Sciatica/ Numbness/ Weakness

Sciatica is a condition that causes pain in the distribution of the sciatic nerve that branches out from the lower back through the hips and buttocks and down to leg. The condition may affect on one or both sides of the body. Compression of sciatic nerve can be caused by a herniated disc, bone spur or narrowing of spine bone causing pain and inflammation on the nerves. The pain radiates along the pathway of the sciatic nerve causing inflammation, pain and numbness in the affected leg.

The symptoms can be mild or severe with mild aching to a sharp, burning sensation or unbearable pain feeling like an electric shock. The condition may worsen with a cough, sneeze or prolonged sitting.The doctor diagnoses the condition by clinical and physical examination. Imaging tests including X-ray, MRI and CT scan may be performed to provide a detailed image of the affected structures. Conventional treatment methods include anti-inflammatory drugs, muscle relaxants, tri-cyclic antidepressants and other medications to relieve the pain and numbness of the affected leg. Physical therapy is initiated when the pain and swelling subsides to correct the posture, strengthen the muscles supporting the back and improve the muscle strength and flexibility.

ALTERNATIVE TREATMENT METHODS AT BETH YEHUDAH ARTHRITIS CENTER , PULLAD AND DAYSTAR CLINIC, ALAPPUZHA FOR SCIATICA /NUMBNESS AND WEAKNESS

Sciatica could be also caused due to other factors apart from the above. Sciatica could be the result of referred pain or due to irritation of the Sciatic nerve or its branches either in the lower back, hip/ buttock, thigh, leg or even the foot. It could also be due to compression from a muscle called Pyriformis in the Hip. At times there are CCPs (chronic constricting points) along the Sciatic nerve or its branches which may result in Sciatica. Many times ligamentous instability of the lower back, Inflammatory conditions in the hip and lower back manifests as Sciatica/ numbness/ weakness in the distribution of the Sciatic Nerve.

Many times a patient with back pain; despite various treatments still has pain and now has been recommended a spine surgery because “MRI shows something”. But is it in fact the disc prolapse on MRI always the cause of the patient’s pain? Medical researchers are asking, “Maybe we should look at the spinal ligaments?”

Patients who are in severe back pain with sciatica usually bring an MRI/ X-ray and/or scan that may show an inaccurate picture of what is causing their pain. In a landmark study by Boden et al in the Journal of Bone and Joint Surgery (Am) 1990, which has been quoted by nearly 2700 other articles Dr Boden does MRI scans of the Lower Back for people who have no lower back pain, sciatica or neural claudication in lower limbs. He gets neuro-radiologists to interpret the MRI without them being told the history and examination findings. He found that 57% of apparently “normal” people above the age of 60 years without any backache or nerve symptoms in legs had “abnormal” MRI changes with 36% having Disc prolapse and 21% having Spinal Canal Stenosis. If 57% of apparently normal people with no previous symptoms have abnormal Spine MRI, how can we be sure that when a patient presents with back pain, that his pain is actually related to the bulging disc? When that disc bulge could certainly be asymptomatic. The MRI cannot show muscle spasms from a simple cervical/ lumbar strain which can cause excruciating pain. Neither can it detect early micro-structural damage at the ligament bone junctions/ enthesitis nor can it detect nerve sheath CCPs (chronic constricting points) along the course of various nerves. Conversely, a herniated disc may be seen on MRI which may be completely painless. Yet that herniated disc will send the patient to surgery. Dr Tejaz John has observed in his clinical practice that at times patients may bring MRI showing disc prolapse towards one side whereas the symptoms are experienced on the opposite side.

Here is a statement from the medical journal Childs Nerv Syst. 2015: “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.” Unlike muscle tissue, ligaments and tendons have a poor supply of blood to regenerate them. This is why ligaments can remain in a weakened and irritable inflammatory state and may not heal. The chronic back pain patient may have history of trauma or overuse to the Spine that result in injury to various spinal ligaments that hold the vertebrae and spinal processes in place. Ligaments can bear a normal amount of stress that causes them to stretch up to their natural limit, returning back to their normal length once the stress is removed. If added (traumatic) stress is applied on the ligament, it is stretched beyond its natural range of extension, and subsequently fails to return to its original length but instead remains permanently overstretched resulting in plastic deformation, diminishing its integrity and attachment to the bone. This causes ligament and soft tissue loosening and subsequent Spinal Instability.

1) PRP Prolotherapy for Back/Hip  Pain with Sciatica Platelet-Rich Plasma Therapy (PRP) has been found to be effective in treating degenerative disc disease by medical researchers by dealing with the problem of spinal ligament instability. The sooner the spinal ligament instability is treated, the better the results and patient satisfaction. In fact, abnormal stress on the spinal ligaments could be an important cause for most pain in degenerative disc disease. In cases of spinal ligament instability, PRP is an effective means of alleviating sciatica and lower back pain because it eliminates pain by stimulating the local immune response to heal the underlying tissues and may help avoid surgery.

PRP prolotherapy is a combination treatment where PRP is injected into region of the joint and dextrose prolotherapy is given to the ligaments of the joint. This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.

How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Table 1: Various biological growth factors released by PRP when activated

PRP injection delivers a high concentration of autologous (patient’s own) platelets to the joints and soft tissues in the lower back. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the joint using PRP injection stimulates the healing process and faster recovery from the musculoskeletal condition.

2) Dextrose Prolotherapy for Sciatica associated with Back/ Hip pain
Dextrose Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the damaged joints. Prolotherapy works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. Prolotherapy is an effective non surgical treatment method used successfully in spinal instability and other spine conditions. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous structures in and around the joint.

Once we know that spinal ligamentous instability is at the root of the problem of back pain leading to sciatica in most patients Dextrose Prolotherapy may offer great results by stimulating the body’s immune system to repair and naturally tighten these ligaments and muscles in the back and hip region.  Instead, most patients are usually prescribed pain tablets and muscle relaxers to cover up the pain, which only leads to further degeneration and an endless “pain management” cycle. This is like treating the symptoms versus correcting underlying spinal instability. Comprehensive Dextrose Prolotherapy can break this cycle by assisting the regeneration of weakened and stretched-out soft tissue structures of the lumbar spine, alleviating pain and instability. Using Prolotherapy, these conditions can be treated properly and safely to give a more desirable symptomatic outcome. Along with the treatment technique, it is important to perform series of movement and muscle strengthening exercises to strengthen the already weakened muscles in chronic lower back ache.

Patient Benefits of PRP Prolotherapy and Prolotherapy:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who wish to avoid if not delay repeated Surgery
• May significantly reduce the symptoms associated with Backache associated with Sciatica.
• Reduced risk of adverse events
• Repairs and tightens ligaments improving spine stability and ease of standing, sitting & walking
• Safe and effective treatment method
• Faster healing and recovery

PRP Prolotherapy results in safe, significant, effective, progressive improvement and reduction of stiffness.

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Avoid if not delay Surgery.
• Significantly reduces the symptoms associated with Inflammation in cases of Sciatica due to neuritis.
• Reduced risk of adverse events compared to oral steroid tablets which are usually taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces pain and discomfort in most patients.
• More effective treatment method in Sciatica due to inflammatory conditions.
• Faster recovery.
• NESTIT treatment results in significant, effective, progressive improvement of pain, function and reduction of stiffness if given in series.
  
   At Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Sciatica/ Numbness/ Weakness conditions. We tailor a customized treatment plan to treat patients suffering from different conditions of Sciatica/ Numbness/ Weakness. To know more Sciatica/ Numbness/ Weakness treatment plans and cost, book an appointment now.