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Keyword: back pain

Sciatica (a shooting pain, tingling or numbness stemming from the sciatic nerve) is one of the most common causes of back and leg pain. It can be debilitating for many people. According to Avery L. Buchholz, M.D., an assistant professor in the Department of Neurosurgery at MUSC Health, conservative management such as physical therapy can effectively treat the vast majority of patients with sciatica.

Sciatica symptoms typically disappear over time, sometimes without any treatment, but Dr. Buchholz believes patients should not have to suffer. He says a partnership between spine surgeons and primary care physicians can help patients with sciatica symptoms find relief faster.

“I’d like to partner with primary care physicians to co-manage these patients. Sciatica pain can be very frustrating for patients, and we’ve found that they appreciate the benefits of a partnership approach to care,” says Dr. Buchholz.

Sciatica Pain Affects Wide Swath of People

Dr. Buchholz says sciatica pain can affect people of any age, but commonly affects older adults (ages 50 to 60) and women during pregnancy. Sciatica is characterized by a cluster of symptoms that affect the sciatic nerve.

Symptoms differ depending on the individual patient and the specific cause. They generally affect the lower back or legs and involve any combination of:

  • Sharp pain
  • Numbness
  • Tingling
  • A burning in the buttocks that travels down the leg (sometimes to the foot)
  • Weakness in the foot or leg

According to Dr. Buchholz, a number of factors or conditions can actually cause those symptoms, including:

  • Disk herniations that push on a nerve
  • Degeneration and boney overgrowth or osteophytes that push on a nerve root
  • Spinal stenosis that causes nerve irritability
  • Rarely, fractures, tumors and infections

Sciatica Treatment Options

Because sciatica pain can come on quite suddenly, Dr. Buchholz says patients experiencing a sudden onset of painful symptoms may seek care at an emergency center. But a conservative treatment approach works best for most patients, he says, especially as a first-line treatment option.

Many patients find sciatica relief after prioritizing rest. Avoiding exercises or positions that irritate the nerve (or otherwise cause pain) can also help. While sciatica often gets better with time, even disappearing entirely, Dr. Buchholz says physical therapy can help accelerate that process while giving the body time to adjust and heal.

“Physical therapy provides relief by strengthening the core (the belly and back muscles), which supports and stabilizes the spine. This action calms the inflamed sciatic nerve and reduces irritation, thus decreasing pain. Physical therapy is useful early on, helping to stretch some of the muscles around the sciatic nerve and decrease inflammation,” he explains.

When conservative therapies are not successful, Dr. Buchholz considers several other sciatica treatments. Based on individual patient circumstances, recommended next steps may include:

  • Steroids, which can help reduce inflammation of the nerve
  • Medication, such as over-the-counter anti-inflammatories or muscle relaxants
  • Injections, including epidural or transforaminal, which can reduce inflammation and pain in cases where an MRI shows a nerve is pinched
  • Surgery, in rare cases, to decompress the nerve root

A Comprehensive Sciatica Treatment Approach

Dr. Buchholz says he’s happy to see any patient who’s suffering from sciatica symptoms.

“Most of the patients I see do well with conservative therapies and never need surgery. Still, those patients often tell me they appreciate someone explaining the nuances of what’s causing their pain and the various treatment options. In the rare case that we are unable to treat a patient’s symptoms conservatively, we can easily discuss surgical options and provide access to specialized surgical procedures,” says Dr. Buchholz.

Dr. Buchholz says MUSC spine specialists are looking forward to partnering with primary care physicians to manage patients affected by sciatica. Primary care physicians are often best suited to identify sciatica from other sources of back pain, which is key. If symptoms persist past a few weeks and physical therapy isn’t providing sufficient relief, a referral to a spine specialist may be the next best step.

“We hope to be a useful resource for primary care physicians and patients with sciatica early in the treatment process, even before any advanced imaging is ordered. Some patients need a little extra reassurance and consulting regarding their symptoms — specifically regarding what to expect and how to move forward with it. We’re ready to be that resource for patients and physicians.”

For more information, contact Dr. Buchholz at buchholz@musc.edu.
 

As interventional pain management therapies rapidly advance, more patients suffering from chronic neuropathic pain could experience relief and quality-of-life improvements from these new treatment options.

According to M. Gabriel Hillegass, M.D., a board-certified interventional pain management physician at MUSC Health, neuromodulation advances related to spinal cord stimulation and radiofrequency ablation are two particularly exciting treatment avenues offering patients excellent results for chronic pain, such as back and joint pain.

Spinal Cord Stimulation for Chronic Back Pain

Neuromodulation uses implanted devices or special needles to treat nerve pain with electrical stimulation. In spinal cord stimulation, an outpatient neuromodulation therapy, electrodes are carefully placed in the epidural space over the spinal cord to override nerve pain signals, thus relieving patients’ pain.

According to Dr. Hillegass, neuromodulation technologies have seen exciting advances in the past 5 years.

“Neuromodulation technologies are developing quickly. In spinal cord stimulation, applications can not only stimulate the nerves along the spinal cord but also the dorsal root ganglion, which is a cell body of the sensory nerves that just exit the spinal cord. Still under development, but soon to come, will be targeted peripheral nerve stimulation applications,” he says.

For spinal cord stimulation procedures, a device consisting of a battery generator and attached wire leads (analogous to a cardiac pacemaker) is implanted under a patient’s skin. Similar to how a pacemaker regulates heart function, this implant modulates the nervous system.

“Stimulation procedures are pretty stable therapies,” says Dr. Hillegass, noting that the most common complications involve the device’s battery, which may need replacement after several years, or an electrical lead moving, which requires a revision surgery to reset the lead.

Recent advances in neuromodulation therapies:

  • Treating neuropathic pain: Technology advances have made significant strides in treating difficult-to-treat neuropathic pain, particularly post-laminectomy syndrome, or failed back surgery syndrome. Sometimes, someone who has undergone spine surgery still has persistent back pain, often with associated arm or leg pain. This neuropathic pain, or pain arising from abnormally firing nerves, could be due to injury, inflammation or scar tissue.
  • Better delivery: “Within the past 2 to 3 years, the waveforms (or pulse patterns) that the spinal cord stimulators deliver have improved dramatically,” says Dr. Hillegass. “We’re now better able to treat back pain, which we couldn’t do previously with traditional (tonic or paresthesia-based) spinal cord stimulation. Additionally, these novel waveforms are not felt by the patient and seem to have less tolerance than traditional stimulation.”
  • Advanced techniques: An innovative technique stimulates the dorsal root ganglion directly, so doctors can better target specific nerves and potentially help more patients with chronic pain involving a specific nervous distribution.
  • MRI-compatibility: Some newer spinal cord stimulation devices are also MRI-compatible, so patients will be able to undergo an MRI scan, should they need one in their future.

Radiofrequency Ablation for Chronic Joint and Knee Pain

In radiofrequency ablation procedures, specialists attempt to decrease pain signals by using a special needle to lesion a particular nerve, primarily with heat. Here, too, advancing technologies offer more applications for this therapy’s use in chronic pain management.

“Traditionally, radiofrequency ablation was used for facet joints along the spine. We are now starting to learn how to perform these procedures to relieve chronic knee pain, hip pain, groin pain as well as other indications,” says Dr. Hillegass.

One new application of this innovative therapy that’s already in use at MUSC is called COOLIEF. This procedure uses cooled radiofrequency energy to target and treat sensory nerves causing chronic pain such as knee pain.

Because all nerves will try to grow back, radiofrequency ablation procedures are not a permanent fix. The treatment effect tends to last an average 9 to 12 months, so it is often repeated at intervals, depending on a patient’s response to the therapy.

“As we learn more about how to apply radiofrequency ablation to peripheral joints such as the knees and the hips, this procedure may be a new treatment option for patients who are not candidates for joint replacement surgery or those with chronic postsurgical pain and other peripheral nerve pain syndromes,” says Dr. Hillegass.

Interventional Pain Management: Potential Complications

Complications of interventional pain management procedures include:

  • Rarely, infection and nerve injury
  • Spinal cord injury, also rare but possible, depending on the area of interest
  • Procedure does not provide the expected duration of pain relief—the most likely complication

To avoid the problem of insufficient pain relief after more advanced procedures such as spinal cord stimulation, Dr. Hillegass performs a trial with a spinal cord stimulator before implanting the system in any patient.

“The lead is externalized coming through the skin, and the lead and battery are sterilely taped to a patient’s back. Then, we ask a patient to live his or her life with the stimulation on for a week, so we can determine how much pain relief they had and how much their function improved,” explains Dr. Hillegass.

Interventional Pain Management Care Considerations

Before patients are considered candidates for interventional pain therapies:

  1. Evaluation: Doctors complete a thorough assessment, including a comprehensive history and physical and review of previous therapies and interventions.
  2. Diagnostic tests: In some cases, electrodiagnostic or imaging studies may be warranted to confirm that the source of a patient’s pain is coming from the expected nerve distribution.
  3. Psychological screening: Most insurance policies require a psychological evaluation for patients who are considering spinal cord stimulation. “If a patient has a severe untreated psychiatric disorder, such as severe depression, then they’re not a good candidate for the therapy at that time. Patients may need to optimize their mental health prior to pursuing any of these advanced interventional pain options,” says Dr. Hillegass.

At MUSC Health, those mental health resources can be found all under one roof. “As an academic medical center, we have resources throughout the university in terms of mental health support and robust addiction medicine services, both inpatient and outpatient. We’re able to collaborate easily with interdisciplinary teams to take care of patients with complicated pain histories,” he explains.

New Potential for Chronic Pain Relief

Patients who were previously not suitable candidates for standard interventional pain management therapies may be a better fit for these newer therapies.

The number of patients who could see relief from these therapies—and the potential quality-of-life improvements—is sizeable, says Dr. Hillegass.

“Patients who had failed back surgery and are not doing well on conservative therapies should be referred for evaluation for some of these advanced interventional pain options. It could dramatically decrease patients’ reliance on chronic opioids, which is a major problem in our country. These interventional pain management treatments are proving to be effective therapies. Patients experiencing chronic pain would benefit from exploring these new options,” he says.

For more information, contact Dr. Hillegass at hillegass@musc.edu.
 

Spine surgery can offer patients significant relief for chronic back or leg pain related to disc herniation. Yet traditional surgical approaches require a lengthy recovery that can make many patients hesitant. The endoscopic discectomy procedure uses less invasive techniques, so patients can see relief sooner — with much less downtime.

“Endoscopic spine surgery techniques have been perfected over the last decade. In endoscopic discectomy procedures today, patients can be up and moving (and go home) the same day as the surgery. They experience the same degree of pain relief as they would with an open procedure – but with a shorter and less painful recovery,” says Dr. Bruce M. Frankel, M.D., a neurosurgeon at the MUSC Health Spine Center.

Less Invasive Spine Surgery Offers Multiple Benefits

In an endoscopic discectomy procedure, Dr. Frankel makes a tiny incision in the patient’s back, then introduces a small dilator right next to a disc herniation in the spine. Under direct visualization with an endoscope, he then shaves off the disc herniation to free the pinched nerve that’s causing the pain.

According to Dr. Frankel, patients experience several benefits from this endoscopic approach:

  • Less downtime: “There’s a shorter recovery, with most patients on their feet soon after surgery. Patients experience significantly less postoperative pain than with traditional operations.”
  • Similar outcomes: “Outcomes are similar to those from open procedures. While open procedures work quite well, patients can experience setbacks from the significant pain they experience during their recovery. We eliminate that setback with an endoscopic approach.”
  • Minimal sedation: “Patients don’t need to be intubated like they would during open operations.”
  • Less blood loss: “Most patients have minimal to no blood loss. In an open procedure, blood loss poses a larger concern.”
  • Shorter procedure: “Traditional spine surgeries can last several hours. We can complete an endoscopic discectomy procedure in 30-45 minutes.”
  • Lasting results: “Patients typically see long-term and hopefully permanent leg pain relief.”

Dr. Frankel has seen how chronic nerve pain severely limits patients’ lives. With endoscopic approaches to spine surgery, he hopes to help patients add quality and function back to their day.

“Less invasive spine surgery techniques offer significant benefits with little downside to patients. It’s an alternative to other complicated surgeries such as large back fusion procedures that may have significant downsides and may not offer permanent results. Endoscopic techniques help patients affected by chronic back or leg pain feel better, so they get back to their daily activities without undergoing a complicated surgery,” says Dr. Frankel.

MUSC Spine Center Has a Treatment Option for Everyone

Endoscopic discectomy is just one way specialists at the MUSC Health Spine Center treat chronic back and leg pain. The specialists at the center find the right treatment solution for each patient, including non-operative treatments, such as pain management and physical therapy.

The center’s spine specialists are trained in all types of surgical approaches: They are proficient in open and traditional surgeries, when such an approach will provide the best outcome for patients. And they perform a range of less invasive spine surgeries in addition to endoscopic discectomy, including minimally invasive rhizotomies, fusions and reconstructions.

The multidisciplinary spine center tackles patients’ pain from multiple angles. Depending on individual circumstances, patients may meet with one or more of the following care specialists:

  • Pain physicians
  • Physical therapists
  • Physiatrists
  • Surgeons, specializing in orthopaedics or neurosurgery

“Our approach to back and spine care is both multimodal and collaborative. Our goal is to match every patient with a treatment that offers the relief they seek,” he says.

For more information, contact Dr. Frankel at frankel@musc.edu.

Complex spinal deformities can cause debilitating pain, restricted movement, even low self-worth. MUSC Health Spine Center specialists partner with patients to get them relief – no matter the patient’s age or cause of the pain.

“There's a lot we can do to help people who have back pain related to a complex spinal deformity. With our skilled surgeons and comprehensive support team, we have capabilities today that we didn’t have before,” says Charles Reitman, M.D., an orthopaedic surgeon and co-director of the MUSC Health Spine Center.

Spine surgery can be complex. To avoid complications, Dr. Reitman pays particular attention to patients’ health prior to greenlighting surgery. Working together with patients, he helps improve their symptoms and self-image.

Common Causes of Back Pain From Spinal Deformities

Many adults with spinal deformities suffer from the effects of an untreated childhood ailment. However, spinal deformities may occur at any age and be caused by other factors, including:

  • Injury
  • Cancer
  • Infection
  • Inflammatory conditions, such as rheumatoid arthritis
  • Degenerative disease
  • Postoperative complications

“The main types of spinal deformities include sagittal plane deformities, such as kyphosis, and coronal plane deformities, such as scoliosis. For both these conditions, corrective spine surgery can be pretty complicated,” says Dr. Reitman.

Partnering With Patients to Make Spine Surgery Happen

Because spine surgery can pose so many complications, Dr. Reitman says many spine surgeons may be reluctant to perform surgery on older patients or those in less-than-ideal health.

The team at MUSC Health Spine Center works with patients to make spine surgery possible for them, regardless of their health impediments.

“A patient with a severe sagittal plane or coronal plane deformity, for example, may be in severe pain, unable to stand up straight and may have limited function. That patient shouldn't think twice about getting evaluated for spine surgery — no matter their health or age,” he says.

Dr. Reitman notes the importance of patients taking ownership over their health prior to spine surgery, which helps avoid complications and ensures more effective results. Dr. Reitman works with patients to overcome health hurdles before surgery.

Common roadblocks that can impede healing and recovery include:

  • Smoking
  • Overweight or obesity
  • Heart disease or lung disease
  • Diabetes
  • Low bone density
  • Poor bone quality


Dr. Reitman emphasizes: “If patients commit to tackling any health problems they have (with our support), then we can often get them through surgery safely and effectively. That’s our goal: to find patients relief, safely and help them lead a more fulfilling life.”

Spine Surgery Offers More Than Back Pain Relief

When patients optimize their health prior to surgery, Dr. Reitman says they optimize their chances of success.

“Spine surgery is not a walk in the park for anyone. At MUSC, we have a high-level, coordinated critical care team that can handle complicated cases. For patients who commit to ensuring they can reach their ideal health prior to surgery, it’s more than worth it,” says Dr. Reitman.

“With many complex spinal deformities, the body is in a position that it simply wasn't meant to be in. Corrective surgery does more than relieve pain – it improves patients’ self-image and self-worth. Even though it’s a high-risk surgery with potential complications, the vast majority of patients who have been through it tell me that they’d do it all over again, in a second. Patients say spine surgery gave them their life back. That’s what we’re here to do, for as many patients as we can,” he says.

For more information, contact Dr. Reitman at reitman@musc.edu.

 

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