“Sciatica” – or pain in the Sciatic nerve – is a term that gets used a lot to describe pain in the back, hip, gluteals and legs. What is the Sciatic nerve? How does it get injured? What are the symptoms like? What can be done to treat it? Let’s look deeper into these questions.
In our spines, nerves branch off of the spinal cord and exit the spine at different levels. Nerves exiting at multiple levels in the low back and pelvis join, mix, and then split off again in a seeming tangle. The largest nerve is named the Sciatic nerve and travels down the leg and connects the spinal cord with the muscles and tissue of the leg.
If a nerve is being squeezed or pinched, a person can feel numbness, tingling, and sometimes pain and weakness in the distribution of that nerve. The most common site for nerve compression is at the level of the spine where nerves exit (before they start to join and mix). The most common nerves to get pinched and irritated are the L5 or S1 nerves. When this happens, a patient may feel a burning or electric type pain that travels down the back of the leg and sometimes into the feet and toes. This is often referred to as “sciatica”. Sciatica is a non specific term and does not mean that the sciatic nerve is being pinched. Patients can feel different types of sciatic pain depending on the location of the nerve compression.
The cause of nerve compression can be different from person to person but is often due to a bulging disc in the spine or arthritis of the spinal joints, or both. The severity of sciatic pain also varies from person to person.
In some people sciatic pain will improve on its own over the course of a few weeks, in others the pain may persist and require more intensive treatment. Occasionally surgery needs to be considered. For many, injections near the nerve roots in the spine can reduce nerve inflammation and irritation. At Nexus we have the experience and expertise to help treat your pain in the safest and most effective way possible.
About 10 years ago, I started doing yoga. Well, to be truthful, my wife started doing yoga after she injured her hip riding horses. The injury was chronic-she had hip pain all the time but especially when riding (something she loves to do). After a while, I gave it a try. Wow was it difficult at first. We got some DVD’s and I desperately tried to follow along with what the instructor was doing but to know avail. The DVD was a complete yoga routine with one move quickly followed by another. I couldn’t keep up. I then found a DVD for beginners that demonstrated only one position at a time. The next problem was that I was too stiff, inflexible, and trying to contort my body to do the moves simply hurt. However, I knew that if I didn’t do something, I would continue to get stiffer and stiffer as I aged until my body was frozen in a “fetal position” (we tend to contract into a flexed position with aging). So, I persevered, and with time found a way into the practice of yoga. Over the last 10 years, I have been up and down and never very consistent with it but, I am happy to say, I am much more flexible than I was when I started.
Exercise of all kinds is helpful for persons with chronic pain. It lubricates the joints, increases blood flow to the painful areas and washes out toxins that can build up in the muscles and joints. For patients with back pain, exercise helps the disc exchange fluids, which is how the disc obtains its nutrition. Exercise of any kind relieves chronic muscle tension. However yoga is magical. The movements pump fluid to the disc, blood to the muscles, tendons and ligaments and the deep breathing helps expand lung volume (the amount of air that the lungs can hold).
Yoga-are you kidding? I’m too old, too stiff, too fat, in too much pain,……The facts is, any one can do yoga and receive the benefits if they will stick to it. You can do it a your local gym or at a yoga studio but you don’t have to. I just do it at home with the aid of a DVD. I started with “Yoga for Inflexible People” by Judi Rice. You can get it on Amazon for 10.99. Once I got more comfortable, I moved to yoga tapes by Rodney Yee.
Words of advise-yoga moves are called postures. They generally will have you get into a posture and hold it for some amount of time- 5 deep breaths, 60 seconds, etc. When doing a posture, move slowly into position and hold yourself at the place just before you feel pain. DO NOT PUSH YOURSELF INTO THE PAIN ZONE. Yoga is completely non-competitive and all yoga moves are endless. You can never completely do the position because once you get it; there is always more you can do. So, since there is no end point or nothing to achieve, there is no need to try and achieve it. You simply put your body into position and hold it at the point just before you feel any pain. Another point is consistency especially at the beginning. When I started, I pushed too hard and it was agony. If I could go back and start again, I would be gentler. That way you won’t feel sore the next day. It’s not fun if you’re in pain while your doing it. Make sure you breath with the exercise-that is key.
Anyway, for people with chronic pain exercise is essential and, besides walking, yoga is one of the simplest things you can do. If you stick to it, it’s becomes fun and you really do feel better after your work out.
Richard Rosenthal MD
Narcotic (opiate) pain medications can be a God-send for patients with chronic pain. When used appropriately, they can improve sleep, mood and help patients return to normal function. It is only when they are used for non-medical purposes that problems arise. It may start by just taking a few extra pills when your tired or had a bad day. In susceptible persons, pain medications can improve mood-making the patient feel euphoric or on top of the world. They can also improve energy levels. However, this is a siren’s song which sucks you in by making you think the medications are helping you function. Later on, the drug turns on you by causing depression, anxiety, and fatigue. The good times are gone but you can’t stop taking the drug because if you do, you experience the severe consequence of withdrawl; nausea, vomiting, diarrhea, shaking, tremors, irritability, headache, etc. Although these symptoms resolve with time, they are often severe enough to keep the patient taking the drug despite the negative consequences. Untreated, addiction can lead to death from overdose.
Addiction does not happen to everyone taking opiate type pain medications. In fact, some people are not susceptible to addiction at all because they never experience the euphoric effects of the drug. Who develops an addiction is determined by many factors but it is thought that some patients are at increased risk for addiction; these include patients with a family history of addiction in a parent or sibling, patients with psychiatric disorders such as anxiety and depression, and anyone who inappropriately uses the drug to “feel better,” that is to self treat for negative emotions. So what exactly is addiction?
Addiction is defined as a pattern of compulsive drug use characterized by loss of control of drug use, continued use despite harm to self or others, and a preoccupation with obtaining and using the drug. Doctors can distinguish appropriate drug use from addiction; addicts tend to over use their prescription, run out early and tell a story in order to obtain an early refill. They may go to several doctors to get prescriptions so that they always have enough pills. Because the euphoric effects of the drug tend to wear off quickly (patients become tolerant quickly), the number of pills needed to “get high” increases every 2-3 months. Before long, patients are taking 25 lortab a day. To obtain this number of pills, they have to spend a good deal of time going from doctor to doctor or getting them over the internet.
Addiction needs to be distinguished from physical dependance. Physical dependance is not a sign of addiction. Addiction is a psychological disease or a disease of the mind. Physical dependance occurs when discontinuing the drug causes a withdrawal syndrome-ie-some type of physiological response. Many drugs have this charictaristic. For example, drugs taken for high blood pressure need to be discontinued slowly or the patient may have a stroke. Opiate drugs taken for pain also must be slowed weaned or the patient may experience a withdrawal response described above. All patients taking opiates on a daily basis become physically dependant-ie-experience withdrawal if the drug is stopped abruptly. Not all patients taking an opiate are addicted.
Our job, as pain medicine physicians, is to distinguish patients taking the drug as prescribed for pain from those who are abusing the drug. This is the reason that we perform a screening exam before prescribing an opiate for the first time. The results of the screening stratify patients into three groups-low, medium and high risk of addiction. Based on the results, we are better able to help patientstreat their pain without causing harm by adding to the addiction of those who are abusing the medications.
Finally, addiction is a disease (defined as any impairment from normal functioning) and has a treatment. We do not judge patients who are diagnosed with addiction any more than we judge patients diagnosed with diabetes. We do, however, refuse to contribute to their problem by giving them more opiates. Instead, we try to guide them into appropriate treatment for the problem.
Some type of emotional response often accompanies chronic pain; for example, many patients feel worn out, anxious, and even depressed. This is understandable; Life is difficult enough, but adding the stress of constant pain can wear out even the most optimistic persons. We know that pain is more than just “hurting.” Pain can affect the physical, emotional, and spiritual well being of a person. It affects our sleep and mood and causes us to feel tired and lethargic. It can also cause job and marital problems. Pain patients may feel like they are a burden to their spouse and friends. In short, people in pain can feel like their life is spinning out of control.
Fortunately, there are things you can do to feel better. One of them is meditation. This word comes with a lot of baggage and often brings to mind religious connotations. You may think of a Buddhist monk, head shaven, sitting in a stiff, upright position. Not anymore; there are now several companies that make CD’s (or MP3’s) that put your brain into a meditative state while you listen with headphones. Nothing could be simpler.
Meditation is a natural state in which our brain slows down. Normally, in a waking state, the signal frequency of brain activity is relatively fast. The more stressed a person feels, the faster the brain goes. Meditation slows our brain down creating a pleasurable, floating feeling. The use of tones to create slow brain wave states was discovered by a physicist in the 1800’s. He discovered that when you introduce tones with a certain frequency into each ear, you can entrain the electrical activity of the brain causing it to slow down to the same frequency as the tones. These slow brain wave states are referred to as meditation and result in the production of euphoric, anti-stress chemicals within the brain.
The benefits of meditation have been proven by multiple scientific studies. People who meditate have been shown to have less stress, anxiety, depression and addictions. In fact, people who meditate have been shown to be healthier and age more slowly. In our fast paced world, everyone would benefit by taking 20 minutes out of their day to slow down and re-center themselves. This is especially true for patients with pain. One of my patients who began using the technology said that after meditating at lunch, he felt as if he was waking up for a second time, as refreshed as if he had slept through the night after only 20 minutes.
Richard Rosenthal MD
Fibromyalgia is unfortunately a relatively common disease affect over 5 million Americans with a 9:1 ratio of women to men. For years, the only help we could offer was counseling patient on good diet, sleep habits and mild exercise. While these suggestions still hold true, there are now newer medications shown in clinical studies to help patients with this painful condition
So, what is fibromyalgia? Patients with the disease (any alteration from normal function) complain of widespread pain often described as muscle aches. They also have several associated conditions; 10-80% of patients report headaches, 40% report multiple chemical sensitivities, up to 20% report bladder pain and frequent urination, 20% chronic pelvic pain, 30-80 report irritable bowel syndrome, 75% report TMJ and 25% have major depression. So what is causing all of these problems? It can’t just be a problem in the muscles or patients wouldn’t have all the associated conditions.
It turns out that the problem is in the central nervous system (brain) and that people who report fibromyalgia symptoms have low levels of some critical neurotransmitters (brain chemicals) that help to dampen pain threshold. In other words, patients with fibromyalgia experience pain more easily due to these low levels of neurotransmitters. This is what the new drugs target and correct. There are 3 drugs now approved for the treatment of fibromyalgia-Savella, Cymbalta and Lyrica
Savella was approved for use January 2009. It is in the class of an anti-depressant but it is not being used for that purpose here. It works by raising the levels of serotonin and norepinephrine in the central nervous system. These brain chemicals play a role in the perception of pain and returning them to normal levels helps in alleviating the pain. The usual dose is 50mg twice a day but can be raised to 100mg twice a day. To avoid side effects, the doctor may start on a lower dose and slowly raise it to the therapeutic level. The drug can take up to 3 weeks to work. The side effects can include nausea (35% of patients experience this side effect), constipation (16%), hot flashes (11%), excessive sweating (8%), and heart palpitations (8%). The side effects can improve over time. A minority of patients develop high blood pressure so patients should have their blood pressure monitored every 6 months. The drug does not cause weight gain.
Cymbalta was approved for use in 2008. It works in the same way as Savella. The recommended dose is 60mg a day. Common side effects include nausea, vomiting, dry mouth, constipation and loss of appetite. The side effects can improve over time. Cymbalta can cause or exacerbate high blood pressure so patients should have their blood pressure checked every 6 months. Another concern with Cymbalta is the potential for interaction with other drugs the patient is taking so the ask the doctor and pharmacist about drug interactions.
Lyrica for approved for use in the treatment of fibromyalgia in 2004. It is in the class of an anti-convulsant (a class of drugs used to treat seizures but it is not used for that purpose here). The medication works by decreasing activity in over-active nerve cells in the brain. The dose is increase slowly from 150mg/day up to 450mg/day. The most common side effects are dizziness, weight gain, fatigue, difficulty concentrating and swelling in the hands or feet. All three drugs carry the warning that they may increase suicidal thoughts or behavior.
Fibromyalgia is not a problem that has a treatment. Patient should no longer have to suffer with the condition. Exercise is still a mainstay in the treatment but the newer drug therapies are showing promise in returning patients back to normal functioning.
Richard Rosenthal MD
I was approached by a patient today who said that he/she has had many repeat radiofrequency treatments (once a year for several years) and wanted to know if surgery could be done to fix the problem once and for all. This is certainly a reasonable question; after all, if something is wrong, why not fix it? The answer varies depending on each patients individual situation; In general, surgery is intended to fix structural abnormalities (damage to the spine) that cause pain and which do not respond to more conservative treatments (simpler treatments). In fact, according to the Mayo Clinic website, back surgery is needed in only a small number of cases. The majority respond to simpler treatments such as radiofrequency lesioning.
“So if I have a disc problem (disc buldge, disc herniation, degenerative disc, etc), why don’t I need surgery to fix it?” There are two responses to this question. First, many people have abnormalities on an MRI (such as those above) that do not cause pain. A study was done several years ago on a group of college students (18-21 years old). None of them had back pain. All of them had an MRI. The results of the study were surprising. Of the 100 students in the study, 20% of them had some type of abnormality seen on their MRI- (disc herniations, degenerative discs, disc buldges, etc) despite that fact that they didn’t have back pain. From this we learned that MRI’s are sometimes too sensitive-it allow doctors to see spinal abnormalities but it does not tell us if they are causing pain. Another reason you don’t necessarily need surgery for a disc problem is that many problems respond to less invasive therapies. For example, we have successfully treated many patients with disc herniations who had severe leg pain (sometimes so bad that they could not walk). Some of these patients responded (got better) with a simple epidural steroid injection, some required a radiofrequency procedure on the nerve. Either way, the symptoms improved (the leg pain resolved) without the need for an expensive and more invasive procedure. In some patients, the pain returned and they needed to have a repeat procedure. However, as long as the radiofrequency procedures alleviate the pain, there is no need to perform a more invasive procedure that may require a long recovery with many missed days of work.
“So what happens to the herniated disc if you don’t operate on it? Doesn’t it just keep pressing on the nerve causing problems later on?” First, in the majority of cases, the pain from a herniated disc is not caused by the disc pressing on the nerve. Instead, the pain comes from the disc material causing a severe inflammatory reaction to the nerve. This is why epidural steroids have an effect to improve the symptoms. In addition, the herniated disc material does not just sit there, it is simply reabsorbed by the body-ie- the body breaks it down and digests it. If a new MRI is taken a year later, the herniation is gone.
“When do I need surgery for back pain?” Surgery is required to prevent permanent damage to nerves, or other spinal structures. Usually a patient must have some symptom other than pain to be considered for surgery-arm/leg numbness and weakness, loss of bowel/bladder control, infection, etc. Evan in these circumstances, if a simpler treatment will safely return function of the arm or leg, then surgery is not needed. Surgery is usually necessary if you have broken bones in the spine that may result in injury to the spinal cord or nerves. Another condition that sometimes requires surgery is spinal stenosis (bones in the spine pressing on nerves). Since these conditions are rare, most patients with back pain can find relief without undergoing surgery. However, if no treatment is working (the patient is not able to get pain relief by any other means) surgery may be considered. However, it is good to remember that not all surgeries are a success. In fact, some patients may actually be worse off after surgery than they were before.
In summary, surgery should be considered as a last resort (or not at all) if the only symptom is pain. Treatments such as radiofrequency lesioning are less invasive and can be repeated as many times as necessary as long as they provide a reasonable period of pain relief. If there are other symptoms such as muscle weakness caused by damage to spinal nerves, and if no other treatment will relieve the symptoms, then surgery should be considered.
Richard M. Rosenthal MD
How can we improve patient outcomes by improving business practices and approaches? The answer to this may not seem clear, but as the Marketing Director for Nexus Pain Care, I am tasked with many things. The most important I feel is community awareness of pain and how this can impact a patient’s overall quality of life. There are many tools to accomplish this, but the best is face to face interaction with referring physicians in the local community. Business the ‘old fashion way’ in a sense, sitting down and talking with providers and their staff about improving patient outcomes when it comes to chronic pain. How is this business one may ask? Well, I not only represent Nexus Pain Care, but I also represent our patients to a certain degree. When a physician refers a patient to Nexus, we ensure that they are treated with the care and quality that every patient deserves. I then convey this not only to the referring physician, but each and every provider I come in contact with.
Nexus is committed to quality care, and Dr Rosenthal has the leadership and experience to get patients better. Business in medicine differs slightly than business as we traditionally think of. Practices do have a bottom-line as it relates to dollars, but the most important aspect to our business is patients. All of us at Nexus are aware of how important the patient is, but not because of charges or revenue, but because these patients lead lives much like our own. The difference is that they are burdened with debilitating chronic pain, and it is our job to make them better. Thanks to our Medical Director, Richard Rosenthal M.D., and his associates, Nexus is fully capable to make our patients better. As a former Marine Infantry Officer, I truly believe what makes an organization successful are the people that work inside that organization. Nexus Pain Care is a perfect example of this, quality people dedicated to a common goal…getting our patient better. Every call, every visit, every interaction you will not only be met with a smile, but a dedicated professional who represents the beginning of your path to a pain free life. I invite you to see for yourself, if you feel like your pain has not been addressed properly, or if you are looking for some answers to your pain questions, call for an appointment today..
Marketing Director, Nexus Pain Care
This past week Dr. Rosenthal received a thank you letter from a previous patient who has since moved to a different state. Here are a few of her comments:
“…just wanted to again say ‘thank you!’ to you and your staff!…It has really made me apreciate how great you were with me. I’ve been reading online horror stories of how terrible people are treated with chronic pain. I believe you are one of the best. Of course in the medical community you are, but you’re also good with patients….Thanks again for such exceptional treatment. Take care.”
Such a letter always is received with much appreciation. And with Thanksgiving two days away, Nexus Pain Care would like to thank all of our patients and wish them a very happy Thanksgiving.