Understanding Sciatica Pain with Dr. Dominic Pelle

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host Nada Youssef and you're listening to Health Essentials Podcast by Cleveland Clinic. Today, we're broadcasting from Cleveland Clinic Main Campus here in Cleveland, Ohio. We're here with Dr. Dominic Pelle. Thank you so much for being here today.

Dominic Pelle:   Thanks for having me.

Nada Youssef:   Sure, thing. Dr. Pelle is a spine surgeon in Cleveland Clinic Center for Spine Health. Today, we're talking about sciatica. Please remember this is for informational purposes only and it's not intended to replace your own physician's advice. Let's just start with very general, what is it? What is sciatica?

Dominic Pelle:   Sciatica is what happens when you experience pain that radiates down the leg because of an issue with the nerve. So it's not necessarily just an issue with the sciatic nerves, a nerve most people have heard about. It's kind of a bit of a misnomer. The pain can be in different distributions, but it essentially is pain that it usually begins in the back, travels down the leg in some form or another, usually across the buttock into the thigh, sometimes below into the knee, and sometimes all the way into the foot or the toes.

If that pain is coming from a nerve in the back, we call that sciatica, or we call that more specifically, radiculopathy.

Nada Youssef:   And that only goes to one side of your body?

Dominic Pelle:   No, it can be both sides. So it depends on the cause of it. Sometimes if you have herniated discs on both sides, or you have just stenosis of the nerves or a pinching off in the nerves as they come down, sciatica can be bilateral. Oftentimes, the exit where the nerve root leaves the body can be smaller than it usually is. Sometimes you get it on both sides that way too. Unilateral or bilateral sciatica can be.

Nada Youssef:   What are the common symptoms? I know you mentioned pain shooting down a leg. Are there any other common symptoms?

Dominic Pelle:   Yeah. The sort of trifecta of nerve pain in the leg is generally, or symptoms, is generally pain, numbness and/or weakness. It could be a combination of those things or it can just be one of those things. Sometimes people present with just an isolated weak muscle group and that can be from sciatica or a pinched nerve in the back. Sometimes they present with just pain or sometimes they present with just numbness or all of those things.

Nada Youssef:   So is this pain chronic? Does it go away?

Dominic Pelle:   That's a great question. It sort of depends on the cause of the pain. Let's talk disc herniations for a second. If you have a disc herniation in your back and it's pinching a nerve as it travels down your leg or it's pinching a nerve in your back and you get pain that travels down your leg, almost 90% of the time that'll just go away. Activity modifications, sometimes medication. I know we're going to get into some of the treatment options later on, but most often that doesn't require me. It doesn't require surgery. Okay? If it's due to something that probably won't go away, then we start talking about different treatment options for that. The first thing we usually do if something like a herniated disc is say, "Just wait it out." If I see somebody that's had leg pain for a couple of days, we have an MRI and it shows a disc herniation, the answer is time.

Nada Youssef:   Okay, great. Let's talk about the sciatic nerve. Where is it located? Where's the actual nerve?

Dominic Pelle:   The sciatic nerve itself is not really... Even though it's called sciatica, I wouldn't say it's the focus of this talk. Typically, the nerves exit the lumbar spine. So you have L1, 2, 3, 4, and 5, and then you have an S1 nerve root. Those are the symptomatic routes that you can get leg pain from. Then they kind of coalesce together as they travel down your leg and they travel into your leg. The lower lumbar nerves and the sacral nerves will form some of the sciatic nerve as it travels down the back of your leg. But a lot of times people have pain from L2 or L3 up in the front of their thigh or in their hip area and they still call that sciatica. It's just a pinched nerve higher up in the lumbar spine.

Nada Youssef:   I see. So you're feeling the pain in a different location.

Dominic Pelle:   Correct? Yeah, it's a referred. The problem is in the spine and where you feel that generally, is in the leg.

Nada Youssef:   Are there different types of sciatica.

Dominic Pelle:   Not really. It's just pain that shoots down the leg or numbness or weakness. There's different causes of it. Okay? I always, when I'm educating residents or fellows, we talk about what's the diagnosis, why we did surgery. If they say, "A herniated disc," or they say, "Lumbar spinal stenosis," that's not correct. The answer is because of the pain, the radiculopathy or the sciatica or whatever you want to call it. The cause of that can be different things. What I'm describing is the symptoms that the patient is experiencing.

Nada Youssef:   Okay. Let's talk about some of the causes. What are some of the causes for that?

Dominic Pelle:   So disc herniation's relatively common cause, disc degeneration and arthritic development. Nobody's really free of spine arthritis, right? It kind of affects us all. Most people have an episode of back pain in their lives. Most often, that's not due to arthritis or a problem in the spine. But when it is, we're upright, we stand on two legs, right? And because of that, our discs start to degenerate over time. As that happens, right? That disc can bulge backwards a little bit. A little bit different than a big herniation. It's just kind of a little bit of a bulge. The joints in the back of our spine can grow a little bit bigger. The ligaments that connect the levels together, they can hypertrophy or also get a little bit bigger over time and all of that can sort of coalesce together to pinch the nerves as they come down.

If it's in the center of the canal, that's stenosis and that causes a different set of symptoms. If it's along the sides of the canal where the nerve lives, sometimes that will just pinch a specific nerve and causes sciatica or radiculopathy . If it's as the nerves exit, it will also cause a sciatica or radiculopathy . So those are the three areas that you can have a problem in the lumbar spine.

Nada Youssef:   It sounds like all of them are because of age, unless it's maybe an injury?

Dominic Pelle:   Yeah. Age, injury or disc herniation. Sometimes disc herniations occur in nice young, healthy backs that have no problem, no arthritis whatsoever. It's just bad luck. Okay? A weak disc, genetic issue. The disc is like a jelly donut, right? So the inside of it can herniate out if there's a weakness on the outside. That can happen in a healthy desk.

Nada Youssef:   Can we talk about some of the risk factors for sciatica?

Dominic Pelle:   Yeah. Again, age is a risk factor, previous injury, disc degeneration, weight is a big one, core strength. The stronger your core is, the more support you have for your lumbar spine. That's why people tend to get issues in the lumbar spine as opposed to thoracic spine because we have the support of the rib cage in the thoracic spine. The lumbar spine is just our muscles that support us and that's why we always talk about core strengthening with some of these issues.

Nada Youssef:   You mentioned weight-

Dominic Pelle:   Mm-hmm (affirmative).

Nada Youssef:   ... and I know a lot of pregnant women usually complain from sciatica. Is that the root right?

Dominic Pelle:   No, it's not just weight. This is a little bit outside my area of expertise in terms of obstetric care, but when you're pregnant, your ligaments loosen up a little bit due to the circulating hormones in your body and that could be a logical conclusion for why sometimes these women deal with disc issues as opposed to when they're not pregnant. I wouldn't say it's just a weight phenomenon by any means.

Nada Youssef:   Okay. Great. Does this develop kind of over time then with just like you said, with age the pain, does it come kind of all of a sudden or is it slowly?

Dominic Pelle:   Yeah, it's a great question. it depends on what it's coming from. Let's say that you're a healthy young person and you get a disc herniation. Pain's immediate, right? And it just comes on, it shoots down the leg and hopefully over time, gets better. If it doesn't get better, that's sort of where I come in. However, oftentimes that is just an immediate thing. If you have a slow arthritic process, sometimes you have some good days, you have some bad days, and then you notice that it just starts to get worse as time goes on and then the pain just kind of persists there. So it can depend. It's so variable. That's what's very interesting about spine surgery in general. There's so many different causes for why somebody may hurt in their leg and because of that, different treatments for it.

Nada Youssef:   What about the hip? Can it be a confusion for sciatica?

Dominic Pelle:   Absolutely. In fact, I just got done seeing a patient that has hip arthritis that was referred to me for a nerve issue. When you examine her hip, it's very painful. It was painful in the groin. It's painful when they put weight on it. So these are all things that when you see your physician, they should be able to work out. Hip arthritis and hip arthritic pain or hip issue's generally groin pain. It hurts when you put weight on it. If someone's in the office and they're ranging your hip, they're moving your leg around and it kind of reproduces the pain you have, that's a hip issue. Okay?

If you have pain that sort of starts in your back, kind of radiates towards the hip or down the leg, it's associated with numbness, tingling, sometimes weakness, most likely that's a nerve issue. That's a sciatic issue as opposed to a hip issue. That's something we think about with every patient that we see. The last thing we want to do is subject somebody to a course of treatment when it's not really their back. Right? We want to make sure it's their back before we do anything else or make sure it's something else.

Nada Youssef:   Can you give us maybe signs that we may have sciatica and need to see a specialist?

Dominic Pelle:   Sure. The one thing I'd say is you'd know, right? So it's not a subtle pain, right? Typically, at least what I see, and that's a little bit biased because I see people that have generally failed conservative treatment, but it's the, "My leg hurts, it's numb, it's tingling. I can't move my foot as good as I did before. I didn't have this pain a month ago and I have it now." These are all reasons you should seek medical.

Nada Youssef:   Great. Let's talk about diagnosis. How do you diagnose with the other kinds of things that you do in the office?

Dominic Pelle:   Yeah. It's kind of the standard thing. We take a good history. Okay? Are you telling me the things that make sense for sciatica? Okay? If you tell me it hurts in my groin and it hurts when I put weight on my leg, I'm going to think it's your hip. If you say that I have numbness and tingling down my leg, I'll think it's probably from sciatica or a pinched nerve in your back. We match that with the imaging. Okay? So typically, it's diagnosed or the diagnosis is confirmed with an MRI. Okay? We always like to start with plain x-rays. The reason being is because plain x-rays tell us a lot of information the MRI cannot. Okay? Most pointedly, they tell us what your spine looks like when you put weight on it. Okay? So there are certain conditions where the bones may move in the spine abnormally. The only way to really diagnose that if when you lay down, they reduce, is when you stand up.

The only way for me to see what your spine looks like when it stands up is with a plain x-ray. I tend to want to have plain X-rays first, but an MRI will show the nerves very well. An MRI is great to confirm pressure on a nerve, disc herniation, arthritic condition that's pressing on the nerve. Those will all show up quite nicely in the MRI to confirm the diagnosis. Then certainly, the physical examination is of paramount importance. There's certain things that really key us in to, this is probably a punched nerve, right? There's a special test called the straight leg test where we raise your leg and if it reproduces the pain down your leg, that's very good indicator of the fact that it's coming from your low back.

If I raise your other leg, okay? Let's say you have pain down the right leg and I raise your left leg and it shoots the pain down your right leg, that's an even better indicator that the pain is coming from a pinched nerve in your back. Aside from that, we can test all the specific lumbar nerve roots with a physical examination, muscle strength wise in the leg. Everybody that comes to the office has to walk from me. So if you come to my office, I'll always make you walk. Okay? I want to see what you look like when you're loading your spine, when you're trying to pivot from one foot to the other and you change the way your weight looks, that's all very important. Most often, I have people walk on their toes, walk on their heels so I can see that they have the strength in their calves and in the front of their legs to be able to do that.

Nada Youssef:   So it's a physical assessment that you actually do in the office to see what they [crosstalk 00:11:31].

Dominic Pelle:   Mm-hmm (affirmative), every patient that comes to the office.

Nada Youssef:   Good. With treatments, before we go into surgery, and hopefully we don't have to, but what are the nonsurgical treatments?

Dominic Pelle:   Nonsurgical treatments usually resolve the problem. The first thing it's time, right? We talked about that earlier. If you have a disc herniation, time will usually just take it away. Okay? The other thing is physical therapy, core strengthening is important. Okay? So you stretch your low back, you strengthen your core. This will all support your spine and take pressure off the spine by strengthening the support system around it. Most patients we refer to physical therapy as well. There are certain medications we can give that are good medications for nerve pain, non addicting type medications. The first thing is usually when a disc herniates or they have sciatica, sometimes that's associated with muscle spasms in the back too. It kind of sets everything off at once. So we'll give a low dose muscle relax and a medication that will help relax the lining of the nerves or the membrane of the nerves. We'll do those two in combination and probably the mainstay of medication treatment is an anti-inflammatory.

Usually in an acute phase, that would be something like a steroid where we'd give somebody a tapering dose of steroid where they start high and they get lower on it and sometimes it's an anti-inflammatory like ibuprofen or Motrin. Typically, it's those three things: medications, therapy, and just giving it time. Let's say none of that works, times going on and the pain's still bad. Oftentimes, we may send somebody for an injection and the injection may be diagnostic and it may tell me that the pain's coming from this nerve. Let's say I think the pain is coming from L5 and I give you an injection in L5 and you get better, but it gets worse again. At least I know diagnostically speaking, that's where the problem is. If we can address that surgically, we'll probably have a pretty good result. The other thing injections can be is therapeutic. So if I give you an injection and it takes away your pain for months and months and months and months, well then we've done the job. You don't need surgery, just have the injection. Okay? So we use injections in that setting as well.

Nada Youssef:   How about something like a massage? Is a massage would help at all?

Dominic Pelle:   Yeah. Massage sort of fits into this category that people ask me a lot of questions about. Usually, that's in it's probably not going to hurt you, it's probably okay. Right? So inversion tables, right? People love their inversion tables. Do they hurt? Probably not.

Nada Youssef:   Can you tell me what that is? [crosstalk 00:13:43].

Dominic Pelle:   That's a table where essentially you hang somewhat upside down, right? So you strap your legs in and you hang on an incline and the idea is you take gravity off the spine and it kind of expands everything. That's probably not hurting people without a specific injury to their back. I don't think you could fight gravity. Right?Over time, that's all going to sink down and probably come back again. But if it gives you some relief, I don't think it'll hurt you. Same thing with a massage. It's probably not going to change your sciatica. It's not going to cure your sciatica, but it may help some of the muscle spasms. It may give you some temporary relief probably. I say probably because everybody's different, their medical conditions are different, but probably not going to hurt you. Right? So that kind of fits into that category. If it's helping you, you've done it, it's proven safe for you. Go ahead, keep doing it. It's okay.

Nada Youssef:   You said time was the first thing when I asked for nonsurgical treatments.

Dominic Pelle:   Yes.

Nada Youssef:   When is it too long? When is it you're waiting too long and when should I know this pain... I should wait longer. I should not?

Dominic Pelle:   Yeah. It's a great question and it's a little bit difficult to answer because everybody's a little bit different in how bad their sciatica is and how they experience pain. Let me give you just some facts that we talk about. Usually, you're not indicated for surgery unless you've at least had six weeks of pain and in that six weeks you've had to have gone through kind of the myriad of conservative treatments that we just discussed. You have to have pain for at least six weeks, so at least I know that your body's just not going to make it better on its own. Okay?

The other thing, when should you seek treatment? I think if you have burning, terrible pain down your leg, it's a good idea to just go to the doctor anyway to get it checked out kind of right away. It's usually not an emergency, but to initiate the process of treatment right away is probably the best case scenario. In terms of how long to wait before an intervention, if we're talking surgery, once you get out to over a year of symptoms, sometimes it takes you longer to get better after surgery. It doesn't mean you won't do well with surgery, but sometimes it just takes a little bit longer to get better. We try to get to people kind of in between six weeks in a year. Okay?

That's different. If your pain is unrelenting, you can't go to work, you can't stand up, you have to be admitted to the hospital. That can happen with sciatica and it doesn't mean that that person just doesn't experience pain as tough as somebody else. It's just sometimes it's much worse in certain people. If that's the case, then we have a conversation about, "How do we get you better a little bit quicker?" That could be different if you're having progressive weakness. If you say, "Listen, I was walking fine and now my foot doesn't raise that well, and then a couple of weeks go by and now my foot doesn't raise at all." You should seek treatment. Okay? You need to be treated then. So that kind of changes the timetables a little bit, if that makes sense.

Nada Youssef:   Yeah, definitely. Let's talk about surgery. What is done in this kind of surgery?

Dominic Pelle:   Okay. So it depends on the cause of the sciatica, right? We said the sciatica is what we're treating, but the cause of that is all different kinds of things. Let's say it's a disc herniation and I'm going to treat that surgically. I tend to do that with a microdiscectomy. It's a small minimally invasive approach where we make a little incision right in the mid line, use a microscope to get down to the spine and then just drill away some of the bone over where the nerve lives, push the nerve to the side and take the disc herniation out. Okay? We don't take the whole disc out and do a fusion at that time. We usually can get by with a small surgery, usually takes about an hour and a half to do, minimal blood loss and people go home the same day. So that's for a herniated disc.

For lumbar spinal stenosis, if that's causing your sciatica type pain, usually that's a procedure called a laminectomy where we will come down on both sides of the spine and drill out some of the bone and some of the ligaments away that's pressing on the nerves. At the end of the day, spine surgery, no matter the indication, whatever you're doing it for, usually has a certain set of goals. One is to decompress the nerves that are being pinched and in certain cases, to stabilize the spine with a fusion if it needs it. Okay? Most often, isolated cases of disc herniations and lumbar spinal stenosis doesn't necessitate a fusion. We don't usually have to factor that in to these discussions. It's usually a small procedure, usually out of the hospital the same day, but the goal is to decompress the nerves. So we just do whatever we have to do to get that goal met to attain that goal.

Nada Youssef:   Now you mentioned treatments is usually mostly non-surgical, correct?

Dominic Pelle:   Mm-hmm (affirmative). That's correct.

Nada Youssef:   Most people don't need sur- Okay. Can we talk maybe about some preventable measures. We can't help aging for now, but is there anything else that we can do to help? Is stretching everyday a thing. Is that what we should be doing?

Dominic Pelle:   I think the more we try to be healthy as individuals, the better off our spine health will be just as a consequence of that. Weight management is a big issue. I always tell people in the office, the spine sort of functions as a crane. Okay? The muscles are the counterweight of that crane. Right? The weight that we have in the front of our body is sort of the weight the crane's trying to lift. The more weight you have in front, the more the counterweight has to work, the more you get back strains and back issues. So weight management is a big deal for our spine health. It's easy to say you have back pain every day or sciatica. It's easy for me to sit in the chair. I don't hurt. I can say, "Lose weight," but it's hard on folks. Right?

But nonetheless, that's something to continue to try every day that'll help us in our spine health goals. Other things that you can do is to stretch like we talked about. So stretch your lumbar spine out. Reach down and you can easily accessible things on the internet, but we have certain promotional, not promotional, but pamphlets that we give patients at times to kind of help them figure out stretches for them and also core strengthening. The more we strengthen our abdominal musculature, the more pressure that takes off the lumbar spine, the better it is.

Nada Youssef:   All right. I have one more question for you.

Dominic Pelle:   Yeah.

Nada Youssef:   Let's say one of our audiences thinks they have sciatica and they want to see a physician. Do they go straight to a spine surgeon? Do they see their primary physician? What kind of doctor should they see?

Dominic Pelle:   I think the easiest pathway to do would be to see your primary care doctor because you have a relationship with them already. That being said, people with sciatica and if they think they have sciatica, call the Center for Spine Health. We're happy to see you and we always have new appointments that are open and new ways to get patients in. So we'd love to see at the Center for Spine Health. If you think that's what you have, I'd say come see us.

Nada Youssef:   Great. Thank you so much. It's been a pleasure.

Dominic Pelle:   All right. My pleasure.

Nada Youssef:   Thank you and thank you again for our listeners for joining us today. We hope you enjoyed this podcast. To learn more about sciatica and treatment options available, please visit ClevelandClinic.org/spine and to listen to more of our Health Essentials Podcast from our Cleveland Clinic experts, make sure you go to ClevelandClinic.org/HEPodcast and for more health tips, news information from Cleveland clinic, make sure you follow us on social media, Facebook, Twitter, and Instagram @ClevelandClinic, Just one word. Thank you. We'll see again next time.