|The Bike Doc
Joined: 08 May 2003
Location: Corpus Christi and Warda, Texas
|Posted: Sun May 06, 2012 1:24 pm GMT +0000 Post subject:
Work obligations have kept me from getting back to you quickly. Finally, I have had a chance to do some literature review to try to better answer you question.
You have tough predicament. For the readers, sciatica is pain, numbness and/or weakness to the leg from compression of the sciatic nerve either from a herniated (bulging) disc or bone compression. The disability can be mild to significant such as in your case, having to quit riding your bicycle. There have been various treatments used in the past such as steroid and analgesic injections to the nerve where it emerges from the spine, nonsteroidal anti-inflammatory drugs, muscle relaxants, physical therapy, manipulative therapy (chiropractic) therapy, discectomy (surgical removal of the herniated disc with fusion of the spinal vertebra above and below the herniated disc) and mini discectomy which involves only a partal removal of the disc materials to reduce bulging of the involved disc.
Some patients receive benefit from one therapy more than another. Critical analysis of multiple studies using what is called metaanalysis, looking at larger populations rather than a small isolated study, show overall nonsignificant improvement in sciatica symptoms for almost all approaches. What works for one individual may not work for another and for those that there was no benefit their lack of improvement or worsening symptoms, often negate the net improvement effect of those who did benefit.
So it is a tough call for recommending surgery. Before pursuing surgery, look at nonsurgical therapies and start at the dining table. Weight reduction will reduce the compressive load on the spinal column, vertebra and discs thereby reducing the compressive forces on the spine that can aggravate disc herniation and nerve compression. Talk to your primary care doctor about referral to a clinical nutritionist or a program such as Weight Watchers.
Look at adding nonimpact exercise such as swimming to help you increase your calorie burning, as dieting alone, without exercise, has a high failure rate in bringing weight down and keeping it down. Look at riding a stationary recumbent bicycle which will allow you to do nonimpact exercising of your legs without you having to bend over at the waste and further compress your spinal vertebra and discs. If you tolerate the recumbent stationary bicycle, you may be able to graduate to riding a recumbent bicycle or tricycle on the streets (though traditional mountain bikes rule off road). Physical therapy may help give you some relief while you are working on the above issues.
If you fail the above nonsurgical interventions, then consider surgery and visit with your primary care doctor and the orthopedic doctor/neurosurgery doctor. Ask for a review of the literature on the surgery the doctor is proposing with specific focus on long term outcomes. Do some homework looking at published clinical studies through PubMed http://www.ncbi.nlm.nih.gov/pubmed
I have copied four recent reviews of clinical trials and metaanalysis of different modalities of therapy for sciatica that I gleaned from PubMed.
Paul K. Nolan, MD
AKA: The Bike Doc
Radiology. 2011 Aug;260(2):487-93. Epub 2011 May 25.
Comparative prospective randomized study comparing conservative treatment and percutaneous disk decompression for treatment of intervertebral disk herniation.
Erginousakis D, Filippiadis DK, Malagari A, Kostakos A, Brountzos E, Kelekis NL, Kelekis A.
2nd Radiology Department, University General Hospital Attikon, 1 Rimini St, Haidari 12462, Athens, Greece.
To compare short-, intermediate-, and long-term functional results concerning pain reduction and mobility improvement between conservative therapy and percutaneous disk decompression (PDD) in patients with intervertebral disk herniations.
MATERIALS AND METHODS:
The study received approval from both the university ethics panel and the institutional review board. Patients provided informed consent for the study. Over the past 4 years, two randomized groups of 31 patients with sciatica due to intervertebral disk herniation were prospectively studied and compared with the t test. The control group underwent conservative therapy (administration of analgesics, antiinflammatory drugs, muscle relaxants, and physiotherapy) for 6 weeks. The decompression group underwent fluoroscopically guided PDD. Pain reduction and mobility improvement were recorded at 3-, 12-, and 24-month follow-up on a numeric visual scale (NVS) (range, 0-10).
The control group had a mean pain score of 6.9 NVS units ± 1.9 prior to conservative therapy. This was reduced to 0.9 NVS units ± 2.0 3 months after therapy; however, it increased to 4.0 NVS units ± 3.4 at 12-month follow-up and further increased to 4.0 NVS units ± 3.4 at 24-month follow-up. The decompression group had a mean pain score of 7.4 NVS units ± 1.4 prior to PDD. This was reduced to 3.0 NVS units ± 2.4 at 3-month follow-up and further reduced to 1.7 NVS units ± 2.4 at 12-month follow-up and 1.6 NVS units ± 2.5 at 24-month follow-up. No complications were noted.
When compared with conservative therapy, PDD shows improved amelioration of symptoms at 12- and 24-month follow-up.
© RSNA, 2011.
Cochrane Database Syst Rev. 2011 Feb 16;(2):CD008112.
Spinal manipulative therapy for chronic low-back pain.
Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW.
Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, PO Box 7057, Room D518, Amsterdam, Netherlands, 1007 MB.
Many therapies exist for the treatment of low-back pain including spinal manipulative therapy (SMT), which is a worldwide, extensively practiced intervention.
To assess the effects of SMT for chronic low-back pain.
An updated search was conducted by an experienced librarian to June 2009 for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2009, issue 2), MEDLINE, EMBASE, CINAHL, PEDro, and the Index to Chiropractic Literature.
RCTs which examined the effectiveness of spinal manipulation or mobilisation in adults with chronic low-back pain were included. No restrictions were placed on the setting or type of pain; studies which exclusively examined sciatica were excluded. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life.
DATA COLLECTION AND ANALYSIS:
Two review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. Sensitivity analyses and investigation of heterogeneity were performed, where possible, for the meta-analyses.
We included 26 RCTs (total participants = 6070), nine of which had a low risk of bias. Approximately two-thirds of the included studies (N = 1 were not evaluated in the previous review. In general, there is high quality evidence that SMT has a small, statistically significant but not clinically relevant, short-term effect on pain relief (MD: -4.16, 95% CI -6.97 to -1.36) and functional status (SMD: -0.22, 95% CI -0.36 to -0.07) compared to other interventions. Sensitivity analyses confirmed the robustness of these findings. There is varying quality of evidence (ranging from low to high) that SMT has a statistically significant short-term effect on pain relief and functional status when added to another intervention. There is very low quality evidence that SMT is not statistically significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.
High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.
Int Orthop. 2011 Nov;35(11):1677-82. Epub 2011 Jan 15.
The efficacy of coblation nucleoplasty for protrusion of lumbar intervertebral disc at a two-year follow-up.
Zhu H, Zhou XZ, Cheng MH, Shen YX, Dong QR.
Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu, 215004, People's Republic of China.
The purpose of this study was to evaluate longer-term efficacy over a two-year follow-up of coblation nucleoplasty treatment for protruded lumbar intervertebral disc.
Forty-two cases of protruded lumbar intervertebral disc treated by coblation nucleoplasty followed-up for two years were analysed. Relief of low back pain, leg pain and numbness after the operation were assessed by visual analogue pain scale (VAS). Function of lower limb and daily living of patients were evaluated by the Oswestry Disability Index (ODI).
Operations were performed successfully in all cases. Three patients had recurrence within a week of the procedure. Evaluation of the 42 patients demonstrated significant improvement rate of VAS: defined as 66.2% in back pain, 68.1% in leg pain, and 85.7% in numbness at one-week after the operation; 53.2%, 58.4%, 81.0% at one-year; and 45.5%, 50.7%, 75.0% at two-year follow-up. One week after the operation, obvious amelioration occurred in all the patients, but the tendency decreased. Before operation, the mean value of ODI was 68.2 ± 10.9%. The value at one week was 28.6 ± 8.2%; one-year at 35.8 ± 6.5%; and two-years at 39.4 ± 5.8%.
Coblation nucleoplasty may have satisfactory clinical outcomes for treatment of protruded lumbar intervertebral disc for as long as two-year follow-up, but longer-term benefit still needs verification.
Pain Med. 2010 Aug;11(:1149-68.
The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain.
Ghahreman A, Ferch R, Bogduk N.
Department of Neurosurgery, John Hunter Hospital, NSW, Australia.
Transforaminal injection of steroids is used to treat lumbar radicular pain. Not known is whether the route of injection or the agent injected is significant.
A prospective, randomized study compared the outcomes of transforaminal injection of steroid and local anesthetic, local anesthetic alone, or normal saline, and intramuscular injection of steroid or normal saline. Patients and outcome evaluators were blinded as to agent administered.
The primary outcome measure was the proportion of patients who achieved complete relief of pain, or at least 50% relief, at 1 month after treatment. Secondary outcome measures were function, disability, patient-specified functional outcomes, use of other health care, and duration of relief beyond 1 month.
A significantly greater proportion of patients treated with transforaminal injection of steroid (54%) achieved relief of pain than did patients treated with transforaminal injection of local anesthetic (7%) or transforaminal injection of saline (19%), intramuscular steroids (21%), or intramuscular saline (13%). Relief of pain was corroborated by significant improvements in function and disability, and reductions in use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. Over time, the number of patients who maintained relief diminished. Only some maintained relief beyond 12 months. The proportions of patients doing so were not significantly different statistically between groups.
Transforaminal injection of steroids is effective only in a proportion of patients. Its superiority over other injections is obscured when group data are compared but emerges when categorical outcomes are calculated. Over time, the proportion of patients with maintained responses diminishes.
• Pain Med. 2010 Aug;11(:1141-3.