FAQ Category: Lumbar Spine

Muscle weakness of the tibialis anterior muscle from a herniated disc can cause the foot to drag when walking. The tibialis anterior picks the ankle up and pulls the foot toward the face. Nerves in the lumbar spine control function of this muscle. Pressure from the disc on the spinal nerve root can lead to loss of nerve supply to the muscle. The result is muscle weakness that can be severe enough to result in a foot drop.

It’s a fairly rare condition. Some studies have been done but no one has really explained exactly what happens and why. Could it be prevented? Is surgery needed? How soon should surgery be done?

The reason the mechanism behind a loss of tibialis anterior strength is difficult to determine is because there isn’t just one nerve that goes to this muscle. It appears from other studies that most patients have footdrop when the L5 nerve root is affected. But there are a fair number of people with L4 nerve root irritation or compression who also develop foot drop. And sometimes the S-1 nerve root is affected, too.

In a recent study from Japan, a group of patients with footdrop were analyzed after surgery. Most of the patients with herniated discs were affected at the L5-S1 level. Some (but not as many) patients had disc herniation at the L3-4 or L4-5 levels. More than half of the disc group had compression of multiple nerve roots (not just one). They also had a free floating piece of disc called a sequestrated fragment pressing on the nerves contributing to this multi-level phenomenon.

Most of the patients recovered strength of the tibialis anterior after surgery. They scored a four or five on the manual muscle test (out of a total of five points), indicating near normal or normal function. For those who still had foot drop, there was no apparent predictive factor before surgery. In other words, there was no way to tell before surgery who would recover and who wouldn’t.

Most surgeons do review all of the possible complications from any surgery. The most common concerns are for infection, delayed wound healing, and blood clots. Specific complications from the planned surgery are usually pointed out as well. Patients don’t always hear everything that’s said — the stress of the situation can make it seem like they never heard any warnings before surgery.

You most likely signed a waiver notifying you of any and all possible complications. Your signature indicated at the time that you had read and understood everything on the page.

Preventing permanent foot drop and restoring full function requires careful attention and early intervention. Since the majority of patients having this surgery have a good outcome, even without knowing who will (or won’t) recover, surgery is carried out as early as possible to prevent long-term consequences of nerve impingement. It’s possible that further treatment may help you. Be sure and make a follow-up appointment with your surgeon and find out what else (if anything) can be done for your condition.

Giant cell tumors are so named because when viewed under a microscope, giant cells with multiple nuclei are observed. They affect the bones, particularly the long bones, such as the distal femur (end of the thigh bone near the knee), proximal tibia (top of the lower leg bone), and distal radius (one of two bones in the forearm).

Giant cell tumors of the sacrum are relatively rare. They are benign in the sense that they don’t usually spread to other parts of the body. And they don’t cause death directly. But they can be very invasive, spreading locally into more and more of the bone where they originated. The tumor can metastasize to the lungs. This is rare, but occurs in one to five per cent of patients.

A giant cell tumor in the sacral area can be very invasive locally. If it is removed, it often comes back as patients have a high rate of recurrence. In some cases, the tumor may turn into a malignant tumor. This type of occurence is relatively uncommon but it can happen. The prognosis is poor in these cases.

Most tumors of the sacrum (including giant cell tumors) are slow growing. There aren’t very many signs or symptoms until it gets big enough to press on nearby nerves, blood vessels, or soft tissues. That also means by the time the patient starts having some problems and gets a diagnosis, the problem can be very far advanced.

Treatment can involve major surgery with removal of the affected bone. Complications such as bowel and bladder loss or sexual dysfunction can develop (either as a result of the tumor or in the process of removing the tumor). The tumor can come back again, so patients are followed for at least two years.

Painful leg cramps during the day or at night can be very disturbing — both to daily activities and to sleep. And many aging adults complain of this problem, so it has caught the interest of doctors and scientists around the world.

So far, scientists still don’t know exactly what causes leg cramps to start. In the case of spinal stenosis, pressure on the spinal nerves leads to pain, especially when standing upright and/or walking. Stenosis is a narrowing of the spinal canal around the spinal cord. This type of narrowing can also affect the foraminal spaces (holes) where the spinal nerves pass through the vertebral bone in order to travel down to the legs.

But a recent study from Japan also showed that decompressive surgery such as your father had doesn’t really give the kind of pain relief doctors and patients expect. They have identified various other health conditions that may be linked with leg cramps but still don’t know the mechanism that leads to this symptom.

It may be a problem at the motor unit of the muscle. Once the nerves were unimpaired, the motor units fired up too much, causing hyperexcitability. This hyperexcitability of the motor units then resulted in leg cramps.

It’s possible the lumbar nerve roots affected were damaged beyond repair. Removing the pressure from around them was too little too late. And possibly, since many surgical patients can walk farther after surgery but still have pain, perhaps muscle fatigue and a build-up of cell byproducts in the legs leads to leg cramps.

It’s clear that leg cramps disturbs peoples’ quality of life. Further study is needed to really get down to the bottom of leg cramps. Besides finding out what causes this problem, there’s a need to find treatment that works well. Decompressive surgery may help some walk further but doesn’t really improve the symptoms for all patients.

Tumors of the sacrum are rare but can create serious problems. They can be benign or malignant. They may be primary, which means they develop first right in the sacrum. Osteosarcoma of the sacrum is a primary bone tumor. It didn’t metastasize from someplace else to the sacrum — it started right in the bone.

Surgery to remove the tumor isn’t always possible right away. The tumor can be too large or too enmeshed with other structures to remove it easily. Radiation may be used first to shrink as much of the tumor as possible.

Tumors that are advanced by the time they are diagnosed make surgery difficult and complex. Removing the tumor, a procedure called resection, isn’t always a straightforward process. The anatomy of the pelvic and sacral areas is a challenge. Bowel, bladder, and sexual function are easily disrupted by any changes in this area. The patient’s preoperative health can also make a difference (e.g., diabetes, high blood pressure, heart disease).

For those patients who can have surgery, multiple procedures may be needed to reconstruct vital bowel and bladder structures. Removal of the entire sacrum (called sacrectomy) can be a major undertaking, especially if the sacroiliac joints are compromised by the tumor. This anatomical area provides support, stability, and biomechanical function for the entire lower body.

It sounds like your brother-in-law is scheduled for a hemi-sacrectomy (removal of half the sacrum). Most likely, the surgeon won’t just take the bone out and leave the patient with half a sacrum. Usually for such a large area removed, bone from a bone bank is transplanted to replace the missing piece.

Sometimes metal plates, screws, or pins are needed to hold everything together until the bone can fuse itself in place. Patients can regain walking skills again. In fact, studies show that between 57 and 84 per cent of patients who have sacral amputation followed by radiation therapy are able to get up and walk again. There is a long period of recovery and rehab before this can be accomplished.

Epidural steroid injections have been around for a long time. They are used to treat back and/or leg pain caused by disc problems or spinal stenosis (narrowing of the spinal canal). As you probably know from your experience, the surgeon uses fluoroscopy, a special type of X-ray that allows him or her to see the needle advancing toward and into the epidural space. This helps assure accuracy in getting the steroid where it can do the most good.

There are different places where the surgeon can insert the needle and inject the fluid. The type of problem you have determines the location of the injection. For example, spinal stenosis from thickening of the bone and ligaments along the back of the spine may respond better to a transforaminal approach. The needle is inserted from the side at an angle.

In such cases, an interlaminar technique might not work as well because the injected fluid can’t get past the hypertrophied tissue. And in order to reduce pain from pressure on the spinal cord, it’s best to have an injection that bathes the entire tissue with the steroid fluid. It may be necessary to inject the epidural space from both sides, not just from one side.

In the case of disc protrusion pressing or irritating a spinal nerve root, either approach (transforaminal or interlaminar) work fine. A one-sided translaminar approach works well if the disc is only protruding on one side of the spine. But if it’s more of a central protrusion, then either the interlaminar technique or simultaneous transforaminal approaches (both sides at the same time) may be needed.

You may want to talk with your surgeon more about this procedure. Which technique was used in the first two procedures? What are the likely reasons it didn’t have any apparent effect? Why does the surgeon think a third injection will be any more effective than the first two injections? The answers to these questions may help you in making the final decision about this third injection.

If you are attending patient education classes at a pain clinic, it’s likely that you have been treated in a variety of ways without complete success. The team there has probably evaluated your case and made this recommendation for the classes you are now attending.

The information provided in these types of classes is geared toward informing you about chronic pain and what you can do to become more functional — in other words, doing more and staying active despite the pain.

That doesn’t mean there aren’t any treatment methods left to try. A nerve block such as you are suggesting works well for the right patients. Usually, there must be a strong suspicion or even evidence that the nerve is the problem. Many times nerves become irritated or compressed by the soft tissues around them. Sometimes scar tissue from a previous injury, surgery, or other trauma can entrap the nerve. Injecting the nerve without changing the underlying problem is only a temporary solution.

Ask your physician if this treatment might help you. Understanding your own pain patterns and the causes of chronic pain will help you evaluate new treatment ideas that come your way. Until something more effective is found, put into practice what you learn in class. This can be a very good way to reclaim your life and get back some ground lost over the years.

Steroid injections into the epidural space have been used for pain coming from herniated discs as well as pain from spinal stenosis (narrowing of the spinal canal). This space is the area between the bony ring of the spine and the covering of the spine called the dura. The dura is the sac that encloses the spinal fluid and nerves of the spine.

When doing an epidural steroid injection, the doctor inserts a needle through the skin so that the tip of the needle is in the epidural space. The epidural space is normally filled with fat and blood vessels. Fluid such as the lidocaine and cortisone that is injected during an injection is free to flow up and down the spine and inside the epidural space to coat the nerves that run inside the spinal canal.

The steroid injection is an antiinflammatory combined with a numbing agent. The dual effect is to reduce swelling around the spinal cord or spinal nerves and stop painful messages from being sent to the brain. There are several openings in the bones that surround the epidural space where a needle can be placed.

Surgeons are fine-tuning the use of steroid injections to get the best results — quick pain relief that is long-lasting. Although the steroid injection has the same biologic effects on local cells and tissues, where it is injected determines what areas are bathed in the drug. For example, discs tend to push backwards, putting pressure on the spinal cord from the front or anterior epidural space. The logical place to inject the steroid mixture is in the area where the spinal nerves are being compressed or irritated.

So, yes, you could possibly benefit from this treatment. But there are other steps that can be taken first, which don’t require needle injection into the epidural space. Your primary care physician can guide you through the steps of conservative care. Usually, an oral antiinflammatory drug is prescribed along with physical therapy. If you don’t get any pain relief with these approaches, then a steroid injection might be considered.

The sciatic nerve travels underneath the piriformis muscle in the deep buttock area. In some people, the nerve passes through the muscle belly. Prolonged or repeated contractions of the piriformis muscle compresses or irritates the sciatic nerve enough to cause pain, numbness, and tingling in the buttock. The symptoms may travel down the leg along the pathway of the sciatic nerve. This condition is called piriformis syndrome.

Treatment for piriformis syndrome starts with analgesics (pain relievers) and physical therapy. The therapist helps the patient change posture that might be contributing to the problem. Stretching the piriformis muscle often helps, as well as mobilizing the sciatic nerve. The therapist guides the patient through these steps, but in some cases, the painful symptoms persist.

Doctors turn to injections of the piriformis next. Steroids, local anesthetics (numbing agents), and botulinum toxin (BOTOX) may be used. BOTOX is a paralyzing agent that works temporarily to help stop piriformis muscle contractions. Side effects may depend on the type of injection performed.

Steroids can weaken the soft tissues leading to a delay in healing and further injury later. BOTOX is often accompanied by dry mouth. That doesn’t sound like much but it can be very distressing. Sometimes local anesthetics are combined with other medications such as clonidine for more effective pain reduction. Clonidine blocks pain messages from going up the spinal cord to the brain. It can be accompanied by dizziness and low blood pressure.

With any injection, there is a risk of nerve damage, hematoma (bleeding), and temporary loss of motor function if the motor nerve (along with the sensory nerve) is injected by mistake. But most of the time, they provide short-term relief from the painful symptoms. Repeat injections may be needed to get the maximum benefit. If no improvement (or minimal improvement) occurs after three injections, the treatment is discontinued.

Physical therapists are trained to handle a wide range of musculoskeletal problems. Their particular expertise is with the human movement system. That means they look at the whole person, not just one moving part that’s having problems on any given day.

But it is true, that once trained and out in the field, some therapists do specialize in a particular problem or body part. When it comes to back pain, there are several different ways therapists approach the problem. Manual therapists (those trained to do joint mobilization and manipulation) are more highly skilled at treating back pain problems compared to a general practitioner.

But a good general practitioner can get you started. And if you need more specialized treatment than they can offer, they will make a referral. Since the therapist is most likely to know where to send you (if even needed), the process is more streamlined than trying to figure out for yourself where to go or who to see.

Give your therapist a call and ask this question directly. It will answer your question and may save you time in the long run.

Exercise therapy has been shown effective with chronic low back pain (LBP). But physical therapists and other researchers are still grappling with what kind of exercise is best? Lately, there’s been a trend to use the core training or stabilizing exercises you mentioned. It seems these may be helpful during the early phases of recovery.

This type of exercise program focuses on specific muscles of the abdomen and trunk. Contracting these deep inner and outer corset muscles can help reduce pain and improve function. They do so by controlling spinal segmental motion.

Studying exercise and back pain is a challenge. The patients are heterogenous (very different). So it’s difficult to find a homogenous group to compare treatments with. Homogenous means they are more alike than different.

There are also many ways to study exercise. More than one treatment approach can be combined with other treatments such as manipulation or general exercises. Sometimes patients receive additional information to help them understand back pain. Adding this type of patient education may improve the results of an exercise program alone.

There are many possible factors to consider in sorting out what type of exercise(s) work and with which patients. In one recent study, working adults with recurrent nonspecific low back pain were placed in one of two treatment groups. Nonspecific means there was no medical cause for the back pain. It wasn’t something serious like a tumor, fracture, or infection. With nonspecific low back pain, symptoms typically occur with active movement.

The patients were randomly placed in either a spinal stabilization exercise program (the exercise group) or in a daily walking program (the reference group). A physical therapist supervised both groups for eight weeks.

Each subject in the exercise group was given a specific program teaching them how to contract and hold stabilizing muscles. The exercises were done during daily activities and in a variety of different positions (sitting, standing, moving). Patients were taught how to activate the stabilizing muscles whenever they were in situations that might cause pain. Positions known to cause pain were avoided. Patients were encouraged to breathe correctly and avoid increasing abdominal pressure with breath holding.

The walking (reference) group was told about the benefits of daily walks. They were advised to walk as fast as was comfortably possible without setting off their pain for a total of 30-minutes every day. If pain developed or increased, they were to slow down. The 30-minute walk could be done in two sessions of 15 minutes each.

There were many different ways to measure the outcomes or results of each type of exercise. There’s pain, disability, general health, patient satisfaction, self-confidence in attempting activities, and so on. With these two groups, there was a benefit to overall general health for everyone. But the stabilization exercise group was more satisfied with their results and felt they had more confidence on the job.

Since there’s an apparent benefit to either of these exercise approaches, it can’t hurt to follow one, the other, or even both. There may be an added benefit of doing both a walking program and core training. The important thing is to start an exercise program and stick with it. All the studies show that daily exercise benefits overall health. Specific exercises such as core training to improve spinal stabilization may be more effective in preventing a second bout of low back pain.

Degenerative disc disease, the break down of the discs in the back, is a major cause of lower back pain in adults. Although older adults are affected most often, any adult can be affected. There are three predictable stages of degenerative disc disease. These stages develop slowly over a period of 20 to 30 years. The first stage is temporary dysfunction. The second stage is unstable. And the third stage in the cascade of events is stabilization.

What’s really happening? Well, first the center of the disc (called the nucleus starts to break down. It loses its ability to absorb water and becomes dehydrated. This is the dysfunctional stage. Instability occurs as the outer covering of the disc develops fissures or tears.

The disc weakens and starts to collapse. Some say the disc is dying. In the final phase, the disc becomes stiff and fibrous. Although it’s collapsed down and the nearby soft tissues get compressed, the overall segment stabilizes.

These various stages can be seen on MRI scans. When looking at imaging studies of the discs, healthy discs have a white center (nucleus), while the annulus (outer covering) seems dark. The nucleus will get darker as the disc degenerates until it becomes black, which means complete degeneration.

They call it black disc disease or disc desiccation. Desiccation just means dried out. Completely normal discs have a white center or nucleus. Those with severely degenerated discs show up with a black nucleus. And those in between are gray.

Degenerative disc disease is a problem usually linked with aging. Disc degeneration follows a predictable pattern. First, the nucleus in the center of the disc begins to lose its ability to absorb water. The disc becomes dehydrated. Then the nucleus becomes thick and fibrous, so that it looks much the same as the annulus (fibrous outer covering of the disc).

As a result, the nucleus isn’t able to absorb shock as well. Routine stress and strain begin to take a toll on the structures of the spine. Tears form around the annulus. The disc weakens. It starts to collapse, and the bones of the spine compress.

Treatment for degenerative disc disease begins with a conservative (nonoperative approach). Medications such as antiinflammatories and antidepressants have been found helpful with certain patient population groups. Physical therapy is often the first-line of hands-on treatment. Core training of the trunk (abdomen and back) muscles is used to stabilize the spine. Patients are taught correct posture, lifting techniques, the importance of movement, and other specific exercises that are appropriate for each individual.

When there is acute (recent) low back pain, spinal manipulation by a physical therapist or chiropractor has been shown to be effective. Chronic low back pain requires a different approach altogether with a multidisciplinary team of experts addressing physical, social, emotional, and psychologic issues.

When conservative care fails to reduce pain or restore movement or function, then more invasive treatment such as surgery may be considered. Spinal fusion is the most common procedure done for this problem. But the operation is invasive, provides inconsistent results, and low overall long-term satisfaction. Some studies showed that doing nothing had as much effect as having a fusion.

Like all treatments for low back pain patients, it works for some, but not all, patients. Finding those patients for whom fusion would work best may help narrow down the field and produce better results.

As a result of these mixed reviews for fusion, surgeons have turned their focus in other directions looking for a better solution. The latest development has been what’s called motion-sparing technology. This refers to surgical procedures designed to preserve motion at the diseased level so that the adjacent segments don’t start to degenerate, too.

There are several types of motion-sparing procedures including supportive rods placed alongside the spine, polymers (manmade plastics and proteins) injected into the disc, and total disc arthroplasty (disc replacements).

Disc replacements are fairly new in the United States. Only a small number of patients qualify for this operation. They must have a stable spine and disc degeneration (not a herniated disc). There must be no stenosis (narrowing of the spinal canal), osteoporosis (low bone density or brittle bones), or obesity. Women who are pregnant and anyone with scoliosis, previous lumbar fusion, spinal infection, or vertebral fracture are also not good candidates for disc replacement at this time.

Over the past few decades, employers, individuals, and communities have spent large amounts of time and money in an effort to prevent back pain in working adults. And they have continued to do so without any real proof that what they were doing was working.

In a recent study, researchers from the Department of Orthopedic Surgery at the University of Washington in Seattle took the time to review high-quality studies to see what might be working. This is the first study to step back and take a look at high-quality research studies and report on their findings.

Types of prevention techniques they looked at included patient education, exercise, braces, and orthotics (shoe inserts). Changes in work policies and activity modification (work and recreation) were also included. A final category included ergonomic equipment. This would include anything that helped people reduce the workload or reduce stress on the back.

Things like back supports, shoe inserts, stress management, and back education had no effect on reducing or preventing the incidence of back pain in working adults. Reduced lifting programs had no effect either. In the end, what they found was that exercise was the most effective in preventing low back pain. So, what kind of exercise is best?

It appears that exercise programs of all kinds work well. There seems to be a general benefit to exercise that results in reduced episodes of low back pain and fewer days lost at work when back pain does occur. What’s the explanation for this? It’s not clear yet if there is a simple answer.

There may be ways in which exercise affects the body that go beyond the biology. Maybe people feel more confident after exercising. The results are reflected in their general health including reducing incidents of back pain. Maybe they are less fearful of injury and somehow this lends to lower episodes of such injuries.

It’s possible that combining two or more prevention techniques would have even better results than exercise alone. There’s no proof for this at the present time. So, the best we can say is to encourage all of your employees to participate in sports and activities on a regular basis.

Current recommendations from the American College of Sports Medicine (ACSM) and U.S. Centers for Disease Control and Prevention (CDC) are for a minimum of 30 minutes of moderate-intensity physical activity most (if not all) days of the weeks.

Some employers are providing gym memberships for their employees, providing an on-site area to work out, and/or extending the lunch hour by 30 minutes for those who want to use that time to exercise. Each business employer is encouraged to find creative, low-cost ways to create a corporate culture that promotes physical activity and exercise. The proven results are fewer sick days from back pain with possible increased productivity and lower medical (insurance) costs.

There aren’t any studies specifically assessing driving skills in patients taking narcotic (opioid) medications. Most of the recommendations are common-sense. Patients are told NOT to drive when there are any cognitive (mental thought processes) effects or impairments. Likewise, they should not participate in dangerous recreational or work activities.

But what are these impairments? Well, falling asleep easily would be one. Slower reflexes and reactions or decreased coordination fit this category. So does decreased concentration or clouded thought processes such as simple math calculations or making a quick decision about simple things.

Medications that are considered narcotics affect the central nervous system. The adverse effects described here are most likely to occur when the drug is first started, when increasing a dose, and when taking other drugs at the same time that can also affect the nervous system. Other drugs can refer to prescribed medications, alcohol, and illegal substances such as marijuana, cocaine, crack, meth, and so on.

In some cases, opioids can actually improve driving ability. Decreased pain (the primary intended effect of the medication) improves cognitive function. Still, anyone who is a bus driver, truck driver, pilot, or makes a living driving other types of heavy equipment should be cleared to drive by the physician prescribing the meds before before doing so on their own.

If we could find a way to prevent back pain, it would save many people the pain of the condition as well as the expense of treatment. Many studies have been done trying to find a successful answer to back pain prevention.

In a hospital setting such as you are talking about, small patients may not be the biggest challenge. Standing on their feet for long hours, moving beds or other equipment, and lifting supply boxes may be the greater challenge.

Many health care programs have invested time and money in teaching preventive lifting techniques and working out shared lifting responsibilities to reduce lifting. Some programs offer advice on manual materials handling. Studies aren’t showing that these methods really bring about a change in the number of back injuries, episodes of back pain, or sick days lost due to back pain.

What they have found is that health care workers who exercise routinely are less likely to take sick days. In one study where half the workers were from the health care industry, lower work absence (28 days) was reported in those who exercised compared with control groups (155 days) over the same period of time (13 months).

Most of the studies focused on abdominal and back extensor muscle strength, power, and flexibility. The most successful exercise programs were supervised, consisted of 45 to 60 minute sessions, and took place twice a week. The length of time patients met ranged from three months to a full year. The patients in the exercise groups had stronger abdominal and back muscle strength.

Exercise appears to be a better way to reduce the risk of back injury and/or episodes of back pain — even better than no lift policies, ergonomic training, and mechanical lifting. In fact, exercise was also more effective than shoe inserts, back supports, stress management, or back education.

First, talk with your mother’s therapist. Let her know the situation at home. There may be several ways to approach the problem. Identifying the true cause for her difficulty is important. Is it primarily the problem of pain? Or is there muscle weakness preventing the movement? Even weakness in the legs can have a profound effect on seemingly simple tasks such as the sit-to-stand motion.

There’s no doubt that low back pain limits lumbar spine motion, hip motion, and the coordination between the two. This has been proven and confirmed in several research studies. It may be a protective response to avoid loading spinal structures. But it definitely causes a change in how energy is transferred between bones and soft tissues in the spine, pelvis, and leg.

And that inefficient energy flow or transfer then places even more demand on the spine. A vicious cycle gets started of back pain-altered biomechanics-soft tissue injury-and more back pain. Without enough transfer of energy and muscle power, everyday activities such as standing up from a sitting position become difficult, if not impossible due to pain.

Until the underlying problem is analyzed and solved, there are some practical steps that can be taken. One is to consider raising the surface of the toilet and chair where your mother tends to sit most often. A special raised toilet seat can be purchased from a health supply store. These are often used after a total hip replacement when patients can’t bend the hip too much. But they also work well for folks with back pain that limits their ability to get up and down.

If your resources aren’t limited, there are motorized chairs that lift the seat up and help the individual stand. These should not replace a rehab program designed to restore normal strength and movement, but they can be very helpful during the interim. The physical therapist may have other ideas as well. Each patient is unique with individual differences that must be taken into consideration.

Sciatica isn’t really a diagnosis as much as it’s a set of symptoms. Low back or buttock pain that travels down the leg (sometimes all the way down to the foot) is the usual complaint. The sciatic nere is usually involved, which is why the condition is called sciatica.

Pressure on (or irritation of) the sciatic nerve or any of the spinal nerve roots that make up the sciatic nerve can lead to sciatica. The symptoms can be mild to severe with numbness, weakness, muscle atrophy, and even difficulty moving the leg. The symptoms are usually only on one side, but they can be present bilaterally (down both legs) if central pressure (in the middle) is placed on the nerve tissues.

Treatment of sciatica often requires finding out what’s causing the problem. A disc protruding out of the disc space and compressing or irritating the spinal nerve has a very different treatment approach than a tumor pressing on the nerve.

The diagnosis begins with the patient’s report of his or her symptoms, what brought them on (if anything), what makes the pain better or worse, and so on. This can help the examiner pinpoint the cause of the problem. Special clinical tests can also be conducted. For example, if the clinician suspects involvement of the sciatic nerve, the straight leg raise test is done.

In this test, the patient sits or lies down on his or her back (supine position). In the sitting position, the examiner passively straightens the patient’s leg. In the supine position, the straight leg is passively lifted. Rrepoducing the symptoms with these movements is usually a positive test indicating the presence of sciatica.

A positive straight-leg raise doesn’t tell us what’s causing the problem. Further testing is needed for a more definitive diagnosis. X-rays or more advanced imaging with MRI or CT scans may be ordered.

With spondylolisthesis, there is a fracture in the bony ring along the back of the vertebra. If the bone separates at the fracture site, it’s called spondylolisthesis. The affected vertebra slips forward over the one below it. The result can be a narrowing of the spinal canal (opening where the spinal cord travels down the spine). As the spinal canal gets smaller, any pressure or pulling on the spinal cord or nerve roots can cause neurologic problems.

When making the diagnosis, CT imaging is a better diagnostic tool (more accurate, more reliable) than X-rays. With these conditions, the fracture can be missed on X-rays depending on the patient’s position (standing up or lying down. The effects of gravity and postural muscles can really make a difference on X-ray results.

Whether or not spondylolisthesis is really the cause of low back pain remains a topic for discussion. Studies have not proven a clear and conclusive link between the two. There are just as many people with spondylolisthesis who do not have back pain, as there are people with back pain who have spondylolisthesis.

It’s natural to make the assumption that low back pain in someone who has a spinal defect seen on X-ray or CT scan must be caused by that condition. But this just isn’t so. Surgeons, scientists, and others are studying this problem looking for ways to prevent spondylolisthesis and reduce back pain from any cause.

Most often, degenerative disc disease (DDD) occurs as part of the aging process. But there are other factors that can accelerate this condition and bring it on sooner. The most common is repetitive physical loading of the spine from overtraining and strenuous exercise.

Activities that involve repeated rotations of the vertebra (twisting motions of the spine) put athletes at increased risk. Sports such as high-load swimming, baseball, gymnastics, and soccer are particularly problematic.

Heredity is also a major factor for DDD. This condition tends to occur in families. More than half of all cases of DDD in the upper lumbar spine (L1-2, L2-3) have a hereditary component. And about one-third of the DDD in lower lumbar levels (L345) can be accounted for through heredity.

Although the evidence is still controversial, there are some experts who think obesity can be linked to DDD. Highly skilled athletes aren’t usually obese, but their body mass index (BMI) (calculated using height and weight) is often greater than nonathletes.

In one study from Japan, a group of athletes with DDD were compared with another (control) group of nonathletes. The athletes had both higher BMIs and a higher incidence of degenerative disc disease.

Many doctors do use injections into the back or areas in the back to help relieve back pain. The injections may contain medications that reduce the inflammation, which in turn relieves the pain (corticosteroids) or anesthetics, medications that numb the area. A combination of medications can be given too.

A lot of research has been done on this issue and the general agreement is that – often – there is not a big benefit to having the injections. Many of the studies found little or no improvement among patients who had the injections and those who had the fake injections, or placebos. However, the injections to work for some people, just as the placebos do. So some doctors do try the injections, having come to the conclusion that this would be a treatment that that could benefit fir particular patient.