Maureen Dwight, Registered Physiotherapist, Clinical Musculoskeletal Specialist, Advanced Spinal Practitioner ISAEC
When you are experiencing searing low back pain, sciatic leg pain or repeated episodes of back spasms, it is natural to wonder if surgery might be the answer. In the 30 years I have been working with spinal surgeons in downtown Toronto I have seen an evolution in our understanding of who benefits from back surgery and who is better off managing their symptoms with a cocktail of time, medication and therapy. We now know that even when your symptoms are intense, surgery is unlikely to be the solution. Long term studies tell us that given enough time there is a 95% chance that you will recover without surgery. In fact most people will see substantial improvement in their symptoms within 3 months.
That said, three months can seem endless when your back pain won’t let you get out of bed or the pain in your leg doesn’t let you sit for more than a few minutes. At this stage in your recovery it can be hard to hear that there is no instant solution however when the pain begins to lessen, and it will, most people are relieved that they avoided surgery. The right combination of medication and physical therapy can help many people manage until natural healing takes away the symptoms.
When is back pain an emergency?
Most experts agree that there is one back condition which should be treated as an emergency. The condition is called Cauda Equina syndrome. This uncommon condition results from pressure on the spinal nerves in the lumbar area where they fan out to look like a horse’s tail. Pressure on these nerves can result in loss of control in the bowel or bladder functions.
If your back pain is accompanied by a sudden loss in control of either of these functions this should prompt a trip to the emergency department. Left too long these changes can be permanent.
Discussion of this condition often prompts people to worry about their stress incontinence (peeing with strenuous activity, coughing, sneezing), or urinary frequency however these are not signs of cauda equine syndrome. With this condition you have:
• Uncontrolled urination and/or
• Uncontrolled defecation and/or
• Numbness, tingling in the anal and/or genital area
Despite the potential serious nature of this condition you still may not need surgery. Depending on the severity of the pressure on the nerves and on what your surgeon finds in the examination, he/she may choose to monitor the situation. Close monitoring of the symptoms is required and if you are receiving therapy, manipulation of the spine should be avoided. Once your symptoms stabilize a core exercise program should be instituted with a knowledgeable spine physical therapist.
Surgery for Sciatica
Sciatica is a particularly nasty condition which often starts with lower back pain but as it worsens the pain extends into the buttock and leg. It is typically caused by a pinched nerve and depending on the location of the pressure and the intensity of the symptoms, the pain can radiate down to your calf and foot.
Whether you are a candidate for surgery is determined by the cause of the pressure and your response to conservative treatment. Once again most episodes of sciatica will see substantial improvement within 3 months however if the pain persists and is caused by a herniated disc, or a narrowed spinal canal (stenosis), surgery can be an option.
Herniated disc and sciatica
The most common surgically treated sciatica is caused by a herniated disc. In this condition the center of the disc (nucleus) breaches the outer rings (annulus). If the disc protrusion is large or if it is located more to the side (laterally) it can pinch the nerve by pressing it against the walls of the spinal tunnels (canal and foramina).
Surgery for this condition is elective – meaning that once the surgeon confirms that you will benefit from a procedure you can decide whether you would prefer surgery or would like to try to manage your symptoms conservatively. In the most common type of procedure the surgeon removes the offending nucleus to relieve the pressure on the nerve (i.e. discectomy, microdiscectomy).
The intensity of the pain can prompt many people to choose surgery, and this option should help you to get rid of the pain more quickly, however if you decide that surgery is not for you the long term studies confirm that even with this condition most people get better. With time the pressure comes off the nerve as the herniation shrinks, much like a grape drying into a raisin. The pain abates once this natural process creates sufficient space in the spinal tunnels for the nerve to function.
Treatment of Disc Herniation Sciatica
While you are waiting to get better, or to see the surgeon, your therapy team’s focus should be on helping you to manage your pain. Your body needs time to heal and medication and/or other pain relieving types of therapy i.e. acupuncture, massage, physiotherapy, can be helpful to get you through the wait. Once the worst is over the focus should shift to physiotherapy to restore your core, correct your posture and education on long-term prevention strategies.
Therapy is also important if you decide to go the surgical route as it will help you to maximize your recovery. When opting for this type of surgery it is important to understand that the primary goal is to relieve your leg pain. After a successful procedure you still may have low back and/or buttock pain. When you are ready to begin therapy your physical therapist will work with you to restore core strength as this will help to manage these residual symptoms.
Sciatica and spinal stenosis
Sciatica can also be caused by an over-growth of bone which can be a result of wear and tear on the spine. For the pain to radiate down the leg this over-growth of bone is usually restricting the nerve as it exits the spinal canal (foramen). On your MRI the radiologist may differentiate the location of the narrowing by indicating it is at the foramen or in the lateral recess.
Some people are born with a congenitally smaller spinal canal. Inflammation or more minor bony over-growths can comprise the nerves in these restricted canals more quickly.
In this surgical procedure the surgeon typically elects a decompression to enlarge the space for the nerves to exit. They remove sufficient bone and/or soft tissue to provide enough room for the nerves to function.
Treatment of Sciatica caused by spinal stenosis
When your sciatica is caused by stenosis most people try to manage their pain conservatively before turning to the surgeon for help. This can be quite effective if this type of sciatica comes on suddenly as this presentation suggests that there may be dynamic elements contributing to the compression. Soft tissue protrusions (discs, ligaments, etc.), inflammation and posture can all put pressure on the nerves in the canal. These dynamic contributors can be temporary and should respond to therapy consisting of posture correction and exercises to reduce the lordosis (sway) in the back. If inflammation is suspected the addition of ice, medication, acupuncture and/or other physiotherapy modalities to reduce swelling can be useful.
Even when the X-rays and MRI’s show a nerve entrapment or a congenitally small canal these approaches can help you to control your symptoms. Once the pain improves it is important to continue your exercises and be aware of your posture as the size of the canal is still restricted and resuming old habits can cause the symptoms to reoccur.
If your decision is to have surgery, therapy is still an essential component of your recovery. The restriction of the nerve in the foramen often leaves specific muscle weaknesses which can remain even once the surgeon relieves the pressure off the nerve.
If the weakness has lasted more than a few months it can be difficult to restore this strength as your body may have started to compensate. You begin to adapt to the weakness and learn to function without the muscle. A knowledgeable spinal therapist will know where to look for these specific weaknesses and then can help you to learn to integrate this strength back into your everyday function. Without this type of therapy I find that symptoms are more likely to occur down the road as compensatory patterns cause postural adaptations that contribute to the recurrence of dynamic stenosis.
Neurogenic claudication and spinal stenosis
Spinal stenosis does not always present as sciatica. When the narrowing is located in the central canal, rather than as the nerves exit the foramina, some people will experience a heavy, numbing sensation in their legs as they walk. They may also feel tingling in their feet. If these symptoms are relieved by bending forward, crouching or walking with a shopping cart your stenosis may be causing neurogenic claudication1.
Surgery is typically considered when walking becomes quite restricted. It is important to discuss with your surgeon your expectations for function as some people can have quite a restriction in their canal and yet are able to walk for several miles. Other people can’t walk a block before feeling symptoms. Getting a good surgical outcome is often determined by your expectations as your goal is to walk further without symptoms following the procedure. You may choose to delay surgery if you are functioning at a high level.
Treatment spinal stenosis with neurogenic claudication
Although the presentation is slightly different, the treatment is essentially the same for neurogenic claudication as it is for sciatica caused by spinal stenosis. Posture is an important component of your program as the more swayed (lordotic) your back is, the more symptoms you will have while walking.
If your decision is to have surgery, therapy is still an important component of your recovery. Many people have been inactive for months or years as the pain limited activity. Add to this the fact that spinal stenosis typically affects us as we get older and many people find that they have lost substantial amounts of fitness by the time they have surgery. In addition to working on posture and muscle imbalances your post-operative program should focus on regaining your endurance for walking to help you to return to favorite activities such as golfing, traveling, bird watching and/or hiking.
1 Neurogenic claudication causes similar symptoms to another condition where the restriction is in the blood vessels in your legs. This condition is differentiated by the term vascular claudication.