylolisthesis, or foraminal or lumbar stenosis commonly referred to as spinal narrowing.
However, many patients are diagnosed with “sciatica” when, in fact, their sciatic nerve is not getting pinched.
This problem with accurate diagnosis can lead to long-term problems of hit and miss and potentially harmful treatments. In research from doctors in the United Kingdom, the researchers called the identification of clinically relevant subgroups of low back pain the number one low back pain research priority in primary care. (6)
What does this mean?
- Patients with leg pain, should be checked for a low back pain origin in the sciatic region for proper treatment.
- Patients with knee pain, should be checked for a low back pain origin in the sciatic region for proper treatment.
- Patients with hip pain, should be checked for a low back pain origin in the sciatic region for proper treatment.
Surgery for Sciatica
When the above non-surgical treatments are unsuccessful, the recommendations may turn towards lumbar spine surgery. This recommendation may be confirmed by an “abnormality” on an MRI scan. You may get a sciatica surgery options such as laminectomy and spinal fusion, Your surgeon will provide you with realistic expectations of the surgery and the appropriate warning involved.
- Writing in the European Journal of Pain, doctors found that some patients with sciatica still experience pain and disability 5 years after surgery. They wrote in their conclusion “Although surgery is followed by a rapid decrease in pain and disability by 3 months, patients still experience mild to moderate pain and disability 5 years after surgery. “(7)
- In the journal Expert opinion on emerging drugs, doctors say that pain medications and surgery are not the answer and researchers need to look into gene therapy and stem cell therapy for back pain. (8) This will be discussed below.
Sciatica and long-term risk of increased levels of disability. Sciatica and low-self esteem and depression in older men
In this side-note we are looking at research from a Swedish team publishing in the journal Age and Ageing who made these observations:
- about 49% of those with low back pain and 54% of those with low back pain with sciatica diagnosis rated their health as poor/very poor.
- Men with any low back pain had poor self-estimated health, depressive symptoms, dizziness, fall tendency, suffered from other diseases and had low physical activity, used walking aids.(9)
It is important to realize the significance of a patient’s depression and overall disability in offering care. This is especially important in the patient who has had failed treatments for back pain. Please see our accompanying article When depression and anxiety prevent healing of back pain.
Non-surgical sciatica treatment
It is important to note that many people have herniated disks or bone spurs that will show up on MRI’s and other imaging tests but cause no symptoms. So a herniated disc according to MRI does not cause sciatica in all patients.
The sciatica complaint very possibly is a simple ligament problem in the sacroiliac joint. For the majority of people who experience pain radiating down the leg, even in cases where numbness is present, the cause of the problem is not a pinched nerve but sacroiliac ligament weakness.
Sciatica may be due to ligament laxity in the sacroiliac joint, which can cause radiating pain down the side of the leg, as well as numbness, a symptom that has traditionally been attributed only to nerve injury.
Indications the symptoms are caused by a “pseudo sciatica” ligament injury rather than nerve injury
- You can sit in a chair and raise your leg straight out in front of you without reproducing your pain.
- Your low back pain is greater than your leg pain. Leg pain is 25% or less of the pain.
- The pain isn’t to the point of causing you to sweat.
- No numbness in your leg or foot.
- You experience numbness, but can touch the area and have sensation of touch there. This is a referral sensation, generally from a ligament injury, not a nerve injury.
Prolotherapy treatment for Sciatica
Rather than boosting degeneration in the low back with cortisone, or taking the drastic approach of surgery, we recommend regenerative ligament repair with Prolotherapy. Prolotherapy eliminates pain in the local ligament, in this case the sacroiliac ligament in the sacroiliac joint, as well as the referred pain, and is curative in most cases of “diagnosed” sciatica.
Questions about Prolotherapy treatment for Sciatica? Ask us
1 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. Clinical Medicine Insights Arthritis and Musculoskeletal Disorders. 2016;9:139-159. doi:10.4137/CMAMD.S39160.
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