Posted on September 29, 2024
In patients over the age of 70, the usual cause of sciatica (buttock or leg pain) is from some form of degenerative spinal stenosis (narrowing).
This narrowing can be in the CENTRAL spinal canal, or as a result of a PINCHED NERVE as the nerve exits the spinal canal. In some cases, nerve pain occurs as disc material presses on the exiting nerve or from bony narrowing.
Some patients experience listhesis (slippage) of the vertebrae, leading to further canal narrowing and nerve pinching.
Patients with such stenosis have severe walking limitation. Many can hardly make it to their mailbox. Some can hardly stand for more than 5 or 10 minutes. Most patients find some relief when pushing a shopping cart or walker, and many bend forward with walking. Leg cramps at nighttime can also occur.
If the pain has been unresponsive to physical therapy and medication, initial treatment typically begins with epidural injections. These injections place steroid directly onto the areas of nerve inflammation. If there is an inflammatory component to the pain, the anti-inflammatory steroid should quiet the pain.
There are three types of epidural injections. These are:
• A midline approach
• One along the exiting nerve roots
• Just above the tailbone (a caudal approach)
Often, if possible, we start with the midline epidural injection at the affected level. If there’s no response to this approach, we may administer an injection along the exiting nerve roots with transforaminal injections.
If these initial injections are successful, a single repeat injection can be given every three months.
However, in cases where there is severe central canal or bony canal narrowing, steroids may not help. Instead, there may be an anatomy problem that may necessitate a surgical solution or minimally-invasive procedure to create room in the narrowed spinal canal.
Short of major surgery, it may be possible to remove excess ligament in the back of the spinal canal through the MILD procedure. MILD (Minimally-Invasive Lumbar Decompression) is a 20 minute procedure requiring only a quarter-inch incision.
Alternatively, it may be possible to place a spinal “spacer” device through the VERTIFLEX procedure. This creates more room in the center of the canal and opens up along the exiting nerve roots.
Vertiflex is also a 20-minute procedure, sometimes referred to as a “jack in the back.” While the patient is comfortably sedated, it is performed through a small one-inch incision.
All options recommended, of course, will depend on many factors including prior surgery, spinal listhesis (slippage), presence of scoliosis, whether you are on blood thinners, and your underlying medical status.
In any case, we will try to find the least invasive approach to successfully treat your sciatica and restore your comfort and ability to resume a more active life.