Diseases, Disorders information

If you don’t have a cauda equina syndrome and you see someone with sciatica which is a rational way to approach it, a brief period of bed rest, followed by active mobilization and therapy with or without modalities as needed acutely, nonsteroidal, most likely some form of analgesics, epidural or oral steroid therapy, that would certainly seem intuitively to be plausible, but again there are very few studies in the literature that document the efficacy in a statistically valid manner. The exception to that was in the Clinical Orthopaedics and related research, just the last issue of the journal, where the study from Scandinavia showing that epidural steroids in a randomized prospective study, may in fact, have some benefit in this pathology, but that is literally hot off the presses. If you take a patient to surgery to remove the disc and the gold standard for that is the so-called microdiscectomy which is essentially an outpatient procedure, you should be just about 100% successful at relieving the sciatica, assuming you have four of these signs, root pain, root irritation, straight leg raising, root compression signs, motor or sensory deficit and a corresponding myelographic or MRI findings, in other words, what you are seeing in the objective imaging modalities, has got to be precisely concordant with the patient’s symptoms and physical examination, and these are older data, but other studies have verified those. Again, remember we are only treating the leg pain, we are not treating the back pain.
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Here is an example of that, here is a patient who presented with a trunk shift, no neurologic deficit, failed to respond to conservative care after eight weeks, was then referred, and you can see the plain films do show the trunk shift, but not much else. This patient came MRI in hand, courtesy of the referring physician, and in fact, MRI shows this very, very large disc prolapse, it’s a pretty old MRI as you can see, which is just about 40% of the cross section area of the canal, and when you have a prolapse that big, most of the time it’s a free fragment, so-called sequestered fragment, it’s actually broken off and this was the homunculus that was removed at the time of surgery, and you can see that was a very large fragment indeed. Patient’s like this are extremely gratifying to treat surgically because literally they will wake up, and in the recovery room, be pain free, and that is a very, very happy patient and a very happy surgeon.
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