Aug 30, 2016

Interview Transcript

Dr. Miller: Persistent sciatica - what can you do before you need surgery? We're going to talk about that next on Scope radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Petron. David Petron is a non-operative sports medicine physician who specializes in many different sports injuries as well as common injuries to the joints and back. David, what is sciatica?

Dr. Petron: Well, that's a general term that people use for pain going down the leg related to a nerve. In reality though, the vast majority of people, it's not really coming from the sciatic nerve but a group of nerves in the lower back that make up the sciatic nerve.

Dr. Miller: This is in the lumbar part of the spine . . .

Dr. Petron: Exactly.

Dr. Miller: . . . lower spine, and sometimes the part even below the lumbar, the sacrum.

Dr. Petron: Usually the very lower part of the spine. And the most common reason for it usually isn't an injury but it's prolonged sitting and then the disc weakens and the disc bulges out or sometimes herniates out and then presses against the nerve and you get pain - really bad pain - for the most part, down the leg.

Dr. Miller: So not only do you have or could have back pain but it radiates, that's the important distinguishing feature of sciatica . . .

Dr. Petron: Exactly.

Dr. Miller: . . . is it radiates down the outside of the leg down past the knee.

Dr. Petron: Most of the time the buttocks and then sometimes all the way down into the ankle. And sometimes it skips areas. So sometimes, people come in and they have ankle pain but the real source of the pain is their lower back.

Dr. Miller: So it doesn't have to be due an acute injury, it can come on suddenly or maybe insidiously?

Dr. Petron: Almost never is it an acute injury. And it can happen all ages. We see it in our college athletes all the time. But the most common reason is really prolonged sitting. We're not designed to sit for hours at length. And so the most common presentation I'll get is somebody will go on a vacation and they'll be sitting in a plane for a prolonged period of time and then they'll go to a medical conference and they're sitting for a long time. And they come back and they try to figure out how this happened and they think they picked up luggage or did something to injure it, but most of the time it's just the prolonged sitting.

Dr. Miller: Now my understanding is that most of the time sciatic pain will resolve on its own with physical therapy and doing the right things and avoiding sitting and it just gets better on its own. But, when it doesn't, and it goes beyond three, four, five weeks, what do you offer the patient?

Dr. Petron: The vast majority of problems - around 90% - get better without surgery. Two things drive us towards surgery. One is progressive neurologic changes, with the most common thing being weakness, usually weakness in the foot. And the second thing is pain. So sometimes people get to the point where they just can't tolerate the pain.

Dr. Miller: It's getting worse.

Dr. Petron: It's getting worse and they have to have something done. There's a study called the Sport Trial that was done, where they took a group of patients - one in the non-operative group and one in the operative group - and followed them out and the results at a year were about the same. So, a lot of people that were in the non-operative group ended up getting better over time. There was a fair amount of crossover in that study. In other words, the people that started out where they were going to have surgery they started getting better and they jumped over to the non-surgery group. And there was also people that were in the non-surgery group that said, "I can't take this anymore. Put me in the surgery group." So there was a fair amount of crossover in the two groups. But in general, the ultimate outcome with sciatica is it gets better over time.

Dr. Miller: Was this what tempered the kind of rush to surgery maybe 20 years ago?

Dr. Petron: I think so. And I mean, we have a lot of good spine surgeons out there now that are just more patient with the patient. A lot of times they send them to somebody like myself where they can get an injection that a lot of times can help the pain and then ultimately they just, with time, get better.

Dr. Miller: Well, let's talk about that. You offer certain modalities and procedures so that patients can get better faster. What is it that you do to relieve the pain?

Dr. Petron: The most common one for sciatica is called the selective nerve root block. So it's really similar to an epidural but it's actually much safer than a blind epidural that you might get with pregnancy. These injections that I do are done under fluoroscopic guidance, or X-ray guidance, so you can be very precise in where you place the material. So rather than it just going in the epidural space, we find out what nerve is specifically involved and then put the medicine directly over that nerve.

Dr. Miller: And what medicine do you put over the nerve?

Dr. Petron: Usually a corticosteroid and some type of lidocaine.

Dr. Miller: So you put the . . . let's say you make the initial injection with the lidocaine and the pain goes away. Then you make your injection of the corticosteroid. How long does that effect last? How long will that help the patient?

Dr. Petron: Sometimes it helps them forever. Sometimes it doesn't help at all. It's that variable.

Dr. Miller: How often is it effective? I mean, person to person.

Dr. Petron: I would say the vast majority of people, it's effective and sometimes it eliminates the pain completely. Sometimes it cuts down the pain significantly. And the biggest thing it does is that group that had that severe pain in the early stages that were begging for surgery, then it can . . .

Dr. Miller: Buy them a bit more time to let nature heal.

Dr. Petron: . . . buy them more time. Exactly, let their body heal itself. But it greatly eliminates that pain, and if you've ever had this kind of sciatic pain, you know what I'm talking about.

Dr. Miller: So, do you select patients for the shot based on the intensity of the pain?

Dr. Petron: I really do. It's really based more on what they're feeling. So, if their pain is very mild then a lot of times I might use some medication as well as some physical therapy. But it they have severe pain, the results of the injection can be so immediate that I feel like I should offer that right away.

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