Hopefully, you will feel better with PT and medical interventions for your sciatica in the first few weeks of PT after the onset of your pain. There is good evidence to support that the higher the level of your fear of movement and pain initially, the better the chance you will benefit from reducing your leg pain with treatment as far out as one year following your injury.
Studies vary on the prevalence of sciatica annually, however recent reviews of nine large studies found that the injury ranges between two and 34 percent of adults each year.
On the surface, with results such as shorter hospital stays, less blood loss, and a lower chance of infection, it would seem that minimal access surgery would be more cost effective than an open spinal surgery. However, the instrumentation required for these techniques is often expensive and can outweigh the savings. A review of the literature comparing cost of minimal access surgery to open surgery found that there is no economic difference in the two techniques. However, several studies that suggested cost-saving with minimal access surgery were excluded from the review as they did not meet requirements of detailed methodology or long term follow up on clinical outcomes. There is a need for more detailed studies comparing cost-effectiveness of minimal access surgery to open conventional spine surgery in order to better understand the economic details of these surgical approaches.
Surgical techniques for lumbar spine fusion can be separated into two categories based on amount of tissue disruption. Minimal access surgery is reported to have better short term perioperative results as it utilizes small incisions and minimal muscle disruption. This technique involves use of a tube or sleeve to complete a muscle dilating or muscle splitting approach. Conventional surgery or open spine surgery involves lifting or stripping the musculature along the spine to gain access to the spine. Patients undergoing minimal access cervical or lumbar surgery report less blood loss, lower chance of infection shorter hospital stays and less pain medication and often a faster return to activity.
This important nerve bundle gives sensation and motor supply to the pelvic organs and lower limbs. When injured, persons with CES often have many functional problems with their bladder and/or bowels, experience decreased sensation in their crotch area, and may have sexual dysfunction.
In a study by Seo-Young Kim, MD, et al, they found 1/3rd of the studied subjects with overactive bladders had their highest level of spinal cord injury at or above the 2nd lumbar spine level. Two-thirds of the studied subjects thus had underactive bladders and had their highest level of spinal cord injury at or below the 3rd lumbar spine level.
Spinal stenosis is the narrowing of the spinal canal which can lead to pressure on the spinal cord or nerve roots, resulting in pain in the back and legs. This condition is usually caused by changes related to aging in the disc, lumbar vertebra, and supporting structures. Surgery to relieve this pressure accesses the spine through the back and then the excess bone, thickened ligaments and degenerative disc tissue is removed to create space. This improved space often decreases the cause of pain and may relieve back and leg pain, however these results are very inconsistent. In a recent review article by McGregor et al, the authors looked to see if active rehab improved outcomes more than usual care. They did find that there was moderate evidence to support that active rehab following a spinal stenosis decompression surgery increased the long term improvement for leg pain.
Spinal cord stimulation is the use an electrode implanted into the spinal cord to help control chronic pain. This implanted electrode provides stimulation to the nerves that come from the source of the pain. This electricity changes the impulse of both the excitatory and inhibitory neurotransmitters to effectively block the sensation of pain. Since its inception in the 1960s many innovations such as smaller and more effective electrodes, and better surgical techniques have made SCS an increasingly viable option for treating chronic back pain.
Patients with failed back surgery syndrome are typically treated with conventional medical management, which mostly includes medicines for pain and depression, physical therapy, and psychosocial therapy. Other treatments may include epidural injections, nerve blocks, and home based electrical stimulation units (TENS). If these usual courses of treatment continue to fail, the last options are either to perform another back surgery or to implant a spinal cord simulator. According to a recent report by Shivanand et al, repeat back surgery has poor outcomes ranging from only twenty-two to forty percent success rate. Repeat surgery also increases the risk for complications and is very expensive. Spinal cord simulator implantation has been shown in several studies as a viable option and Shivanand et al have shown it to have less than half the complications, shorter hospital stay and similar total cost over the first two years compared to repeat back surgery.
According to a recent study by Aleksiev the type of exercise, strengthening or flexibility, does not matter. Both caused a similar pain decreasing effect for patients with low back pain over a ten year period. The most important aspect of the exercise, according to this study, was the frequency, the more the better. It was also shown in this study that the use of an abdominal brace during daily whole-body movements or exercises also further increased the pain reducing effect of exercise over a ten year period.
There is a lot of evidence that increasing abdominal strength can help to decrease low back pain. This increased strength improves lumbar spine stability and can decrease the effect of sudden loads on the muscles, joints, discs and ligaments in the spine which is often the cause injury and pain. According to a recent study by Aleksiev in 2014 there is new evidence that performing abdominal bracing for every day movements that involve the whole body can decrease pain. He found that over a ten year study the groups doing the abdominal bracing had decreased intensity and frequency of pain by more than one and a half times over the group doing exercise alone. The hypothesis by Aleksiev is that performing the abdominal brace frequently through out the day greatly increases the frequency of said exercise, and thereby improving the strength gains. Doing this exercise also seemed to have the effect of reminding people to do their other exercises, again increasing overall abdominal strength.
An injection into the disc can help to alleviate symptoms. There is controversy over whether lidocaine alone or lidocaine with a steroid is more beneficial, with the latest overview of the literature showing a lidocaine injection alone is just as effective as when combined with a steroid. This is something that you can discuss further with your surgeon, knowing that you have options as far as what they are actually injecting, possibly with the same result.
If you are looking into this procedure talk with a medical doctor that has performed this technique and discus with them the procedures positives and negatives.
There are multiple options out there: physical therapy, injections, medications, surgery and facet joint radiofrequency denervation. Each person’s case will be different as well as the intervention. It is a discussion to have with your healthcare provider.
According to the longest prospective study to date on lumbar fusion due to degenerative spondylolisthesis, the best long term outcomes occur when the result is a solid fusion. The body needs time without movement to fully fill in the spaces from the surgery around the bone graft and or instrumentation in order to complete the solid fusion. If there is too much movement during this critical healing phase this biological process may not run its full course and the result may be incomplete fusion. Even though twelve weeks seems like a long time, it will be over before you know it, and will greatly enhance your likelihood of a successful result.
When surgeons suggest using ceramics as an adjunct to a posterior lumbar fusion they aren’t meaning chips of your dinner plates. They use base substances that form ceramics, such as B-tricalcium phosphate or hydroxyapatite. In scientific studies these types of substances have been shown to attract osteopromotive cells called mesenchymal cells. It was then shown in animal studies that these substances needed to be used in conjunction with bone marrow cells in order to see positive bone growth. It is in this way that ceramics have become an option as a bone graft extender to increase the amount of bone available.
This systemic review utilized search terms such as Quality Adjusted Life Years (QALYs), cost-benefit and cost-effectiveness in specific relation to economic studies. Two studies both demonstrated that patients with spondylolisthesis treated with a surgical procedure had gains over non-operative treatment in terms of QALYs ranging from 0.0991 to 0.22 during a two-year horizon and one going on to further analyze at a four -year horizon showing a QALY of 0.34.
While there seems to be an increasing amount of interest related to this topic the authors of this review conclude that there must be research efforts that focus on “higher quality trials with pre-determined cost values and longer follow up”.
A recent review by McGregor, et al, mentions a few studies that support pre surgery rehabilitation. There is a suggestion by McGregor, et al, that the older age of spinal stenotic patients puts them at greater risk for comorbidiites and have a greater need for rehabilitation to improve outcomes. Along the same lines there is evidence from Nielsen, et al, whose study included both pre and post operative rehab with good results. This included both length of stay in the hospital and functional recovery. McGregor, et al, suggest that there is usefulness in looking at the entire care pathway in a more holistic way rather than simply focusing on the surgery. Based on these few examples there is evidence that pre surgical rehab can improve surgery and there is a need for more research in this area.
There are numerous treatment options for back pain caused by discs. Injections sometimes work but there is debate over if the type of injection matters or if it is the needle itself that does the trick. There are also nerve ablative therapies that deaden the nerves so you don’t feel the pain, but those nerves also send signals to muscles and other important tissues so this is a desperate measure. Other types of injections are showing promise in the literature, called methylene blue injections. Conservatively, however there is always physical therapy, which can help alleviate symptoms through manual techniques and change body mechanics and inner core strength to prevent future problems.