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!

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

Sciatica is a very common neuropathic pain that is caused by damage to the sciatic nerve, a large nerve that runs from the lower back region down the end of each leg. It is the largest single nerve in the body.
This condition affects around 4 out of 10 people at some point of their lives. The nature of the pain varies from a mild ache to a sharp stinging sensation and may cause feelings of numbness and extreme weakness.

Causes of sciatica
The causes for the onset of sciatica are numerous. Some of them are as follows:
-slipped lumbar disc
-muscle inflammation
-internal bleeding
-pregnancy
-obesity
-awkward sleeping position
-uncomfortable footwear
-spinal injury

How can physical therapy help?
There are many ways of treating sciatica, such as medication, acupuncture and surgery, which can provide relief. The most common and easy treatment method however is physical therapy. A progressive and controlled exercise routine that is specifically tailored to the nature of the condition in consultation with a physical therapist acts as an effective remedy in treating the problem. It alleviates pain and also eliminates the chances of relapse.

Physical therapy exercises used to treat sciatica are of many types. They are a combination of core strengthening, muscular stretching and aerobic conditioning routines, which aim at correcting the root of the problem.

The different types of exercises employed to treat sciatica include the following:
Strengthening exercises
These aim at strengthening the spinal column and the pelvic region, which includes the hips and buttocks. They help in making the muscles and ligaments in this region more robust and allow for improved flexibility and support. Lunges and squats are some of the examples.

Stretching exercises
These provide pain relief through improved agility and flexibility. The most important aspect of these routines is stretching and exercising the hamstring. Hamstring, stretches, calf stretches and tricep stretches are a part of stretching exercises.

Aerobic conditioning
These are cardiovascular exercises of low intensity, which provide pain relief through the release of endorphins and the facilitation of fluid and nutrient exchange. Examples of these are swimming and brisk walking.

Reduce Sciatica Pain With Physical Therapy

Sciatica refers to the pain one experiences due to the irritation or compression of nerve roots contributing to formation of Sciatic nerve. The sciatic nerve is the longest and widest nerve in the body, running from the lower back, down to the back of each leg. The pain can occur in the lower back and spread to the hips, buttocks and leg. Sciatica generally affects one side of the body. There are numerous causes of irritation of the sciatic nerve and sciatica.
 
Some of them are:
 
1. Spinal Stenosis
The narrowing of the spinal canal caused by natural wear and tear of the vertebrae (individual bones in the spine protecting underlying nerves) of the spine is known as spinal stenosis. The narrowing may put pressure on the roots of the sciatic nerve, causing pain.
 
2. Herniated Disc
A disc is made up of cartilage and acts as a cushion between vertebrae, allowing flexibility of the spine. A herniated or slipped disc occurs when a disc is temporarily pushed out of place, putting pressure on the sciatic nerve.
 
3. Spondylolisthesis
It is a condition where one of the lower vertebrae slips forward over another. This also causes a collapse of the disc space between both, causing the nerve to get pinched. This may cause sciatica.
 
4. Piriformis Syndrome
Piriformis is a muscle found deep inside the buttocks, which connects the lower spine to the upper thighbone, running directly over the sciatic nerve. Spasming of this muscle can pressurize the sciatic nerve, triggering symptoms of sciatica.

5. Sacroilitis
Sacroillac joints are the place where the lower spine meets the pelvis and inflammation of one or both of these joints causes sacroilitis. This can give rise to symptoms of sciatica as it causes pain in the lower back, buttocks and legs.
 
6. Spinal tumors
Very rarely, tumors growing inside or along the spine may put pressure on the sciatic nerve.
 
7. Infection or injury
Muscle inflammation, infections, fractures or any other spinal injury may lead to irritation or compression of the sciatic nerve.
 
8. Pregnancy
Pregnant women may suffer from sciatica due to weight gain, expansion of the uterus or increased fluid retention or other changes occurring in the body, which put pressure on the sciatic nerve.
 
9. Other causes
Osteoarthritis and fractures caused by osteoporosis may also affect the sciatic nerve, producing symptoms of sciatica.

Top 9 Causes Of Sciatica Nerve Pain - You Need To Know About

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

Gridhrasi is what Sciatica is known as in Ayurveda. It is the disorder that causes mild to agonizing pain in the sciatic nerve or neuralgia. These nerves, emerging from the pelvis, run along the hamstring and may cause intense pain in one or both the legs when a person suffers from Sciatica. Sciatic pains fill your life with misery as the simplest of daily activities cause sudden and excruciating pain. There are two types of sciatica i.e. true sciatica and pseudo sciatica. Sciatica may be caused due to bulging disc or herniated disc, degenerative disc disease, piriformis syndrome, pregnancy or trauma etc. 

According to Ayurveda, Sciatica is caused due to impairment in Vata i.e. the dosha responsible for the functional ability and movement of the body and also in some cases due to impairment in the Kapha i.e. the dosha that is responsible for body fluids and lubrication. Ayurvedic herbs that improve the symptoms of Sciatica are:

1. Babunah is also known as Bitter Chamomile. Not only is it used to relieve and reduce the pain faced by a sciatica patient, but it is also used for treating problems such as rheumatism due to the advancement of age. Compressed bitter chamomile flowers are prescribed for sciatica.
2. Guggul is also known as Indian Bdellium. Since guggulu is well known for its anti-inflammatory properties, it relaxes the sciatic nerves.
3. Rasna is also known as Vanda Orchid. Intense or agonizing pain due to the sciatic nerve issues can be reduced by this ayurvedic herb due to its anti-inflammatory properties. 
4. Juniper oil is extremely helpful when massaged onto the thigh muscles with firm strokes or pressure. It is used extensively in massage therapy for treating sciatica since the extent of reduction in sciatic nerve pain is tremendous. 
5. Jaiphal is also known as Nutmeg. After being mixed with sesame seeds oil, nutmeg is coarsely powdered and then fried till it turns brown. This is then applied to those areas where the sciatic pain is intense for instant relief.
6. Kumari is also known as Indian Aloe. Properties of Indian Aloe are extremely helpful in treating lower back ailments such as sciatica and lumbago.
7. Shallaki is also known as Boswellia or Frankincense. Containing anti-inflammatory properties, shallaki is applied externally to get relief from sciatic nerve pain. 

Ayurvedic preparations such as yogaraja guggulu, Vataganjakusha, Saindhavadi taila are also very useful in treating Sciatica.

Ayurvedic Treatment of Sciatica

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