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Back Clinic Sciatica Chiropractic Team. Dr. Alex Jimenez organized a variety of article archives associated with sciatica, a common and frequently reported series of symptoms affecting a majority of the population. Sciatica pain can vary widely. It may feel like a mild tingling, dull ache, or burning sensation. In some cases, the pain is severe enough to make a person unable to move. The pain most often occurs on one side.

Sciatica occurs when there is pressure or damage to the sciatic nerve. This nerve starts in the lower back and runs down the back of each leg as it controls the muscles of the back of the knee and lower leg. It also provides sensation to the back of the thigh, part of the lower leg, and the sole of the foot. Dr. Jimenez explains how sciatica and its symptoms can be relieved through the use of chiropractic treatment. For more information, please feel free to contact us at (915) 850-0900 or text to call Dr. Jimenez personally at (915) 540-8444.

Hamstring Syndrome, Sciatica, and Chiropractic

Hamstring Syndrome, Sciatica, and Chiropractic

The hamstring muscles are three muscles in the back of the thigh. The sciatic nerve goes through or around and down the legs into the feet. Hamstring syndrome is a condition where injury or spasm apply pressure compressing the sciatic nerve.

  • The nerve can become pinched between the hamstring muscles and the pelvic bone or the band of tissue that connects the hamstring muscles.
  • This can cause discomfort, tingling, numbness, and pain down the back of the leg, hip, buttock, and into the foot.
  • Pain can present when sitting down or stretching the hamstrings.
  • Pain reduces when lying flat on the back.

Hamstring Syndrome, Sciatica, and Chiropractic

Hamstring syndrome

This condition could be the result of wearing and tearing to the back muscles and hamstring muscles. It is often seen in individuals that play sports involving running, kicking, and/or jumping. But it can happen to anyone from some awkward leg motion causing the muscles to spasm that can twist around the sciatic nerve or pull on it, causing various symptoms. A doctor or chiropractor will diagnose the condition by examining the symptoms, physical activities, and leg. Most individuals diagnosed with hamstring syndrome report discomfort or pain where they sit down. The pain gradually worsens when performing physical activities, regularly sitting, and when flexing the knee. Hamstring syndrome usually gets better within a few weeks with proper rest and home care. A doctor or chiropractor will recommend exercises and stretches to strengthen the muscles.

Home care

  • Ask the doctor or chiropractor about taking over-the-counter pain medication:
  • Acetaminophen – Tylenol
  • Ibuprofen – Advil, Motrin
  • Naproxen – Aleve
  • Read and follow all label instructions.
  • Use an ice pack on the pain area for 10 to 20 minutes at a time.
  • Try to do this every 1 to 2 hours for 3 days or until the swelling goes down.
  • After 2 or 3 days, if the swelling is gone, apply heat.
  • Use a warm water bottle, heating pad, or warm cloth over the area.
  • Avoid sitting if possible, unless it feels better than standing.
  • Take short walks to keep the muscles stretched.
  • Don’t do anything that causes symptoms to worsen.
  • Return to normal physical activities slowly.
  • If symptoms do not improve, then contact a doctor or chiropractor.

Body Composition

Short-term effects of coffee

  • Coffee increases short-term blood pressure slightly.
  • Caffeine falls under stimulants, or substances that excite the systems throughout the body.
  • Ingesting caffeine can cause the body to experience increased excitement, especially in the cardiovascular system.
  • This excitement causes the heart rate and blood pressure to rise
  • Then it lowers back down to baseline levels for most healthy individuals.
  • It is recommended to drink coffee in moderation, safe for individuals with pre-existing cardiovascular conditions.

de Ridder, Roel et al. “Neurodynamic sliders promote flexibility in tight hamstring syndrome.” European journal of sports science vol. 20,7 (2020): 973-980. doi:10.1080/17461391.2019.1675770

Matsuda, Dean K. “Editorial Commentary: Proximal Hamstring Syndrome: Another Pain in the Buttock.” Arthroscopy: the journal of arthroscopic & related surgery: official publication of the Arthroscopy Association of North America and the International Arthroscopy Association vol. 34,1 (2018): 122-125. doi:10.1016/j.arthro.2017.08.260

Park, Jung Wee et al. “Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain.” The bone & joint journal vol. 102-B,5 (2020): 556-567. doi:10.1302/0301-620X.102B5.BJJ-2019-1212.R1

Tight, Sore, Painful Gluteal Muscles and Chiropractic Release

Tight, Sore, Painful Gluteal Muscles and Chiropractic Release

The Gluteus Maximus Muscle is the largest and the outermost of the gluteal muscles. It stretches from the sacrum and coccyx, parts of the spinal column, down to the femur. The other gluteal muscles include the gluteus minimus and medius. They each have a role in the normal function of the hips and legs. They are prone to tightness resulting in soreness, aches, and pain around the hips and in and around the buttocks.

Tight, Sore, Painful Gluteal Muscles and Chiropractic Release

The Gluteal/Rear End Muscles

There are three rear-end muscles:

  • The Gluteus Maximus extends the hip and rotates the thigh outwards, straightens the legs when moving, and provides strength.
  • Gluteus Minimus
  • Gluteus Medius
  • The minimus and medius are underneath the Maximus and stabilize the hip when:
  • Walking
  • Jumping
  • Other physical activities

There is another group of diagonal muscles under the gluteus minimus that attaches to the femur. The uppermost is the piriformis that is attached to the sacrum. The sciatic nerve and major arteries run below it.

Tightness and Irritation

The primary function of the muscles is to open the hips and push the legs out. Sitting for long periods shortens the gluteal muscles causing them to become tight, limiting normal hip function. The gluteal muscles are susceptible to tightness brought on from overuse and lack of development/strength. This can develop into tender/tight muscle bands that interfere with the normal function of the muscles. To get an example of what is happening imagine flexing and contracting one of the bicep muscles 6-10 hours a day. It would be extremely sore, tight, and tender.

Sports and Physically Active

Athletes and individuals that are physically active can also have tight gluteal muscles. This can cause post-game/exercise muscle soreness. Intense activities force the gluteal muscles to work overtime to support the back and knees. Sports that require a lot of leg muscle activation include:

  • Running
  • Soccer
  • Football
  • Crossfit
  • Dancing
  • Weight training

Awkward Walking Gait

Individuals that move with an unusual gait are vulnerable to straining the muscles. What happens is the muscles become stiff from the awkward positions/postures. This places additional strain on the back and hip muscles and worsens their overall posture. The hip muscles are also attached to the pelvis, and when the muscles begin to tighten they can pull on the gluteal muscles. Irritation of the sacroiliac joint can also place pressure on the piriformis, causing spasms that affect the gluteal muscles. Piriformis muscle spasms can also place pressure on the sciatic nerve, causing sciatica.

Diagnosis and Treatment

An examination will be necessary to diagnose whether the soreness or pain is due to muscle inflammation or other cause. Sciatica symptoms and problems at the hip level that involves the gluteus minimus and medius can be felt in the leg. The examination includes seeing and feeling muscle reactions, responses, contractions through a series of motion exercises and movements that involve different muscles. Common treatment includes:

  • Range of motion exercises
  • Strengthening exercises like bridging and resistance bands
  • Deep tissue massages
  • Heat and cold packs
  • Physical therapy
  • Electric muscle stimulation

Tightness in the glutes can be managed with chiropractic treatment. This includes:

  • Soft tissue work
  • Spinal joint manipulation
  • Lifestyle adjustments
  • Stretching
  • Diet
  • Health coaching

Simple exercises can help engage and strengthen the muscles. These include:

Body Composition

Insulin Resistance

Individuals that sit for long periods of time, don’t get enough physical activity, and have an unhealthy diet can experience insulin resistance. This happens when insulin is not able to transport excess blood sugar out of the blood and into the muscles. A study found that women who sat for eight hours a day had an increased chance of developing diabetes. Diabetics can be inclined to have more fat within the body, specifically visceral fat. This further encourages insulin resistance. Diabetics also experience rapid loss of muscle mass as they age, intensifying symptoms and further affecting body composition.


Cochrane, Darryl J et al. “Does short-term gluteal activation enhance muscle performance?.” Research in sports medicine (Print) vol. 25,2 (2017): 156-165. doi:10.1080/15438627.2017.1282358

Coratella, Giuseppe et al. “The Activation of Gluteal, Thigh, and Lower Back Muscles in Different Squat Variations Performed by Competitive Bodybuilders: Implications for Resistance Training.” International journal of environmental research and public health vol. 18,2 772. 18 Jan. 2021, doi:10.3390/ijerph18020772

Distefano, Lindsay J et al. “Gluteal muscle activation during common therapeutic exercises.” The Journal of orthopedic and sports physical therapy vol. 39,7 (2009): 532-40. doi:10.2519/jospt.2009.2796

Kalyani, Rita Rastogi et al. “Age-related and disease-related muscle loss: the effect of diabetes, obesity, and other diseases.” The lancet. Diabetes & endocrinology vol. 2,10 (2014): 819-29. doi:10.1016/S2213-8587(14)70034-8

Selkowitz, David M et al. “Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes.” The Journal of orthopedic and sports physical therapy vol. 43,2 (2013): 54-64. doi:10.2519/jospt.2013.4116

Sciatic Nerve Pain In Rainy Conditions

Sciatic Nerve Pain In Rainy Conditions

Rain generally comes with a drop in barometric pressure. A low-pressure system you may have heard from the local weather forecast. Lower pressure outside can cause tissues inside the body to swell and irritate sensitive nerves. For those who have sciatic nerve pain, rainy, hot, humid weather can cause the nerve tissues to expand causing increased compression, inflammation, and pain.

Sciatic Nerve Pain In Rainy Conditions

Rainy Weather

For anyone who is prone to inflammation, there are ways to cope with rainy weather-related symptoms, including:

  • Stay inside air-conditioned areas where the humidity level is lower.
  • Use a dehumidifier to keep the indoor air at 40-60% relative humidity for comfort.
  • Utilize vent fans in the kitchen and in laundry areas and after baths/showers in bathrooms.

Easy Physical Activity

Easing the pain can also be done through:

  • At work, school, home adjust the seat to work for you. Individuals with sciatic nerve pain already know how to make adjustments to chairs and other places for sitting.
  • If you’re heading out to a baseball or soccer game, you may want to use a comfortable sideline seat that provides cushion and support. If attending a pro game, check online or call to see if you can bring a therapeutic seat cushion.
  • Stretch throughout the day and evening
  • Try not a hunch over or crouch
  • Whether job occupation, house, or yard work use a stool or a pair of kneepads
  • Take a regular stand up, move around, and stretch breaks
  • Walking will keep the muscles, tendons, and nerves stretched and loose
  • Light exercise will help bring down swelling


Going on a trip whether road or flight, seats might not be comfortable or supportive. Tips that can help maintain comfort to mitigate the pain, include:

  • Adjust the seat for proper posture to maintain spinal curvature
  • Use lumbar support
  • Maintaining a workout routine is key leading up to your trip. If the body is inactive for a period of time, the back muscles are more likely to spasm when having to sit in tight quarters.
  • Don’t overpack. Carrying around heavy luggage increases the risk of straining the muscles.
  • Pack pain medication or anti-inflammatories on hand in case of a flare-up.


  • Target inflammation with ice therapy
  • Using topical heat or a heating pad can get the blood circulation flowing through the area
  • Wear compression garments over the affected areas to bring down swelling and promote blood and nerve circulation.

Chiropractic Rainy Day Relief

Chiropractors know the whole musculoskeletal system. Chiropractic massage therapy induces deep muscles relaxation and the release of endorphins/natural painkillers. A regular spa massage can release sore muscles and tension, chiropractic massage focuses on soothing and healing sciatica. Adjustments or spinal manipulations allow the disc/s rest back into position and relieve the pressure on the sciatic nerve. This will lessen the pain and generate nerve signal flow and mobility.

  • Spinal decompression relieves the compression of the nerves that are causing sciatica pain. This includes techniques to lengthen the spine and enhance the space between the vertebrae.
  • A chiropractor will recommend exercises to prevent nerve aggravation and help release the pressure that comes from the inflamed and tight muscles.
  • Exercises include stretching programs that can be done at home to release pressure on the nerve and ease irritations.

Body Composition

About Fat

Fat, also known as adipose tissue, contributes to overall body weight. This is also the type that individuals want to get rid of when talking about weight loss. Two different kinds of fat:

  • Subcutaneous fat is the fat that is beneath the skin.
  • Visceral fat lies deep in the abdominal cavity and surrounds the organs.
  • Having a certain amount of fat tissue is necessary for a healthy body.
  • The body stores unused energy from food as fat. This is to provide a reliable source of fuel when the body needs it.
  • Fat tissue acts as insulation to keep the body warm and as a cushion to protect the vital organs.
  • Fat is an endocrine organ. This means that it releases hormones and regulates blood sugar.
  • The problem/issue is excess body fat. This is what leads to higher body weight and altered hormone release that can make the excess weight condition worse.

National Institutes of Health. (2019.) “Sciatica.”

StatPearls [Internet]. (2020) “Anatomy, Sciatic Nerve.”

Zwart, J A et al. “Warm and cold sensory thresholds in patients with unilateral sciatica: C fibers are more severely affected than A-delta fibers.” Acta neurologica Scandinavica vol. 97,1 (1998): 41-5. doi:10.1111/j.1600-0404.1998.tb00607.x

Zwart, John-Anker, and Trond Sand. “Repeatability of dermatomal warm and cold sensory thresholds in patients with sciatica.” The European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society vol. 11,5 (2002): 441-6. doi:10.1007/s005860100333

The Sciatic Nerve

The Sciatic Nerve

The sciatic nerve is the largest in the body and is created by five nerve roots that come together and exit the lower spine. It goes through the buttocks on either side and down the thighs all the way to the heels and soles of the feet. The sciatic nerve connects the spinal cord to the muscles of the thigh, leg, and foot. Any type of pain and/or neurological symptom/s that comes from the sciatic nerve is known as sciatica. The symptoms can be felt along the nerve’s path. This could be the:

  • Low back
  • Buttocks
  • Thighs
  • Calves
  • Feet
  • Or it could be a combination of all the areas


The Sciatic Nerve

Neurological Symptoms

When the nerve is compressed,  neurological symptoms can accompany the pain. These include:

Thigh muscle weakness

If the thigh muscles are affected, weakness can be felt when bending or flexing the knee.

Leg and foot muscle weakness

Weakness can be felt while attempting to bend the knee or pointing the foot/toes upward/downward. This can lead to foot drop, which makes lifting the front part of the foot when walking difficult. Difficulty can also present when getting up from a sitting position or walking on the tiptoes.


Loss of sensation can happen when the nerve impulses/transmissions cannot pass all the way through. Common areas affected by numbness are the:

  • Side of the calf
  • Side of the heel
  • Bottom of the foot
  • Top of the foot


This is an abnormal sensation felt on the skin. It is brought on by improper nerve transmission. This sensation can include:

  • Tingling
  • Tightness
  • Pins-and-needles
  • Crawling feeling along the back of the thigh and/or leg

The Sciatic Nerve Gets Affected

The sciatic nerve can become:

  • Irritated
  • Compressed
  • Inflamed
  • This lumbar/low back radiculopathy means that the pain originates in and around the lumbar and/or sacral/sacrum nerve roots.


Physical forces could affect the nerve following common conditions:

Disc Herniation

A disc in the lower back can bulge or herniate. This causes irritation that can lead to compression of a nerve root.


Stenosis means the opening where the sciatic nerve exit into the buttocks begins to get narrow in size. This creates a clog with the other nerve roots that compresses or irritates the sciatic nerve. Degenerative changes in the spine like the thickening of the facet joint capsules and/or ligaments can also compress the sciatic nerve.


Instability of a vertebral segment happens when one vertebra slips over the one below it, known as spondylolisthesis. There are also vertebral defects like spondylolysis which is a complete dislocation of one or more vertebrae. This can directly compress the sciatic nerve roots.

Inflammatory Response

The body’s own chemicals can irritate the nerve causing inflammation. These chemical irritants include:

  • Hyaluronic acid
  • Fibronectin protein fragments leak out of degenerated or herniated discs onto and around the sciatic nerve roots.
  • There are times when degenerated discs can cause nerve tissues to grow into a disc. The tissue penetrates the outer and inner layers of the disc, causing inflammation and pain.
  • Some studies have shown how an immune system response can contribute to sciatic pain when there is exposure to the disc material from herniated disc/s.

Glycosphingolipids which are fats, and neurofilaments which are protein polymers. They are secreted by the immune system and have been found to have high levels in individuals with sciatica. It is believed they are released in reaction to the nerve roots and exposed disc material. This can lead to inflammation of the sciatic nerve.

Body Composition

The physical characteristics of an individual can also affect the sciatic nerve. Research has shown an increased risk of sciatica in:

  • Overweight individuals
  • Obese individuals
  • Older individuals
  • Tall individuals

Work Injuries

Individuals with certain jobs can have an increased risk of developing sciatica. Examples include:

  • Semi-Truck operators
  • Machine operators
  • Construction workers
  • Hairstylists
  • Office workers
  • Athletes that lift weights

This comes from:

  • Sitting for long amounts of time
  • Poor posture
  • Constant bending forward or sideways
  • Regularly lifting the arms above shoulder level
  • All are risk factors.

Vitamin B12 deficiency

Adequate levels of vitamin B12 are important for nerve health. Vitamin B12 supports the myelin sheath that covers and protects the nerves. It is important in nerve function and in transmitting impulses. Sciatica can present from vitamin B12 deficiency. However, this is more common in individuals 60+.

Body Analysis

Alleviating Nerve Pain Through Clinical Nutrition

Clinical nutrition is a powerful tool to help alleviate sciatica. Many individuals can relieve their pain through diet adjustments. Here are a few diet tips to alleviate sciatic nerve pain through clinical nutrition:

  • Sometimes, sciatica can be triggered by constipation from an unhealthy diet
  • Incorporate fiber-rich foods
  • Fruits and vegetables will prevent constipation
  • Oily fish like salmon and halibut are rich in omega 3 fatty acids
  • Fresh pineapples and berries are anti-inflammatories that support healing and boost the immune system
  • 2-3 cups of green tea
  • Add turmeric, ginger, and garlic to meals
  • B-Vitamins are important to take in when going through sciatica and are found in green peas, spinach, navy beans, nuts, bananas
  • Foods that are rich in A-Vitamins like dairy products, dark leafy vegetables, orange-colored fruits, eggs, and oily fish
  • Foods rich in C-Vitamins, like citrus and tomatoes
  • K-Vitamins like  broccoli and spinach
  • Drink plenty of water, between 6 to 8 glasses a day

Foods to Avoid

  • Nutritionists recommend cutting out meat products except for oily fish for the first two weeks.
  • Foods that contain sunflower oil, corn oil, sesame oil, margarine, and partially hydrogenated oil.
  • Stressor foods like caffeine, processed food, soda, refined sugars, and chocolate.
  • Alcohol

Giuffre BA, Jeanmonod R. Anatomy, Sciatic Nerve. [Updated 2018 Dec 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:

Heuch I, Heuch I, Hagen K, Zwart JA. Association between body height and chronic low back pain: a follow-up in the Nord-Trøndelag Health Study [published correction appears in BMJ Open. 2015;5(10):e006983]. BMJ Open. 2015;5(6):e006983. Published 2015 Jun 15. doi:10.1136/bmjopen-2014-006983.

Kumar, M. Epidemiology, pathophysiology and symptomatic treatment of sciatica: A review. nt. J. Pharm. Bio. Arch. 2011, 2.

Quero L, Klawitter M, Schmaus A, et al. Hyaluronic acid fragments enhance the inflammatory and catabolic response in human intervertebral disc cells through modulation of toll-like receptor 2 signaling pathways. Arthritis Res Ther. 2013;15(4): R94. Published 2013 Aug 22. doi:10.1186/ar4274.

Shiri R, Lallukka T, Karppinen J, Viikari-Juntura E. Obesity as a Risk Factor for Sciatica: A Meta-Analysis. American Journal of Epidemiology. 2014;179(8):929-937. doi:10.1093/aje/kwu007.

Different Individuals Different Sciatica Treatment Approaches

Different Individuals Different Sciatica Treatment Approaches

Living with sciatica can be debilitating and exhausting. Find out how different individuals reduced their pain from this condition. Sciatica has different treatment options. It is often a matter of trial and error to find a treatment/therapy that works for the individual. These include:

  • Physical therapy
  • Medication
  • Chiropractic
  • Injections
  • Acupuncture
  • Surgery

Different Individuals Different Sciatica Treatment Approaches

Different individuals with sciatica share what works for them. Here are their stories.

Rudy Found Relief With Self Care

A bad fall left Rudy, a graphic designer, with a broken pelvis and broken foot. I was in the hospital for a few days, and when I came home, I noticed I was hobbling. I had developed sciatica. I was in a lot of pain but decided to try the treatment that had helped me manage chronic migraines. This was yoga. Specifically, it was hot yoga sessions that, despite the pain, worked. However, for others, he recommends not staying still. The body can’t stay stagnant with no movement.

Rudy follows a plant-based diet. Eating right has helped significantly. He starts the day with a green smoothie and sips one throughout the day. This reduces inflammation and pain. His stress would also contribute to the pain. Anything felt from a pain perspective becomes amplified when in a sad, frustrated, confused mood. Rudy’s advice is to get the body moving. And follow a plant-based anti-inflammation diet.

Medication and a Topical Pain Balm Work For Jose

Jose, 66, figured how his sciatica developed was when he decided to insulate the garage. I was bending, twisting, turning, and contouring my body every which way. A week after the job, I developed excruciating pain that got worse over the following weeks. I would jolt out of bed at 2-3 in the morning with severe pain. My doctor gave me steroids that didn’t do anything. I could barely sit down and had to go through a careful method of getting into a chair. I was prescribed Vicodin – hydrocodone/acetaminophen. I took them for a week and a half.

The pain went away, but it came right back as soon as I stopped taking the meds. The meds were only masking the pain. I decided only to use it when the pain was excruciating. This was because I was worried about addiction. I tried chiropractic, massage, acupuncture, cupping, and physical therapy. Unfortunately, I was not feeling any real relief. Then I went to a pain management doctor, who ordered an X-ray and an MRI.

The doctor informed me that my spine was in great shape. The pain management doctor gave me a piriformis injection and, later, an epidural steroid injection. There were still no positive results. My primary care doctor prescribed gabapentin. This is an anti-epilepsy medication that has been shown to help some cases of back pain. Most of the major pain is gone, and I’m pretty sure it’s from the gabapentin along with weekly deep massage sessions. I also use CBD cream with arnica. Movement is important; during the day, I make sure to stand up and walk around.


Epidural Injections Work For Isabel

Isabel has chronic pain. This comes from arthritis, migraines, and fibromyalgia. Sciatica developed as a result of these conditions. Soon she couldn’t get into the car or even empty the dishwasher without going through excruciating pain. Nerve ablation or physical therapy was ineffective at relieving the pain. Then my doctor suggested getting an epidural injection. This is not the same type of injection as when having a baby. It is not the same at all. The injection includes a steroid medication called a corticosteroid that is an anti-inflammatory, along with an anesthetic. I tried it and got some relief, but the pain came back. However, after a month and a half, I began to feel more relief. The pain is not completely gone. I do feel better, but there is still some pain. My doctor told me that patients are all different and require different amounts of medication and time to work.

Surgery Gave Pablo His Life Back

Pablo, 50, is no stranger to back pain or back surgery. After living with chronic back pain from a roll-over auto accident, Pablo underwent a laminectomy. A doctor removed a portion of the vertebra in 1998 and spinal fusion in 2004 that fused the discs from L5 to S1. Life was going well until I was laid off from my desk job. I started working at a warehouse doing light work, but I would still help lift moderate/heavy bags, boxes, etc. I just pushed through the pain, thinking it was a strain that would go away.

However, during the last six months, the pain was so bad I had to stop working. I needed a cane to get out of a chair. Friends and family told me I was walking like a 90-year-old. I also lost feeling in a couple of my toes. In 2021 I had another fusion and had a broken screw from my earlier fusion repaired. The surgery went well, and they said as long as I don’t do any heavy lifting, I should be alright. Although there is still pain, it is much less than it was before the surgery. My doctor recommended a new desk job and a physical therapy rehabilitation, stretching, and strengthening program.

Body Composition

Calories burned from 10,000 steps

Estimations of how many calories are burned from exercises like walking or running depends on how heavy an individual is. Heavier people use more energy to move than lighter people. Estimates revolve around 100 calories burned per mile for a 180-pound person. 10,000 steps comes to around roughly 5 miles. Assuming an individual weighs 180 pounds means 100 calories x 5 miles equals 500 calories. Over a week, it becomes 3,500 calories. However, lighter or heavier individuals will burn less or more calories while walking the same number of steps or distance.

How A Doctor Of Chiropractic Heals Sciatica

How A Doctor Of Chiropractic Heals Sciatica

The spinal cord is the information pathway that transmits signals from the brain to the rest of the body. The body’s limbs and organs cannot function properly without regular communication flowing through the spinal cord. Understanding how the sciatic nerve responds to the other parts of the body can clarify how a doctor of chiropractic heals sciatica.  When severe pain presents normal communications are overridden for the sake of body and health preservation. The sciatic nerve is an important part of the spinal cord and requires a trained professional to aid in proper and effective healing.

11860 Vista Del Sol, Ste. 128 How A Doctor Of Chiropractic Heals Sciatica

Basics On Sciatica

Sciatica happens when the nerves are compressed/pinched in some form. Lower back conditions can be the cause of such compression. Sciatica can be reduced and healed. Conditions that can lead to sciatic pain include:

  • Herniated discs
  • Subluxations
  • Disc Degeneration
  • Spinal Stenosis
  • Lower back disc bulge
  • Piriformis syndrome


Sciatica often includes:

  • Sharp pain
  • Numbness
  • Burning
  • Tingling sensation
  • Individuals can also experience weakness down the leg.

Normal activities can become strained as individuals experience these symptoms. Pressure on the nerve can be decreased and healed with professional chiropractic care. The human spine consists of 31 pairs of nerves. Five of these pairs are in the lumbar/lower back region and five are right below that area in the sacral region. The sciatic nerve starts in the lower back. It goes down through the hips, buttocks, thighs, knees, calves, and ends in the foot.

Causes could be something as simple as sitting on a bulging wallet or sitting for extended lengths of time can result in a decreased blood flow to the area. Also, direct trauma to the gluteal muscles from automobile accidents, sports, and work injuries can lead to sciatic nerve issues and pain.

Treatment Options

Tests and examinations will be conducted to figure out the origin of the pain to develop a personalized treatment plan to expedite the healing process. Treatment can include:

  • Chiropractic treatment
  • Decreasing muscle tension
  • Core stabilization
  • Spinal decompression
  • Rehabilitation therapy

Chiropractic treatment is designed to help the body activate its own healing system. It is non-invasive and drug-free providing an organic alternative. Advanced cases of sciatica can result in muscle weakness or a loss of sensation in the legs, if not properly treated. Individual treatment plans vary depending on an individual’s specific needs.


Prevention is important once the condition is healing to not cause flare-ups. Sciatica symptoms can return, especially if proper and continued care to the spine is not maintained. Preventative care and maintenance are essential for ensuring a healthy spine and body. These tips can help avoid back injuries that can lead to sciatica and help with reoccurrences:

  • Practice proper posture
  • Regular exercise/physical activity with safe movements
  • Bend at the knees, especially when lifting heavy objects
  • Follow specific instructions given by a chiropractor

Body Composition

Healthy Snacks


Eggs make a great snack that will keep the body full and help to eat less. They are a great source of protein and fat and have a healthy variety of vitamins and minerals. Hard-boiled eggs are easy to make ahead of time and are portable.


Cheese is a great snack for protein and fat. But it is important to watch the serving size if watching/limiting calories. Cottage cheese is highest in protein but cream cheese and cheese sticks are also good options. Cheese can be paired with a serving of fruit or vegetables like grape tomatoes, bell peppers, celery, apples, or pears.


Jerky is convenient and portable and is a great way to pack in extra protein throughout the day. The best option is grass-fed. Remember that some jerky is high in sodium if limiting sodium.

Greek Yogurt

Natural Greek yogurt is a great option for a high-protein snack. However, many yogurts are high in sugar. Therefore choose yogurt with less than 10 grams of sugar per serving, or opt for plain yogurt to avoid the sugar altogether. The yogurt can be sweetened with honey, fresh fruit, or mixed into a smoothie.

Hummus and Guacamole Dips

Hummus is a great source of plant-based protein and is balanced with carbohydrates, fat, and fiber. It is the olive oil in the hummus that provides a healthy dose of heart-healthy polyunsaturated fats. Guacamole is a delicious source of healthy fats. Both dips are calorie-dense, therefore it is important to be aware of portion sizes. These can be paired with carrot sticks, bell peppers, or celery.


The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the musculoskeletal system’s injuries or disorders. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request. We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, CTG*
phone: 915-850-0900
Licensed in Texas & New Mexico


National Institutes of Health. (2019.) “Sciatica.”

North American Spine Society. (2012.) “Clinical Guidelines for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy.”

StatPearls [Internet]. (2020) “Anatomy, Sciatic Nerve.”

StatPearls [Internet]. (2020) “Sciatica.”

Sciatica Flare-Ups: Causes and Chiropractic Care

Sciatica Flare-Ups: Causes and Chiropractic Care

Sciatica is a very common and painful issue. Keeping it in check can be difficult especially with various causes that can generate flare-ups. Individuals managing sciatica need to pay attention and be vigilant of the negative activities/movements that could cause symptoms to reappear. A few common causes include:
  • Excessively tight-fitting pants
  • Improperly lifting heavy objects
  • Poor posture
  • Weight gain
  • Not stretching out
  • Wearing the wrong shoes
Knowing what not to do is just as effective for helping sciatica flare-ups as knowing what is best.  
11860 Vista Del Sol, Ste. 128 Sciatica Flare-Ups: Causes and Chiropractic Care

Sciatica Causes

The sciatic nerve is the longest nerve. It comes out the spine through the pelvis, down the leg to the foot. There is one sciatic nerve on each side of the body, and either can become irritated, injured, and inflamed. However, it�s rare that both are irritated at the same time. The underlying causes can vary. Most of the time the cause is a herniated disc that presses against the nerve, causing the pain. Even though this happens in the lower back, an individual might only feel pain in the buttocks and the back of the leg. Other causes of sciatic nerve pain include:
  • Bone spurs
  • Degenerative disc disease
  • Muscle inflammation
  • Muscle spasms
  • Spinal stenosis
  • Spondylolysis

Making Sciatica Flare-ups Worse

What makes sciatica worse depends on the underlying cause. For most, this is a herniated or bulging disc that presses against the nerve. With this type of case, any increase in pressure on the discs can worsen the symptoms. Sitting down in fact puts more pressure on the spinal discs, worsening the pain. Lying down can also worsen symptoms. When the pain is peaking, lying down for a little while can help, but for too long can worsen symptoms. Standing with a neutral spine, and walking around a bit, can help with nerve pain relief and the healing process.  

Improper/Poor Posture

Poor posture, especially the rounding of the lower back. This usually happens when sitting. The rounded low back becomes a bad habit that individuals think will help with the pain. This can cause a flare-up. The spine has a natural S-curve and the more an individual can maintain that natural curve, the better off they will be.  

Weight Gain

Too much weight can cause flare-ups with added stress/pressure on the spine, especially the low back. Maintaining a healthy weight will help relieve the added pressure, however, many who experience sciatica have trouble exercising. This is where a physical therapist and chiropractor can assist an individual with customized exercise and diet programs to overcome this obstacle. Eating is a way that individuals deal with pain, anxiety, and depression. But weight gain and poor health can worsen sciatica. Individuals that are overweight tend to experience more inflammation throughout the body, making sciatica even worse.  


Not stretching, especially as the body gets older tightens the muscles, ligaments, and tendons. And stretching improperly can injure these areas. There are recommended and non-recommended stretches for individuals dealing/managing sciatica. Stretches that require bending the low back can place added pressure on the lumbar spine, causing sciatica flare-ups.  
11860 Vista Del Sol, Ste. 128 Sciatica Flare-Ups: Causes and Chiropractic Care

Lifting Heavy Things

Lifting and improperly lifting heavy objects can worsen sciatica. This has to do with the rounding of the low back. Any time the spine is taken out of its natural S-curve, there is undue pressure on the joints and discs. When lifting heavy objects in this position the problem is worsened. When possible avoid lifting anything heavy while dealing with sciatica. It�s healthy to stay active, but there is no need to do intense workouts at home or the gym, especially heavy lifting.  
11860 Vista Del Sol, Ste. 128 Sciatica Flare-Ups: Causes and Chiropractic Care

Tight Pants

Tight pants can contribute to sciatica. Whether shorts, jeans, or skirts, wearing overly-tight, form-fitting pants should be avoided until the sciatica is gone. And even after it is not recommended to wear overly tight-fitting clothing, as this can cause blood and nerve circulation problems.


Like tight pants, the wrong shoes without adequate support can cause flare-ups. For example, high heels force weight distribution to the front of the feet. For the body to compensate, it�s normal to push the pelvis and hips forward. When the body is in this position for a long time it starts to place stress on the hamstrings, which will exacerbate sciatica. Shoes without adequate support place added stress on the feet, which gets transferred up the leg to the hamstrings. Customized shoe inserts designed especially for individuals with sciatica can help in preventing symptoms.  


Sciatica takes time to heal. Avoiding making it worse and taking all the steps to help it heal, can bring the body back to normal within 2 weeks. For most, it takes around 4 weeks for the pain to go away. This depends on various factors. For example, if sciatica develops during pregnancy, it could take longer to get rid of the pain. One sign that shows improvement is called centralization meaning the pain is moving out of the leg and into the spine. This is a good sign that the individual is on the right track.

Body Composition


Meal Planning

The convenience of food delivery is wonderful, but remember that frequently eating food prepared away from home increases the risk of weight gain and obesity. Restaurants tend to serve oversized portions and prepare meals with excessive calories, sodium, and sugar. The benefit of eating from home is that individuals have more control over the ingredients and cooking methods used to prepare the food. It helps to plan meals and snacks in advance to make sure they are balanced. Here are the types of foods that should be included in a balanced meal plan:
  • A variety of whole fruits
  • Non-starchy vegetables – leafy greens, red and orange veggies
  • Starchy vegetables – potatoes, green peas, legumes, winter squash
  • Grains, with the goal to make at least � from whole-grain sources
  • Low-fat or fat-free dairy milk, yogurt, cheese
  • Protein from various sources – lean meats, seafood, eggs, nuts & seeds, and soy products
  • Healthy cooking oils – olive oil or canola oil
  • Nuts and nut butter
  • Fresh or frozen fruits
  • Dried herbs and spices

Dr. Alex Jimenez�s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*  
Sciatica. MedlinePlus. Accessed November 29, 2018. Sciatica Sciatic Nerve Pain During Pregnancy. babyMed. Updated on August 29, 2018. Accessed November 29, 2018. Shiel WC. Degenerative Disc Disease and Sciatica. MedicineNet. Last reviewed August 10, 2018. Accessed November 29, 2018.
Sciatica Relief Through Chiropractic-Health Coaching Weight Loss

Sciatica Relief Through Chiropractic-Health Coaching Weight Loss

Back pain combined with sciatica is the number one cause of temporary disability all over the world. The spine is a complex interconnected system that supports the entire body. Being overweight does not help. Losing weight can help relieve sciatica and prevent future episodes. It can be done through chiropractic health coaching. According to research, overweight individuals have a higher risk of developing sciatica. The more weight the body carries the more stress is placed on the spine and joints, which can irritate/inflame the sciatic nerve.  
11860 Vista Del Sol, Ste. 128 Sciatica Relief Through Chiropractic-Health Coaching Weight Loss

Causes and Symptoms

To understand how sciatica is affected by the weight of the body one needs to understand how it works. A breakdown of the causes and symptoms.
  • The sciatic nerve runs from the lower spine, through the glutes, down the back of the thigh, and is attached under the foot.
  • The nerve becomes compressed or irritated where it exits the lower spine. This can be caused by a bulging or herniated disc, narrowing of the spinal canal, or bone spurs.
  • Symptoms include a sharp pain that spreads out from the low back and down the back of the leg. It also causes tingling, numbness, and weakness.

Indirect Cause Being Overweight

Being overweight can indirectly cause sciatica. When the body has to support added/extra weight it can cause problems. That extra weight also places tremendous stress on the joints, especially those in the spine. The lower back takes most of the force from this stress, which is how sciatica develops. The stress slowly pulls the spine out of alignment and compresses the discs between the vertebrae, which then compresses the sciatic nerve, causing pain and discomfort.  

Sciatica and Weight Loss

Keep in mind that weight loss is not a cure for sciatica. Weight loss will surely help relieve sciatica pain but there are other issues at work that are combined with excess weight and are causing sciatica. Weight loss is only a step in the right direction. The most recommended and effective ways to lose weight and relieve sciatica pain is having a healthy diet, exercise, and chiropractic health coaching. Other things that can be done to relieve sciatic nerve pain include:

Exercise With Sciatica

Regular exercise will help reduce the symptoms and strengthen the body’s core and leg muscles. There are a variety of things that make sciatica worse like:
  • Sitting too much
  • Sedentary lifestyle
  • Wearing shoes with no support
  • Lifting, bending, twisting, reaching, overuse
Exercise is the best antidote to sitting too much and living a sedentary. Exercising with sciatica does not mean a full gym routine but doing the right exercises that will not worsen the condition. The important thing is staying active. Avoiding exercise will only make sciatica worse. For example, yoga is great for sciatica and health in general. A 30-minute session of yoga 3 times a week combined with another form of exercise twice a week can produce optimal results.

Weight Training

Weight training will work with sciatica with certain adjustments and avoiding specific exercises that can cause pain and should be discussed with a doctor, chiropractor, physical therapist depending on the individual’s sciatic condition.  

Form and Posture

Weight training form is essential. Practice slow repetitions with special attention to physical form. Proper posture, maintaining a neutral spine, and avoiding rounding the lower back will help avoid worsening sciatica, and prevent further injury/s.  

Avoid Overhead and Straight Leg Exercises

Not until the sciatica pain reduces avoid overhead lifting exercises and straight leg exercises, as these can cause flare-ups. Also, avoid intensive abdominal exercises that require doing crunches.

Know The Limits

When sciatica is present, the body is in healing mode, the key is to not overdo it. This exercise is minimal, to help in the recovery process, and strengthen the muscles. Too much exercise can prolong the recovery.

Losing Belly Fat

Losing belly fat with sciatica is possible. But it will take a sustained effort that will be well worth it when sciatica. Losing the fat needs concentration on three things:


Eating whole nutritious foods with plenty of vegetables, and staying away from processed and sugary foods. This is where a health coach and nutritionist can offer the greatest recommendations and develop a customized diet/health plan.


Weight training, yoga, cardio, or a combination of all is probably best. Whatever regimen is chosen the objective to stick with it.

Lifestyle adjustments

This includes improving posture, workstation set up, adjusting sitting routines, and limiting activities that cause back pain/sciatica.  
11860 Vista Del Sol, Ste. 128 Sciatica Relief Through Chiropractic-Health Coaching Weight Loss

Chiropractic Health Coaching

The full-body approach outlined is how chiropractic treats sciatica. Chiropractic can relieve the pain quickly with massage, spinal adjustments, and physical therapies. This is why chiropractic health coaching is ideal for those who have a hard time making nutrition, exercise, and lifestyle changes on their own. Numerous studies show that chiropractic promotes weight loss, reduced pain, improved posture, and increased well being. And it is done in a safe, non-invasive, medication-free way.

Body Composition


Eating Out A Significant Contributor For Weight Gain

When eating out, there is a tendency to consume excess empty calories and increase fat storage. This is why preparing food is so important. It gives the individual direct control over what is being consumed and allows trying out different dietary approaches to see which one works best for improving body composition and gut health. Even for those that don�t enjoy cooking, consult a chiropractic health coach to see what options are available.  

Dr. Alex Jimenez�s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*
National Institute of Neurological Disorders and Stroke. (2020.) �Low Back Pain Fact Sheet.�� North American Spine Society. (2012.) �Clinical Guidelines for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy.��
Sleeping With Sciatica and A Better Night’s Rest

Sleeping With Sciatica and A Better Night’s Rest

Trying to get a proper night’s rest and healthy sleep with sciatica can be difficult. Here we discuss how to combat sciatica discomfort for a better night�s rest. The sciatic nerves are the two largest nerves in the body. They run from the low back through the:
  • Hips
  • Buttocks
  • Down each leg into the feet
When the nerve gets:
  • Irritated
  • Inflamed
  • Pinched
  • Compressed
Sciatica can cause pain, tingling, numbness in the butt, lower back, leg, calf, and foot. It is a common condition that affects many individuals.

Is It Sciatica

Sciatica happens when the nerve becomes pinched from a bulging or herniated disc. In rare cases, the pain can result from a tumor putting pressure on the nerve or damage to the nerve caused by disease. The location and intensity of the pain depend on where the injury or damage occurred and how bad it is. Sciatica pain can be described as:
  • Dull
  • Sore
  • Numbing
  • Jolting
  • Throbbing
  • Hot
  • Stabbing
  • Radiating
11860 Vista Del Sol, Ste. 128 Sleeping With Sciatica and A Better Night's Rest
For many sciatica usually resolves within a matter of weeks. However, once sciatica has presented future episodes are almost guaranteed to resurface and if not treated properly can lead to more serious problems.


The sciatic nerve/s can affect several areas of the body, making symptoms vary. The most common include:
  • Lower back pain starts at the low back, runs along the hips and buttocks down each leg.
  • Pain radiates/spreads down the butt/leg area sometimes described as a shooting pain and usually occurs on just one side.
  • Pain while sitting for long periods of time places pressure on the gluteal muscles, lower back, and nerves. This can cause or worsen the condition. When having to sit for a while, it is recommended to get up every hour or so and walk/move around. This gets the blood flowing and stretches out the tightened muscles.
  • Hip pain, as the sciatic nerves run through the hip joint and in some cases can cause pain to settle in the hip. Injuries in the hip can mimic the symptoms of sciatica. If there is hip pain that does not improve with time get checked by a doctor to rule out other causes like osteoarthritis, bursitis.
  • Numbness, some experience weakness in the legs and an altered sensation of numbness. This is caused by a herniated disc in the lower lumbar region.
  • Burning/tingling like a pins and needles sensation, especially in the feet and toes.


There are several conditions that can cause sciatica:
  • Degenerative Disc Disease is where the discs of the spine deteriorate and become susceptible to painful herniation.
  • Spondylolisthesis is a painful condition where the lower vertebrae slip forward onto the bone directly below impinging the sciatic nerve.
  • Muscle Spasms and involuntary contractions of the muscles can cause sciatica if they compress the nerve.
  • Pregnancy sciatica is not uncommon. As the baby grows it places pressure on the nerve causing aches and pains.
  • Lumbar spinal stenosis is when the spaces in the low back begin to narrow compressing and irritating the nerve.
  Risk factors include:
  • Age, as the spine gets older it becomes more susceptible to herniated discs and bone spurs, which are leading causes of sciatica.
  • Obesity and excess weight create added stress on the spine, which can inflame the nerves.
  • Occupation/work that requires standing/sitting for long periods or if a lot of heavy lifting is involved there is added pressure on the back increasing the risk for back problems.
  • Individuals with diabetes have an increased risk for nerve damage. When nerves are damaged, they can cause radiating pain.

Night Time

Sleeping at night can be a challenge, especially not being able to get into a comfortable position. Sleep deficits and insufficient sleep can reduce the body�s tolerance to pain and worsen inflammation. Many wake up with increased symptoms. This is likely due to the fact that when the body is laying down the discs draw in and absorb fluid, which results in increased pressure within the disc, creating more pressure on the nerve. But there are some things to do to lessen pain and get a good night�s sleep. This includes changing sleep position, stretching, and practicing healthy sleep hygiene.  
11860 Vista Del Sol, Ste. 128 Sleeping With Sciatica and A Better Night's Rest

Sleeping Positions

  • Sleeping on the back is considered the best sleeping position for sciatica because it eases pressure on the low back and discs where the nerves are located.
  • Sleeping on the side can be more comfortable and is a good position because it doesn�t place direct pressure on the muscles, discs, or sciatic nerve. But, it is important that the mattress is supportive enough to keep the spine aligned. If more support is needed place a pillow between the legs.
  • Sleeping with the knees elevated can help take the pressure off the low back. To achieve this place a pillow under the knees or, with an adjustable bed, use it to elevate the foot of the bed.
  • Sleeping with a body pillow provides extra comfort and helps the body remain in a certain position throughout the night. These pillows come in a variety of shapes, sizes.


Stretching can provide relief. It�s important to stretch to keep the body flexible and to prevent pain. Gentle stretches before bed, and after waking up will loosen the muscles and ligaments surrounding the spine and joints.
  • Reclining pigeon pose is a yoga pose that opens the hips and eases lower back pain.
  • Lying on the back with both knees bent.
  • Lift the right leg and place the ankle on the top of the left knee. Hold the stretch for 15 to 30 seconds.
  • Repeat with the other leg.
  • Sitting pigeon pose stretch is similar to the reclining pigeon but is done while sitting.
  • Sitting on the floor with knees bent. Keep balance by placing the hands on the floor.
  • While seated, place the right ankle on the top of the left knee.
  • Lean forward and move the upper body forward. Hold for 15 to 30 seconds.
  • Repeat with the other leg.
  • Forward pigeon pose is a more advanced version of the pigeon stretch.
  • Start in a plank or push-up position.
  • Move the right leg in front so that the right knee is toward the right wrist and the right foot toward the left wrist.
  • Stretch the left leg out behind. The top of the foot should be on the ground and toes flat against the floor.
  • Shift the weight forward onto the hands or elbows. Feel the stretch in the right glute.
  • Repeat steps with other leg.
  • The knee�to the opposite shoulder is a simple stretch that is easy and pain-relieving.
  • Lie on back with legs extended.
  • Bend the right leg, grasp the knee and pull it toward the abdomen.
  • Straighten the leg and then repeat these steps with the left leg.
  • Do three times on each side.
  • Sitting spinal stretch can help open the vertebrae to relieve sciatica pain.
  • Sit on the floor with the legs extended.
  • Bend the right knee so that the foot is next to the inside of the left knee. Keep the right foot flat on the ground.
  • Move the left arm around so that the elbow is on the outside of the right knee. Place right hand behind for balance.
  • Gently turn toward the right, looking behind. Hold the position for 15 to 30 seconds.
  • Repeat with the other leg.
  • Standing hamstring stretch can ease pain in the hamstrings.
  • Stand and place one heel on an elevated surface, like a chair.
  • Fully extend the knee and flex the ankle by pointing the toes toward the ceiling.
  • Bend forward at the hips keeping the spine in a neutral position. Hold for 15 to 30 seconds.
  • Repeat with the other leg.
11860 Vista Del Sol, Ste. 128 Sleeping With Sciatica and A Better Night's Rest

Sleep Hygiene

Proper sleep hygiene helps prepare for a good night�s sleep. Here are some tips to help improve sleep hygiene.
  • A nighttime routine will help unwind the body before bedtime. Start the routine 30 minutes before planning to go to sleep. Some things to do to help unwind:
  • Take a warm bath
  • Listen to relaxing/soothing music
  • Meditation
  • Reading
  • Get a new mattress. An old, sagging mattress can worsen sciatica and strain the back. The best mattresses for sciatica pain combines contour comfort to ease pressure points at the hips and shoulders with the proper support to keep the spine aligned.
  • Eye masks can help with artificial light which can fool the mind along with the circadian clock into thinking it�s daylight. Keeping out unwanted light all night can help.
  • Avoid blue light too close to bedtime like lamps and device screens. These are great for the day, as they help boost attention, reaction time, and mood. But at night it can be disruptive. Turn off electronics at least 30 minutes before bed to help the body adjust.
  • Room temperature control has found that most sleep better in a cool room. The optimal temperature is between 60 and 67 degrees.
  • Avoid exercise close to bedtime. Working out before bed can interfere with sleep. This is because exercise releases adrenaline keeping the mind and body alert.
  • Avoid stimulants before bedtime like caffeine, sugar, etc. which will keep the body up.

Medical Intervention

Sciatica pain can be mild or severe. Stretching or changing up sleeping position can help ease discomfort. But if the pain is severe or chronic, and if it prevents getting a good night�s sleep, consult a chiropractic professional.

InBody Spotlight


Sleep And Body Composition

A lack of sleep makes it harder to gain muscle and harder to lose fat.
  • Sleeping less means fewer opportunities to secrete growth hormone and develop muscle
  • Testosterone is negatively affected by lack of sleep
  • Sleeping less can increase cortisol levels, impairing muscle development
  • Irregular sleep throws off the body’s cycles, making the body feel hungrier
  • Sleeping less is linked to eating more snacks, increasing energy levels
  • Lack of sleep can cause reductions in Basal Metabolic Rate by 20%, reducing total energy output
  • Being tired reduces spontaneous movements, reducing total energy output
If trying to get into shape and change body composition, sufficient sleep is vital. Any positive changes to get more sleep are going to have positive changes in efforts to change body composition.

Dr. Alex Jimenez�s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*
Siengsukon, Catherine F et al. �Sleep Health Promotion: Practical Information for Physical Therapists.��Physical therapy�vol. 97,8 (2017): 826-836. doi:10.1093/ptj/pzx057
Texas Supreme Court’s Decision in “Texas Board of Chiropractic Examiners et al v. Texas Medical Association” Case

Texas Supreme Court’s Decision in “Texas Board of Chiropractic Examiners et al v. Texas Medical Association” Case

After all of these years, I am happy to announce that the Texas Supreme Court has finally made a decision regarding the Texas Board of Chiropractic Examiners et al v. Texas Medical Association case on January 29th, 2021. With great honor and gratitude, I’d like to continue to extend sincere thanks to everyone who worked hard on this case and whose tremendous efforts resulted in the decision. Thanks to the Supreme Court’s decision, chiropractors in Texas can now carry on their jobs accordingly. Below, I have provided a letter from Board President, Mark R. Bronson, D.C., F.I.A.N.M. on behalf of the Texas Board of Chiropractic Examiners stating the Texas Supreme Court’s decision in the Texas Board of Chiropractic Examiners et al v. Texas Medical Association case on January 29th, 2021. – Dr. Alex Jimenez D.C., C.C.S.T.



February 1, 2021


On behalf of the Texas Board of Chiropractic Examiners, I extend our sincere thanks and appreciation to everyone whose efforts resulted in the Texas Supreme Court’s decision in Texas Board of Chiropractic Examiners et al v. Texas Medical Association on January 29, 2021. Special thanks are due to all the attorneys at the Office of the Attorney General who worked on this case over these years.


The decision properly affirmed the validity of the Board’s scope of practice rule, which the court clearly said does not exceed our statutory scope of chiropractic practice. The court unequivocally held that the Board�s rules do not violate Occupations Code Chapter 201 or run counter to the chapter’s objectives set by the Texas Legislature, and in fact, carefully observe the statutory boundary between the medical and chiropractic professions. This decision, which recognizes the common sense and long-standing inclusion of associated nerves in chiropractic diagnosis and treatment, preserves and strengthens the essence of chiropractic.


Thanks to the court’s decision, our licensees can now fulfill their duties as vital portal-of-entry healthcare providers in Texas without fear. The court’s decision reaffirms the principles of economic freedom that have made Texas the best state in the nation to be a chiropractor.




Mark R. Bronson, D.C., F.I.A.N.M. Board President
Texas Board of Chiropractic Examiners





The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*


Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas & New Mexico*


Testing For Piriformis Syndrome or Sciatica through Chiropractic

Testing For Piriformis Syndrome or Sciatica through Chiropractic

Identification of piriformis syndrome or sciatica requires proper testing and examination. The piriformis muscle begins at the sacrum near the sacroiliac joint and is attached to the femur/thigh bone at the outer area of the hip. The sciatic nerve passes typically under or through the muscle before going down the back of the thigh.  

11860 Vista Del Sol, Ste. 128 Testing For Piriformis Syndrome or Sciatica through Chiropractic

The piriformis helps turn the hip outward and bring the thigh outward to one side while the hip is bent. This could be when raising the knee and bringing the leg out. An example is stepping out of a car. The muscle also helps to stabilize when walking, running, and standing. Individuals with the sciatic nerve passing through the piriformis have an increased chance of developing piriformis syndrome. It can also be called piriformis sciatica since it is not true sciatica.  



Piriformis syndrome does not always present the same way. Common symptoms include pain, tingling, and numbness in the buttocks that becomes worse when sitting. Other symptoms can include:

  • Pain when sitting, standing, or walking.
  • Pain when getting up from a seated/squatting position
  • Pain in the sacroiliac joint
  • Pain and/or pins and needles, burning, tingling, or itching sensation
  • Movement helps to reduce pain symptoms
  • Numbness in the foot

Many of these symptoms can be mistaken for sciatica. This is why proper testing is necessary to provide the appropriate treatment; otherwise, the condition could worsen or create new injuries.



  • Primary piriformis syndrome happens when splitting the piriformis muscle, the sciatic nerve, and/or the sciatic nerve does not run along the normal path.
  • Secondary piriformis syndrome is more common and is caused by inflammation of the soft tissues, muscle spasms, etc. And the result is nerve compression.
11860 Vista Del Sol, Ste. 128 Testing For Piriformis Syndrome or Sciatica through Chiropractic
  • Direct trauma to the buttock area can definitely cause inflammation, scarring, and contraction of the piriformis muscle. This could be the result of an automobile accident or a fall.
  • The most common cause is a progressive tightening of the muscle brought on from a weakened piriformis muscle.



Because of the close relation between piriformis syndrome and sciatica, a chiropractic medical professional will perform various tests to determine if symptoms are spinal disc-related or caused by the sciatic nerve getting pinched or impinged piriformis muscle. A chiropractor will examine the low back, hip, pelvis, sacroiliac joint, walking gait, posture, and leg length. They will test various body reflexes as well. Other tests can include:

  • Palpation/manipulation of the piriformis muscle
  • A Straight leg raise will be done to see if there is localized pain when pressure is applied to the piriformis muscle and the tendon. The chiropractor will flex the hip at a 90-degree angle and extend/straighten the knee.
  • A Freiberg test will be done to see if pain presents around the piriformis or reproduces symptoms.
  • The Pace maneuver test looks for pain and/or weakness during rotation of the hip when sitting.
  • The F.A.I.R test stands for flexion, adduction, and internal rotation. This test has the individual lie on the non-affected side while the chiropractor guides the painful leg into hip flexion, turns it in toward the body, and gently turns the lower leg outward.
  • The Beatty maneuver tests for pain while lying on the non-affected side, and the chiropractor elevates the flexed symptomatic leg.
  • Testing for pain or weakness in specific positions is usually conducted for one minute or when the individual experiences symptoms.
11860 Vista Del Sol, Ste. 128 Testing For Piriformis Syndrome or Sciatica through Chiropractic

In addition to a physical exam, a chiropractor will utilize imaging scans to rule out any other causes. This can include X-rays, MRIs, or CT scans. Once the source has been diagnosed, treatment can begin. Many individuals choose to wait and see what happens, hoping the problem will go away. But the sooner the root issue is dealt with, the sooner an individual can get back to living pain-free.

Sciatica Pain Rehabilitation



The Journal of the Osteopathic Medical Association. (November 2008) Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach

Medication For Sciatica and Natural Chiropractic Medicine

Medication For Sciatica and Natural Chiropractic Medicine

The use of prescription medication for sciatica is being discouraged while natural treatments/therapies are becoming the new standard. This is currently happening in the United Kingdom and its National Institute for Health and Care Excellence. The focus is to reduce the use of medication for sciatica and aim for natural treatments unless absolutely necessary. This is to help reduce the opioid epidemic, along with reducing the use of medications and their negative side effects that cause other conditions and illnesses.  
11860 Vista Del Sol, Ste. 128 Medication For Sciatica and Natural Chiropractic Medicine
The National Institute for Health Care Excellence has updated its guidelines with specific language that discourages the use of multiple classes of drugs for various ailments/conditions like sciatica. The United States has already set up similar guidelines limiting the use of prescription medications for sciatica until after a regimen of non-pharmacological treatment/therapies like physical therapy, chiropractic, acupuncture, massage, etc. If no improvement is seen in four to six months then medication can be administered. The guidelines say that individuals with acute or chronic sciatica should not be given gabapentinoids, this is a class of drugs designed to treat seizures, other antiepileptics, oral corticosteroids, and opioids. They also report that there is no evidence on the use of antidepressants for sciatica. However, it is recognized that it can benefit some individuals but should not just be handed out for every case.

Medication for Sciatica

Medication does work for sciatica. It’s the side effects and addiction issues they are trying to avoid. Options include:
  • Nonsteroidal anti-inflammatory drugs
  • Gabapentinoids
  • Corticosteroids
  • Benzodiazepines
Opioids have been overprescribed for all types of pain. However, they don�t help in repairing the damaged/pinched nerves and only relieve/sedate the pain symptoms. In addition side effects like confusion, dizziness, and sleep problems are increased leading to more health issues.

Treatment Options

When it comes to acute pain over the counter medications, NSAIDs, oral steroids, and gabapenitoids can be recommended for a brief period and not long term. This is just to settle the pain until a non-medication treatment plan is developed to realign, adjust, and restore the sciatic nerve to its proper position. A physician or physical therapist/chiropractor can diagnose the difference between actual sciatica and low back pain.  
11860 Vista Del Sol, Ste. 128 Medication For Sciatica and Natural Chiropractic Medicine

Physical Therapy and Chiropractic

Chiropractic treatment and physical therapy for sciatica first look to determine the cause of the condition and how the individual spends their day as far as do they sit or stand for a good portion of the day along with the types of activities like lifting, bending, stretching, twisting, etc. The nerves are irritated and send signals to the brain. This could be tingling with pain, numbness, or a combination. The body wants to protect itself. Once the source of irritation is identified the chiropractor or physical therapist works with the patient to workout/massage/release the muscles, ligaments, joints to work the sciatic nerve back to full health and function. The chiropractor/therapist challenges the nerve to get back into proper form in a safe fashion. How the condition resolves depends if it�s acute or chronic. In acute cases, the pain level is higher but is easier to treat. The faster chiropractic and physical therapy intervention are sought out the better the odds additional treatment will not be required. The first sessions of chiropractic and physical therapy are designed to calm the system down. Then the body will begin to heal itself within about four weeks without medication.

Conservative Therapy

Preference for non-surgical treatment is the way to go whenever possible. Only when significant weakness in the leg or foot from nerve compression, surgery could be necessary. It can become an emergency situation if there is numbness around the groin and if it affects bowel or bladder function. Six to eight weeks of conservative treatment is the key. And if no improvement correlated with an MRI is achieved, then surgical treatment could be the next phase of treatment.

Sciatica Treatment


Dr. Alex Jimenez�s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*
When Sciatica Is Not Spine Related

When Sciatica Is Not Spine Related

There are other causes of sciatica that are not spine-related. It is sometimes called non-spinal pathology, which means not related to the spine. The most common cause of sciatic pain is a herniated disc. Non-spine-related causes of sciatica can imitate/copy the symptoms of a herniated disc in the low back. When a lumbar herniated disc causes sciatica, people typically report a sudden onset of pain with leg pain worse than any back pain that might be present. In addition to pain in the leg, there are also reports of leg weakness, numbness, and tingling. Leg pain becomes worse after:
  • Long periods of sitting/standing
  • Forward bending
  • Body maneuvers that increase pressure in intervertebral discs
  • Coughing
  • Sneezing
Individuals also report when lying down and the spine is extended the back pain reduces and alleviates the pain. Determining the source of sciatica pain correctly means that it is important to:
  • Characterize the activities leading up to when the symptoms first presented
  • Location of the pain
  • Associated factors that reduce and worsen the pain
  • Medical history
11860 Vista Del Sol, Ste. 128 When Sciatica Is Not Spine Related
Because there are quite a few non-spine-related causes, it can be helpful to keep in mind:
  • The way the sciatic nerve runs through the lower body. It starts in the lower lumbar and upper sacral nerve roots. It exits through the pelvis and runs down the back of the thigh to the knee where it branches out into nerves that provide the motor and sensory functions to the legs and feet.
  • Non-spinal sciatica causes. Non-spinal causes usually are the result of irritation of the nerve itself. The most common ways to irritate the nerve is compression, traction, or injury.
  • Symptoms perceived as sciatica may not be related to the nerve at all. Injury/s to structures close to the nerve, like the hip, can copy symptoms caused by irritation of the nerve.

Hip joint disorders can emulate sciatica symptoms

Because the sciatic nerve is close to the hip joint, an injury to the hip could resemble symptoms of sciatica. Whatever the cause of the hip injury, those with hip pathology often report pain in the groin, upper thigh, and buttocks. The pain gets worse with activity, specifically bending, and rotation of the hip. Leg pain that turns into a limp when walking means that more likely the hip, and not the lower back, is the cause of the leg pain. X-rays and if necessary MRIs of the hip can help in determining if the hip is the cause of leg pain. An example of hip pathology that mimics spine-related sciatica:

Hip Osteoarthritis

This is characterized by the loss of cartilage. This results in the narrowing of the ball and socket joint. Individuals with arthritis of the spine and hip, a doctor could use a steroid injection as a therapeutic providing pain relief and a diagnostic to help identify the root cause/pain generator.  


The femoral head can collapse from a lack of blood flow. Risk factors include:
  • Alcohol abuse
  • Sickle cell disease
  • Chronic steroid use
  • Femoral neck fracture
  • Hip dislocation

Femoroacetabular Impingement

This can stem from constant abnormal rubbing between the femoral neck and acetabulum from a bone deformity of the femur, or the acetabulum. Hip impingement at the joint can start the onset of arthritis along with tears of the labrum. This is cartilage that surrounds the hip joint and provides stability.

Trochanteric Bursitis

There are fluid-filled sacs called bursas/bursae that help decrease friction between the bones, surrounding tendons, and muscles. They are at multiple locations on the body. Bursitis means that the bursa is inflamed and can be quite painful. The greater trochanter is a bony outward bump that extends from the femur. Trochanteric bursitis refers to inflammation of the bursa that separates the greater trochanter with the muscles and tendons of the thigh. Common symptoms are pain on the outside of the thigh that worsens by pressing on the area and can interfere with proper sleep when lying on the affected side.

Femoral Neck Stress Fracture

Incomplete fracture/s of the femoral neck typically occur in individuals that walk or run long distances regularly like runners and soldiers. The pain is usually focused around the groin and can be subtle when it presents. Walking or running makes the pain worse.

Sacroiliac joints and fractures

The sacroiliac joints connect the spine to the pelvis. There are two joints, one on either side of the sacrum. While they are relatively immobile, they go through tremendous force doing routine daily activities. Sacroiliac joint pathology that can mimic spine-related sciatica include:


This is inflammation of the sacroiliac joints. The pain presents in a slow fashion with no obvious injury or cause. The pain is usually localized to the buttocks and can radiate down the back of the thigh. It is believed to be caused by irritation of the sciatic nerve by the inflammatory molecules in the sacroiliac joint or could present as referred pain from the joint. This is pain that is detected in a location other than the area of the pain generator. The pain reduces with light walking.  
11860 Vista Del Sol, Ste. 128 When Sciatica Is Not Spine Related

Sacral Fracture

A fracture of the sacrum can occur in those with a weakened bone after a minor injury and without trauma. Risk factors include:
  • Advanced age
  • Osteoporosis
  • Chronic steroid use
  • Rheumatoid arthritis
  • Vitamin D deficiency.
The pain usually localizes in the low back that radiates to the buttocks, or groin, and worsens with activity.


Trauma to the pelvis or thigh can definitely cause sciatica pain and symptoms. With high-energy injuries, it is possible for the nerve roots of the sciatic nerve to get pulled or torn. More common causes include:
  • Posterior hip dislocation
  • Pelvic fracture
The hamstring muscles are in close proximity to the sciatic nerve. A torn hamstring can irritate the sciatic nerve either through direct compression from the localized bleeding known as a hematoma or from an inflammatory response triggered when the injury happened.  

Penetrating trauma

If some sharp object like a tool or shrapnel penetrates any area where the sciatic nerve is, it could cause sciatica by cutting the nerve. Or the object tears the nerve, known as a laceration. Most cases of trauma-induced sciatica result from a mild form of nerve injury known as neuropraxia. This is an injury that temporarily blocks nerve function. Neuropraxia can develop from the shock waves that surround the object as it travels through the tissue.

Benign tumors and metastatic cancer

Discovering cancer during diagnosis for sciatica is rare. Symptoms that increase the possibility of cancer being the cause include:
  • Cancer in medical history
  • 50 years and older
  • Leg pain that goes on through the night
  • No relief from lying on the back
  • Night sweats
  • Unexplained weight loss
When back pain presents in a subtle fashion without a history of trauma or injury and is not affected by activity or changes in position can also suggest cancer as the cause. Tumors usually cause sciatica by applying direct compression on the nerve. They can be benign or malignant. Tumor/s can arise from the sciatic nerve itself:


Shingles is a painful rash that occurs on one side of the body. It is caused by the varicella-zoster virus, which is the virus that causes chickenpox. The virus can lie dormant in nerve cells for years without causing any symptoms. Older individuals and individuals with underlying conditions in an immunocompromised state can cause the virus to activate. If the virus reactivates around the buttock and thigh, it can feel like sciatica. The presence of a red rash with blisters around the painful area is consistent with shingles.

Childbirth and endometriosis

During pregnancy, the pelvis can become compressed between the growing baby and the bones in the pelvis. Also, having the hips and knees flexed and supported in stirrups too long can also cause sciatica. However, pregnancy-related sciatica is often temporary. A less common cause that occurs in women is endometriosis. Endometriosis is the growth of tissue somewhere other than the uterus, usually the ovaries and fallopian tubes. In some cases, this tissue can accumulate around the sciatic nerve or the nerve itself. As the tissue responds to the changes taking place during a normal menstrual cycle, recurrent sciatica pain can present.

Vascular diagnoses

Arteries and veins in the pelvis and lower extremities that have become abnormal can cause sciatica. Either through compression or lack of oxygen from poor blood flow. An aneurysm can happen when the wall of the artery weakens and cannot withstand the pressure of the blood flowing through. This enlarges the artery and in some cases, the artery grows large enough to compress the nerve. Peripheral artery disease can cause sciatica when not enough blood is circulated from the heart to the muscles in the legs. If not enough oxygen is delivered to the muscles, leg pain and numbness can occur. It’s called claudication and is characterized by pain that is aggravated when walking and relieved when standing still. Risk factors for peripheral artery disease include:
  • Smokers both current and those who have quit
  • High blood pressure
  • High cholesterol
  • Diabetic

Diabetes/high blood sugar

Diabetic peripheral neuropathy happens from nerve damage caused by high blood sugar. Nerves that are exposed to chronic high blood sugar can get damaged from the disruption of proper blood flow or from an alteration of the cellular structure of the nerve.

Prescription meds

Nerve and muscle damage can happen as a side effect from prescription meds. Neuropathy and myopathy can cause symptoms that mimic sciatica brought on by disc herniation. Sometimes, if the medication is no longer taken the symptoms go away. The list of medications include:
  • Chemotherapy agents
  • Antibiotics
  • Statins medication to help lower cholesterol

Piriformis syndrome and back pocket wallets

The piriformis muscle originates on the sacrum, runs through the sciatic notch, shown above, and attaches the top of the femur. The sciatic notch also includes the sciatic nerve. Piriformis syndrome is caused when the piriformis muscle compresses the sciatic nerve. Individuals typically report pain in the buttocks that shoots down the same leg and is made worse when sitting. Piriformis syndrome can be difficult to diagnose, but physical exam maneuvers have been developed in aiding the diagnosis of the syndrome. They involve some form of hip abduction resistance and external rotation to cause a contraction of the piriformis muscle.  
11860 Vista Del Sol, Ste. 128 When Sciatica Is Not Spine Related

Back pocket wallet

Also known as wallet neuritis, and wallet sciatica are terms that have been used to describe compression of the sciatic nerve by a heavy/bulky wallet in a back pocket. It is similar to symptoms of piriformis syndrome and presents in the buttocks and the same leg that can get aggravated from sitting. Usually, if the wallet is the sole cause, taking the wallet from the back pocket to another pocket or other storage option often brings pain relief.

Conclusion non-spine related causes

While the majority of sciatica cases are caused by a back problem, injury, etc. There are various causes outside of the spinal column. Being able to describe the:
  • Location
  • Pain severity
  • Associated symptoms
  • Factors that aggravate and alleviate the pain
These can absolutely help your doctor, chiropractor, specialist accurately diagnose and generate an optimal customized treatment plan for spine-related or non-spine-related sciatica.

Chiropractors & Sciatica Syndrome Expose


Dr. Alex Jimenez�s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*
Times When Surgery for Sciatica Could Be Necessary

Times When Surgery for Sciatica Could Be Necessary

Surgery for sciatica is sometimes necessary if medications, chiropractic, and physical therapy are not working to relieve sciatica symptoms, but don�t worry. Individuals sometimes have sciatica that just does not respond to conservative treatment can find relief through surgical procedures.


11860 Vista Del Sol, Ste. 128 Times When Surgery for Sciatica Could Be Necessary

Questions begin to pop up, as to which procedure makes the most sense, what will the experience be like, and how long will it be until you can get back to a normal, pain-free life?


Sciatica is pain that runs down the longest nerve in the body, known as the sciatic nerve. Pain starts in the lower back and spreads down one leg, into the calf and possibly the foot. It is rare but sciatica can occur in both legs. The pain is mild to severe and feels worse when sneezing, coughing, bending, and standing/sitting in certain positions. The pain is often accompanied by numbness, tingling, or weakness in affected legs.

Sciatica a set of symptoms caused by other medical problems like an injury, tumor, or the most common cause around 90% of the time is a herniated disc in the lower back. The soft-gel center of the disc pushes through the tough exterior, where it can pinch or press on the sciatic nerve causing pain.

Research shows that sciatica affects 1% to 5% of the population, and around 40% will experience sciatica at some point in their life. Men between the ages of 30 and 50 have a higher risk along with smokers, individuals that sit for a long time, and those that perform physically strenuous work. Doctors and chiropractors can diagnose cases of sciatica with a medical history and physical exam. Diagnostic imaging can also be used in some cases.

When it’s Time to Consider Surgery for Sciatica


11860 Vista Del Sol, Ste. 128 Times When Surgery for Sciatica Could Be Necessary

Most individuals with sciatica respond positively with non-surgical treatments like chiropractic, physical therapy, acupuncture, medication, spinal injection/s, etc. This makes spine surgery a rarely needed treatment for low back and leg pain caused by sciatic nerve compression. But there are situations when surgery for sciatica could be beneficial.

  • With bowel or bladder dysfunction, this is also rare, but it can happen with spinal cord compression and cauda equina syndrome.
  • Spinal stenosis, where the doctor believes that surgery is the best approach.
  • There are neurologic dysfunctions like severe leg weakness
  • Symptoms become severe and non-surgical treatment is no longer effective

There are different types of surgical procedures for spine surgery. A spine surgeon will recommend the best approach for each patient’s sciatica. Which procedure they recommend will be based on the disorder causing sciatica with the entire procedure clearly explained so that you understand completely. Ask any questions to better understand the surgeon’s recommendation. Remember, the final decision is always up to you. A second opinion is recommended before deciding.

Sciatica usually goes away on its own with the majority of cases managed with conservative treatment. Depending on the cause, this could be heat or ice packs, chiropractic, therapeutic massage, pain medication, stretching exercises, physical therapy, or injections. �

Sciatica for Surgery Options

Surgery for sciatica is performed to relieve the added compression/pressure on the nerves and relieve the pain. Options include a microdiscectomy and laminectomy. Each has its similarities and differences when it comes to the preparation, process, and recovery for the operation. �


During a microdiscectomy, part or all of the herniated disc is removed. Research has shown the effectiveness of relieving pain to be around 80 to 95 percent of patients. The operation is done in a hospital or surgery center and requires about one hour to complete. General anesthesia is administered during this procedure.

  • A surgeon will make an incision over the affected disc.
  • Skin and tissue covering the disc will be opened and moved for better access. Some of the bone could be taken out as part of the procedure called a laminotomy.
  • The surgeon will use various tools to remove all or part of the herniated disc.
  • Once the removal is done, the surgeon will close the incision and send you to a recovery room.
  • To quicken the healing process patients are encouraged to start walking within hours of the procedure.
  • Most go home the same day. Some patients will have to stay at the hospital for observation. This could be from other conditions present.
  • You will not be allowed to operate a vehicle the same day. Therefore a designated driver will be necessary.


third and fourth lumbar vertebrae lumbar vertebra lumbar spine vertebral bone

Preparation for a laminectomy is similar to a microdiscectomy. The lamina is the back part of the vertebrae, which protects the spinal canal. This procedure relieves pain by creating space for the nerves to move around.

  • The procedure takes about one to three hours from start to finish.
  • Both sides of the laminae are removed, along with the spinous process in the middle.
  • The patient lies face-down as the surgeon makes an incision near the affected vertebrae.
  • Skin and muscles are moved around and various tools/instruments are used to remove all or part of the lamina. Overgrowth of bone or spinal disc could also be removed.
  • The incision is stitched or stapled, bandaged, and sent to a recovery room.
  • Just like a microdiscectomy the individual will be encouraged to begin walking the same day.
  • Most individuals leave the hospital after surgery, however, a one to possible three-night could be required for others.
  • A driver does need to be designated for the ride home.

A microdiscectomy is recommended for stenosis caused by a herniated disc. However, if the stenosis is caused by another health issue/condition like bone spurs developed from arthritis, then a laminectomy could be the best approach. Laminectomies are usually performed on individuals in their 50s or 60s. While micro discectomies vary when it comes to age but are usually performed on younger individuals.



At home, post-op rules need to be followed no matter what surgery for sciatica was performed. The incision area needs to stay clean and no lifting of heavy objects, bending and sitting for extended times. Surgery for sciatica is considered safe with complications being uncommon. All operations come with risks. These include nerve damage, blood clots, and infection.

The provider needs to know about unusual symptoms after the procedure. This could be fever, excess drainage, or pain around the incision area. Pain meds could be prescribed to ease the post-surgery pain, and chiropractic along with physical therapy could be implemented to speed recovery. Individuals are typically cleared to return to work two to four weeks after the procedure. It could be six to eight weeks if their job/occupation is physically demanding and strenuous.

Depending on how complex the spine surgery is an individual could be sitting upright the same day and walking within 24 hours. A course of pain meds could be prescribed to help manage postoperative pain. Instructions will be given on how to sit, rise, get out of bed, and stand in a careful manner. The body needs time to heal, so a doctor could recommend activity restriction. This could be anything that moves the spine too much. For sure contact sports, twisting, or heavy lifting during recovery are to be avoided. Report any problem/s like fever, increased pain, infection right away.

Spine Surgery Relief

Many individuals benefit from sciatica surgery, but it doesn�t work for everyone. A small percentage of individuals continue to feel discomfort in the weeks/months after. And sciatica can return in the future and in a different location. Your healthcare provider can help you decide if surgery for sciatica is the right choice for you.

Treating Severe & Complex Sciatica Syndromes


Dr. Alex Jimenez�s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.*

Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*

What is Degenerative Disc Disease (DDD)?: An Overview

What is Degenerative Disc Disease (DDD)?: An Overview

Degenerative Disc Disease is a general term for a condition in which the damaged intervertebral disc causes chronic pain, which could be either low back pain in the lumbar spine or neck pain in the cervical spine. It is not a �disease� per se, but actually a breakdown of an intervertebral disc of the spine. The intervertebral disc is a structure that has a lot of attention being focused on recently, due to its clinical implications. The pathological changes that can occur in disc degeneration include fibrosis, narrowing, and disc desiccation. Various anatomical defects can also occur in the intervertebral disc such as sclerosis of the endplates, fissuring and mucinous degeneration of the annulus, and the formation of osteophytes.


Low back pain and neck pain are major epidemiological problems, which are thought to be related to degenerative changes in the disk. Back pain is the second leading cause of the visit to the clinician in the USA. It is estimated that about 80% of US adults suffer from low back pain at least once during their lifetime. (Modic, Michael T., and Jeffrey S. Ross) Therefore, a thorough understanding of degenerative disc disease is needed for managing this common condition.


Anatomy of Related Structures


Anatomy of the Spine


The spine is the main structure, which maintains the posture and gives rise to various problems with disease processes. The spine is composed of seven cervical vertebrae, twelve thoracic vertebrae, five lumbar vertebrae, and fused sacral and coccygeal vertebrae. The stability of the spine is maintained by three columns.


The anterior column is formed by anterior longitudinal ligament and the anterior part of the vertebral body. The middle column is formed by the posterior part of the vertebral body and the posterior longitudinal ligament. The posterior column consists of a posterior body arch that has transverse processes, laminae, facets, and spinous processes. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology�)


Anatomy of the Intervertebral Disc


Intervertebral disc lies between two adjacent vertebral bodies in the vertebral column. About one-quarter of the total length of the spinal column is formed by intervertebral discs. This disc forms a fibrocartilaginous joint, also called a symphysis joint. It allows a slight movement in the vertebrae and holds the vertebrae together. Intervertebral disc is characterized by its tension resisting and compression resisting qualities. An intervertebral disc is composed of mainly three parts; inner gelatinous nucleus pulposus, outer annulus fibrosus, and cartilage endplates that are located superiorly and inferiorly at the junction of vertebral bodies.


Nucleus pulposus is the inner part that is gelatinous. It consists of proteoglycan and water gel held together by type II Collagen and elastin fibers arranged loosely and irregularly. Aggrecan is the major proteoglycan found in the nucleus pulposus. It comprises approximately 70% of the nucleus pulposus and nearly 25% of the annulus fibrosus. It can retain water and provides the osmotic properties, which are needed to resist compression and act as a shock absorber. This high amount of aggrecan in a normal disc allows the tissue to support compressions without collapsing and the loads are distributed equally to annulus fibrosus and vertebral body during movements of the spine. (Wheater, Paul R, et al.)


The outer part is called annulus fibrosus, which has abundant type I collagen fibers arranged as a circular layer. The collagen fibers run in an oblique fashion between lamellae of the annulus in alternating directions giving it the ability to resist tensile strength. Circumferential ligaments reinforce the annulus fibrosus peripherally. On the anterior aspect, a thick ligament further reinforces annulus fibrosus and a thinner ligament reinforces the posterior side. (Choi, Yong-Soo)


Usually, there is one disc between every pair of vertebrae except between atlas and axis, which are first and second cervical vertebrae in the body. These discs can move about 6? in all the axes of movement and rotation around each axis. But this freedom of movement varies between different parts of the vertebral column. The cervical vertebrae have the greatest range of movement because the intervertebral discs are larger and there is a wide concave lower and convex upper vertebral body surfaces. They also have transversely aligned facet joints. Thoracic vertebrae have the minimum range of movement in flexion, extension, and rotation, but have free lateral flexion as they are attached to the rib cage. The lumbar vertebrae have good flexion and extension, again, because their intervertebral discs are large and spinous processes are posteriorly located. However, lateral lumbar rotation is limited because the facet joints are located sagittally. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology�)


Blood Supply


The intervertebral disc is one of the largest avascular structures in the body with capillaries terminating at the endplates. The tissues derive nutrients from vessels in the subchondral bone which lie adjacent to the hyaline cartilage at the endplate. These nutrients such as oxygen and glucose are carried to the intervertebral disc through simple diffusion. (�Intervertebral Disc � Spine � Orthobullets.Com�)


Nerve Supply


Sensory innervation of intervertebral discs is complex and varies according to the location in the spinal column. Sensory transmission is thought to be mediated by substance P, calcitonin, VIP, and CPON. Sinu vertebral nerve, which arises from the dorsal root ganglion, innervates the superficial fibers of the annulus. Nerve fibers don�t extend beyond the superficial fibers.


Lumbar intervertebral discs are additionally supplied on the posterolateral aspect with branches from ventral primary rami and from the grey rami communicantes near their junction with the ventral primary rami. The lateral aspects of the discs are supplied by branches from rami communicantes. Some of the rami communicantes may cross the intervertebral discs and become embedded in the connective tissue, which lies deep to the origin of the psoas. (Palmgren, Tove, et al.)


The cervical intervertebral discs are additionally supplied on the lateral aspect by branches of the vertebral nerve. The cervical sinu vertebral nerves were also found to be having an upward course in the vertebral canal supplying the disc at their point of entry and the one above. (BOGDUK, NIKOLAI, et al.)


Pathophysiology of Degenerative Disc Disease


Approximately 25% of people before the age of 40 years show disc degenerative changes at some level. Over 40 years of age, MRI evidence shows changes in more than 60% of people. (Suthar, Pokhraj) Therefore, it is important to study the degenerative process of the intervertebral discs as it has been found to degenerate faster than any other connective tissue in the body, leading to back and neck pain. The changes in three intervertebral discs are associated with changes in the vertebral body and joints suggesting a progressive and dynamic process.


Degeneration Phase


The degenerative process of the intervertebral discs has been divided into three stages, according to Kirkaldy-Willis and Bernard, called ��degenerative cascade��. These stages can overlap and can occur over the course of decades. However, identifying these stages clinically is not possible due to the overlap of symptoms and signs.


Stage 1 (Degeneration Phase)


This stage is characterized by degeneration. There are histological changes, which show circumferential tears and fissures in the annulus fibrosus. These circumferential tears may turn into radial tears and because the annulus pulposus is well innervated, these tears can cause back pain or neck pain, which is localized and with painful movements. Due to repeated trauma in the discs, endplates can separate leading to disruption of the blood supply to the disc and therefore, depriving it of its nutrient supply and removal of waste. The annulus may contain micro-fractures in the collagen fibrils, which can be seen on electron microscopy and an MRI scan may reveal desiccation, bulging of the disc, and a high-intensity zone in the annulus. Facet joints may show a synovial reaction and it may cause severe pain with associated synovitis and inability to move the joint in the zygapophyseal joints. These changes may not necessarily occur in every person. (Gupta, Vijay Kumar, et al.)


The nucleus pulposus is also involved in this process as its water imbibing capacity is reduced due to the accumulation of biochemically changed proteoglycans. These changes are brought on mainly by two enzymes called matrix metalloproteinase-3 (MMP-3) and tissue inhibitor of metalloproteinase-1 (TIMP-1). (Bhatnagar, Sushma, and Maynak Gupta) Their imbalance leads to the destruction of proteoglycans. The reduced capacity to absorb water leads to a reduction of hydrostatic pressure in the nucleus pulposus and causes the annular lamellae to buckle. This can increase the mobility of that segment resulting in shear stress to the annular wall. All these changes can lead to a process called annular delamination and fissuring in the annulus fibrosus. These are two separate pathological processes and both can lead to pain, local tenderness, hypomobility, contracted muscles, painful joint movements. However, the neurological examination at this stage is usually normal.


Stage 2 (Phase of Instability)


The stage of dysfunction is followed by a stage of instability, which may result from the progressive deterioration of the mechanical integrity of the joint complex. There may be several changes encountered at this stage, including disc disruption and resorption, which can lead to a loss of disc space height. Multiple annular tears may also occur at this stage with concurrent changes in the zagopophyseal joints. They may include degeneration of the cartilage and facet capsular laxity leading to subluxation. These biomechanical changes result in instability of the affected segment.


The symptoms seen in this phase are similar to those seen in the dysfunction phase such as �giving way� of the back, pain when standing for prolonged periods, and a �catch� in the back with movements. They are accompanied by signs such as abnormal movements in the joints during palpation and observing that the spine sways or shifts to a side after standing erect for sometime after flexion. (Gupta, Vijay Kumar et al.)


Stage 3 (Re-Stabilization Phase)


In this third and final stage, the progressive degeneration leads to disc space narrowing with fibrosis and osteophyte formation and transdiscal bridging. The pain arising from these changes is severe compared to the previous two stages, but these can vary between individuals. This disc space narrowing can have several implications on the spine. This can cause the intervertebral canal to narrow in the superior-inferior direction with the approximation of the adjacent pedicles. Longitudinal ligaments, which support the vertebral column, may also become deficient in some areas leading to laxity and spinal instability. The spinal movements can cause the ligamentum flavum to bulge and can cause superior aricular process subluxation. This ultimately leads to a reduction of diameter in the anteroposterior direction of the intervertebral space and stenosis of upper nerve root canals.


Formation of osteophytes and hypertrophy of facets can occur due to the alteration in axial load on the spine and vertebral bodies. These can form on both superior and inferior articular processes and osteophytes can protrude to the intervertebral canal while the hypertrophied facets can protrude to the central canal. Osteophytes are thought to be made from the proliferation of articular cartilage at the periosteum after which they undergo endochondral calcification and ossification. The osteophytes are also formed due to the changes in oxygen tension and due to changes in fluid pressure in addition to load distribution defects. The osteophytes and periarticular fibrosis can result in stiff joints. The articular processes may also orient in an oblique direction causing retrospondylolisthesis leading to the narrowing of the intervertebral canal, nerve root canal, and the spinal canal. (KIRKALDY-WILLIS, W H et al.)


All of these changes lead to low back pain, which decreases with severity. Other symptoms like reduced movement, muscle tenderness, stiffness, and scoliosis can occur. The synovial stem cells and macrophages are involved in this process by releasing growth factors and extracellular matrix molecules, which act as mediators. The release of cytokines has been found to be associated with every stage and may have therapeutic implications in future treatment development.


Etiology of the Risk Factors of Degenerative Disc Disease


Aging and Degeneration


It is difficult to differentiate aging from degenerative changes. Pearce et al have suggested that aging and degeneration is representing successive stages within a single process that occur in all individuals but at different rates. Disc degeneration, however, occurs most often at a faster rate than aging. Therefore, it is encountered even in patients of working age.


There appears to be a relationship between aging and degeneration, but no distinct cause has yet been established. Many studies have been conducted regarding nutrition, cell death, and accumulation of degraded matrix products and the failure of the nucleus. The water content of the intervertebral disc decreases with the increasing age. Nucleus pulposus can get fissures that can extend into the annulus fibrosus. The start of this process is termed chondrosis inter vertebralis, which can mark the beginning of the degenerative destruction of the intervertebral disc, the endplates, and the vertebral bodies. This process causes complex changes in the molecular composition of the disc and has biomechanical and clinical sequelae that can often result in substantial impairment in the affected individual.


The cell concentration in the annulus decreases with increasing age. This is mainly because the cells in the disc are subjected to senescence and they lose the ability to proliferate. Other related causes of age-specific degeneration of intervertebral discs include cell loss, reduced nutrition, post-translational modification of matrix proteins, accumulation of products of degraded matrix molecules, and fatigue failure of the matrix. Decreasing nutrition to the central disc, which allows the accumulation of cell waste products and degraded matrix molecules seems to be the most important change out of all these changes. This impairs nutrition and causes a fall in the pH level, which can further compromise cell function and may lead to cell death. Increased catabolism and decreased anabolism of senescent cells may promote degeneration. (Buckwalter, Joseph A.) According to one study, there were more senescence cells in the nucleus pulposus compared to annulus fibrosus and herniated discs had a higher chance of cell senescence.� (Roberts, S. et al.)


When the aging process goes on for some time, the concentrations of chondroitin 4 sulfate and chondroitin 5 sulfate, which is strongly hydrophilic, gets decreased while the keratin sulfate to chondroitin sulfate ratio gets increased. Keratan sulfate is mildly hydrophilic and it also has a minor tendency to form stable aggregates with hyaluronic acid. As aggrecan is fragmented, and its molecular weight and numbers are decreased, the viscosity and hydrophilicity of the nucleus pulposus decrease. Degenerative changes to the intervertebral discs are accelerated by the reduced hydrostatic pressure of the nucleus pulposus and the decreased supply of nutrients by diffusion. When the water content of the extracellular matrix is decreased, intervertebral disc height will also be decreased. The resistance of the disc to an axial load will also be reduced. Because the axial load is then transferred directly to the annulus fibrosus, annulus clefts can get torn easily.


All these mechanisms lead to structural changes seen in degenerative disc disease. Due to the reduced water content in the annulus fibrosus and associated loss of compliance, the axial load can get redistributed to the posterior aspect of facets instead of the normal anterior and middle part of facets. This can cause facet arthritis, hypertrophy of the adjacent vertebral bodies, and bony spurs or bony overgrowths, known as osteophytes, as a result of degenerative discs. (Choi, Yong-Soo)


Genetics and Degeneration


The genetic component has been found to be a dominant factor in degenerative disc disease. Twin studies, and studies involving mice, have shown that genes play a role in disc degeneration. (Boyd, Lawrence M., et al.) Genes that code for collagen I, IX, and XI, interleukin 1, aggrecan, vitamin D receptor, matrix metalloproteinase 3 (MMP � 3), and other proteins are among the genes that are suggested to be involved in degenerative disc disease. Polymorphisms in 5 A and 6 A alleles occurring in the promoter region of genes that regulate MMP 3 production are found to be a major factor for the increased lumbar disc degeneration in the elderly population. Interactions among these various genes contribute significantly to intervertebral disc degeneration disease as a whole.


Nutrition and Degeneration


Disc degeneration is also believed to occur due to the failure of nutritional supply to the intervertebral disc cells. Apart from the normal aging process, the nutritional deficiency of the disc cells is adversely affected by endplate calcification, smoking, and the overall nutritional status. Nutritional deficiency can lead to the formation of lactic acid together with the associated low oxygen pressure. The resulting low pH can affect the ability of disc cells to form and maintain the extracellular matrix of the discs and causes intervertebral disc degeneration. The degenerated discs lack the ability to respond normally to the external force and may lead to disruptions even from the slightest back strain. (Taher, Fadi, et al.)


Growth factors stimulate the chondrocytes and fibroblasts to produce more amount of extracellular matrix. It also inhibits the synthesis of matrix metalloproteinases. Example of these growth factors includes transforming growth factor, insulin-like growth factor, and basic fibroblast growth factor. The degraded matrix is repaired by an increased level of transforming growth factor and basic fibroblast growth factor.


Environment and Degeneration


Even though all the discs are of the same age, discs found in the lower lumbar segments are more vulnerable to degenerative changes than the discs found in the upper segment. This suggests that not only aging but, also mechanical loading, is a causative factor. The association between degenerative disc disease and environmental factors has been defined in a comprehensive manner by Williams and Sambrook in 2011. (Williams, F.M.K., and P.N. Sambrook) The heavy physical loading associated with your occupation is a risk factor that has some contribution to disc degenerative disease. There is also a possibility of chemicals causing disc degeneration, such as smoking, according to some studies. (Batti�, Michele C.) Nicotine has been implicated in twin studies to cause impaired blood flow to the intervertebral disc, leading to disc degeneration. (BATTI�, MICHELE C., et al.) Moreover, an association has been found among atherosclerotic lesions in the aorta and the low back pain citing a link between atherosclerosis and degenerative disc disease. (Kauppila, L.I.) The disc degeneration severity was implicated in overweight, obesity, metabolic syndrome, and increased body mass index in some studies. (�A Population-Based Study Of Juvenile Disc Degeneration And Its Association With Overweight And Obesity, Low Back Pain, And Diminished Functional Status. Samartzis D, Karppinen J, Mok F, Fong DY, Luk KD, Cheung KM. J Bone Joint Surg Am 2011;93(7):662�70�)


Pain in Disc Degeneration (Discogenic Pain)


Discogenic pain, which is a type of nociceptive pain, arises from the nociceptors in the annulus fibrosus when the nervous system is affected by the degenerative disc disease. Annulus fibrosus contains immune reactive nerve fibers in the outer layer of the disc with other chemicals such as a vasoactive intestinal polypeptide, calcitonin gene-related peptide, and substance P. (KONTTINEN, YRJ� T., et al.) When degenerative changes in the intervertebral discs occur, normal structure and mechanical load are changed leading to abnormal movements. These disc nociceptors can get abnormally sensitized to mechanical stimuli. The pain can also be provoked by the low pH environment caused by the presence of lactic acid, causing increased production of pain mediators.


Pain from degenerative disc disease may arise from multiple origins. It may occur due to the structural damage, pressure, and irritation on the nerves in the spine. The disc itself contains only a few nerve fibers, but any injury can sensitize these nerves, or those in the posterior longitudinal ligament, to cause pain. Micro movements in the vertebrae can occur, which may cause painful reflex muscle spasms because the disc is damaged and worn down with the loss of tension and height. The painful movements arise because the nerves supplying the area are compressed or irritated by the facet joints and ligaments in the foramen leading to leg and back pain. This pain may be aggravated by the release of inflammatory proteins that act on nerves in the foramen or descending nerves in the spinal canal.


Pathological specimens of the degenerative discs, when observed under the microscope, reveals that there are vascularized granulation tissue and extensive innervations found in the fissures of the outer layer of the annulus fibrosus extending into the nucleus pulposus. The granulation tissue area is infiltrated by abundant mast cells and they invariably contribute to the pathological processes that ultimately lead to discogenic pain. These include neovascularisation, intervertebral disc degeneration, disc tissue inflammation, and the formation of fibrosis. Mast cells also release substances, such as tumor necrosis factor and interleukins, which might signal for the activation of some pathways which play a role in causing back pain. Other substances that can trigger these pathways include phospholipase A2, which is produced from the arachidonic acid cascade. It is found in increased concentrations in the outer third of the annulus of the degenerative disc and is thought to stimulate the nociceptors located there to release inflammatory substances to trigger pain. These substances bring about axonal injury, intraneural edema, and demyelination. (Brisby, Helena)


The back pain is thought to arise from the intervertebral disc itself. Hence why the pain will decrease gradually over time when the degenerating disc stops inflicting pain. However, the pain actually arises from the disc itself only in 11% of patients according to endoscopy studies. The actual cause of back pain seems to be due to the stimulation of the medial border of the nerve and referred pain along the arm or leg seems to arise due to the stimulation of the core of the nerve. The treatment for disc degeneration should mainly focus on pain relief to reduce the suffering of the patient because it is the most disabling symptom that disrupts a patient�s lives. Therefore, it is important to establish the mechanism of pain because it occurs not only due to the structural changes in the intervertebral discs but also due to other factors such as the release of chemicals and understanding these mechanisms can lead to effective pain relief. (Choi, Yong-Soo)


Clinical Presentation of Degenerative Disc Disease


Patients with degenerative disc disease face a myriad of symptoms depending on the site of the disease. Those who have lumbar disc degeneration get low back pain, radicular symptoms, and weakness. Those who have cervical disc degeneration have neck pain and shoulder pain.


Low back pain can get exacerbated by the movements and the position. Usually, the symptoms are worsened by the flexion, while the extension often relieves them. Minor twisting injuries, even from swinging a golf club, can trigger the symptoms. The pain is usually observed to be less when walking or running, when changing the position frequently and when lying down. However, the pain is usually subjective and in many cases, it varies considerably from person to person and most people will suffer from a low level of chronic pain of the lower back region continuously while occasionally suffering from the groin, hip, and leg pain. The intensity of the pain will increase from time to time and will last for a few days and then subside gradually. This �flare-up� is an acute episode and needs to be treated with potent analgesics. Worse pain is experienced in the seated position and is exacerbated while bending, lifting, and twisting movements frequently. The severity of the pain can vary considerably with some having occasional nagging pain to others having severe and disabling pain intermittently.� (Jason M. Highsmith, MD)


The localized pain and tenderness in the axial spine usually arises from the nociceptors found within the intervertebral discs, facet joints, sacroiliac joints, dura mater of the nerve roots, and the myofascial structures found within the axial spine. As mentioned in the previous sections, the degenerative anatomical changes may result in a narrowing of the spinal canal called spinal stenosis, overgrowth of spinal processes called osteophytes, hypertrophy of the inferior and superior articular processes, spondylolisthesis, bulging of the ligamentum flavum and disc herniation. These changes result in a collection of symptoms that is known as neurogenic claudication. There may be symptoms such as low back pain and leg pain together with numbness or tingling in the legs, muscle weakness, and foot drop. Loss of bowel or bladder control may suggest spinal cord impingement and prompt medical attention is needed to prevent permanent disabilities. These symptoms can vary in severity and may present to varying extents in different individuals.


The pain can also radiate to other parts of the body due to the fact that the spinal cord gives off several branches to two different sites of the body. Therefore, when the degenerated disc presses on a spinal nerve root, the pain can also be experienced in the leg to which the nerve ultimately innervates. This phenomenon, called radiculopathy, can occur from many sources arising, due to the process of degeneration. The bulging disc, if protrudes centrally, can affect descending rootlets of the cauda equina, if it bulges posterolaterally, it might affect the nerve roots exiting at the next lower intervertebral canal and the spinal nerve within its ventral ramus can get affected when the disc protrudes laterally. Similarly, the osteophytes protruding along the upper and lower margins of the posterior aspect of vertebral bodies can impinge on the same nervous tissues causing the same symptoms. Superior articular process hypertrophy may also impinge upon nerve roots depending on their projection. The nerves may include nerve roots prior to exiting from the next lower intervertebral canal and nerve roots within the upper nerve root canal and dural sac. These symptoms, due to the nerve impingement, have been proven by cadaver studies. Neural compromise is thought to occur when the neuro foraminal diameter is critically occluded with a 70% reduction. Furthermore, neural compromise can be produced when the posterior disc is compressed less than 4 millimeters in height, or when the foraminal height is reduced to less than 15 millimeters leading to foraminal stenosis and nerve impingement. (Taher, Fadi, et al.)


Diagnostic Approach


Patients are initially evaluated with an accurate history and thorough physical examination and appropriate investigations and provocative testing. However, history is often vague due to the chronic pain which cannot be localized properly and the difficulty in determining the exact anatomical location during provocative testing due to the influence of the neighboring anatomical structures.


Through the patient�s history, the cause of low back pain can be identified as arising from the nociceptors in the intervertebral discs. Patients may also give a history of the chronic nature of the symptoms and associated gluteal region numbness, tingling as well as stiffness in the spine which usually worsens with activity. Tenderness may be elicited by palpating over the spine. Due to the nature of the disease being chronic and painful, most patients may be suffering from mood and anxiety disorders. Depression is thought to be contributing negatively to the disease burden. However, no clear relationship between disease severity and mood or anxiety disorders. It is good to be vigilant about these mental health conditions as well. In order to exclude other serious pathologies, questions must be asked regarding fatigue, weight loss, fever, and chills, which might indicate some other diseases. (Jason M. Highsmith, MD)


Another etiology for the low back pain has to be excluded when examining the patient for degenerative disc disease. Abdominal pathologies, which can give rise to back pain such as aortic aneurysm, renal calculi, and pancreatic disease, have to be excluded.


Degenerative disc disease has several differential diagnoses to be considered when a patient presents with back pain. These include; idiopathic low back pain, zygapophyseal joint degeneration, myelopathy, lumbar stenosis, spondylosis, osteoarthritis, and lumbar radiculopathy. (�Degenerative Disc Disease � Physiopedia�)




Investigations are used to confirm the diagnosis of degenerative disc disease. These can be divided into laboratory studies, imaging studies, nerve conduction tests, and diagnostic procedures.


Imaging Studies


The imaging in degenerative disc disease is mainly used to describe anatomical relations and morphological features of the affected discs, which has a great therapeutic value in future decision making for treatment options. Any imaging method, like plain radiography, CT, or MRI, can provide useful information. However, an underlying cause can only be found in 15% of the patients as no clear radiological changes are visible in degenerative disc disease in the absence of disc herniation and neurological deficit. Moreover, there is no correlation between the anatomical changes seen on imaging and the severity of the symptoms, although there are correlations between the number of osteophytes and the severity of back pain. Degenerative changes in radiography can also be seen in asymptomatic people leading to difficulty in conforming clinical relevance and when to start treatment. (�Degenerative Disc Disease � Physiopedia�)


Plain Radiography


This inexpensive and widely available plain cervical radiography can give important information on deformities, alignment, and degenerative bony changes. In order to determine the presence of spinal instability and sagittal balance, dynamic flexion, or extension studies have to be performed.


Magnetic Resonance Imaging (MRI)


MRI is the most commonly used method to diagnose degenerative changes in the intervertebral disc accurately, reliably, and most comprehensively. It is used in the initial evaluation of patients with neck pain after plain radiography. It can provide non-invasive images in multiple plains and gives excellent quality images of the disc. MRI can show disc hydration and morphology-based on the proton density, chemical environment, and the water content. Clinical picture and history of the patient have to be considered when interpreting MRI reports as it has been shown that as much as 25% of radiologists change their report when the clinical data are available. Fonar produced the first open MRI scanner with the ability of the patient to be scanned in different positions such as standing, sitting, and bending. Because of these unique features, this open MRI scanner can be used for scanning patients in weight-bearing postures and stand up postures to detect underlying pathological changes which are usually overlooked in conventional MRI scan such as lumbar degenerative disc disease with herniation. This machine is also good for claustrophobic patients, as they get to watch a large television screen during the scanning process. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology.�)


Nucleus pulposus and annulus fibrosus of the disc can usually be identified on MRI, leading to the detection of disc herniation as contained and non contained. As MRI can also show annular tears and the posterior longitudinal ligament, it can be used to classify herniation. This can be simple annular bulging to free fragment disc herniations. This information can describe the pathologic discs such as extruded disc, protruded discs, and migrated discs.


There are several grading systems based on MRI signal intensity, disc height, the distinction between nucleus and annulus, and the disc structure. The method, by Pfirrmann et al, has been widely applied and clinically accepted. According to the modified system, there are 8 grades for lumbar disc degenerative disease. Grade 1 represents normal intervertebral disc and grade 8 corresponds to the end stage of degeneration, depicting the progression of the disc disease. There are corresponding images to aid the diagnosis. As they provide good tissue differentiation and detailed description of the disc structure, sagittal T2 weighted images are used for the classification purpose. (Pfirrmann, Christian W. A., et al.)


Modic has described the changes occurring in the vertebral bodies adjacent to the degenerating discs as Type 1 and Type 2 changes. In Modic 1 changes, there is decreased intensity of T1 weighted images and increased intensity T2 weighted images. This is thought to occur because the end plates have undergone sclerosis and the adjacent bone marrow is showing inflammatory response as the diffusion coefficient increases. This increase of diffusion coefficient and the ultimate resistance to diffusion is brought about by the chemical substances released through an autoimmune mechanism. Modic type 2 changes include the destruction of the bone marrow of adjacent vertebral endplates due to an inflammatory response and the infiltration of fat in the marrow. These changes may lead to increased signal density on T1 weighted images. (Modic, M T et al.)


Computed Tomography (CT)


When MRI is not available, Computed tomography is considered a diagnostic test that can detect disc herniation because it has a better contrast between posterolateral margins of the adjacent bony vertebrae, perineal fat, and the herniated disc material. Even so, when diagnosing lateral herniations, MRI remains the imaging modality of choice.


CT scan has several advantages over MRI such as it has a less claustrophobic environment, low cost, and better detection of bonny changes that are subtle and may be missed on other modalities. CT can detect early degenerative changes of the facet joints and spondylosis with more accuracy. Bony integrity after fusion is also best assessed by CT.


Disc herniation and associated nerve impingement can be diagnosed by using the criteria developed by Gundry and Heithoff. It is important for the disc protrusion to lie directly over the nerve roots traversing the disc and to be focal and asymmetrical with a dorsolateral position. There should be demonstrable nerve root compression or displacement. Lastly, the nerve distal to the impingement (site of herniation) often enlarges and bulges with resulting edema, prominence of adjacent epidural veins, and inflammatory exudates resulting in blurring the margin.


Lumbar Discography


This procedure is controversial and, whether knowing the site of the pain has any value regarding surgery or not, has not been proven. False positives can occur due to central hyperalgesia in patients with chronic pain (neurophysiologic finding) and due to psychosocial factors. It is questionable to establish exactly when discogenic pain becomes clinically significant. Those who support this investigation advocates strict criteria for selection of the patients and when interpreting results and believe this is the only test that can diagnose discogenic pain. Lumbar discography can be used in several situations, although it is not scientifically established. These include; diagnosis of lateral herniation, diagnosing a symptomatic disc among multiple abnormalities, assessing similar abnormalities seen on CT or MRI, evaluation of the spine after surgery, selection of fusion level, and the suggestive features of discogenic pain existence.


The discography is more concerned about eliciting pathophysiology rather than determining the anatomy of the disc. Therefore, discogenic pain evaluation is the aim of discography. MRI may reveal an abnormally looking disc with no pain, while severe pain may be seen on discography where MRI findings are few. During the injection of normal saline or the contrast material, a spongy endpoint can occur with abnormal discs accepting more amounts of contrast. The contrast material can extend into the nucleus pulposus through tears and fissures in the annulus fibrosus in the abnormal discs. The pressure of this contrast material can provoke pain due to the innervations by recurrent meningeal nerve, mixed spinal nerve, anterior primary rami, and gray rami communicantes supplying the outer annulus fibrosus. Radicular pain can be provoked when the contrast material reaches the site of nerve root impingement by the abnormal disc. However, this discography test has several complications such as nerve root injury, chemical or bacterial diskitis, contrast allergy, and the exacerbation of pain. (Bartynski, Walter S., and A. Orlando Ortiz)


Imaging Modality Combination


In order to evaluate the nerve root compression and cervical stenosis adequately, a combination of imaging methods may be needed.


CT Discography


After performing initial discography, CT discography is performed within 4 hours. It can be used in determining the status of the disc such as herniated, protruded, extruded, contained or sequestered. It can also be used in the spine to differentiate the mass effects of scar tissue or disc material after spinal surgery.


CT Myelography


This test is considered the best method for evaluating nerve root compression. When CT is performed in combination or after myelography, details about bony anatomy different planes can be obtained with relative ease.


Diagnostic Procedures


Transforaminal Selective Nerve Root Blocks (SNRBs)


When multilevel degenerative disc disease is suspected on an MRI scan, this test can be used to determine the specific nerve root that has been affected. SNRB is both a diagnostic and therapeutic test that can be used for lumbar spinal stenosis. The test creates a demotomal level area of hypoesthesia by injecting an anesthetic and a contrast material under fluoroscopic guidance to the interested nerve root level. There is a correlation between multilevel cervical degenerative disc disease clinical symptoms and findings on MRI and findings of SNRB according to Anderberg et al. There is a 28% correlation with SNRB results and with dermatomal radicular pain and areas of neurologic deficit. Most severe cases of degeneration on MRI are found to be correlated with 60%. Although not used routinely, SNRB is a useful test in evaluating patients before surgery in multilevel degenerative disc disease especially on the spine together with clinical features and findings on MRI. (Narouze, Samer, and Amaresh Vydyanathan)


Electro Myographic Studies


Distal motor and sensory nerve conduction tests, called electromyographic studies, that are normal with abnormal needle exam may reveal nerve compression symptoms that are elicited in the clinical history. Irritated nerve roots can be localized by using injections to anesthetize the affected nerves or pain receptors in the disc space, sacroiliac joint, or the facet joints by discography. (�Journal Of Electromyography & Kinesiology Calendar�)


Laboratory Studies


Laboratory tests are usually done to exclude other differential diagnoses.


As seronegative spondyloarthropathies, such as ankylosing spondylitis, are common causes of back pain, HLA B27 immuno-histocompatibility has to be tested. Estimated 350,000 persons in the US and 600,000 in Europe have been affected by this inflammatory disease of unknown etiology. But HLA B27 is extremely rarely found in African Americans. Other seronegative spondyloarthropathies that can be tested using this gene include psoriatic arthritis, inflammatory bowel disease, and reactive arthritis or Reiter syndrome. Serum immunoglobulin A (IgA) can be increased in some patients.


Tests like the erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP) level test for the acute phase reactants seen in inflammatory causes of lower back pain such as osteoarthritis and malignancy. The full blood count is also required, including differential counts to ascertain the disease etiology. Autoimmune diseases are suspected when Rheumatoid factor (RF) and anti-nuclear antibody (ANA) tests become positive. Serum uric acid and synovial fluid analysis for crystals may be needed in rare cases to exclude gout and pyrophosphate dihydrate deposition.




There is no definitive treatment method agreed by all physicians regarding the treatment of degenerative disc disease because the cause of the pain can differ in different individuals and so is the severity of pain and the wide variations in clinical presentation. The treatment options can be discussed broadly under; conservative treatment, medical treatment, and surgical treatment.


Conservative Treatment


This treatment method includes exercise therapy with behavioral interventions, physical modalities, injections, back education, and back school methods.


Exercise-Based Therapy with Behavioral Interventions


Depending on the diagnosis of the patient, different types of exercises can be prescribed. It is considered one of the main methods of conservative management to treat chronic low back pain. The exercises can be modified to include stretching exercises, aerobic exercises, and muscle strengthening exercises. One of the major challenges of this therapy includes its inability to assess the efficacy among patients due to wide variations in the exercise regimens, frequency, and intensity. According to studies, most effectiveness for sub-acute low back pain with varying duration of symptoms was obtained by performing graded exercise programs within the occupational setting of the patient. Significant improvements were observed among patients suffering from chronic symptoms with this therapy with regard to functional improvement and pain reduction. Individual therapies designed for each patient under close supervision and compliance of the patient also seems to be the most effective in chronic back pain sufferers. Other conservative approaches can be used in combination to improve this approach. (Hayden, Jill A., et al.)


Aerobic exercises, if performed regularly, can improve endurance. For relieving muscle tension, relaxation methods can be used. Swimming is also considered an exercise for back pain. Floor exercises can include extension exercises, hamstring stretches, low back stretches, double knee to chin stretches, seat lifts, modified sit-ups, abdominal bracing, and mountain and sag exercises.


Physical Modalities


This method includes the use of electrical nerve stimulation, relaxation, ice packs, biofeedback, heating pads, phonophoresis, and iontophoresis.


Transcutaneous Electrical Nerve Stimulation (TENS)


In this non-invasive method, electrical stimulation is delivered to the skin in order to stimulate the peripheral nerves in the area to relieve the pain to some extent. This method relieves pain immediately following application but its long term effectiveness is doubtful. With some studies, it has been found that there is no significant improvement in pain and functional status when compared with placebo. The devices performing these TENS can be easily accessible from the outpatient department. The only side effect seems to be a mild skin irritation experienced in a third of patients. (Johnson, Mark I)


Back School


This method was introduced with the aim of reducing the pain symptoms and their recurrences. It was first introduced in Sweden and takes into account the posture, ergonomics, appropriate back exercises, and the anatomy of the lumbar region. Patients are taught the correct posture to sit, stand, lift weights, sleep, wash face, and brush teeth avoiding pain. When compared with other treatment modalities, back school therapy has been proven to be effective in both immediate and intermediate periods for improving back pain and functional status.


Patient Education


In this method, the provider instructs the patient on how to manage their back pain symptoms. Normal spinal anatomy and biomechanics involving mechanisms of injury is taught at first. Next, using the spinal models, the degenerative disc disease diagnosis is explained to the patient. For the individual patient, the balanced position is determined and then asked to maintain that position to avoid getting symptoms.


Bio-Psychosocial Approach to Multidisciplinary Back Therapy


Chronic back pain can cause a lot of distress to the patient, leading to psychological disturbances and low mood. This can adversely affect the therapeutic outcomes rendering most treatment strategies futile. Therefore, patients must be educated on learned cognitive strategies called �behavioral� and �bio-psychosocial� strategies to get relief from pain. In addition to treating the biological causes of pain, psychological, and social causes should also be addressed in this method. In order to reduce the patient�s perception of pain and disability, methods like modified expectations, relaxation techniques, control of physiological responses by learned behavior, and reinforcement are used.


Massage Therapy


For chronic low back pain, this therapy seems to be beneficial. Over a 1 year period, massage therapy has been found to be moderately effective for some patients when compared to acupuncture and other relaxation methods. However, it is less efficacious than TENS and exercise therapy although individual patients may prefer one over the other. (Furlan, Andrea D., et al.)


Spinal Manipulation


This therapy involves the manipulation of a joint beyond its normal range of movement, but not exceeding that of the normal anatomical range. This is a manual therapy that involves long lever manipulation with a low velocity. It is thought to improve low back pain through several mechanisms like the release of entrapped nerves, destruction of articular and peri-articular adhesions, and through manipulating segments of the spine that had undergone displacement. It can also reduce the bulging of the disc, relax the hypertonic muscles, stimulate the nociceptive fibers via changing the neurophysiological function and reposition the menisci on the articular surface.


Spinal manipulation is thought to be superior in efficacy when compared to most methods such as TENS, exercise therapy, NSAID drugs, and back school therapy. The currently available research is positive regarding its effectiveness in both the long and short term. It is also very safe to administer under-trained therapists with cases of disc herniation and cauda equina being reported only in lower than 1 in 3.7 million people. (Bronfort, Gert, et al.)


Lumbar Supports


Patients suffering from chronic low back pain due to degenerative processes at multiple levels with several causes may benefit from lumbar support. There is conflicting evidence with regards to its effectiveness with some studies claiming moderate improvement in immediate and long term relief while others suggesting no such improvement when compared to other treatment methods. Lumbar supports can stabilize, correct deformity, reduce mechanical forces, and limit the movements of the spine. It may also act as a placebo and reduce the pain by massaging the affected areas and applying heat.


Lumbar Traction


This method uses a harness attached to the iliac crest and lower rib cage and applies a longitudinal force along the axial spine to relieve chronic low back pain. The level and duration of the force are adjusted according to the patient and it can be measured by using devices both while walking and lying down. Lumbar traction acts by opening the intervertebral disc spaces and by reducing the lumbar lordosis. The symptoms of degenerative disc disease are reduced through this method due to temporary spine realignment and its associated benefits. It relieves nerve compression and mechanical stress, disrupts the adhesions in the facet and annulus, and also nociceptive pain signals. However, there is not much evidence with regard to its effectiveness in reducing back pain or improving daily function. Furthermore, the risks associated with lumbar traction are still under research and some case reports are available where it has caused a nerve impingement, respiratory difficulties, and blood pressure changes due to heavy force and incorrect placement of the harness. (Harte, A et al.)


Medical Treatment


Medical therapy involves drug treatment with muscle relaxants, steroid injections, NSAIDs, opioids, and other analgesics. This is needed, in addition to conservative treatment, in most patients with degenerative disc disease. Pharmacotherapy is aimed to control disability, reduce pain and swelling while improving the quality of life. It is catered according to the individual patient as there is no consensus regarding the treatment.


Muscle Relaxants


Degenerative disc disease may benefit from muscle relaxants by reducing the spasm of muscles and thereby relieving pain. The efficacy of muscle relaxants in improving pain and functional status has been established through several types of research. Benzodiazepine is the most common muscle relaxant currently in use.


Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)


These drugs are commonly used as the first step in disc degenerative disease providing analgesia, as well as anti-inflammatory effects. There is strong evidence that it reduces chronic low back pain. However, its use is limited by gastrointestinal disturbances, like acute gastritis. Selective COX2 inhibitors, like celecoxib, can overcome this problem by only targeting COX2 receptors. Their use is not widely accepted due to its potential side effects in increasing cardiovascular disease with prolonged use.


Opioid Medications


This is a step higher up in the WHO pain ladder. It is reserved for patients suffering from severe pain not responding to NSAIDs and those with unbearable GI disturbances with NSAID therapy. However, the prescription of narcotics for treating back pain varies considerably between clinicians. According to literature, 3 to 66% of patients may be taking some form of the opioid to relieve their back pain. Even though the short term reduction in symptoms is marked, there is a risk of long term narcotic abuse, a high rate of tolerance, and respiratory distress in the older population. Nausea and vomiting are some of the short term side effects encountered. (�Systematic Review: Opioid Treatment For Chronic Back Pain: Prevalence, Efficacy, And Association With Addiction�)




Anti-depressants, in low doses, have analgesic value and may be beneficial in chronic low back pain patients who may present with associated depression symptoms. The pain and suffering may be disrupting the sleep of the patient and reducing the pain threshold. These can be addressed by using anti-depressants in low doses even though there is no evidence that it improves the function.


Injection Therapy


Epidural Steroid Injections


Epidural steroid injections are the most widely used injection type for the treatment of chronic degenerative disc disease and associated radiculopathy. There is a variation between the type of steroid used and its dose. 8- 10 mL of a mixture of methylprednisolone and normal saline is considered an effective and safe dose. The injections can be given through interlaminar, caudal, or trans foramina routes. A needle can be inserted under the guidance of fluoroscopy. First contrast, then local anesthesia and lastly, the steroid is injected into the epidural space at the affected level via this method. The pain relief is achieved due to the combination of effects from both local anesthesia and the steroid. Immediate pain relief can be achieved through the local anesthetic by blocking the pain signal transmission and while also confirming the diagnosis. Inflammation is also reduced due to the action of steroids in blocking pro-inflammatory cascade.


During the recent decade, the use of epidural steroid injection has increased by 121%. However, there is controversy regarding its use due to the variation in response levels and potentially serious adverse effects. Usually, these injections are believed to cause only short term relief of symptoms. Some clinicians may inject 2 to 3 injections within a one-week duration, although the long term results are the same for that of a patient given only a single injection. For a one year period, more than 4 injections shouldn�t be given. For more immediate and effective pain relief, preservative-free morphine can also be added to the injection. Even local anesthetics, like lidocaine and bupivacaine, are added for this purpose. Evidence for long term pain relief is limited. (�A Placebo-Controlled Trial To Evaluate Effectivity Of Pain Relief Using Ketamine With Epidural Steroids For Chronic Low Back Pain�)


There are potential side effects due to this therapy, in addition to its high cost and efficacy concerns. Needles can get misplaced if fluoroscopy is not used in as much as 25% of cases, even with the presence of experienced staff. The epidural placement can be identified by pruritus reliably. Respiratory depression or urinary retention can occur following injection with morphine and so the patient needs to be monitored for 24 hours following the injection.


Facet Injections


These injections are given to facet joints, also called zygapophysial joints, which are situated between two adjacent vertebrae. Anesthesia can be directly injected to the joint space or to the associated medial branch of the dorsal rami, which innervates it. There is evidence that this method improves the functional ability, quality of life, and relieves pain. They are thought to provide both short and long term benefits, although studies have shown both facet injections and epidural steroid injections are similar in efficacy. (Wynne, Kelly A)


SI Joint Injections


This is a diarthrodial synovial joint with nerve supply from both myelinated and non-myelin nerve axons. The injection can effectively treat degenerative disc disease involving sacroiliac joint leading to both long and short term relief from symptoms such as low back pain and referred pain at legs, thigh, and buttocks. The injections can be repeated every 2 to 3 months but should be performed only if clinically necessary. (MAUGARS, Y. et al.)


Intradiscal Non-Operative Therapies for Discogenic Pain


As described under the investigations, discography can be used both as a diagnostic and therapeutic method. After the diseased disc is identified, several minimally invasive methods can be tried before embarking on surgery. Electrical current and its heat can be used to coagulate the posterior annulus thereby strengthening the collagen fibers, denaturing and destroying inflammatory mediators and nociceptors, and sealing figures. The methods used in this are called intradiscal electrothermal therapy (IDET) or radiofrequency posterior annuloplasty (RPA), in which an electrode is passed to the disc. IDET has moderate evidence in relief of symptoms for disc degenerative disease patients, while RPA has limited support regarding its short term and long term efficacy. Both these procedures can lead to complications such as nerve root injury, catheter malfunction, infection, and post-procedure disc herniation.


Surgical Treatment


Surgical treatment is reserved for patients with failed conservative therapy taking into account the disease severity, age, other comorbidities, socio-economic condition, and the level of outcome expected. It is estimated that around 5% of patients with degenerative disc disease undergo surgery, either for their lumbar disease or cervical disease. (Rydevik, Bj�rn L.)


Lumbar Spine Procedures


Lumbar surgery is indicated in patients with severe pain, with a duration of 6 to 12 months of ineffective drug therapy, who have critical spinal stenosis. The surgery is usually an elective procedure except in the case of cauda equina syndrome. There are two procedure types that aim to involve spinal fusion or decompression or both. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology.�)


Spinal fusion involves stopping movements at a painful vertebral segment in order to reduce the pain by fusing several vertebrae together by using a bone graft. It is considered effective in the long term for patients with degenerative disc disease having spinal malalignment or excessive movement. There are several approaches to fusion surgery. (Gupta, Vijay Kumar, et al)


  • Lumbar spinal posterolateral guttur fusion


This method involves placing a bone graft in the posterolateral part of the spine. A bone graft can be harvested from the posterior iliac crest. The bones are stripped off from its periosteum for successful grafting. A back brace is needed in the post-operative period and patients may need to stay in the hospital for about 5 to 10 days. Limited motion and cessation of smoking are needed for successful fusion. However, several risks such as non-union, infection, bleeding, and solid union with back pain may occur.


  • Posterior lumbar interbody fusion


In this method, decompression or diskectomy methods can also be performed via the same approach. The bone grafts are directly applied to the disc space and ligamentum flavum is excised completely. For the degenerative disc disease, interlaminar space is widened additionally by performing a partial medial facetectomy. Back braces are optional with this method. It has several disadvantages when compared to anterior approach such as only small grafts can be inserted, the reduced surface area available for fusion, and difficulty when performing surgery on spinal deformity patients. The major risk involved is non-union.


  • Anterior lumbar interbody fusion


This procedure is similar to the posterior one except that it is approached through the abdomen instead of the back. It has the advantage of not disrupting the back muscles and the nerve supply. It is contraindicated in patients with osteoporosis and has the risk of bleeding, retrograde ejaculation in men, non-union, and infection.


  • Transforaminal lumbar interbody fusion


This is a modified version of the posterior approach which is becoming popular. It offers low risk with good exposure and it is shown to have an excellent outcome with a few complications such as CSF leak, transient neurological impairment, and wound infection.


Total Disc Arthroplasty


This is an alternative to disc fusion and it has been used to treat lumbar degenerative disc disease using an artificial disc to replace the affected disc. Total prosthesis or nuclear prosthesis can be used depending on the clinical situation.


Decompression involves removing part of the disc of the vertebral body, which is impinging on a nerve to release that and provide room for its recovery via procedures called diskectomy and laminectomy. The efficacy of the procedure is questionable although it is a commonly performed surgery. Complications are very few with a low chance of recurrence of symptoms with higher patient satisfaction. (Gupta, Vijay Kumar, et al)


  • Lumbar discectomy


The surgery is performed through a posterior midline approach by dividing the ligamentum flavum. The nerve root that is affected is identified and bulging annulus is cut to release it. Full neurological examination should be performed afterward and patients are usually fit to go home 1 � 5 days later. Low back exercises should be started soon followed by light work and then heavy work at 2 and 12 weeks respectively.


  • Lumbar laminectomy


This procedure can be performed thorough one level, as well as through multiple levels. Laminectomy should be as short as possible to avoid spinal instability. Patients have marked relief of symptoms and reduction in radiculopathy following the procedure. The risks may include bowel and bladder incontinence, CSF leakage, nerve root damage, and infection.


Cervical Spine Procedures


Cervical degenerative disc disease is indicated for surgery when there is unbearable pain associated with progressive motor and sensory deficits. Surgery has a more than 90% favorable outcome when there is radiographic evidence of nerve root compression. There are several options including anterior cervical diskectomy (ACD), ACD, and fusion (ACDF), ACDF with internal fixation, and posterior foraminotomy. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology.�)


Cell-Based Therapy


Stem cell transplantation has emerged as a novel therapy for degenerative disc disease with promising results. The introduction of autologous chondrocytes has been found to reduce discogenic pain over a 2 year period. These therapies are currently undergoing human trials. (Jeong, Je Hoon, et al.)


Gene Therapy


Gene transduction in order to halt the disc degenerative process and even inducing disc regeneration is currently under research. For this, beneficial genes have to be identified while demoting the activity of degeneration promoting genes. These novel treatment options give hope for future treatment to be directed at regenerating intervertebral discs. (Nishida, Kotaro, et al.)



Degenerative disc disease is a health issue characterized by chronic back pain due to a damaged intervertebral disc, such as low back pain in the lumbar spine or neck pain in the cervical spine. It is a breakdown of an intervertebral disc of the spine. Several pathological changes can occur in disc degeneration. Various anatomical defects can also occur in the intervertebral disc. Low back pain and neck pain are major epidemiological problems, which are thought to be related to degenerative disc disease. Back pain is the second leading cause of doctor office visits in the United States. It is estimated that about 80% of US adults suffer from low back pain at least once during their lifetime. Therefore, a thorough understanding of degenerative disc disease is needed for managing this common condition. – Dr. Alex Jimenez D.C., C.C.S.T. Insight


The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas*& New Mexico*�


Curated by Dr. Alex Jimenez D.C., C.C.S.T.




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