The different types of patients with Sciatica from a lumbar disc

Manoj Krishna.Spinal Surgeon

www.spinalsurgeon.com

Type 1: Sciatica without disc protrusion

• Predominant leg pain• Increased on sitting• Eased on walking• MRI shows disc degeneration but no neural compression• Rx- Interbody Fusion• Mechanism: ? Sinuvertebral Nerve Irritation.

– ? Leakage of chemicals into disc space

Type 2: Small central disc protrusion

• Causes more back pain than sciatica• These symptoms more likely to become

chronic• Contained disc – still within PLL• 38% do poorly from discectomy• Rx- Do well with a Interbody Fusion

Type 2Contained Central Disc Protrusions

Spasms, Locking

Left thigh and leg pain

Sitting < 5 minutes

Type 3: Large Central Disc protrusion- Cauda Equina Syndrome

• History of back pain• One day the back pain disappears and patient

gets sciatica with buttock numbness and dribbling, or bilateral leg pain

• Surgical emergency• Urgent discectomy needed

Type 3Cauda Equina Syndrome.

Type 4: Sequestered postero-lateral disc protrusion

• Present with unilateral sciatica• Severe pain initially• Highest chance of settling spontaneously • Manage with an epidural injection or just pain

relief till the pain settles

Type 4Pain settled on its own at 6 weeks from onset

May develop back pain later

Type 5: Contained postero-lateral disc protrusion

• Not extruded into the disc space• Often Broad based• 38% persistent sciatica with discectomy( Carragee)• Less likely to settle spontaneously with

conservative measures• Or- may settle and develop an instability pattern,

with recurring episodes of leg pain• Needs an interbody fusion

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Type 5Intermittent LBP several years.

Then Rt sciatica – LBP settled.

Scoliotic tilt and stooped forwards 40 degrees. Rt SLR=40

L5 decreased sensation

Type 6: Far lateral disc protrusion• Often at L34• Not easy to see on an MRI scan• Causes thigh pain- and quads wasting• Rx: Nerve Root Block- usually all that is

needed• Discectomy: Needs a far-lateral approach• Or , consider doing an interbody fusion• 7% of disc herniations

Type 6RD Fraser et al- Adelaide. JBJS 199730 casesForaminal Nerve Root BlocksOnly 3 needed surgery

Type 7: Small disc protrusion in a tight spinal canal causing Stenosis

• Patients have a narrow spinal canal with no symptoms

• Even a small disc protrusion tips the balance causing a combination of leg pain, heavy legs, loss of co-ordination

• Neuro deficit is out of proportion to the size of the disc protrusion

• Needs urgent decompression- risk of cauda equina syndrome

Type 8Features of both left sciatica and spinal stenosis

Need to worry that this could progress to a cauda equina syndrome

Struggling to walk

Acute onset, rapid progression

Type 9: Recurrent Herniation at same level

• 10% at 2 years( McGirt et al, Spine, 2009) • Higher if larger annular defect• Higher if limited discectomy done• But...more back pain associated with larger

disc removals

Type 8 Discectomy Oct 2000 –

Recurrence of LBP and Lt leg pain.

Pain very severe. ‘ My Life is Hell’

VAS - 9/10

Small Recurrent disc protrusion

10 year outcomes of discectomyYorimitsu et al. Spine.

• 131 cases• 12.5% had a recurrent disc herniation• 75% had back pain• 13% had severe pain• Back pain associated with a degenerate disc at

time of surgery, age less than 35 and reduced disc height

‘the remaining disrupted discs must continuously bear the weight and support the trunk for the rest of the patient’s life’

Epidural Steroids vs DiscectomyButtermann . JBJS, 2004

• RCT• At 6 weeks randomised into 2 groups( N=169)• 92% discectomy group very happy.• 56% of epidural group happy• Subsequent discectomy had a similar

outcome.• Half of patients in epidural group avoided

surgery at 3 years

• How long is it reasonable for a patient to suffer and wait for the pain to settle? ( knowing that they can wake up from surgery with the leg pain gone and if they accept the small risks of surgery?)

• Should the doctor decide?• Or the patient who is experiencing the pain?

Complications of Discectomy• British Association of Spine Surgeons( 2005)• 3.5% dural leaks in primary discectomy• 13% in revision cases• Infections rates 3%( Rohde,Spine)