The intervertebral discs are made-up of two concentric layers, the inner gel-like Nucleus Pulposus and the outer fibrous Annulus fibrosus. As a result of advancing age, the nucleus loses fluid, volume and resiliency and the entire disc structure becomes more susceptible to trauma and compression. This condition is called as degeneration of the disc. The disc then is highly vulnerable to tears and as these occur, the inner nucleus pulposus protrudes through the fibrous layer, producing a bulge in the intervertebral disc. This condition is named as herniated disc. This can then cause compression to the spinal cord or the emerging nerve roots and lead to associated problems of Sciatica radiating pain from back to legs in the distribution of the nerve. Other symptoms could be a weakness, tingling or numbness in the areas corresponding to the affected nerve. Sometimes bladder compromise is also present, which is made evident for urine retention and this need to be taken care as an emergency.
Excessive weight, bad postures, undue movements, improper weight lifting and other kinds of traumas may weaken the intervertebral discs. When this occurs the pulpous nucleus will bulge against the annulus, or even be squeezed through it (extruded disc).

The first steps to deal with a herniated or prolapsed lumbar disc are conservative. These include rest, analgesic and anti-inflammatory medication and in some cases physical therapy. At this point, it is convenient to have some plain X-rays done, in search of some indirect evidence of the disc problem, as well as of degenerative changes on the spine.

If in a few days these measures have failed, the diagnosis has to be confirmed by means of examinations that give better detail over the troubled area, as the MRI, CT which will show the disc, the space behind it and in the first case, the nerves. In some instances, the EMG (electromyography) is also of great value, as this will show the functionality of the nerves and muscles.

Once the diagnosis has been confirmed, one of the best alternatives existing today is the Ozone Discolysis as the results obtained are excellent and practically has no complications. This novel treatment avoids the use of surgery in 80% of those who needed it. In most patients left with painkillers as the only treatment, the symptoms eventually disappear, only that this could take weeks to months. Ozone speeds up these developments, see the same result in a few weeks. The problem has to be seen and approached integrally and frequently the combination of therapies has to be used, most frequently physiotherapy. Also, it has to be known that those who had a herniated disc have 10 times more chances of having another herniation than the rest of the population.

If despite the ozone therapy the symptoms persist, Drill Discectomy/ Laser Discectomy are good alternatives before open surgery (Discectomy) which has to be contemplated in those true emergencies, as mentioned above, this is possibly the first choice.

Once the conservative treatment fails:

Early aggressive treatment plan of pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery & 20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is important even then.

Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures with time spacing depending upon pt`s pathology & response to treatment.

Using precision diagnostic & therapeutic blocks in chronic LBP, isolated facet joint pain in 40%, discogenic pain in 25% (95% in L4-5&L5S1), segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of LBP after conservative treatment has failed.

LESI: Lumbar Epidural Steroid Injection

Indicated in   Acute radicular pain due to irritation or inflammation.

Symptomatic herniated disc with failed conservative therapy
Acute exacerbation of discogenic pain or pain of spinal stenosis
Neoplastic infiltration of roots
Epidural fibrosis
Chronic LBP with acute radicular symptoms
Epidural- lumbar injection
ESI Treatment Plan

Compared to interlaminar approach better results are found with a transforaminal approach where drugs (steroid+ LA/saline +/- hyalase) are injected into anterior epidural space & neural foramen area where herniated disc or offending nociceptors are located. Whereas in interlaminar approach most of drug is deposited in posterior epidural space.Drugs are injected total 6-10 ml at lumbar, 3-6 ml at cervical & 20+ ml, if caudal approach is selected. Lumbar ESI is performed close to the level of radiculopathy, often using paramedian approach to target the lateral aspect of the epidural space on involved side. Cervical epidural is performed at C7-T1 level.

SNRB- Selective Nerve Root Block 

Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy pain if

There is minimal or no radiological finding.
Multilevel imaging abnormalities
Equivocal neurological examination finding or discrepancy between clinical & radiological signs
Postop patient with unexplainable or recurrent pain
Combined canal & lateral recess stenosis.
To find out the pathological dermatome for more invasive procedures, if needed
Intradiscal Procedures 

Provocative Discography - Coupled with CT

A diagnostic procedure & prognostic indicator for surgical outcome is necessary for the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear, finding surgical options & in assessing previously operated spines.

Percutaneous Disc Decompression (PDD)

After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed

Ozone Discolysis: Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a daycare setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. The total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no postoperative discomfort or morbidity and low cost.

Dekompressor: A mechanical percutaneous nucleosome cuts & drills out the disc material somewhat like morcirator debulking the disc reducing nerve compression.

Epidural Adhenolysis or Percutaneous Decompressive Neuroplasty for Epidural Fibrosis or Adhesions in Failed Back Surgery Syndrome (FBSS)

A catheter is inserted in epidural space via caudal/ interlaminar/ transforaminal approach. After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/ hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with epiduroscope.

Procedures That Can Help Treat Slip Disc & Sciatica!

The sciatic nerve is one of the largest nerves in the body. It goes from the lower back all the way down to the base of the leg. When there is a disorder associated with the sciatic nerve, it is known as Sciatica. 

Sciatica, however, does not necessarily need a surgery or a very elaborate procedure to fix the problem. Most commonly, it is treated simply by practicing a number of simple exercises. Here are some of the most common exercises prescribed to treat Sciatica:

1. Reclining Pigeon Pose:
There are three main forms of the pigeon pose. These are sitting, reclining and then forwarding. It is recommended that if you have very recently started your treatment for Sciatica, then certainly you should go for the reclining pose. In this pose, you are supposed to hold your left leg in the air at a right angle to your back. Then, hold your ankle against the knee. Finally, repeat this stretch with the right leg as well.

2. Knee to Opposite Shoulder:
In this stretch, the starting position is on your back side. You have to have your legs out and feet upwards. From this position, try to bring your right leg towards your left shoulder. Hold this for 30 seconds and then release and relax. Repeat this activity three times and repeat the whole procedure with your other leg. Only take your leg as far as it goes.

3. Sitting Spinal Stretch:
At the start of this exercise, sit on the ground with your legs going straight outwards and your feet flexed in the upward direction. Pull your left knee and put it on the outside of your right knee. Finally, place your right elbow on the left knee, so that your body turns to the left. Hold for 30 seconds and then relax. Repeat the procedure with the other knee.

4. Standing Hamstring Stretch:
Put your foot on an elevated surface such that it is above the floor, but not above hip level. Flex your toes forward such that your feet and legs are nearly in a straight line. Bend as far towards the foot as possible. However, do not stretch so far that you feel pain. Finally, repeat this procedure on the other side after release.

Exercises For Sciatica

Sciatica, which is pain along the huge sciatic nerve that runs through the lower back to the back of each leg, can bring about serious, weakening pain. The term sciatica depicts indications of leg pain along with potential shivering, weakness, or numbness that starts in the lower back and goes through the butt cheek and down the vast sciatic nerve in the back of every leg. However, here are some top ways to get pain relief from sciatica:

1. Chiropractic/manual control
Spinal adjustment and manual control performed by properly trained health experts, for example, chiropractors and osteopathic doctors, are centered around giving better spinal cord alignment. These are intended to address various basic conditions, which can bring about sciatic nerve pain.

2. Acupuncture
This practice is based on the goal of achieving or keeping up the strength through an open stream of energy by certain pathways in the body. Hair-thin needles (which are generally not felt) are embedded into the skin, close to the zone of pain.

3. Subjective behavior therapy
This treatment for taking control and evolving self-defeating behaviors can be useful in overseeing sciatica pain, especially in the short term. Sessions with an advisor might be face-to-face or on the web.

4. Massage treatment
Certain types of back rub treatments have proven to have various advantages for back pain, including expanded blood flow, muscle relaxing, and release of endorphins (the body's regular pain relievers).

5. Strengthening activities
Many activities can strengthen the spinal cord and the surrounding muscles, tendons, and ligaments. The greater part of these back exercises center around the lower back, as well as the (stomach) muscles and gluteus (butt cheek) and hip muscles.

6. Stretching
Stretching is usually prescribed to mitigate sciatic pain. Stretching for sciatica is intended to target muscles that cause pain when they are tight and unyielding. Hamstring stretch is very often an essential part of a sciatica exercise program. As part of everyday exercises, many people do not stretch these muscles, which extend out from the pelvis to the knee in the back of the thigh.

7. Low-impact aerobic activity
Some types of low-impact cardiovascular workout, for example, walking, swimming, or pool therapy, are generally parts of the recovery, as high-impact action increases the exchange of liquids and nutrients to make a better environment for healing.

8. Micro-disectomy
In situations where the sciatica pain is because of a lumbar disk herniation, a microdiscectomy is the most widely recognized surgical approach. It is an open surgery done using magnification techniques. In this surgery, just the bit of the herniated disk that is squeezing the nerve is evacuated. Whatever is left of the plate is left in place.

Top Eight Ways To Get Pain Relief From Sciatica!

The term Sciatica is used to describe leg pain, tingling, numbness or weakness that travels down the low back via the sciatic nerve to the back of leg. Sciatic nerve arises from each side of lower spine and passes deep in the buttock along the back of thigh and legs. The pain of Sciatica may be irregular/ infrequent or persistent causing severe agony to the patients. The pain of Sciatica may be confined to low back or hips or may extend up to toes. The pain of Sciatica can be excruciating and "not relieved by painkillers".

What causes Sciatica?

Pain in Sciatica is due to irritation or pinching of Sciatic nerve within the spine. This occurs most commonly due to prolapsed intervertebral disc (slip disc) causing nerve compression resulting in pain.

Is surgery the only treatment for Sciatica?

Most patients can be managed with medication/exercises. So surgery is not the only way out. Patients who have severe pain can also benefit from "Epidural Steroid Injection". This treatment has proven to be effective in avoiding spine surgery in such patients.

What is Epidural Steroid Injection?

Epidural Steroid Injection is a procedure done by a Specialist (Interventional Pain) in an Operation Theatre using X-Ray (Image Intensifier) to locate exact level of injection. A drug mixture consisting of Steroid with Local Anaesthetic is injected at the epidural space of affected nerve root. The steroid washes away inflammatory mediators from the epidural space which decreases the pain. Steroid also decreases the inflammatory response of body to the prolapsed disc. As a result the pain arising from nerve inflammation is decreased. This is a day care procedure i.e. the patients are discharged the same day.

How is the possibility of surgery ruled out?

Epidural Steroid Injection is a proven, safe and an effective treatment that works on the concept of Interventional pain management - to provide relief from persistent and chronic pain of Sciatica. Generally, a single injection is sufficient to relieve patients of the pain. The procedure can be repeated for a maximum 3 times in a year, depending on the patient's response. With effective pain relief, surgery is negated.

Non-Surgical Treatment For Sciatica

The longest nerve in the body is the sciatic nerve. The sciatic nerve starts from the lower part of the spine, through your hip to the back of the leg. So when it is said sciatica, we refer to pain in this nerve. Since the nerve covers the spine, hip and leg, sciatic pain is felt in the areas through which it passes. The lower leg muscles and sensation in the legs, thighs and feet are controlled by this nerve.

Symptoms usually include
1. Pain that radiates from the lower back to the hip and to the leg
2. Sharp, tingling, dull, constant or burning pain
3. Loss of bladder or bowel control
4. Sneezing or coughing increases pain
5. Moving the leg gets difficult so usual activities like walking, sitting and standing become painful

Homeopathic remedies are easy and gentle on the body. Homeopathy aims to boost the body's immune system so it can fight all its weaknesses. The following remedies may prove to be useful:

A) ammonium muriaticum: it is taken for chronic pain in the heel or for chronic backache or when straightening the knee gets difficult as hamstrings contract. It is also taken for limping.

B) bellis perennis: in periosteum injuries, stiffness and deep aches in the spine bellis perennis is used. It is also used for tailbone injuries. It is also helpful for nerve pains during pregnancy.

C) calcarea fluorica: if the vertebra degenerates after trauma to the spine, then calcarea fluorica can be useful.

D) cicuta: the worst back injuries with serious trauma and muscles spasms are treated with cicuta.

E) hypericum: hypericum is suggested for tailbone injuries, temporary paralysis, spinal concussions and for sharp pain that tingles and moves upwards.

F) rhus tox: if after lifting weights, overexerting muscles and exposure to anything wet, you feel tearing and burning pain, then rhus tox is beneficial. Cramps that get better after heat application, but get worse after exposed to the cold are also treated with rhus tox.

G) ruta: stiffness and pain from back injuries, twisting the wrong way and bruises are prescribed with ruta.

Best Homeopathic Remedies for Sciatica Pain

Exercises for Sciatica
Sciatica is often distinguished not as a medical condition but as a set of symptoms that underlie a more serious medical concern such as a slipped disc, degeneration of the spine or the lumbar region etc.
It is important to note the symptoms of Sciatica, as these are quite distinct -
1.Constant pain in one of the buttocks or leg (rarely are both legs affected)
2.The pain worsens on sitting
3.The pain is often described as a sharp & searing pain similar to a burning sensation
4.The pain is often accompanied by a heaviness or numbness that makes movement difficult
5.Shifting of postures (sitting to standing and back to sitting) becomes painful and laborious
An alternative to surgery would be to supplement the oral medication with certain specific exercises.
Reflexology, Acupuncture and Chiropractic manipulation are all considered effective to alleviate the pain to a large extent.
Patients are often encouraged to partake in daily exercise routine, incorporating strengthening and stretching exercises.
The strengthening exercises target the core or abdominal muscles along with the back muscles to provide more support to the back.
The stretching exercises will help to “loosen up” the surrounding muscle groups such as the hamstrings, which then allow for more blood and oxygen circulation alleviating the pain and giving the immune system a much needed boost.
When patients engage in a regular programme of gentle stretching and strengthening exercises, they can recover quickly (in comparison to those who do not exercise) from the flare ups and over time the painful episodes are known to reduce significantly, both in frequency as well as intensity.
Ancient holistic practices such Yoga and Tai-chi are often considered the best form of exercises for the afflicted because of the balanced and slow but controlled movements that complement the ‘breath’ rather than causing further exertion to the already fragile bone density.
It is recommended that expert advice be sought and the exercises should be undertaken only under trained supervision. Please do not attempt to “experiment” with Yoga or Tai-Chi on your own, as improper or wrong posture could lead to irreparable damage to the spine. 


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 Exercises for Sciatica To Keep It Under Check

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