I Have Sciatica. What Can I Expect?
August 23, 2020A large part of treating chronic pain involves educating our patients and managing their expectations. Radicular back pain (i.e., sciatica) is no exception. Patients know there is something wrong because they hurt, and most just want to avoid surgery. But what most patients don’t know is what will happen over time to their back/leg pain.
Most radicular back pain generally is either from nerve root irritation due to canal or foraminal stenosis caused by bony overgrowth or from a new or chronic disc herniation which compresses nerve tissue. After confirming the diagnosis with physical exam and advanced imaging, we then plan how we will treat the pain and start educating the patient on what to expect over time.
Lumbar radicular pain from new disc herniation has a favorable prognosis. Pain and disability can be expected to start improving on its own in a matter of months. However, in the short run they can be quite painful and debilitating. Over time the disc herniation will actually regress and resorb. 50-80% of acute discs herniations will regress >50% at 1-2 years. Even if the disc doesn’t regress much, accommodation will occur leading to symptom reduction. Weakness can be expected to improve 1 grade as well over this time with only 25% experiencing persistent weakness at 2 years. Sensory deficits persist about 50% of the time at 1 and 2 years. Recurrence can occur so patients need to be vigilant with protecting their backs and continuing PT exercises. 25% of patients with complete resolution of pain can have recurring pain in the future.
Lumbar radicular pain from spinal stenosis has a less favorable prognosis. Instead of healing and diminishing over time, this pain is characterized by periodic exacerbations and partial remissions. The data on prognosis bears this out as on study noted that at three years 25% had unchanged symptoms, 25% mildly improved, 25% had sustained improvement, and 25% got worse or needed surgery.
At Specialists in Pain Care we are respectful of our patient’s time and resources and try to find the most simple and safe yet cost effective treatment. Like all physicians we stress wellness factors and sustainable strategies — weight loss, smoking cessation, and increasing exercise capacity. Formal PT, either on land or in the water, can be useful to teach our patients new skills and help re-train their movements and gain strength and coordination. Medications are another modality that has utility. Typically, no single medication can remove all of the pain so we advocate for a balanced approach. Opioids do have a role at least acutely, but as a sole strategy, it is a poor strategy as tolerance and dependence quickly (i.e., months) set in. If opioids are utilized, we will try to get some resolution to the patient’s problem within 3 to 4 months of presentation. The last modality at our disposal is injections. As board certified interventionalists, we utilize real time imaging to target areas of concern. Injections can be quite helpful for symptomatic relief thus promoting the more sustainable options — like core strength building and exercise.
When does surgery come into play? Failure of conservative measures and loss of functionality are two reasons to consider surgery. Prior to getting to the surgeon, hopefully we have done a good job educating the patient on the importance of wellness factors and stressing a cautious and judicious use of opioid pain medication. It is widely known (except amongst our patients) that smoking, sedentary lifestyle, obesity and high dose opioid pain medications are risk factors for poor outcomes following low back surgery.
We are currently accepting new patients and are always happy to help out our referring physicians however we can.
References: Suri 2012. Simotas Spine 2003. Hoy 2014. Croft 1998. Hides 2000. Wahlgren 1997.
