Time heals. That seems to be the conclusion of a recent study conducted with nearly 2,000 patients complaining of sciatica, pain associated with a ruptured disk in the back pressing on the sciatic nerve. The authors of the study, which was published in the Journal of the American Medical Association (JAMA), reported that although surgery could provide immediate relief, most patients had marked improvement within three to six months whether or not they had the surgery. Dr. Jim Ricciardi, spinal surgeon and associate professor of orthopedic surgery at Louisiana State University Health Sciences Center's School of Medicine, explains the causes and treatment options for sciatica.
Q: What exactly is a ruptured disk? A: It's a bulging of the intervertebral disk. Think of the disk as an automobile tire. The inner part, air, is the nucleus pulposus, a gel-like substance that's held by the annulus, which is the outer margin of it. It's a very elegant hydraulic shock absorber, and it's absorbing the force of your body up above it. It's the force of everything we do. Every time we stand up, sit down, or move there's pressure on that disk. As we age, there's a weakening of the annulus, and that's the hole or the crack through which the disk material, the inner part, can poke out and get to the outer part of the disk. There are no pain nerves inside the disk, but the annulus has nerve fibers in it. So when you irritate those, you can get back pain, or you might get back pain and leg pain. Q: How does a ruptured disk cause sciatica? A: The sciatic nerve is the collection of those nerve roots that run down your leg to give nerve supply to the muscles of your lower legs. The gel-like material protruding from the disk can press on those nerves and produce pain that runs down your buttocks, down your leg and eventually to your foot. The pain can be very severe. Q: Can weight gain cause sciatica? A: No, not directly. There is some genetic component. Disk disease, back pain, tends to run in families. It's not a real hard statistic, but we know that, for instance, there are people whose father had the problem, brother had the problem etc. That's true for maybe 10 percent of the population. In general, it's caused by aging. Q: In the study, the authors admit they couldn't conclude what the best course of treatment for sciatica is because so many of the patients in the study didn't follow the treatment they were assigned. Some of the patients chose surgery even though they were assigned another method of treatment. Why did this happen? A: Human beings are human beings. Pain is the deciding factor. Pain is the only thing you can actually treat with surgery. All the studies have shown, including this one, is that the relief of pain comes quicker if you do surgery. But if you look at the patients one, two or five years down the road, you'll find that they basically do the same. It doesn't matter if they were operated on or not, so the only thing that you have to offer a patient with a disk herniation is earlier relief of pain that they wouldn't have if they were treated with a variety of outpatient treatments. Q: What are some of the pros and cons of the surgery? A: Expense is one con. There's about a 15 percent incidence of reherniation, and that often means another surgery. Plus, patients who have surgery usually stay off work longer. You can get an infection; you can have an injury to the nerve. Anything that can happen with any surgery can happen with disk surgery. The pro is earlier relief of pain. That's it. The physician's job is to explain that there's a 75 percent chance that the sciatica will go away in the first six weeks regardless of how you treat it. I tell my patients that the disk is in a place that explains your symptoms, and the natural history of this is to get better. There are some ways to help you get better nerve injections of cortisone are very helpful. Basically the great majority of patients do not need nor will they have surgery. Q: You knew this before the study? A: [A previous] study was done in the 1970s by a guy named Weber. Jim Weinstein ran this current study; he's a good friend of mine and a very bright guy. He's a very honest person, and, as the article said, he's convinced that for most patients, non-operative management is what you should do. Interestingly enough, that's exactly what we [spinal surgeons] do. If you're asking me if this study was a revelation to me, it was not. We've known this because of Weber's study, and everyone quotes that study. Q: What are some non-surgical methods of treating this? A: A lot of it's tincture of time. Certainly pain medicines, anti-inflammatories have been shown to be helpful, and muscle relaxers given within the first five to 10 days for a short period of time. Bed rest for two or three days, no longer until the pain begins to go away. Then the patients can get up and gradually resume normal activities if the pain allows them.