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sciatica

Muscloskeletal Pain? Primary Care Docs Not Giving Good Advice

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Sciatica.  Knee osteoarthritis symptoms.  While these two conditions seem a world apart, there is something they have in common:  Bad advice.

Both of these conditions have solid research on things that you should and should not be doing to help you recover.  The “should” category involves exercise and moving around.  Almost always with musculoskeletal pain, moving around is better and staying sedentary is a very bad idea.  While my opinion is clearly biased on this one, the acceptable medication approach to most musculoskeletal complaints involves the use of NSAIDs like ibuprofen.  Strong pain medication like opioids (Vicodin, Percocet) should not be used, especially initially, and fall into the “should not” category.

In the “should not” category is also imaging.  While plain X-rays may be appropriate to evaluate for osteoarthritis symptoms, advanced imaging like MRI and CT scan should not be ordered unless certain red flags are present.

All of this is well supported by the medical research over the past 10 years or so.  But one of my continued frustrations with all branches of medicine is just how rare it is for doctors to actually crack open medical journals.  The research itself suggests that doctors are, in general, about 19 years behind the medical literature.  That means that this particular article, looking at just how well primary care doctors understand the current recommendations for sciatica and osteoarthritis symptoms, won’t grace the typical doctor’s eyes for two more decades.

Basically, they won’t know that they don’t know until around 2033.

Just in case you think I’m being a little too facetious, let’s look at what researchers found in the study:

  1. Despite the clear benefit, less than 1/3 of physicians would give exercise advice (30.2% for osteoarthritis, 32.8% for sciatica).
  2. Overall, though, at least newer docs were more likely to give advice on exercise (39.6% of newer physicians versus 26.0% of older docs for sciatica / 20.8% for osteoarthritis).
  3. Newer physicians were less likely to order tests like CBC or CMP (9.4% vs 21.9%) or a urinalysis (4.2% vs 16.7%).
  4. For osteoarthritis, X-rays were more often ordered by newer physicians (85.4% vs 69.8%).

Overall, these numbers reflect poorly on the typical primary care doctors’ ability to handle common musculoskeletal complaints.  For my entire chiropractic practice life I have been confronted with patients and people in the community that ask whether they should see his or her primary care doctor or a chiropractor first.  The evidence is very clear–seeing a chiropractic physician first is the best option that will be more likely to lead you down a path with the best and most efficient outcomes.

But clearly I’m biased.

Steroid Injections Result in Only Limited Short-Term Benefits for Sciatica – (11-21-02)

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Steroid Injections Result in Only Limited Short-Term Benefits for Sciatica

Considering that I see sciatica on a daily basis in my office, this study does not surprise me. What does surprise me is how people still does consider chiropractic when considering options for sciatic pain. I’m proud to say that I have not had a single patient that stuck with me for sciatic pain due to a disc herniation go to surgery. Some of the case were tough, but all resolved without surgery. Also, I have occasionally sent patients for epidurals, but not as the only therapy. That may have been the problem with this study. As one tool to lower the level of inflammation, it can allow other therapies to be more effective. The same goes for shoulders. In now way, shape or form do drugs or injections fix whatever was wrong with the problem.

ACR 66th annual meeting: Abstract 530. Presented Oct. 26, 2002.

In patients with sciatica, epidural injections of corticosteroids appear to produce only limited relief and no sustained benefit, according to findings from the largest randomized controlled trial of its kind.Nigel K. Arden, MD, a senior lecturer in rheumatology at the University of Southampton, U.K., and colleagues presented their research here Saturday at the American College of Rheumatology (ACR) 66th Annual Scientific Meeting. According to Dr. Arden, the procedure is fairly common. “In the U.K., for every million population that comes into the hospital, we are doing 800 epidurals,” he said. To evaluate the efficacy of corticosteroid epidurals, the researchers recruited 228 patients with clinical evidence of unilateral sciatica from four hospitals. At baseline, patients from two of the hospitals underwent magnetic resonance imaging (MRI) of the lumbar spine. Patients were stratified based on whether they had acute or chronic sciatica and were then randomized to receive either three weekly lumbar epidural injections of triamcinolone acetonide 80 mg and bupivacaine or three injections of saline into the interspinous ligament.Patients were assessed at 0, 3, and 12 weeks. Both groups improved at 3 weeks, but the active group had a slightly greater but nonsignificant improvement compared with the placebo group (Oswestry score, 33.5 vs. 38.9; P=.053). At three weeks, 60.8% of the participants in the active group and 39.8% of those in the placebo group reported that their sciatica had improved (P=.03). But at 6 weeks and 12 weeks, the differences were no longer significant (P=0.5 and 0.7, respectively). In addition, the researchers also performed several a priori subgroup analyses to explore predictors of response, such as duration and severity of sciatica at study entry, presence of a significant MRI lesion, and the presence of neurological dysfunction; however, none of these predicted a response.”This study was meant to be the definitive study,” Dr. Arden said. “We used the highest dose and most potent steroid possible,” he said. “We even powered it so that we could pick up a nonclinically significant effect,” he added.”There is no quick fix or magic injection,” says Dr. Arden. According to Dr. Arden, the answer may be to combine pain relief with physiotherapy. “Only a small amount of this condition is physical, so if the patient is also depressed, they should also see a psychologist,” he added. Dr. Arden pointed out that pain consultants tend to think these injections work whereas “rheumatologists tend to think they do not work.”Sidney Block, MD, the session moderator and a rheumatologist in private practice in Bangor, Maine, agreed. “I think it has to do with the perspective of the physician,” he said. “Orthopedists, who are not anxious to operate on a patient’s back, will frequently turn to this as a method of pain relief hoping that it will delay the need for surgery.” “Rheumatologists may also turn to this before surgery, but this study raises the question as to whether this therapy is effective,” he said.

 

Epidural corticosteroid injections for sciatica – (06-23-03)

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Epidural corticosteroid injections for sciatica

The epidural for low back pain is always one that hits close to home. In my own practice, I rarely see long term benefit from steroid injections. Flexion/distraction therapy is an extremely effective and safe treatment for sciatic pain. Also, I see a high number of patients that have been told they have sciatica but, clinically have no evidence of it. This may be another example of clinicians using advanced imaging like MRIs instead of using their exam findings and intuition.

Ann Rheum Dis — Abstracts: Valat et al. 62 (7): 639

Read entire article here

Slipped Disc in Back: Common Sciatic Nerve Treatment Falls Short

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MRI finds a slipped disc in back. Options are short, but you decide on a common sciatic nerve treatment from your doctor’s suggestion. But what’s the best option?

The task of deciding what options are the best seems daunting. Medications, injections, chiropractic (my personal favorite), acupuncture, massage, physical therapy and probably 10 others I’m forgetting.

But before you decide on a treatment, we need to back up a little. The conversation needs to start with where you got your diagnosis. The diagnosis of a disc problem (slipped disc, disc bulge, disc herniation – the actual description is quite technical, but you get the idea) can be make quite accurately in a competent physician’s office. Rarely is an MRI needed to diagnose a disc problem, and the guidelines clearly state, that in the absence of red flags, any imaging needs to wait until 4 weeks of conservative treatment. Despite this mainstream medicine seems to want to order MRIs and CT scans at the first sign of back problems.

This is were the problems begin. Numerous studies have confirmed that early MRIs are a bad thing, driving expensive, dangerous and unneeded treatments. But let’s say you made the mistake of not going to a chiropractor first for your back pain and you did get an MRI or CT scan. And this MRI or CT shows that you have some type of problem with the intervertebral discs of your lumbar spine.

Here comes the big question. Do you have leg pain or not? And is this leg pain scleratogenous, radicular or radiating? I don’t really expect you to answer that question, but hopefully you can begin to see that just because your back pain is accompanied by leg pain this does NOT mean that you have sciatica. I can’t tell you how many times I’ve seen patients with leg pain that, after some targeted soft tissue work on his or her low back and glut region (gluteus maximus, posterior hip, rump, derriere–you get the idea), the leg pain gets better or is gone.  There is no way a slipped disc in back would respond that fast.

Sciatica refers to radicular pain that comes from chemical or pressure (from a disc) directly on the sciatic nerve. For those of you unsure of where the sciatic nerve goes, I’ll clarify. It goes into the leg. Despite this, I have seen patients spend tens of thousands of dollars for epidural injections for low back pain that doesn’t involve pain in the leg. I’m not sure there’s ever been an indication to use epidural injections in the lumbar spine for treatment of local back pain (without leg pain). It may be done all the time, but that doesn’t make it right.

Overall, this means that you need to see someone who understands all the nuances of back pain and leg pain. (hint, hint….a chiropractor). Anything short of that and you may get sent in the wrong direction.

Back to this particular article that looked at the effectiveness of epidural steroid injection as a common sciatic nerve treatment.

I have personally referred a small handful of patients out for epidural steroid injections over the years, but they are few and far between. I have never considered spinal injections as a stand alone therapy. At the most, they allow a small window of pain relief, where other options have failed, where other therapies can be used more aggressively.

So what happens if an epidural is the only therapy used? Basically, confirming other studies, these researchers found that they suck. Here are the specifics:

  • Researchers looked at 25 different studies.
  • Epidural corticosteroid injections improved leg pain 6.2 points (out of 100).
  • This was only noted in the short term (2 wks to 3 months).
  • Beyond 3 months, the benefits were even smaller–pretty much non-existent.

So basically, an epidural injection for sciatic pain is very expensive (I’ve seen bills as high as $5,000 per shot) and really does nothing but provide a small amount of pain relief for a short period of time. Worse, it may accelerate destruction of the disc and lead you to surgery. Of course, none of this takes into account the close to 400 cases of fungal meningitis on the East Coast from contaminated vials of the steroid used in this procedure, with almost 30 deaths so far.

Where do I sign up?

WHAT HAPPENED AFTER YOUR MRI?

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It doesn’t happen all the time, but it is not uncommon for a patient to call our office to cancel an appointment because they went to their PCP, the PCP ordered an MRI and now they have to see a specialist. Sound reasonable?

There are multiple layers of “wrong” in this scenario. First and foremost is that, in most situations, we have already identified whether a disc bulge / sciatica was present based on talking to the patient and our exam finding. At this point, without any type of red flags, it is never, ever recommended to order an MRI this early in the treatment. Happens all the time, but apparently, those ordering the MRI are not reading the studies.

Not only is this a tremendous waste of resources, but it is well documented that this starts the patient on a MRI to epidural to surgery pathway, despite evidence that this is not the best pathway for the patient. It is also far too common for the PCP to steer the patient away from chiropractic care to a specialist–when chiropractic care is exactly what they need.

So what about the epidural’s effectiveness in the case of chronic (>12 weeks) radiculopathy (leg pain)? This particular study finds it worse than worthless—actually giving a small injection of saline was massively more beneficial than the steroid injection (Oswestry change after 52 wks– saline 14.3 points improvement, epidural 1.9 points worse). So basically, the epidural clearly made the patient worse as time went on.

The bottom line is that chiropractic care, for all musculoskeletal complaints, is the best place to go to get the best outcomes for your pain. Let the chiropractor decide if an MRI and epidural is appropriate.