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.
MRI of the lumbar spine in sagittal section showing herniated L5-S1 intervertebral disc.
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.
MICRODISCECTOMY/ENDOSCOPIC DISCECTOMY
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.
Axial section of the spine on MRI showing herniated intervertebral disc.
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.
Conclusion
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.
Do you have more questions?
How do I know if my sciatica is severe enough to require surgery?
Surgery is generally considered if you have severe, persistent pain that has not responded to at least 6 weeks of conservative treatments, such as physical therapy, medications, or injections, and if the pain significantly interferes with your daily activities.
How effective is surgery in treating sciatica?
Surgery is highly effective in providing relief from leg pain associated with sciatica, especially in the short to medium term. Many patients experience significant improvement in pain and function within weeks of the procedure.
What are the risks associated with sciatica surgery?
Risks include infection, bleeding, spinal fluid leaks, nerve damage, and the possibility of requiring additional surgeries. However, these complications are relatively rare.
Will my sciatica symptoms return after surgery?
While surgery often provides long-lasting relief, some patients may experience a recurrence of symptoms, especially if there are ongoing degenerative changes in the spine.
What is the recovery time after sciatica surgery?
Recovery time varies depending on the type of surgery, but most patients can return to light activities within a few weeks. Full recovery, including a return to more strenuous activities, can take several months.
Can sciatica be treated without surgery?
Yes, many cases of sciatica can be successfully managed with non-surgical treatments, including physical therapy, medications, epidural steroid injections, and lifestyle modifications.
Is physical therapy required after surgery?
Yes, physical therapy is typically recommended after surgery to help strengthen the muscles, improve flexibility, and support a full recovery.
What are the chances that non-surgical treatments will fail?
Non-surgical treatments are effective for many people, but if there is significant nerve compression, these treatments might not provide sufficient relief, leading to the consideration of surgery.
How does sciatica surgery differ from other back surgeries?
Sciatica surgery, such as a discectomy or microdiscectomy, specifically targets the removal of the disc material or bone pressing on the sciatic nerve, unlike other back surgeries that may address broader spinal issues.
Will I need to stay in the hospital after sciatica surgery?
Most sciatica surgeries, especially minimally invasive ones, are done on an outpatient basis, allowing you to go home the same day. However, in some cases, an overnight stay may be required.
How can I manage sciatica pain before deciding on surgery?
Pain can often be managed with over-the-counter pain relievers, physical therapy, hot or cold packs, and avoiding activities that exacerbate the pain. In some cases, prescription medications or injections may be necessary.
What lifestyle changes can help prevent sciatica recurrence?
Maintaining a healthy weight, engaging in regular exercise to strengthen core muscles, practicing good posture, and avoiding activities that strain the lower back can help prevent sciatica recurrence.
Is sciatica surgery covered by insurance?
Most insurance plans cover sciatica surgery, especially if conservative treatments have been tried and failed. It’s important to check with your insurance provider for specific coverage details.
Can sciatica cause permanent nerve damage if left untreated?
Yes, in severe cases, prolonged nerve compression can lead to permanent nerve damage, resulting in chronic pain, numbness, or weakness in the affected leg.
What are the alternatives to surgery for managing sciatica?
Alternatives include physical therapy, chiropractic care, acupuncture, epidural steroid injections, and lifestyle modifications. These approaches can be effective, especially when combined.
What are the alternatives to surgery for managing sciatica?
Alternatives include physical therapy, chiropractic care, acupuncture, epidural steroid injections, and lifestyle modifications. These approaches can be effective, especially when combined.
How long does the pain relief last after sciatica surgery?
Many patients experience long-term relief from pain after surgery, though the duration can vary. Some patients may have relief for several years, while others might need additional treatment if symptoms recur.
Will I be able to return to work after sciatica surgery?
Most patients can return to work within a few weeks, depending on the type of work they do. Jobs that require heavy lifting or prolonged sitting might require a longer recovery period.
What should I expect during a sciatica surgery consultation?
During a consultation, the surgeon will review your medical history, conduct a physical examination, and possibly order imaging tests like an MRI to confirm the diagnosis and determine the best surgical approach.
Are there any dietary recommendations to help with recovery after surgery?
A balanced diet rich in nutrients that support healing, such as protein, vitamins, and minerals, is recommended. Staying hydrated and avoiding excessive weight gain are also important.
How can I differentiate between sciatica and other types of back pain?
Sciatica is characterized by pain that radiates from the lower back down the leg, often accompanied by numbness, tingling, or weakness. Other types of back pain might not follow this pattern and could be localized to the back or neck.
How is the success of sciatica surgery measured?
Success is typically measured by the reduction or elimination of leg pain, improvement in function and quality of life, and the ability to return to normal activities without significant limitations.
What are the signs that I might need a reoperation after sciatica surgery?
Signs that might indicate the need for reoperation include the return of severe pain, new or worsening symptoms, or the development of complications like infection or spinal fluid leaks
What should I do if I experience new symptoms after surgery?
If you experience new or worsening symptoms after surgery, such as increased pain, numbness, or signs of infection, contact your surgeon immediately for evaluation and possible intervention.
Can I travel shortly after sciatica surgery?
It’s advisable to wait at least a few weeks before traveling, especially if it involves long periods of sitting. Discuss your travel plans with your surgeon to ensure it’s safe based on your recovery progress.
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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