Surgical Treatment of Sciatica of Lumbar Radiculopathy
Sciatica also technically called a lumbar radiculopathy is pain going from the lower back into the either lower extremity. This pain usually goes along the outer or the back of the thigh and leg into the foot; sometimes, the pain may go along the front of the thigh on the inner side of the leg also.
The region where the pain will go depends on the nerve root that is involved and irritated. This irritation is caused due to ischemia or chemical injury. Most common cause of this injury is lumbar disc herniation. Other causes include facet arthritis, synovial cyst, osteophyte due to degenerative change (aging and wear and tear).
This pain can be associated with tingling and numbness and occasionally weakness. Most of the patients with sciatica or lumbar radiculopathy can be treated with nonoperative means. These nonoperative means include medications as well as therapy.
Medications that can be used for sciatica include nonsteroidal antiinflammatory medications, steroids, tricyclic antidepressants like amitriptyline, anticonvulsants like gabapentin and pregabalin.
Therapy includes physical therapy, acupuncture, acupressure and chiropractic care. Patients can also be treated with steroid injections in the form of epidural injection or selective nerve root block.
Patients who fail these modalities of treatment, may need surgical intervention for relief of pain. Also patients who have very severe pain on the onset and are not relieved by pain medication and also need surgical intervention.
Patients who present with sudden onset of neurological deficit in the form of weakness or involvement of bowel or bladder or sudden deterioration of neurological deficit may need emergency surgery to stop the progression and optimize the conditions for recovery.
The principle of surgery for these patients essentially includes decompression of the nerve root so as to give its space for which allows blood supply to the nerve root and resolution of the inflammation. This decompression surgery may be adjunct with fusion in patients who have instability, so that there is no recurrence.
There are multiple surgeries that are performed depending on the indication. These include discectomy, laminectomy, laminotomy and foraminotomy. Fusion surgeries that can be associated with decompression surgeries are posterior spinal fusion, transforaminal lumbar interbody fusion, lateral interbody fusion, anterior interbody fusion, etc.
Discectomy can be either open or with the use of a microscope, also known as microdiscectomy. When discectomy is done with the use of endoscopy, then it is called endoscopic discectomy.
With the development of state of art instrumentation and better optics allowing visualization of magnification with the use of lens, microscope and endoscope, we are able to perform the surgery through smaller incisions allowing full recovery with minimal loss of blood, small incision and minimal morbidity.
In patients with isolated lumbar disc herniation without instability, microdiscectomy is the gold standard procedure in patients. This will also include decompressing the foramen and removing a part of lamina (foraminotomy and laminotomy).
Patients who have compression in the centers and bilateral disc herniations may need either procedure on both sides or removal of complete lamina (laminectomy) to allow for decompression.
For microdiscectomy, procedure is performed usually through a small incision less than 5 cm. A microscope is used for magnification and improved visualization with good illumination. The bone from the back of the spine, that is the lamina is removed to achieve a window to work (laminotomy) through which the disc can be reached and removed. The foramina was also cleared (foraminotomy).
In patients who have instability of the spinal segment, fusion surgery is performed. The bones are roughened (decorticated) and screws and rods are inserted so as to allow stability and healing and fusion to happen. Sometimes biologics like autogenous bone graft, allogeneic bone graft, substitutes like calcium triphosphate or stimulants like bone morphogenic protein or BMP can be used to enhance the fusion.
Patients who undergo microdiscectomy, foraminotomy, laminotomy, laminectomy can usually go home the same day or within 24 hours. These patients usually heal and recover faster and can be back to usual activity within 3 to 6 weeks. Patients who undergo fusion surgery take a longer recovery period and are usually in the hospital for 2 to 4 days.
COMPLICATIONS OF SURGERY
As every other surgery is associated with certain risks and complications, so as the spine surgeries. The surgery can be associated with risk of infection, bleeding, injury to adjacent nerves and muscles, non-recovery or persistence of symptoms, injury to the dural sac and CSF tear, need for reoperation, re-herniation and need for repeat surgery, development of instability and need for fusion surgery, non healing of the fusion, injury to vessels, systemic complications like blood clot, cardiac, neurological, pulmonary complications and even death.
Patients who do not get better with nonsurgical means like medications, therapy and injections may need surgeries to relieve their symptoms. This surgery may vary from microdiscectomy, laminotomy, foraminotomy, laminectomy to instrumented fusion surgeries. Patients usually do well after these surgeries and have good recovery. Recovery time may vary with the type of surgery that is needed and may be 4 to 12 weeks.