What is Sciatica? We as physicians generally don’t use this term since it is vague. People generally don’t have complete damage or compression of the entire sciatic nerve. Generally people have compression of one of the many nerves that comprise the sciatica nerve. The sciatic nerve has branches form the lower lumbar and upper sacral levels. Thus damage or compression of any of these nerves (L4 to S3) can lead to what is called sciatica. When one of these nerves is compromised, we refer to this as a radiculopathy. Thus, when people have a herniated disc or spinal stenosis that causes pressure on these nerves, usually only one or two of the nerves that comprise the sciatic nerve are affected, and not the entire sciatic nerve. This is important because when surgery or injections are considered they must be directed at the exact level that has the nerve injury. Thus, we use the word radiculopathy to describe these conditions since it is more specific.

When speaking of nerves, it is important to realize that a nerve such as the sciatic nerve is not only made up of numerous nerve roots from the spinal cord but also that each of these nerve roots has thousands of nerves within it. There might be a million nerves (or neurons) in the sciatic nerve. The best way to think of the sciatic nerve, or any nerve, is like a telephone cable. One cable has numerous wires within it. Generally, the outer telephone wires are used for homes near the source while the deep inner wires are for the more distant homes. The cable thus gets smaller as it reaches the last homes, which use those deep wires in the middle of the cable. Your nerves are the same way. The outer portion of the main nerve has small nerves that innervate the regions near the spine while the deep middle of the nerve innervates the distant areas such as the hands or feet. This is important since when something, such as a herniated disc, pushes on the nerve, the outer little nerves are affect first. This is why people will often get shoulder pain or buttock pain before they get arm pain. Only when the nerve get further compresses does those deep inner nerves get affected and then the pain radiates down the arm or leg. This also explains why some people can have pain that one day goes further down the arm or leg than on other days. It all depends on the extent of compression of the nerve bundle.

When people get numbness or weakness, this simply implies that the transmission of the nerve is gone due to damage. No sensation means “no nerve information” or the telephone wire has been cut. As long as the nerve is working, you’ll have pain and muscular cramps, but when it goes too far, those cramps become weakness and the pain becomes numbness. This nerve damage often can be resolved with surgery but can sometimes become permanent. In a later newsletter we will discuss the treatments of nerve compression but this month I am focusing on helping you to understand the anatomy. It is also to understand that due to our spinal curvature, most problems occur at those curves. These points are Cervical levels C5-6-7, Thoracic levels T6-7-8, and Lumbar levels L4-5-S1. These levels also result in the most pain since C5-6-7 innervates much of the arm while L4-5-S1 innervates much of the leg. Thoracic issues are less common due to the rigidity of the thorax and usually only represent 10% of spinal issues. I hope you now realize that when we speak of spinal problems, we are talking about spinal nerve root issues and peripheral nerve problems such as the sciatic nerve.

God Bless

The pain associated with SIJ disease is usually located over the buttock area but it can radiate. In fact, there have been many cases where people had fusion surgeries for possible pinched nerves only to find out later that the problem was SIJ related. Thus, the pain can be local or radiate all the way down the leg. As stated previously, women are more affected than men and this is probably due to the wider pelvis in women and childbirth which stretches out the pelvic tissues.

In my experience, the most common cause of the SIJ pain is due to torn ligaments over the SIJ and not the joint itself. A lot of the tissues connect to the bone at this point and these tissues get torn with time and lead to a tendonitis type of picture.  Usually the pain is localized but as stated before can radiate. This syndrome can cause women much distress and pain.

What to do about it? For years injections were utilized to temporarily treat the pain in the joints. Surgeons have used fusions to treat this issue with a six inch incision and long recovery times. I wrote the first paper on an endoscopic approach to treating this problem with a 60% cure rate and a one inch incision.

Of interest, a new procedure has been developed which involves a large bore needle and the insertion of “cement” into the joint area to fuse the joint. The study was done on cadavers but it revealed that the procedure reduced SIJ motion by 50% in patients with SIJ fractures (usually after auto accidents). The question is whether this approach would be viable for regular SIJ pain not associated with fractures. If it is then it would represent an even more minimally invasive approach to treating this problem. It is possible that the insertion of the cement would even destroy some of the ligaments that are torn and causing pain. Currently, there are kits available for doing this procedure. The kits are made for spinal fractures but could be utilized for SIJ issues. It is especially useful for those who cannot undergo the SIJ surgery I devised or a SIJ fusion, such as in old or frail individuals. There is more information on SIJ problems on our website: www.emeraldcoastpain.com

A recent study by the Chinese reveals that the usage of Methylene Blue, which is a common dye, when injected into the intervertebral discs may result in significant and permanent reduction of low back pain. The exact method of how this interaction occurs is unknown but the results reveal a 50% reduction in pain in the treated groups. The study involved 136 individuals, of which 72 were utilized for the study while the others were eliminated due to inconclusive discography results. Half of these patients had a sham injection of saline while the others received the Methylene blue. Results were obtained at two years out, which is standard for long-term studies. The statistical analysis of the data revealed that the results were indeed significant.

What does this mean? Is Methylene blue the cure all for disc related low back pain?

The hard thing with such data is understanding what a 50% reduction correlates to. A novice would think that everyone got half of his or her pain eliminated. In reality, it implies that of the people who received the Methylene blue the average improvement was 50%. Thus some people got no relief while others received much more relief. It is also important to note that the Placebo group has a 15% significant improvement rate. It is also important to note that when the scores were analyzed using Oswestry scales, which is a tricky tests that tries to eliminate bias or errors in the questioning, the results dropped to 35% improvement compared to the 15% for placebo.

So again, you ask, what does this mean?

It means that Methylene blue may be a treatment option for people with chronic low back pain secondary to degenerative disc disease. It also implies that between 35 and 50% of the people will get some degree of significant, permanent relief from the injection. Not bad for a fairly benign chemical. We have been injecting Methylene blue into selected patients for the past six months. Obviously, we do not have long term results at this time, but it appears that 50% of the people get some degree of significant pain reduction with the injection..

This isn’t the first intradiscal injection that has been tested. We have been injecting a mixture of Glucosamine, Chondroitin, and dextrose into the discs since 2004. The results with this injection I think have been better at around 65% improvement (65% of the patients get significant permanent improvement). We have also been injecting Ozone gas into the discs for the past two years. This is based on several studies from Europe that revealed that Ozone gas resulted in 90% success rates for patients with disc related pain. Our results don’t correlate with that and I believe the results are more 50-50 with half of the patients seeing some degree of significant improvement.

None of these injections is considered experimental since there have been studies on all of them. I generally utilize the Glucosamine mixture first, then either the Methylene blue or Ozone gas. I also utilize a discectomy first if it is feasible since there are many studies on discectomy for low back pain offering a 70% success rate.

Now what all this really means!

It means that discogenic or low back pain from degenerative disc disease is hard to treat but there are a multitude of treatment options. Unfortunately, none of them offer greater than a70% success rate. Even spinal fusions only offer a 50 to 70% success rate for disc related low back pain. So if you suffer from low back pain secondary to degenerative disc disease, you shouldn’t give up if one option doesn’t work since there are other options and the fact that one didn’t work doesn’t rule out the other from possibly being effective.

Let’s pray for a pain free world.