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Sciatica Nerve Pain

Back Clinic Sciatica Nerve Pain Chiropractic, Physical Therapy Treatment Team. The common cause is a bulging or ruptured disc (herniated disc) in the spine pressing against the nerve roots that lead to the sciatic nerve. Sciatica nerve pain can also be a symptom of other conditions affecting the spine, such as narrowing of the spinal canal (spinal stenosis), bone spurs (small, bony growths that form along joints) caused by arthritis, or nerve root compression (pinched nerve) caused by injury. In rare cases, sciatica can also be caused by conditions that do not involve the spine, i.e. tumors or pregnancy.

What are the symptoms?

Pain that begins in your back or buttock and moves down your leg and may move into the foot. Weakness, tingling, or numbness in the leg may also occur.

Sitting, standing for a long time, and movements that cause the spine to flex (such as knee-to-chest exercises) may make symptoms worse.

Walking, lying down, and movements that extend the spine (such as press-ups) may relieve symptoms. For answers to any questions you may have please call Dr. Jimenez at 915-850-0900


Multiple Sclerosis, Sciatica, and Nerve Pain

Multiple Sclerosis, Sciatica, and Nerve Pain

Multiple sclerosis and sciatica can exist side by side or have overlapping symptoms. The sciatic nerve begins at the lower back, then through the hips into the buttocks, and separates into both legs into the feet. Sciatica is a type of pain caused by a compressed/pinched or damaged/injured sciatic nerve. The sensation radiates across the nerve with frequency and severity at varying levels, depending on the individual’s body position and/or movement. Individuals with multiple sclerosis can also experience sciatica, believing it’s their multiple sclerosis. Neuropathic pain is a common symptom in multiple sclerosis or MS. It is caused by injury or damage to the nerves of the central nervous system and can cause burning, or sharp, stabbing sensations.

Multiple Sclerosis, Sciatica, and Nerve Pain

Multiple Sclerosis and Sciatic Nerve Pain Difference

MS is an autoimmune disorder where the immune system attacks the protective layer around nerve fibers known as myelin. This affects the central nervous system pathways that regulate feeling and sensation in the body. It can cause painful sensations that include:

  • Muscle spasms
  • Burning, tingling, or aching in the lower legs
  • Electrical shock-like sensations travel from the back toward the legs.
  • Migraines
  • The painful sensations result from the damaged nerve fibers creating interference in the brain’s neural pathways.

Sciatica works differently

An autoimmune response does not damage the sciatic nerve’s pathway, but an added stress/pressure compresses the sciatic nerve. The pain is usually caused by a quick, jerking, twisting, bending, reaching motion that pinches or twists the nerve. Herniated discs and bone spurs are another common cause, along with being overweight can place intense pressure on the sciatic nerve. The critical difference is that multiple sclerosis causes the central nervous system’s signaling pathways to malfunction.

MS and Sciatica

Most individuals, around 40%, will at some point experience some form of sciatica symptoms. This is from age, and all the wear and tear the low back goes through daily. This is why it’s not unusual for individuals with MS to experience sciatica as well. MS can cause body changes that affect activity levels.

  • Decreased mobility can lead to sitting for extended periods that can strain the muscles, tendons, and ligaments, causing sciatica.
  • There is evidence that the lesions that present from MS can extend to the sciatic nerve.
  • One study compared 36 individuals with MS to 35 individuals that don’t have it.
  • All of the participants underwent magnetic resonance neurography to obtain high-resolution nerve images.
  • The research found that those with MS had slightly more lesions on the sciatic nerve than those without MS.

Sciatica Care

It can be challenging to figure out the types of pain being experienced. Sciatica travels down the length of the nerve uniquely and is often felt in only one leg. The pain, tingling, numbness, electrical sensations can present only in the lower back, the buttock, the back of the leg, hamstring, calf, and foot, or in a combination of all the areas. Treatments for sciatica depend on the severity. They include:

  • Chiropractic
  • Physical therapy
  • Posture exercises
  • Lifestyle adjustments
  • Physical activity and exercise
  • Weight loss
  • Cold and hot packs
  • Acupuncture
  • Over-the-counter pain relievers
  • Medications – anti-inflammatories, muscle relaxants, tricyclic antidepressants, and antiseizure medications.
  • Steroid injections – corticosteroids
  • Surgery is a last resort reserved for severe cases that did not improve with other treatments and therapies.

It can be easy to mistake sciatica as a symptom or related condition of multiple sclerosis. Chiropractic can help alleviate sciatica, and although treatment cannot directly treat MS or its symptoms, it can relieve pain and discomfort.


Body Composition


Diabetic Nephropathy

Diabetic nephropathy or diabetic kidney disease is the result of mismanaged diabetes. Kidney failure is a severe medical emergency and can be fatal if not treated. Chronic low kidney function results in:

  • Fluid retention in the body.
  • Inability to filter out metabolites and waste from the blood.
  • Increased risk of infections.

Common symptoms of diabetic kidney disease include:

Increased blood pressure

  • This is the result of increased stress on the body.
  • The kidneys can no longer filter out all the metabolites and excess fluid needed to stabilize the blood pressure.

Proteinuria or protein in the urine

  • Chronic kidney damage results in the protein being excreted through urine.

Fatigue

  • Poor kidney function affects every organ in the body.
  • The organs have to work harder to compensate, leading to fatigue and low energy.

Lower extremity edema

  • Fluid retention usually presents in the lower extremities.
  • Puffy, swollen ankles and legs may appear shiny or waxy.
  • This is common in individuals that have severe diabetic nephropathy.

Shortness of breath

  • As the fluid builds up in the body, additional weight can get stored on and around the lungs.
  • This can make breathing very difficult when lying down or when engaged in physical activity.

Impaired cognition

  • Metabolites in the blood can cause brain damage when not filtered properly.
  • Memory loss
  • Mood changes
  • Loss of consciousness
References

Jende JME, et al. (2017). Peripheral nerve involvement in multiple sclerosis: Demonstration by magnetic resonance neurography. DOI:
10.1002/ana.25068

Mayo Clinic Staff. (2019). Sciatica.
mayoclinic.org/diseases-conditions/sciatica/symptoms-causes/syc-20377435

Murphy KL, et al. (2017). Chapter 4: Neuropathic pain in multiple sclerosis—current therapeutic intervention and future treatment perspectives.
ncbi.nlm.nih.gov/books/NBK470151/

Pain and itching. (n.d.).
nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Pain

Samson K. (2017). In the pipeline-multiple sclerosis neurography, MRI reveals peripheral nerve lesions in MS patients. DOI:
10.1097/01.NT.0000527861.27137.b0

Sciatica: Of all the nerves. (2016).
health.harvard.edu/pain/sciatica-of-all-the-nerve

Sciatica Pain and Symptoms Improvement

Sciatica Pain and Symptoms Improvement

Determining if sciatica pain and symptoms are showing improvement can be as simple as the pain significantly reducing or it could be a bit more complex, depending on the severity of the condition. Chiropractic treatment keeps track of the location and movement of the pain as a reliable indicator that complete relief is getting closer. When the pain retreats up the leg, it is a sign of improvement even with back and buttock aches/pain that feel like it’s worsening.

11860 Vista Del Sol, Ste. 128 Sciatica Pain and Symptoms Improvement

Various Symptoms

The most common symptoms include:

  • Tingling
  • Numbness
  • Sharp pain
  • Dull pain
  • Radiating/spreading pain
  • A feeling like insects crawling or water trickling down the leg
  • Changing sensations in the buttock, back, leg, or foot

Does It Get Worse Before Getting Better?

Sciatica can get worse before it gets better. This is known as centralization where the pain moves or retreats back towards the midline of the spine after repeated movements or guided/chiropractic positioning and adjusting. It can be misleading, making the individual think the sciatica is worsening, or that something has caused a sciatica flare-up. However, healing is taking place. The furthest location away from the low back is the area to pay attention to. It’s different for individuals. It could be the:

  • Foot
  • Calf
  • Back of the thigh

No matter where the pain is pay attention to that particular area. If it feels like the sciatica is getting worse, take a moment to determine where the pain is presenting. If the pain has retreated and there is no pain in the foot, calf, or leg, the sciatica is getting better. What happens is the retreating pain going up the spine increases the pain in the back and buttocks. This means there is an improvement.

11860 Vista Del Sol, Ste. 128 Sciatica Pain and Symptoms Improvement

Sciatica Getting Worse

How to tell if it’s getting worse? An increase in pain could indicate that it is getting worse. But, the key is to pay attention to the location and movement of the pain. When it gets worse the pain is advancing, for example, if there was pain only in the back and buttock yesterday, and today the pain is radiating down the back of the leg into the calf, then the sciatica is getting worse.

Length of Time Sciatic Nerve Pain Lasts

For most individuals, sciatic nerve pain lasts from two to six weeks.

  • The acute pain lasts around 1 to 2 weeks, with lingering discomfort as the condition heals
  • There are factors that can cause sciatica to remain longer, or increase the chances of returning This includes:
  • Tight hamstrings
  • Weight gain
  • Pregnancy
  • Poor posture
  • Improper lifting

Sciatica that lasts more than six weeks is considered chronic. Medical intervention should be sought out if it lasts this long. Non-invasive treatment like chiropractic or physical therapy is recommended to help speed the healing process and reduce pain.

Permanent Cure

Most sciatica cases are caused by a spinal disc disorder in the lower back. Around 85% of sciatica cases are disc-related. There is a chance that sciatica can return. For most individuals, it only takes a small amount of work to keep sciatica at bay. Staying healthy and flexible are two ways to prevent sciatica from returning. This can be done through:

  • Healthy diet
  • Maintain a healthy weight
  • Staying active with 2 ½ hours of physical activity/exercise a week
  • Maintain proper posture
  • Regular stretching
  • Quitting smoking

If overweight it is highly recommended to lose weight. One study showed that obesity increased the risk of hospitalization by 36%. Other factors that increase the potential for sciatica are frequent intense physical activity levels in sports, exercise, DIY projects, etc.

Chiropractic Improvement

Whether dealing with sciatica during pregnancy, from tight hamstrings, or piriformis syndrome, chiropractic can help. A chiropractor can bring relief through:

11860 Vista Del Sol, Ste. 128 Sciatica Pain and Symptoms Improvement

Once the pain is manageable, the chiropractor will get to the root cause. They will utilize:

  • Spinal manipulation to relieve pressure
  • Soft tissue therapy
  • Stretches to release tight muscles
  • Strengthening exercises
  • Physical therapy
  • Nutrition/health coaching
  • Lifestyle adjustments

Surgery is rarely needed and only as a last resort. Chiropractic care will generate improvement and will educate the individual on what to do to prevent sciatica from flaring up.

Body Composition Improvement

Essential Fat vs Storage Fat

There is essential fat in the body. It has a significant role in overall health and is essential for survival. Essential fat is present in the:

  • Organs
  • Bone marrow
  • Nerve cells
  • Brain

Essential fat helps with:

Non-essential/storage fat is adipose tissue that accumulates as an energy reserve. Storage fat affects body shape and appearance.

Disclaimer

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*
email: coach@elpasofunctionalmedicine.com
phone: 915-850-0900
Licensed in Texas & New Mexico

References

National Institutes of Health. (2019.) “Sciatica.” medlineplus.gov/sciatica.html.

North American Spine Society. (2012.) “Clinical Guidelines for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy.” www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf

StatPearls [Internet]. (2020) “Anatomy, Sciatic Nerve.” www.ncbi.nlm.nih.gov/books/NBK482431/

StatPearls [Internet]. (2020) “Sciatica.” www.ncbi.nlm.nih.gov/books/NBK507908/

Nerve Flossing Exercises for Sciatica

Nerve Flossing Exercises for Sciatica

Traditional medical treatment for sciatica can sometimes be not as effective or ineffective for individuals, but nerve flossing is an option that could help. Flossing is not something individuals expect to hear from a medical professional treating their sciatica. However, when sciatica does not respond to common treatment methods like light physical activity or medications, a physician, chiropractor, or physical therapist might suggest combining traditional treatment with nerve flossing to alleviate sciatic nerve pain.

11860 Vista Del Sol, Ste. 128 Nerve Flossing Exercises for Sciatica

Nerve Flossing

The nerves can get jammed/stuck between the tissues and are not able to move, flex as they should. Nerve flossing involves performing gentle exercises to mobilize and stretch the nerves that help reduce irritation, inflammation, and improve mobility, especially in the hips. Nerve flossing is also known as:

The exercises can be done at home with no equipment and simple instructions. When used in combination with other treatments, like chiropractic and physical therapy the effectiveness is increased. Consult with a doctor or doctor of chiropractic for an accurate diagnosis, because what is causing sciatica helps significantly to determine the best treatment plan.

Guidelines

These are simple exercises but they are still exercises that require following safety guidelines to prevent injury or pain. These include:

  • The body will need time to adjust to new exercises so individuals should start slow
  • Only a few repetitions should be done at a time
  • Gradually increase
  • Stop if pain presents with any of the exercises and report the pain to a doctor or chiropractic physical therapist to see if there is a problem with how the exercises are being performed or if the exercises should be done later on after further treatment.
  • Focus on staying relaxed, as tensing up the muscles decreases the effectiveness
  • Breathing properly is key. Individuals unknowingly stop breathing when doing exercises, which is not healthy. Breathe deep in and out.

Nerve Exercises

True nerve flossing is an active movement with motion otherwise, it is just stretching.

Mobilizing floss

  • Lie on the floor with both knees bent, feet flat on the floor, and with space at hip-width
  • A flat pillow can be used for the head if it makes it more comfortable
  • Tuck the chin in and be sure to keep the upper body relaxed throughout the exercise
  • Pull the right leg in towards the chest
  • Keep holding behind the right knee
  • Slowly straighten the leg until there is a comfortable stretch
  • Slowly return the knee to the starting position
  • Breathe deeply, slowly, and try not to press the lower back into the floor
  • Lower the leg back towards the chest then lower it back to the starting position
  • Perform with the left leg
  • Complete five repetitions on each side
11860 Vista Del Sol, Ste. 128 Nerve Flossing Exercises for Sciatica

Seated nerve floss

  • Sitting upright in a chair, knees spaced hip-width, feet flat on the floor, and face forward
  • Extend the left leg
  • Flex the foot toward the body
  • Extend the head up and back looking up at the ceiling
  • Gently lower head and leg down, tucking the chin into the chest while bending the leg slightly backward
  • Extend and lower head at the same time when extending and lowering the leg
  • Perform 10 repetitions
  • Switch legs and repeat the exercise
  • Perform exercise 2–3 times every day

Hamstring floss

  • Stand up straight, raise the right leg onto a step or other stable surface while keeping the leg straight and toes pointed up
  • Keeping the back straight, tilt the head and neck forward until there is a slight pull/stretch in the back
  • Point the toe and bring the chin to the chest
  • Flex the foot and return
  • Repeat five times
  • Return to starting position
  • Switch legs
  • Repeat three sets on each leg
11860 Vista Del Sol, Ste. 128 Nerve Flossing Exercises for Sciatica

Exercise for Piriformis Syndrome

The piriformis muscle joins the base of the spine to the upper leg. Because this muscle is so close to the sciatic nerve, any type of irritation or compression of the sciatic nerve can also cause piriformis syndrome. Piriformis syndrome can cause radiating pain to the:

  • Hips
  • Buttocks
  • Hamstrings
  • Pain when sitting down or walking upstairs

Nerve flossing can also help relieve the symptoms increasing flexibility and range of motion.

Mobilizing stretch

  • Lie flat on the floor on the back
  • Extend both legs
  • Bend the right leg and bring it up
  • Hold the right knee and foot
  • While holding, gently pull the leg across the right side of the body and up toward the right shoulder
  • Return to the original position
  • Repeat five times
  • Gently lower the right leg
  • Switch legs
  • Complete five repetitions on each side two to three times a day

Risks

These exercises are not about pushing the body to its limits or in a way that causes pain. They are designed to rehabilitate, stretch, and strengthen the sciatic nerve making risks for further injury minimal. If there are still concerns about the safety of nerve flossing exercises, check with a doctor, doctor of chiropractic, or physical therapist. If there is severe nerve damage or undiagnosed acute pain, nerve flossing could worsen symptoms. Nerve flossing for acute cases of nerve irritation is not recommended as this can cause nerve root aggravation with the stretching/pulling.

Flossing for Sciatica

More research is needed on how nerve flossing can best help sciatica. It is an easy, natural, medication-free treatment that can help soothe irritated and compressed nerves, improve mobility, and flexibility.

Body Composition

Tracing sources of fatigue

There is a difference between being tired after a long day working, playing, etc, and being tired on a regular daily basis. This can be referred to as Chronic Fatigue Syndrome, a clinical condition where fatigue lasts longer than 6 months. With acute, non-clinical fatigue, it is typical to experience many of the symptoms that hamper an individual’s ability to function. Symptoms can include:

With hectic schedules, sources of fatigue begin to pile up along with unhealthy diet choices that stem from:

  • No time for a well-balanced breakfast
  • No time, or forgetting to make a healthy lunch equals
  • Fast food patterns
  • Unhealthy snacks

Disclaimer

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*
email: coach@elpasofunctionalmedicine.com
phone: 915-850-0900
Licensed in Texas & New Mexico

References

Anikwe EE, Tella BA, Aiyegbusi AI, Chukwu SC: Influence of Nerve Flossing Technique on acute sciatica and hip range of motion, International Journal of Medicine and Biomedical Research, 4(2) May – August 2015, www.ijmbr.com

Jeong UC, Kim CY, Park YH, Hwang-Bo G, Nam CW. The effects of self-mobilization techniques for the sciatic nerves on physical functions and health of low back pain patients with lower limb radiating pain. J Phys Ther Sci. 2016;28(1):46-50. doi:10.1589/jpts.28.46

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.  

Stretching

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.

Shoes

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.  

Improvement

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*  
References
Sciatica. MedlinePlus. https://medlineplus.gov/sciatica.html. Accessed November 29, 2018. Sciatica Sciatic Nerve Pain During Pregnancy. babyMed. https://www.babymed.com/pregnancy/sciatica-pain-during-pregnancy. Updated on August 29, 2018. Accessed November 29, 2018. Shiel WC. Degenerative Disc Disease and Sciatica. MedicineNet. https://www.medicinenet.com/degenerative_disc/article.htm#what_are_the_symptoms_of_radiculopathy_and_sciatica. Last reviewed August 10, 2018. Accessed November 29, 2018.
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.  

 

Symptoms

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.

 

Causes

  • 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.

 

Testing

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

 


References

The Journal of the Osteopathic Medical Association. (November 2008) Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach https://jaoa.org/article.aspx?articleid=2093614

Back and Neck Pain Therapeutic Tools for Wish List

Back and Neck Pain Therapeutic Tools for Wish List

Individuals with neck and back pain should consider adding a few pain-relieving therapeutic tools to the holiday wish list. Spine specialists/experts have some tools for their patients and others who are dealing with back and neck pain. Looking at various points, these therapeutic tools offer the gift of helping to reduce neck and back pain, when unable to see a chiropractor or physical therapist.  
11860 Vista Del Sol, Ste. 128 Back and Neck Pain Therapeutic Tools for Wish List
 

Foam Rollers

Foam rolling is effective for different types of aches and pains, especially backaches. Foam rolling benefits include:
  • Releasing muscle knots and tension
  • Reduces inflammation
  • Decreases pain
  • Improves range of motion
  • Returns flexibility
 

Wedge Pillow

A wedge pillow for the back is a necessity. A wedge pillow removes the stress from the spine and neck when lying down. Flipped around will take the tension off the legs also bringing back pain relief.  
 

Deep Percussive Massager

Percussive massagers can provide a deep massage to various areas of the body especially the lower back. There are a variety of brands available with different levels of technology. However, careful use of these instruments must be exercised. This is because the massage can be intense and can exacerbate or cause further injury, and individuals can develop a tolerance making the massage no longer effective.  
 

Seat Cushion

If sitting at a desk throughout the day or working from home a proper seat cushion is mandatory. Many individuals who sit the majority of their day utilize a combination cushion that includes the seat cushion with lower back support. Individual cushions are great because they can be moved easily and adjusted to fit where needed. Therapeutic seat cushions come with various features available, here are a few to keep in mind. Memory foam and air cells offer the most pressure relief. If there is tailbone pain, focus on a seat cushion with the tailbone cut out for extra relief. An office chair with these features should also be considered.  
 

Inversion Table

Inversion tables are available at reasonable prices, starting around $100. Used correctly this therapeutic tool can successfully help relieve back pain. Inversion tables and cervical traction provide decompression and postural alignment for the spine helping with pain relief. These devices offer gentle decompression through the angle used. Wider angles or full inversion provides more decompression on the back. Individual spinal needs should be discussed with a chiropractor, physical therapist, or physician before using this therapeutic tool.  
11860 Vista Del Sol, Ste. 128 Back and Neck Pain Therapeutic Tools for Wish List
 

Pain Patches and Topical Agents

Pain-relieving patches like Lidocaine, IcyHot, and Salonpas patches are widely recommended for tight and sore areas of the body.  
 

Sitting Standing Desk

A sitting and standing desk can be highly beneficial to back pain. In addition to burning off bonus calories throughout the day, Changing positions and postures throughout the day are recommended. This is to keep the muscles, ligaments, tendons moving, and not in a static position for too long. Changing every 20 to 30 minutes is the recommended time. Sitting and standing desks can provide positional changes that will help with posture, core stability, and circulation. This will help reduce and alleviate pain in the low back, neck, and shoulders. However, the desk needs to be stable and adjusted to the proper height.  
 

Lower Back Sitting Support

These therapeutic tools help reinforce the low back region when seated. Most of us start to slouch forward with the head and shoulders hunched forward after some time at the computer. This strains the whole body, specifically the low back. Lower back supports can help maintain proper alignment of the spine when seated.  
11860 Vista Del Sol, Ste. 128 Back and Neck Pain Therapeutic Tools for Wish List
 

Knee, Thigh, Pelvis Pillow

These pillows have different names but are used in the same way. This is a pillow that can be placed between the legs while sleeping takes the pressure off the pelvis and spine. These types of pillows are great for individuals that sleep on their side. This is because the top leg often shifts down, leading to increased stress on the hips and low back. These pillows help keep the legs aligned during sleep relieving pressure on the low back.  
 

How To Self-Care for Back Pain Books

There are a variety of books that offer tips, and therapies for self-care. These products are not a cure-all. They are intended to help in combination with proper treatment, especially for certain spinal conditions. If pain is limiting daily function, consult a chiropractor, physical therapist, or physician about using the above therapeutic tools.

Doctor of Chiropractic Near Me

 

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*
References
Furlan, Andrea D et al. �Massage for low-back pain.��The Cochrane database of systematic reviews,9 CD001929. 1 Sep. 2015, doi:10.1002/14651858.CD001929.pub3
Osteonecrosis of Femoral Head Misdiagnosed As Sciatica

Osteonecrosis of Femoral Head Misdiagnosed As Sciatica

Osteonecrosis is a condition that causes the death of bone tissue from temporary or permanent loss of blood supply to the affected area. It is commonly known as Avascular necrosis and can lead to miniature/tiny breaks in the bone and the bone/s eventually collapsing. Specifically, it affects the upper part of the femur or femoral head and surrounding joints.  
11860 Vista Del Sol, Ste. 128 Sciatica or Osteonecrosis of Femoral Head? A Common Misdiagnosis
 
It can occur in any bone however, osteonecrosis typically affects the hip/s. Pain associated with osteonecrosis of the hip can be localized to the center of the groin, thigh, or buttock. Because of the hip joint’s close proximity to the sciatic nerve, misdiagnosis for sciatica is common.  
 

Mimicking Sciatica Symptoms

Unfortunately, many health care providers can misdiagnose osteonecrosis hip pain as sciatica. Whatever the cause of the hip injury, most individuals with hip pathology report pain in the groin, upper thigh, and buttocks. That is why a trained medical professional that knows the differences in the symptoms of each condition can make all the difference in making a proper diagnosis. And a proper diagnosis leads to proper and complete treatment of whichever condition it may be. With osteonecrosis, misdiagnosis often delays the proper treatment and continues to progress. Common symptoms of sciatica:
  • Leg pain is the primary symptom can be mild to severe
  • Low back pain is secondary can be mild to severe
  • Nerve-related symptoms
  • Numbness
  • Tingling
  • Shooting pain
  • Pins-and-needles sensation
  • Muscle weakness
  • Hip pain especially flexion and internal rotation of the hip.
  • Leg or foot weakness
11860 Vista Del Sol, Ste. 128 Osteonecrosis of Femoral Head Misdiagnosed As Sciatica
 

Osteonecrosis Symptoms and Similarities

For many, there are no symptoms in the early stages of osteonecrosis. As the condition worsens, the affected joint could present pain symptoms only when weight is placed on it. Eventually, individuals begin to feel the pain even when lying down. Pain can be mild to severe with a gradual development. Other symptoms that mimick sciatica:

Walking Inability

Walking gait is complicated with both conditions which is a major cause behind the misdiagnosis.

Limping

Individuals often limp with osteonecrosis of the hip and spinal disc problems. This is another reason that the condition is misdiagnosed as a spinal disc problem or nerve root compression of the sciatic nerve.

Hip Pain

The tributaries/veins of the sciatic nerve also supply the hip area and often cause confusion between the two conditions.  
 

Differences

Despite all of the similarities. There are differences in both conditions.

Nature of The Pain

  • With sciatica, the pain is related to the nervous system. Movement can complicate the pain. While rest helps to reduce the pain.
  • With Osteonecrosis the pain is geared toward the muscular. Rest does not help reduce the pain. In fact, the pain increases at night.

Location

  • Sciatica pain can radiate through the whole leg from the low back to the toe.
  • Osteonecrosis pain is confined to the hip joint, groin, and radiates to the knee joint only. Osteonecrosis pain does not radiate below the knee joint.

Restricted Movement

  • Osteonecrosis of the hip joint, means the movements involving the hip joint are restricted. Individuals cannot rotate the leg to the right and left. Individuals cannot bend or fold from the hip.
  • With sciatica, the rotation of the leg is not affected. Movements involving stretching the sciatic nerve can cause relief or pain.

Walking Gait Differences

Gait is the way an individual stands and walks.
  • Osteonecrosis of the hip joint causes individuals to not be able to open the hip joint properly or to step properly.
  • With sciatica, an individual tends to lean on their side to relax the compression on the nerve.

Risk Factors

More than 20,000 people enter hospitals for the treatment of osteonecrosis of the hip yearly. Other than the hip, areas of the body likely to be affected are the shoulder, knee, hand, and foot. The condition can occur for a variety of reasons. A few of these include:
  • Fracture – a broken bone can interrupt the blood flow to other sections of the bone.
  • Dislocation of bone or joint/s
  • Alcoholism
  • Trauma
  • Radiation damage
  • Steroid use
Some individuals can have more than one condition or injury that contributes to hip flexor pain. An example is that it is possible to have both hip osteoarthritis and hip impingement. Without proper treatment, the condition can worsen, causing joint or hip pain from the degradation of the bone.  
11860 Vista Del Sol, Ste. 128 Osteonecrosis of Femoral Head Misdiagnosed As Sciatica
 
Anyone can be affected, but osteonecrosis is most common in individuals aged 30 to 50. Treatment options include a total replacement of the hip known as arthroplasty. And if it is sciatica then chiropractic treatment is a first-line treatment protocol. However, a chiropractor can make the distinction between the two and treat sciatica or refer the patient to the proper specialist.
 

Lower Back Pain Relief


 

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*
References
Li, Wen-Long et al. �Exploring the Risk Factors for the Misdiagnosis of Osteonecrosis of Femoral Head: A Case-Control Study.��Orthopaedic surgery, 10.1111/os.12821. 16 Oct. 2020, doi:10.1111/os.12821
The Lumbosacral Joint and Possible Cause For Sciatic Nerve Pain

The Lumbosacral Joint and Possible Cause For Sciatic Nerve Pain

The lumbosacral joint is the first place chiropractors start their investigation with individuals presenting with low back pain and possible sciatica. Because of the importance of the sciatic nerve, almost any lumbar condition has the potential to disturb the nerve that can lead to chronic nerve pain. For many low back conditions, the best way to start is from the bottom and work up.  
11860 Vista Del Sol, Ste. 128 The Lumbosacral Joint and Possible Cause For Sciatic Nerve Pain
 
Starting at the lumbosacral joint L5-S1, the chiropractor will palpate and massage the area. This is because the lumbosacral joint is a central nerve center with all kinds of possible sciatic nerve interference because of the proximity to the various nerve bundles and vertebral discs.  
 
When sciatic nerve issues begin to develop, often the problem will be in this region of the spine. Beginning at the lumbosacral joint can generate vast insight into the root cause of radiating pain in the lower back and legs.  

The Lumbosacral Joint

This pain typically presents when the nerve is inflamed, compressed, or irritated. Numbness or chronic weakness can also happen in the lower extremities and can cause unbearable discomfort. Some of the reasons that make the joint a prime suspect for sciatic pain include:
  • The L5 vertebrae are vulnerable to slipping forward over the connecting S1 vertebrae. The sciatic nerve goes through this area, leaving it open to compression.
  • A disc herniation and/or inflammation can also stress the sciatic nerves.
  • Deterioration of the lumbosacral facet joints is common with older individuals. This can lead to nerve compression and sciatic nerve irritation.
  • Piriformis syndrome can affect the area around the lumbosacral joint, causing nerve compression and inflammation.
The lumbosacral joint is frequently used making it a consistently stressed joint. Overuse, poor posture, and improper body mechanics affect this region of the lumbar spine. And, because of the closeness to the sciatic nerve, it is commonly affected.  
11860 Vista Del Sol, Ste. 128 The Lumbosacral Joint and Possible Cause For Sciatic Nerve Pain
 

Other Spinal Conditions

The lumbosacral joint also experiences problems that stem from chronic conditions, which can involve some form of sciatic pain as a symptom. They include:
  • Degenerative disc disease
  • Lumbar stenosis
  • Sacroiliac joint dysfunction
  • Spondylolisthesis
Sciatica is a condition that represents a series of symptoms. But it is often a symptom of other condition/s that affect the sciatic nerve. If spinal conditions progress, it can bring undue stress and strain to the lumbosacral joint and the sciatic nerve.  

Knowing Where To Begin

The key to a proper and successful treatment plan is an accurate diagnosis. Knowing and understanding the symptoms, spinal conditions, and having an idea of the origin of these types of pain promotes a rapid diagnosis. Our chiropractic and physical therapy team thoroughly investigate the pain source using imaging, palpation, observation, and other diagnostic tools to help get individuals back on track and healthy.

Facet Syndrome Chiropractic 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*
References
Grgi?, Vjekoslav. �Lumbosakralni fasetni sindrom: funkcijski i organski poreme?aji lumbosakralnih fasetnih zglobova� [Lumbosacral facet syndrome: functional and organic disorders of lumbosacral facet joints].�Lijecnicki vjesnik�vol. 133,9-10 (2011): 330-6.
Sciatica or Aneurysm, A Fatal Misdiagnosis

Sciatica or Aneurysm, A Fatal Misdiagnosis

Sciatica or Aneurysm? Knowing how a missed diagnosis could be potentially fatal if not diagnosed accurately could be a deadly mistake! Doctors must not fall for a sciatica diagnosis when a possibly fatal iliac artery aneurysm lies looming and progressing.
11860 Vista Del Sol, Ste. 128 Sciatica or Aneurysm, A Fatal Misdiagnosis

Sciatica or Aneurysm

An example is a patient who visited an emergency clinic after a few weeks for a non-painful pulsing mass on the buttock. There was no:
  • Trauma
  • Injury
  • Back pain
  • Leg pain
  • Prior presentations of pain or sciatica issues
A physical examination found a small pulsing mass on the right buttock. Palpation around the site found no issues with the sensory and motor nerves.
An ultrasound scan of the affected area revealed a developing aneurysm. This was followed by a CT scan of the abdomen along with the pelvis using a contrast dye found the aneurysm developing from the left internal iliac artery. If the mass was not present a doctor could easily diagnose sciatica or persistent sciatic artery. If the iliac artery presents with pulsating lesions is a tip-off that a vascular issue could be impinging on the sciatic nerve. Vascular surgery was discussed with the patient. Surgery was necessary, and the patient underwent sciatic aneurysm repair. The patient was discharged without any complications.

Persistent Sciatic Artery

This is a very rare congenital vascular condition. The sciatic artery runs along the sciatic nerve and functions as the major blood supply to the lower extremities. During human embryo development, the femoral artery begins to form while the sciatic arteries start to return to a less developed state. The process continues until the femoral artery takes over as the major blood supply, with only bits of the sciatic artery left. Persistent sciatic artery can happen either from the sciatic artery not returning to its original size or during normal development the femoral artery developing properly. Most cases of persistent sciatic artery go unknown and are usually detected from another examination for another ailment. Aneurysms often develop based on the arteries/vessel’s tendency for minor trauma/injury when sitting or some form of pressure is applied on the site. Complications include: A vascular surgeon should be consulted. Treatment options include:
  • Surgical exclusion of the aneurysm
  • Surgical excision of the aneurysm
  • Endovascular stenting
  • Endovascular coiling
11860 Vista Del Sol, Ste. 128 Sciatica or Aneurysm, A Fatal Misdiagnosis

Vascular Conditions In The Leg/s That Can Present As Sciatica

The legs’ blood vessels can get infected, bulged, ruptured, or blocked. This can cause sciatica symptoms, like leg pain, weakness, tingling, and numbness. Severe cases could require medical emergency surgery to save the affected limb.

Acute Limb Ischemia

This condition occurs from a decrease or loss of blood supply to the legs. If there is leg pain, it could feel similar to sciatica pain. However, symptoms can progress rapidly and become severe. That’s when it is not sciatica. Acute limb ischemia present one or more of the following symptoms:
  • Pain and/or numbness in the leg while walking and when resting
  • Severe pain at night
  • Sleep problems
  • Pain relief when sitting on a chair with the feet hanging down
  • Feet and ankles become swollen
  • A pale color and lowered skin temperature over the toes and feet when compared to the legs
Acute limb ischemia can develop from an aneurysm, blood clot, or from the thickening of the vessel walls. Treatment should be prompt in order to preserve leg function. Differentiation diagnosis between vascular and other causes like spinal problems that can cause leg pain. A doctor may perform an Ankle/Brachial Index which is a comparison of blood flow in the arms versus the legs. This can be critical in determining if there is vascular insufficiency.
11860 Vista Del Sol, Ste. 128 Sciatica or Aneurysm, A Deadly Mistake!

Acute Compartment Syndrome

This places increased pressure in the muscle tissues of the leg. It can lead to loss of blood supply in and around the affected area. The sciatic nerve can also get compressed from the increased pressure in the buttock, thigh, or leg. The condition can cause pain, numbness, and weakness in the buttock, thigh, and leg. Individuals have also reported an unusual/altered sensation in the web of the great toe. This is similar to sciatica, as well as one or both legs can be affected. Differentiating symptoms include:
  • Leg becomes swollen
  • Pain and tenderness present when touching the leg
  • A pale color and lowered skin temperature over the leg
Acute compartment syndrome is a serious condition that is considered a medical emergency. It is possible for the condition to cause complete dysfunction of the limb if not addressed in time. There are risk factors that increase the chances of developing limb ischemia or compartment syndrome. These are:
  • Diabetes
  • Heart conditions
  • High cholesterol
  • Smoking
  • History of having the condition can also cause a recurrence. This can be from an injury or poor health.
Kidney stones, renal failure, or cysts in the kidney can also cause back and leg pain. Other symptoms can include blood in the urine or difficulty urinating. Any sign of distressing symptoms that present with sciatica can indicate the need for medical attention. This is to check for the possibility of a serious underlying condition or medical emergency. Medical emergencies that are treated in time can help preserve the tissue/s, restore function, and save an individual�s life. It is essential for a chiropractor or physical therapist to be familiar with diagnosing in a way that will help identify sciatica or aneurysm in individuals presenting with musculoskeletal issues/problems. Knowledge of these risk factors, understanding how to screen for non-musculoskeletal symptoms, basic competence in palpation, and how to interpret findings will help discover sciatica or aneurysm if it is there and begin timely treatment. And if it is not there then a sciatica treatment plan can be developed before it worsens.

Sciatic Nerve Pain

 
 

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*
References
  1. Javdanfar A, Celentano C. Sciatic artery aneurysm. West J Emerg Med. 2010;11(5):516-517.
Sciatica Chiropractic Specialist and Abdominal Aneurysm Diagnosis

Sciatica Chiropractic Specialist and Abdominal Aneurysm Diagnosis

Finding the right sciatica chiropractic specialist to diagnose the cause especially, when it is an abdominal aortic aneurysm can be a challenge. There can cause diagnostic confusion with the root cause never being discovered or identified. Fortunately, Dr. Jimenez is a sciatica specialist with over 30 years of experience in differential sciatica diagnosis, and treatment.

Sciatica Chiropractic Specialist Diagnosis

Diagnostic Tools

Abdominal aneurysms are usually discovered for another ailment like a hernia or for routine tests like an ultrasound of the heart or stomach. Diagnosis of an abdominal aneurysm depends on the condition, medical and family history, and the physical examination. If a doctor or sciatica chiropractic specialist suspects an aortic aneurysm, then specialized tests will help with a confirmation.
11860 Vista Del Sol, Ste. 128 Sciatica Chiropractic Specialist and Abdominal Aneurysm Diagnosis

Ultrasonography

The simplest and most used diagnostic test is ultrasonography. It utilizes sound waves for diagnostic purposes that send the recorded images to a monitor. It gives an accurate assessment of the size and location of the aneurysm. The patient will lie on a table while a technician moves a wand around the abdomen.

Computed tomography CT scan

This test is often used in conjunction with ultrasonography if more data/info is needed. Usually, this is to determine the exact location of the aneurysm in relation to the visceral or renal arteries. It provides cross-sectional detail with clear images of the aorta and can detect the size and shape. The patient lies on a table inside a machine. A contrast dye could be injected into the blood vessels to make the arteries more visible on the images known as CT angiography.

Magnetic Resonance Imaging

Magnetic resonance imaging or MRI uses a magnetic field and radio wave energy pulses to record images of the body. The patient lies on a table that slides into the imaging compartment. Contrast dye can also be injected into the blood vessels to make the images more visible known as magnetic resonance angiography.
11860 Vista Del Sol, Ste. 128 Sciatica Chiropractic Specialist and Abdominal Aneurysm Diagnosis

Emergency Symptoms

Certain symptoms can indicate an emergency. The conditions are rare, but it is very important to seek medical attention should any of these symptoms present with back pain:
  • Severe abdominal pain
  • Fever out of nowhere
  • Bowel and/or bladder incontinence
  • Loss of or an unusual sensation in the groin, as well as the legs and possibly into the foot
  • If back pain presents after an injury medical care is recommended to check for damage/injury to the spine.

Abdominal Aneurysm Symptoms

Abdominal aneurysms often don�t present any symptoms, which is why individuals go through their days unaware, and when back pain does present a doctor may only focus on the back pain symptoms and not the cause, leaving the aneurysm to continue to develop and worsen. Aneurysms do occur in women but are more common in men and those ages 65 and older. The main cause is atherosclerosis which is a hardening of the arteries. But injury and infection can also cause an aneurysm. Those with symptoms can include:
  • Throbbing pain around the back or side
  • Deep pain in the back or side
  • Pain in the buttocks, groin, or legs
  • Sciatica symptoms

The Sciatic Connection

A diagnosis of the root cause of the sciatica is crucial for developing an effective treatment plan to alleviate the sciatic pain. If an aneurysm is present then referring the individual to the proper aortic aneurysm repair specialist is a top priority. If sciatica is suspected, a doctor or chiropractor will review medical history and perform a physical examination. Medical imaging tests and diagnostic nerve blocks could be used if necessary. Sciatica pain usually follows the dermatome or areas of the skin that is supplied by the sciatic nerve. The pain can also include deeper tissues called dynatomes.
11860 Vista Del Sol, Ste. 128 Sciatica Chiropractic Specialist and Abdominal Aneurysm Diagnosis

Physical examination

During a physical examination, the sciatica chiropractic specialist will look for various responses when:
  • Straightening the leg with movements that elongate the nerve
  • Gently pressing the toes or calf area
  • Seeing if there is any type of pain associated with these movements in the low back, buttock, thigh, leg, and foot

Sciatica Clinical Tests

Two examples of clinical tests for sciatica include:

Straight leg raise – SLR

The patient lies on their back and the chiropractor lifts one leg at a time with the other leg remaining flat or bent at the knee. If pain presents while lifting the affected leg this is usually an indication of sciatica.

Slump

The patient sits upright with their hands behind their back. The patient then bends/slumps forward at the hips. The neck bends down with the chin touching the chest and one knee is extended as far as possible. If pain occurs in this position, sciatica could be present.
These tests could possibly be positive only when the nerve is mechanically compressed. Other causes like inflammation or chemical irritation of the nerve might not cause pain when performing these tests. This test could also help reveal a possible abdominal aneurysm as abdominal pain could present.

Chiropractic Sciatica Treatment

Manual manipulation improves the alignment of the spine. This technique helps address the underlying condition/s that can cause sciatic nerve pain, like herniated discs or spinal stenosis. Manual manipulation also creates an optimal healing environment. An aortic aneurysm specialist could work with a sciatica chiropractic specialist to help with spinal realignment if the aneurysm caused any kind of shifting or slipping of the discs along with releasing the sciatic nerve if it is compressed.

Massage Therapy

Massage therapy like deep tissue massage can also have benefits. Massage:
  • Improves blood circulation, which also creates an optimal healing response in the body
  • Releases toxins in the low back muscles that spasmed or knotted up
  • Relaxes tight muscles that could be contributing to the pain
  • Releases endorphins or the hormones that function as the body’s natural pain relievers

 

Sciatica Pain Chiropractor

 
 

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*
Underlying Causes: Abdominal Aneurysm and Sciatica Misdiagnosis

Underlying Causes: Abdominal Aneurysm and Sciatica Misdiagnosis

Underlying causes for an abdominal aortic aneurysm can be challenging to diagnose and identify. Combined with sciatica symptoms, doctors could misdiagnose the ailment and prescribe the wrong treatment protocol. Then an individual has to deal with two conditions that were not properly diagnosed, continue to develop, and worsen. This is why finding the right sciatica specialist that can also identify an abdominal aneurysm is so crucial to developing the right treatment plan. There can be a variety of factors that can lead to the development of an abdominal aneurysm. They include:
11860 Vista Del Sol, Ste. 128 Underlying Causes: Abdominal Aneurysm and Sciatica Misdiagnosis

Abdominal Aneurysm Contributing Health Conditions

Health conditions associated with an increased risk for an abdominal aneurysm include:

Atherosclerosis

This condition occurs when there is a buildup of fats, cholesterol, and other substances that create plaque buildup in the bloodstream. This causes vessels to harden and narrow. Atherosclerosis can develop during the young adult stage and becomes an issue later in life.

High Cholesterol

Cholesterol is a waxy, fat-type substance that is found in all the cells in the body. The body needs some cholesterol for the production of hormones, vitamin D, and substances to help digest foods. The body makes all the cholesterol it needs. Too much can build up in the blood vessels, which narrows the bloodstream and hardens the arterial walls.
11860 Vista Del Sol, Ste. 128 Underlying Causes: Abdominal Aneurysm and Sciatica Misdiagnosis

High Blood Pressure

High blood pressure or hypertension refers to a sustained increased force of blood moving through the aorta that can weaken artery walls. It is a common condition that is widespread among individuals that are older, those that smoke, and those that are overweight. There is an estimated 60-70% of individuals over 60 that are diagnosed with high blood pressure.

Inflamed Arteries

When the arteries become inflamed, it can cause blood flow constriction and cause the arterial walls to weaken. This increases the risk of an aneurysm. Arteries can get inflamed through:
  • Genetics
  • High cholesterol
  • Trauma/injury to the abdomen
  • Arterial Disease/s like:
  1. Abdominal Aortic Aneurysm
  2. Thoracic Aortic Aneurysm
  3. Peripheral Arterial Disease
  4. Thoracic Outlet Syndrome
  5. Vasculitis
11860 Vista Del Sol, Ste. 128 Underlying Causes Of Abdominal Aortic Aneurysm and Sciatica Risks

Connective Tissue Disorders

There are hereditary conditions that can weaken the body�s connective tissues. This can lead to degeneration of the aortic walls and raise an individual�s risk for an aneurysm. Two of the most common connective tissue disorders are Ehlers-Danlos syndrome, which affects collagen production, and Marfan Syndrome. This condition increases the production of fibrillin, which is a protein that helps to build the elastic fibers in connective tissue.

Other Risk Factors

Additional health factors can strain the cardiovascular system. This increases the risk of weakening or damaging blood vessels. This significantly raises the chances of developing an abdominal aortic aneurysm. Risk factors include:

Smoking and Tobacco

All types of tobacco use can contribute to diminished cardiovascular health. Individuals that smoke or use some tobacco product pose a significantly higher risk of developing an abdominal aneurysm.

Age

Aneurysms occur most often in older adults. This is because they are more likely to have cardiovascular issues and are more likely to have higher levels of plaque buildup.

Genetics and Family History

Immediate relatives of an individual with an abdominal aneurysm often have a 12-19% chance of developing the condition.

Lack of Physical Activity

Not getting adequate physical activity puts an individual at a higher risk for heart and cardiovascular disease. Aerobic activity done on a regular basis increases the heart rate and blood flow through the body. This keeps the tissues and blood vessels strong and flowing properly.

Gender

Both men and women can develop an abdominal aortic aneurysm. However, the majority of those that do develop the condition are men. This is because men are more likely to go through the heart and cardiovascular issues.

Diagnosis

Underlying conditions that can cause sciatic pain can vary or be a combination of several conditions. The most important action to take is to consult a doctor or chiropractic sciatica specialist for a clinical diagnosis. While rare, sciatica-type pain could be caused by medical conditions like:
  • Spinal tumor
  • Spinal infection
  • Cauda equina syndrome
These factors can contribute to an increased chance of developing an abdominal aortic aneurysm. However, individuals can have unknown risk factors and still develop the condition. Treatments may range from regular monitoring, lifestyle changes, and physical therapy/chiropractic to urgent or emergency surgery. If you feel symptoms of pain in the buttocks, leg, numbness, tingling, or other neurological symptoms in the back and/or leg, it is very important to see a doctor or chiropractor for clinical diagnosis that identifies the cause of the symptoms.

Sciatic Nerve 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*
Abdominal Aneurysm Sciatica and Low Back Pain

Abdominal Aneurysm Sciatica and Low Back Pain

An abdominal aortic aneurysm is an enlarging of the lower portion of the aortic artery that resides in the abdomen. The aorta is the body�s main artery that supplies blood to the body and stretches from the heart down into and through the abdomen. The abdominal aorta is the part that sits within the abdomen. It is below the kidneys and in close proximity to the front of the spine. Because of this closeness sudden intense pain can be felt in the lower back along with sciatica symptoms.
11860 Vista Del Sol, Ste. 128 Abdominal Aneurysm Sciatica and Low Back Pain

Abdominal Aorta Function

Its function is to deliver blood from the heart throughout the body. It circulates blood down through the chest and abdomen. Smaller arteries branch off the artery to the different organs and systems of the body.

Enlargement/Weakening

If it becomes weak or expands in size, the condition is known as an aortic aneurysm. This condition can cause severe abdominal pain, back pain, sciatica and can lead to artery leakage or rupture. This is when it becomes an emergency. Being the largest blood vessel in the body means that a rupture can cause life-threatening bleeding. Aneurysms can develop anywhere on the artery, but most occur in the abdomen portion. Depending on the size and growth rate, treatment/therapies can vary from observation to emergency surgery. Abdominal aneurysms usually progress slowly without symptoms, making them difficult to detect. However, some abdominal aneurysms never rupture. They can start small and remain the same size while others can expand over time, and others faster.

Rupture

A weakened aorta can develop a leak known as a rupture. Blood can also begin to accumulate and pool up between layers in the arterial walls can also lead to rupture known as a dissection. Internal bleeding is the primary complication of an abdominal aneurysm. Loss of blood is considered a potentially fatal medical emergency. Mortality rates increase when the artery leaks. The risk for rupture depends on the:

Size

Aneurysms that are smaller than 5 cm in diameter are considered a low risk for rupture. Aneurysms larger than 5 cm are considered high risk. The size is often the best predictor for predicting the chance of rupture.

Growth Rate

Expansion of more than half a centimeter over 6 months is considered accelerated growth and is a high risk. A faster growth rate has been seen in individuals that smoke or have high blood pressure. Abdominal pain, lower back pain, sciatica, or other symptoms usually do not present until the artery has ruptured. However, in a significantly expanded aneurysm, symptoms similar to a rupture can occur.
11860 Vista Del Sol, Ste. 128 Abdominal Aneurysm Sciatica and Low Back Pain
 

Symptoms

In most cases, the aneurysm develops slowly with no symptoms or minor symptoms like a nagging/gnawing or throbbing sensation in or around the abdomen. This type of aneurysm can be detected from a standard physical exam or from the monitoring of another condition. Symptoms depend on the location and can include some combination of the following:
  • Deep, constant pain in the abdomen or on the side. It could also be a stabbing pain deep inside that is felt between the sternum and the belly button. The pain can be continuous with no relief from rest or adjusting positions. Severe pain can cause individuals to bend over and down.
  • Difficulty standing or the ability to straighten the upper body.
  • Low back pain caused by the abdominal pain radiating/spreading out into the lower spine from the aorta�s closeness to the spine. The pain can also spread to the groin, pelvis, and legs.
  • Sciatica symptoms typically come from low back pain.
  • A pulse near or around the bellybutton. Tenderness, along with a pulsing sensation can be felt. The pulse can be felt through the skin and could be sensitive to touch or pressure.
  • Blood loss will result in low blood pressure, known as hypotension. This causes lightheadedness, dizziness, nausea/vomiting, blurred vision, and confusion. Symptoms are exacerbated when standing generating the feeling of the need to sit or lie down.
  • Shock symptoms from the internal bleeding. This includes:
  1. Sudden and rapid heartbeat
  2. Shallow breathing
  3. Clammy skin
  4. Cold sweats
  5. General weakness
  6. Confusion
  7. Agitation
  8. Anxiety
  9. Loss of consciousness

Causes

Various causes can be involved in developing an abdominal aneurysm, including:
  • Hardening of the arteries known as atherosclerosis. It happens when fat along with other substances build up on the lining of blood vessel/s.
  • High blood pressure can damage and weaken the walls of the aorta.
  • Blood vessel diseases can cause blood vessel inflammation.
  • Aortic infection is rare but a bacterial or fungal infection could cause an abdominal aneurysm.
  • Trauma like being in an automobile accident can cause an aneurysm.

Risk Factors

The pathology principally stays asymptomatic until a rupture occurs. This pathology affects mostly men with quite a few risk factors. Risk factors include:
  • Men develop abdominal aneurysms more often than women.
  • Smoking is the strongest risk factor. It weakens the aortic walls and increases the risk of developing an aneurysm, and rupture. The longer an individual smokes or chews tobacco, the higher the chances.
  • Individuals aged 65 and older are the most targeted group for this condition.
  • A family history of abdominal aneurysms increases the risk.
  • Aneurysm in another blood vessel, like the artery behind the knee or the chest aortic region, could increase the risk.

Sciatic Nerve Compression

Sciatica is usually caused by compression on the nerve. Spinal and non-spinal disorders are known to cause pain include:
  • Low back misaligned vertebral body/s
  • Herniated/bulging/slipped discs
  • Pregnancy/childbirth
  • Spinal tumors
  • Diabetes
  • Constipation
  • Sitting too long
Sciatic nerve compression can cause a loss of feeling known as sensory loss, paralysis of a limb, or group of muscles known as monoplegia, and insomnia.

Proper Diagnosis Is Essential

Because of the many disorders that can cause sciatica, a doctor’s first step is to determine the cause. This involves forming a diagnosis based on a thorough review of an individual’s medical history, a physical and neurological examination. The sciatic nerve has several smaller nerves that branch off. These smaller nerves enable movement motor function and feeling sensory functions in the thighs, knees, calves, ankles, feet, and toes. If a chiropractor determines the patient’s disorder requires treatment by another specialist, then the individual will be referred to the proper doctor. In some cases, the chiropractor could be called upon to continue spinal therapy and help manage the individual’s treatment plan with the other specialist/s.

Sciatica Pain 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*
Finding the Right Spinal Surgeon Asking the Right Questions

Finding the Right Spinal Surgeon Asking the Right Questions

Finding the right surgeon that specializes in an individual’s specific spinal conditions and physical health means doing some research. There are several types of procedures for spinal problems. The type of surgery depends on the condition and an individual’s medical history. If surgery is recommended for a lumbar herniated disc or LHD combined with sciatica here are a few things to think about.  
11860 Vista Del Sol, Ste. 128 Finding the Right Spinal Surgeon Asking the Right Questions
 

Researching a spine surgeon

First and foremost look for surgeons with:
  • Medical credentials like are they board-certified or board-eligible
  • Completed a fellowship in spine surgery
  • Devotes at least 50% of their practice to spinal conditions
  • Specializes in treating herniated disc/s and sciatica. This means they will have added/specialized knowledge and expertise.
It is extremely important that an individual feels comfortable and feels they are able to communicate freely with the surgeon. A professionally qualified surgeon should:
  • Spend adequate time with the individual
  • Answer all questions
  • Provide all information needed about the condition and treatment
  • Listen to what the individual has to say
  • Is open-minded
  • Is not hard to get in contact with
  • Has experience in the latest methods and techniques

What to look at and think about

Individuals can feel uncomfortable asking questions, but thorough communication is key. Remember, it is your body, and it is your right to know the details of the spinal disorder, along with non-surgical and surgical approaches to treatment that are available. There is time to consider the options and make an informed decision about the treatment plan as most spinal procedures are elective. Ask the surgeon all the questions you have to help decide wisely and with confidence. Make sure they address all concerns, and any others not listed.

The surgeon’s specialization/focus

Orthopedic surgeons and neurosurgeons perform spinal procedures. Each will have a specific interest and expertise in certain spinal condition/s. For example, some surgeons may specialize in treating adult or pediatric patients, and some may only treat either lumbar/low back or cervical/neck conditions. Within those groups, some focus on:
  • Spinal deformities
  • Tumors
  • Myelopathy a spinal cord disease
  • Specific spinal cord diseases

Minimal invasive surgery option

Minimally invasive spine involves tiny incisions, that reduces the recovery time needed to heal. With this type, individuals can be up and walking within hours after surgery. Unfortunately, not all conditions can take this approach.

Is the surgery absolutely necessary, or can it be treated non-surgically?

Sciatica and herniated discs can be quite painful and cause disability. Never rush into surgery just to relieve symptoms. As surgery can cause other types of pain symptoms and issues. Herniation and sciatica can be resolved with:
  • Chiropractic
  • Physical therapy
  • Medications
  • Injections
  • Lifestyle changes
  • Diet adjustments
  • Regular exercise
  • Weight loss
However, if there are neurologic symptoms, like weakness in the leg, foot, numbness, or loss of bladder or bowel control – this is considered a medical emergency – then surgery is absolutely needed.  
11860 Vista Del Sol, Ste. 128 Finding the Right Spinal Surgeon Asking the Right Questions
 

The number of similar procedures performed

The surgeon�s experience is very important. The more experienced, the better. Ask if they can refer to other patients who have had similar procedures.

Recovery time

Every patient is unique, as is the type of surgery, and recovery times. They all vary accordingly. General health, physical condition, and the severity of the disorder play a role in how long and how involved recovery time will be. Experienced surgeons can provide more specific answers concerning recovery/healing time.

Complication rate

All surgeries carry some risk of complication. Complication rates that are more than 10% is a red flag. Possible post-surgery complications.

Infection rate

Surgeons should have an infection rate lower than 10%. However higher rates do not always mean that surgeon is at fault as higher rates can come from performing highly complex procedures. Another reason for high infection rates could be the patients themselves like smokers or individuals with diabetes have increased risks for infection. However, do not feel uncomfortable asking the surgeon to explain a high infection rate.

Decide to not opt for spine surgery

As a surgeon produces a diagnosis, they should present a recommended treatment plan, including alternative treatments/therapies. Ask for another explanation of any part of the evaluation, diagnosis, or available treatment options.

Get a second opinion

A second opinion should be encouraged. A second opinion can reinforce the surgeon�s recommendations and offers a new perspective. The surgeon should be comfortable with a second opinion. This does not mean that the individual does not trust the surgeon. It does mean that there is considerable interest in achieving optimal health and making sure that surgery is the absolute right thing to do. Pass on surgeons that discourage or disapprove of second opinions and continue looking.
 

Whiplash Chiropractic Massage Therapy

 

 

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*
Lumbar Stenosis Surgery for Sciatica

Lumbar Stenosis Surgery for Sciatica

Lumbar stenosis surgery for sciatica, like any type of surgical procedure does not always yield the most successful results. This is why it�s important to carefully and methodically assess all of the personal risk factors.

Sciatica causes severe pain and surgery could be an option and hopefully of last resort. However, it� is important to first attempt non-surgical/non-pharmacological treatment/s for six to twelve weeks before surgery to relieve symptoms and root cause. A full course of conservative treatment could include:

  • Physical therapy
  • Chiropractic
  • Aerobic exercise
  • Pain meds
  • Epidural steroid injection
11860 Vista Del Sol, Ste. 128 Lumbar Stenosis Surgery for Sciatica

Sciatica and Stenosis

Sciatica can be caused by stenosis. This is when the spinal canal narrows, constricting, and pinching the nerves specifically the sciatic. Around ninety percent of cases stem from a herniated disc compressing the nerve roots. The damaged disc extends out and pinches the roots of the sciatic nerve. This pinching causes: �

  • Pain
  • Numbness
  • Tingling
  • Muscle weakness

If it stays like this for a long time an individual can experience incontinence, along with permanent nerve and muscle damage.

BulgingandHerniatedDiscs ElPasoChiropractor

Lumbar Stenosis Surgery Options

  • Lumbar stenosis surgery depends on the cause of sciatica: A single herniated disc could be pressing the nerve, which would only require the removal of just that portion of the disc that�s causing the compression. This procedure is known as a discectomy or microdiscectomy.
  • If the stenosis is caused by a bone problem like an arthritic bone spur, then space has to be made in the canal. This means a portion of the lamina or the back of the spinal column. This is called a hemilaminectomy. Sometimes the whole lamina has to be removed. This is known as a laminectomy.
third and fourth lumbar vertebrae lumbar vertebra lumbar spine vertebral bone
  • If there is the instability of the spinal column, some of the lumbar vertebrae will be fused together to prevent further instability and added nerve compression.

A non-operative treatment course lasting a few weeks to months could reduce swelling in the nerve and improve sciatica symptoms. What happens is sometimes the disc gets reabsorbed over time and does not irritate the sciatic nerve.

Surgical Success

If the non-surgical options yielded minimal positive results or completely failed and surgery is the last resort talk with your surgeon to discuss the risks and benefits. The discussion will focus on factors like:

  • Age
  • Health status – levels of wellness and illness
  • Underlying conditions
  • Bodyweight
  • Smoker
  • Type of work

Individuals sixty-five and older, multiple health problems, being overweight or a smoker will place an individual at a higher risk of post complications from surgery. Studies found individuals who underwent surgery for sciatica from lumbar stenosis, identified added risk factors that could affect the outcome including:

  • Depression: this was because there were patients that continued to have sciatica symptoms after surgery. This means they are more likely to take antidepressants or anticonvulsants.
  • Quality of life from health perspective was low.
  • Previous spine surgery
11860 Vista Del Sol, Ste. 128 Lumbar Stenosis Surgery for Sciatica

Knowing about these factors and the possible success of sciatica surgery is something to keep in mind. The best way to understand what and how the surgery will be beneficial is to understand the risks and to remember that the risks are not the same for everybody.

Optimization

Surgical success depends on making sure patients are optimized before surgery. Increasing the chances of successful surgery after conservative treatment/s a surgeon will ask the patient to take these steps:

  • Weight loss is difficult, but it has been shown to improve surgical outcomes.
  • A healthy but sensible diet with a moderate calorie deficit is essential.
  • Light aerobic exercise, such as stationary or recumbent cycling can help keep the body’s blood flowing properly.
  • Exercising with pain is difficult but it will increase the cardiovascular system along with keeping the heart and lungs healthy enough to undergo surgical stress.
  • If the exercising causes too much pain ask the doctor about anti-inflammatory, muscle relaxants, or steroid medication along with the non-surgical treatment that can provide relief allowing exercise to resume.

Quit smoking

Smoking increases the rate of spinal degeneration and impairs the body�s ability to heal properly and optimally after surgery. If the surgery is elective, meaning it is not a medical emergency, then it is strongly encouraged to quit smoking before surgery. This will increase the chances of eliminating the habit. Don’t be afraid to get support. cancer.org/smokeout.

Pro-activeness

If taking antidepressant/s for depression, do not quit taking the medication thinking it will improve sciatica surgery success. Mental health is extremely important. The same goes for anticonvulsant meds as well. Stopping anticonvulsant medication for spinal surgery will more than likely cause extended damage or pre/post-surgical complications. Pre-existing conditions like depression means bringing the mental health provider and other specialists into the pre-surgical discussion.


 

Chiropractor Sciatica Symptoms

 


 

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

 

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.

 

Treatment

 

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

 

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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