BACK PAIN 2: SCIATICA & SPINAL STENOSIS
My blog last week was Giving Back Pain a Quick Exit. This week I want to talk about two specific back conditions that many of us seniors have already experienced: sciatica and spinal stenosis.
Sciatica refers to pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg. Typically, sciatica affects only one side of your body. Spinal stenosis is a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine. Spinal stenosis occurs most often in the lower back and the neck.
I’ve had sciatica off and on for years and now do a series of stretches every morning to prevent future attacks. And I’ve had spinal stenosis for the past 4 years. The toes in my right foot and then further up my foot started going numb in 2014. Three toes in my left foot followed. I’ve read that numb feet are a symptom of diabetes but since I regularly exercise, keep my weight down and eat mostly right, I had my doubts. I went to a podiatrist in Ventura who checked me out and told me I did not have diabetes but the numbness was most likely caused by problems in my spinal cord. Really! That was a surprise. To make a long story short, I had X-Rays and an MRI and was told by an orthopedic surgeon I had spinal stenosis. He recommended that I not seek surgery unless it worsened. Now, four years later, the numbness in my feet has gotten worse. I think it might be time for surgery.
Let’s first look at sciatica. Here are excerpts from a February 2016 Harvard University article titled Sciatica: Of all the nerve:
Sciatica is one of the most common, yet misunderstood, types of pain. As many as 40% of people will get it during their life, and it becomes more frequent as you age.
“People who suffer from acute or chronic back pain tend to be more susceptible to sciatica,” says Dr. Jeffrey N. Katz, professor of medicine and orthopedic surgery at Harvard Medical School
A look at sciatica
Sciatica tends to get lumped in with regular back pain, but it is different. Pain strikes when a root that forms one of the sciatic nerves, or the nerve fibers themselves, become pinched or irritated. You can feel the pain anywhere along the nerve’s branch—low back, buttocks, leg, calf, or foot.
No two sciatic pain episodes are alike. They can vary from a dull soreness, numbness, or tingling to feelings of an electric shock, throbbing heat, or stabbing pain. The severity can range from an annoying ache to pain so intense it makes it tough to walk or stand.
A common culprit for sciatica is a herniated disc (also referred to as a ruptured disc, pinched nerve, or slipped disc). Discs can weaken over time. Or a vertebra can slip forward and the nerve fibers become compressed, like a garden hose with a kink in it. This can happen because of an injury or trauma, but is often the result of years of bending and sitting for long stretches.
Osteoarthritis also can narrow the opening through which the nerve roots exit the lower spine, injuring the nerve fibers. Another cause is piriformis syndrome, in which the piriformis muscle in the buttock compresses the sciatic nerve.
Treatment options
Sciatica often goes away by itself within a few hours or days. However, some attacks can come and go for several weeks or even months.
Rest can help with the pain. So can medications such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs like ibuprofen (Motrin) and naproxen (Aleve). Applying ice to the area for about 15 to 20 minutes, three times a day, during the first 48 to 72 hours also may help with soreness.
If the pain is especially intense or persists for a long time, you may opt for steroid injections or pills.
If episodes become frequent and the pain begins to interfere with regular movements and daily life, you may want to consider surgery, which involves paring back discs so they do not impinge on nerve roots. You should consult with your doctor about whether steroids or surgery might work for you.
Get moving again
Once the pain subsides, you will want to take steps to prevent recurring attacks. Your best move? Get moving
“Many people fear that activity causes their pain, but low-impact activity and exercise can help strengthen the area and prevent future attacks,” says Dr. Katz. This can include exercises like water aerobics, riding a stationary bike, daily back stretching and even yoga.
“These can help strengthen the affected area, and perhaps keep episodes from returning, or at least lower their intensity and frequency,” says Dr. Katz. Physical therapy also can help strengthen muscles around the spine, which may take some pressure off your discs, he adds.
Back exercises for sciatica
Daily stretching and strengthening exercises may help to prevent flare-ups. Perform these three exercises daily after an episode ends and with your doctor’s approval.
- Lie on your back with both knees bent. Pull your left knee to your chest, and hold this position for five to 10 seconds. Repeat on the other side. Do five to 10 times with each leg.
- Lie with your knees bent. Pull both knees to your chest and hold this position for five to 10 seconds. Rest and repeat. Do five to 10 times.
- Lie with your knees bent, and cup your hands behind your head or stretch your arms to the side. Flatten your lower back to the floor. Hold this position for five to 10 seconds. Rest and repeat. Do five to 10 times
Now, let’s look at spinal stenosis, which I’m going to limit to the lumbar variety. Here are excerpts from another Harvard University article published in May 2008, Treating lumbar spinal stenosis:
Medications and physical therapy can help — and so can surgery.
In older adults, one of the most common causes of lower back (lumbar spine) pain is spinal stenosis — a narrowing of the spinal canal that puts pressure on the spinal cord, the nerve roots branching from it, or both. The effects may extend to the buttocks, thighs, and lower legs as well, causing further pain, numbness or tingling, and weakness. In severe cases, bowel and bladder control may be affected. The symptoms of spinal stenosis can severely curtail normal activities, including walking and standing. When the symptoms become chronic, they may set the stage for health problems related to inactivity, such as cardiovascular disease, obesity, and depression.
The main cause of spinal stenosis is age-related changes in bone and other spinal tissues. It’s the main reason for spinal surgery in people over age 65.
The usual recommendation for treating lower back pain is to take a conservative approach, trying other options — medications, physical therapy, lifestyle modification, and possibly injections into the spine — before resorting to surgery. These strategies don’t always work for people with symptomatic spinal stenosis, who are usually older and have other conditions that exacerbate their back problems. Only about 20% improve substantially without surgery.
Ouch, my spinal nerves
Most lumbar spinal stenosis is caused by degeneration in the disks, the ligaments, or the joints between the vertebrae (facet joints).
Disc deterioration can contribute to nerve pinching in several ways. The disk casing may weaken and give way — what’s known as a ruptured or herniated disk — permitting the gelatinous contents to extend into the spinal canal and impinge on the spinal cord or nerve roots. With age, disks shrink, reducing the spaces between the bones of the facet joints. Stress on these surfaces can produce osteoarthritic changes, including bone spurs, which narrow the spaces through which nerve roots leave the spine. Disk shrinkage can also cause the ligament that lines the back side of the spinal canal to fold inward, crowding the spinal cord and nerve roots.
Diagnosing lumbar spinal stenosis
Your physician can usually diagnose spinal stenosis on the basis of your symptoms, your medical history, and a physical exam. Imaging studies — usually MRI or CT scans — may be needed to confirm the diagnosis or assess your condition before deciding on surgery.
The hallmark of spinal stenosis is neurogenic claudication — low back, buttock, and leg pain that worsens with walking or standing and improves with sitting, crouching, or leaning forward.
Treatment
The goal is relieving pain and discomfort while improving mobility and function. Unless symptoms are severe, your physician will usually try other strategies before suggesting surgery. Even if your symptoms don’t improve much while you’re taking the conservative route, they’re not likely to worsen, and you are not likely to suffer progressive nerve damage. But chronic disabling symptoms can put you at risk for other health problems. If pain and discomfort are interfering with your normal activities and quality of life, you may prefer surgery sooner rather than later.
Here are the options:
Conservative treatment. Physical therapy is the foundation of nonsurgical treatment. The aim is to strengthen abdominal and back muscles, preserve motion in the spine, and improve overall fitness. Stretching, strengthening, and aerobic activity (bicycling, for example) are usually recommended.
Injections of corticosteroids into the space surrounding the nerve roots or into the facet joints can reduce inflammation and relieve pain for weeks to months. Anesthetic injections may also be given.
There’s some clinical evidence that chiropractic manipulation helps relieve pain, but it hasn’t been found more effective than traditional nonsurgical care. Controlled clinical trials show that acupuncture consistently reduces low back pain, but — again — there’s no reliable evidence that it’s better than other treatments.
This Harvard lumbar spinal stenosis article was published 10 years ago but since then spinal surgical procedures have come a long ways. Here’s a bit of information from a recent article by the Mayo Clinic Staff, Spinal Stenosis Diagnosis & Treatment.
Decompression procedure
With this procedure, needle-like instruments are used to remove a portion of a thickened ligament in the back of the spinal column to increase spinal canal space and remove nerve root impingement. Only patients with lumbar spinal stenosis and a thickened ligament are eligible for this type of decompression. The procedure is called percutaneous image-guided lumbar decompression (PILD). It has also been called minimally invasive lumbar decompression (MILD), but to avoid confusion with minimally invasive surgical procedures, doctors have adopted the term PILD.
Surgery
Surgery may be considered if other treatments haven’t helped or if you’re disabled by your symptoms. The goals of surgery include relieving the pressure on your spinal cord or nerve roots by creating more space within the spinal canal. Surgery to decompress the area of stenosis is the most definitive way to try to resolve symptoms of spinal stenosis.
Research shows that spine surgeries result in fewer complications when done by highly experienced surgeons. Don’t hesitate to ask about your surgeon’s experience with spinal stenosis surgery. If you have any doubts, get a second opinion.
Examples of surgical procedures to treat spinal stenosis include:
- Laminectomy. This procedure removes the back part (lamina) of the affected vertebra. A laminectomy is sometimes called decompression surgery because it eases the pressure on the nerves by creating more space around them.In some cases, that vertebra may need to be linked to adjoining vertebrae with metal hardware and a bone graft (spinal fusion) to maintain the spine’s strength.
- Laminotomy. This procedure removes only a portion of the lamina, typically carving a hole just big enough to relieve the pressure in a particular spot.
- Minimally invasive surgery. This approach to surgery removes bone or lamina in a way that reduces the damage to nearby healthy tissue. This results in less need to do fusions.
While fusions are a useful way to stabilize the spine and reduce pain, by avoiding them you can reduce potential risks, such as post-surgical pain and inflammation and disease in nearby sections of the spine. In addition to reducing the need for spinal fusion, a minimally invasive approach to surgery has been shown to result in a shorter recovery time.
In most cases, these space-creating operations help reduce spinal stenosis symptoms.
I hope this information on sciatica and spinal stenosis has given you a good introduction to these specific back conditions that so many of have had, have now, or will have.