If I have a suspected disc rupture clinically, and my MRI confirms an extrusion or sequestration do I need to have surgery?
No. Not unless your neurological signs are worsening or you have signs of cauda equina compression (for example progressive weakness and loss of bowel and bladder in a matter of days).
And an extrusion or sequestration does not mean you should skip an MDT assessment! In my experience the likelihood of responding to an MDT assessment looking for centralization or a direction preference is certainly lower in such patients, however some patients do respond and Centralize. This has been shown in multiple studies, of which was 2011 study by Hanne et al, where they concluded Centralization was very common even in ruptured discs.
Essentially the message here is treat the patient not the scan, and give every patient with sciatica an evaluation to determine their response rather than making assumptions based on pathology on imaging. But if they are not responding within a small amount of sessions (typically 3-5 is enough to truly determine if they are a responder, and in many cases, it can be done faster than this), they need to be educated about this and their options.
Does surgery have a role in sciatica? Should we be telling everyone not to have surgery?
For some people with severe leg pain surgery may in fact be a suitable and necessary solution.
The vast majority of people get better with time, even with disc ruptures, and so if they can avoid going under the knife they will get better. The difficulty is that the pain can be severe and so even if you were told that in 6-18 months (most patients with severe sciatica from a disc rupture will improve with natural history within this time frame, with some improving in shorter time-frames), some people cannot put up with the pain for this long even if they knew the problem would resolve with time.
What are the options if you have had an MDT assessment, and you are not a responder?
- Firstly, you may need to address the chemical irritation around the nerve with either medication or an injection, and you then may be reassessed and proven to be a responder to the MDT assessment
- Other medications such as Lyrica or Endep, are a type of medication that target neuropathic (nerve pain) can make the symptoms bearable whilst natural recovery ‘fixes’ the problem (these must be given under the guidance of a doctor, sports doctor or surgeon)
- If you can survive the first few months, the symptoms whilst often still being constant or frequent may be less severe
- You may find that seeing someone (ideally an MDT trained clinician) who can guide you to safely increase your activity, correct your posture and give you strategies to restore motion may reduce pain levels which can allow you to cope
- Even those with confirmed disc ruptures can usually do some form of exercise. As long as the level of exercise is progressed gradually, a return to running, sport and other activities can be resumed which has both physical and psychological benefits
If I consider surgery and all efforts at other conservative options have failed, what kind of operation would I have and what are the outcomes?
Various types of operations are offered by surgeons for sciatica, and range from micro-discectomy, laminectomy, fusion and artificial disc replacement and insertion of ‘spacers’ between the discs to increase the room for the exiting nerves.
Unfortunately, the type of operation offered seems to vary wildly from surgeon to surgeon, and it is not uncommon that the same person is offered very different kinds of surgery when they see multiple surgeons. One would hope that financial concerns do not motivate the surgeon’s selection on type of surgery offered. Their training does seem to have a big impact, and there are certainly some surgeons for example who seem to do fusions on most of their sciatica patients, where others would usually offer a discectomy for the same presentation.
Fusion operations are costlier, more invasive, have higher risks of complications and increased length of operation time and post-operation hospital stay. And yet the research clearly shows they do not have superior outcomes to less invasive surgery like discectomy, and so most of the world guidelines on low back pain do not recommend them (Delitto et al, 2012, NICE UK low back pain guidelines, 2009).
Other operations like disc replacements, and the use of artificial ‘spacers’ do not show superior outcomes, and again are costlier and involve more risk without proven benefit.
Miscrodiscectomy, or a laminectomy (essentially like a discectomy where a fragment of disc is removed, however they also remove a small part of the bone called the lamina to gain access to the disc fragment) can have excellent outcomes, particularly in those with leg pain.
I am not a surgeon, and many may disagree with my opinion, but in over 10 years of predominantly treating patients with sciatica it appears to me those who should consider surgery are most likely to do well in the following circumstances:
- They have constant leg pain (and often do not have back pain)
- They are not coping despite medications and injections and so may not be able to tolerate the time required for natural history and healing
- They have a clearly identified extrusion or sequestration on imaging
- They do not have dominant psychosocial factors (those that may have a chronic pain syndrome, and would be less likely to do well with surgery)
- The level of pain is severe enough that it is interfering with their sleep and work
Do I need to improve my core strength to get rid of my back pain?
No!
This seemingly ingrained belief of the public has come from health practitioners telling people that the cause of their back pain is from a weak core.
There is no evidence to support this, and in fact the evidence shows that whether you do Pilates, specific core stability exercise, specific motor control exercises or just do non-specific exercise like running, the outcomes are similar. In fact, the conclusion from a recent systematic review (Smith et al, 2014), which is considered the highest level of evidence, was that there is strong evidence that stabilisation exercises are not more effective than any other form of exercise in the long term for low back pain.
This does not mean that exercise is not good for low back pain! It these same clinical guidelines referenced earlier all support exercise and being active with low back pain and sciatica. The key is that it does not need to be specific. You just need to get moving!
Exercise is good for low back pain.
And whether you do structured Pilates sessions, high performance training or just your own home program they will all be of benefit. So, which form of exercise you choose is less important, but you need to get moving and choosing something to you enjoy should be a priority!
For an assessment of your low back pain or sciatica, come and see our McKenzie specialist physiotherapist Joel Laing at Absolute Health & Performance in Melbourne’s CBD.
# Melbourne physio
# Melbourne CBD physio
References:
Werneke, M. and Hart, D.L., 2003. Discriminant validity and relative precision for classifying patients with nonspecific neck and back pain by anatomic pain patterns. Spine, 28(2), pp.161-166.
Albert, H.B., Briggs, A.M., Kent, P., Byrhagen, A., Hansen, C. and Kjaergaard, K., 2011. The prevalence of MRI-defined spinal pathoanatomies and their association with Modic changes in individuals seeking care for low back pain. European spine journal, 20(8), pp.1355-1362.
May, Stephen and Alessandro Aina. “Centralization And Directional Preference: A Systematic Review”. Manual Therapy 17.6 (2012): 497-506. Web.
Smith, B.E., Littlewood, C. and May, S., 2014. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC musculoskeletal disorders, 15(1), p.1.
Delitto, A., George, S., Van Dillen, L., Whitman, J., Sowa, G., Shekelle, P., Denninger, T. and Godges, J. (2012). Low Back Pain. J Orthop Sports Phys Ther, 42(4), pp.A1-A57.
NICE Guidelines for Low-Back Pain. (2009). Journal of the National Medical Association, 101(9), p.974.
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