Understand Low back pain : Radicular Sciatic Pain

Lumbar spines are composed of few structures which may cause low back pain. Spinal pathology usually involves few of those structures – not only one structure- making the diagnosis of low back pain sometimes tricky.

Conservative spinal treatment like Physical therapy, Chiropractor adjustments, Acupuncture sessions, Massage sessions, Meditation are not targeted treatments, meaning, same treatment may tackle all these structures at the same time.

The pattern of pain complaints and good physical examination assist to establish a “Differential Diagnosis” meaning, list of possible causative structure by order of possibility being the “The main generator of Pain”.

Interventional Pain Injections are targeted injections directed to a specific structure/s. These directed blocks have both diagnostic and therapeutic purpose. If you target a specific structure and got a good relief, so this structure is part of the pain process. If pain relief was 70-80%, so that structure is the main generator of pain and needs to be tackled to get the most pain relief. If you get pain 20-30% pain relief from targeting that structure, though it would be a pain generator but it is probably not the “main generator of pain”. Tackling that minor generator of pain is not essential but would also help to add more relief to patient if tackling the main generator is not giving enough relief.

There are few patterns of low back pain that help in diagnosis and tailoring a treatment plan;

Radicular (Sciatic) Pain: As disc pathology gets worse, disc material is squeezed out outside disc boundaries causing disc bulge and may pinch on nerve roots causing radicular (sciatic) pain down one or both legs that may be accompanied with numbness and tingling down the legs. The disc material might leak outside the disc causing chemical irritation and inflammation of the nerve root at that level. Each nerve root supplies specific muscles and skin zone. Muscle weakness or sensory changes in such zones can pinpoint the related causative nerve root.

Radiculat pain pattern is characterized by;

1) Low back pain shooting down one of both legs,

2) Radicular pain is accompanied by sensory changes +/- motor weakness,

3) Pain may got worse with sitting, bending, push down, sneezing and sitting on toilet seat.

4) Pain gets better standing up, changing postion. 

After trying conservative treatment with no significant help, patient might try fluoroscopy guided Interventional Pain Injections or procedures. Physician usually start with,

Interlaminar Epidural Steroid Injection (IL-ESI): A steroid injection +/- local anesthetic is injected straight in the middle of the back into the spine where medicine goes directly to affected disc and spread to get nerve roots on both sides. This shot usually good for purely internal disc pain or in case of bilateral radicular (sciatic) pain down both legs.

Transforaminal Epidural Steroid Injection (TFESI): when patient has a radicular pain. A nerve block of steroid +/- local anesthetic is injected to target specific nerve roots. It provides both diagnostic and therapeutic purposes. Each lumbar nerve root supply specific muscles and skin sensory area in the leg. The radicular pain pattern may help doctor to predict which nerve roots are affected but TFESI helps to confirm the diagnosis and treatment.

Spinal Cord Stimulator (SCS): Epidural needle placement in spine and wiring in two leads wires to lie internally along the spinal cord, Stimulator is connected to a battery that produces minor buz "electrical waves and pulses like TENS" to block the pain signals from reaching the brain for pain perception. A trial for 5-9 days before permanent placement is warranted if it helps with pain. It is used for cases did not show pain relief with injection treatments.

Minimally Invasive Micro-Endoscopic Discectomy: is a minimally invasive procedure with a small skin opening to introduce a fine instrument to punch out piece of isolated bulging disc causing a pinch on a nerve to relief pressure on that nerve and eliminate radicular pain.

All above procedures are usually performed at an ambulatory same day surgical center. Above procedures usually take about 3 minutes, 5 minutes, 30 minutes and 45 minutes respectively.