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“Muscular spasms that result from sitting too much are the most common cause of back pain,” according to Jaspal “Ricky” Singh, MD, assistant professor of clinical rehabilitation medicine and director of the Interventional Spine program at Weill Cornell Medicine.

When seated for long periods, people tend to slouch and underutilize the core muscles that support the lower back. Sitting puts 40% to 90% more stress on the back than standing, so it’s easy to see why sitting at an office desk for eight hours a day or spending copious amounts of time camped out on the sofa, streaming back-to-back episodes of your favorite television show can culminate in or aggravate back pain. “A sedentary lifestyle and insufficient physical activity can weaken the body’s core, and this can result in muscle spasms and back pain,” explains Dr. Singh.

Other causes of chronic lower back pain include osteoarthritis (OA), spinal stenosis (narrowing of the spinal canal), and degenerative disk disease. OA wears away the protective layer of cartilage on the vertebrae and may be accompanied by bone overgrowth or the formation of bone spurs. “OA typically causes pain with standing, walking, and sometimes lying down, while sitting and leaning forward often provide relief,” says Dr. Singh. With spinal stenosis, the spinal canal has narrowed due to thickening of ligaments or membranes and/or bone spurs, all of which may press on the nerves that run through the canal. Intervertebral disks, which function as shock absorbers and cushion the spine during motion, are located between the vertebrae. With age, these disks begin to dehydrate and become less flexible. This process is known as degenerative disk disease.

Home Remedies That Help

The treatment for back pain typically depends on its cause and location. Fortunately, back pain can often be at least partially relieved by home remedies, either alone or in combination with noninvasive techniques, such as professional massage and physical therapy. If you have minor or moderate back pain, Dr. Singh says it’s safe to try these at-home remedies: rest, ice, and gentle stretching. But he stresses that rest does not mean bed rest. “I recommend relative rest, which means avoiding strenuous exercise and heavy lifting, but absolutely not taking to one’s bed because this can lead to weakened muscles, which will make the muscles stiff, and this can aggravate the pain,” he explains. Keep in mind: When applying ice it should be wrapped in a towel and applied to the affected area for 15 to 20 minutes four times a day for several days. Never place ice directly on the skin.

If rest and ice in combination with gentle stretching do not alleviate the pain within seven to 10 days, it’s time to seek medical attention. Dr. Singh says, “If you are having trouble functioning— can’t get dressed, can’t sit comfortably at work, or if you are experiencing weakness in the leg— it’s time to see a doctor.”

Testing 1,2,3

Depending on the severity and location of the pain, your primary care physician might refer you to an orthopedic specialist, a sports medicine specialist, or a pain management specialist. They might also recommend diagnostic testing to help identify the origin of the pain.

The types of tests that are most commonly ordered for diagnosing the causes of back pain are x-ray, and magnetic resonance imaging (MRI). “X-ray will let us know if there is a fracture, or arthritis, or even if there is a deformity, such as scoliosis, that might be causing the pain,” says Dr. Singh.

“If back pain is not improving with physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs), then we consider MRI. X-ray is best at detecting bony structural problems, whereas MRI is better at imaging soft tissue injury and evaluating symptoms, such as pain that radiates down the leg or back pain that develops in a patient who was previously diagnosed with cancer,” explains Dr. Singh.

Once the cause of back pain is identified, an appropriate course of treatment can be determined.

Dr. Singh stresses that one of the most important considerations regarding back pain is avoiding it. “Mobility is medicine,” says Dr. Singh. “To avoid back pain, keep exercising and staying active”.

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“The narrowing can occur when vertebral discs or joints degenerate,” explains physical therapist Daniel Salazar, DPT, UCLA Medical ­Center, Santa Monica. “There also can be excessive growth of bone spurs from overloading the joints, which, in turn, can lead to more narrowing.”

Trauma from a mechanical force (a car accident for example) also can narrow the spaces where nerves travel. However, age-related degeneration is the most common reason why people ages 65 and older experience this condition.

Spinal stenosis can occur anywhere along the spine, but it most often occurs in the lumbar spine. Since the lumbar nerves extend down the legs to the toes, spinal stenosis causes numbness, tingling, weakness/heaviness, or pain in the back, legs, and buttocks.

Diagnosing Spinal Stenosis

Diagnosis involves a detailed history of symptoms and a physical exam, with a focus on testing for sensation, motor strength, reflexes, and assessing how you walk. It’s possible to have signs of stenosis visible on imaging scans without any symptoms. In other words, you can have some narrowing but no pain. That’s why imaging (usually magnetic resonance imaging [MRI]) should only be used to confirm a suspicion of spinal stenosis derived from a medical history and physical exam.

Prevention and Risk Factors

Spinal stenosis is common with aging but it’s difficult to know who will actually develop symptoms. The good news is that in most cases, the degenerative process can be somewhat controlled by changes in lifestyle.

“Being overweight, especially for people who carry most of the weight in the stomach area, creates muscle imbalances between the front and back of the body,” explains Salazar. “The spinal muscles in the back have to work harder against gravity, and this overloads the spine.”

It’s simple to say just lose weight, but it can be a challenge to achieve. Many people do best when they have support. Being held accountable through support groups or partnering with someone else who’d like to lose weight helps many people succeed. It’s also helpful to consult with a registered dietitian, who can develop an eating plan that’s realistic for you.

Treatment Protocols

The general protocol for treating back pain typically starts with nonsteroidal anti-inflammatory drugs (NSAIDs)  and physical therapy followed by interventional pain management strategies for persistent pain (e.g., anesthetic and steroid injections). Surgical intervention is the last resort. When it comes to exercise for spinal stenosis, physical therapists will conduct a thorough assessment to determine where your muscular imbalances are and how to correct them safely and effectively. According to Salazar, a lack of core strength or weakness (which involves the abdominals, pelvic floor, diaphragm, and smaller back muscles) places bigger demands on the back extensors. Another area of focus is posture.

“Many people have poor postural awareness when standing, walking, and sitting and often sustain postures with too much lumbar extension,” says Salazar. “Incorrect lifting, which often involves lumbar extension, also can overload the spine and worsen stenosis.”

Exercise can help you feel better quickly, sometimes during a single session. But regular exercise is essential to staving off further damage and maintaining muscular strength.

Research shows that most people with pain from spinal stenosis successfully manage the condition without the need for surgery.

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Bone spurs can also form at the edges of the bones that make up your spinal column, called vertebrae. Bone spurs of the spine may not cause any symptoms and you can’t see them or feel them. But, if they grow large enough they can cause two spinal conditions. If they squeeze (compress) the spinal cord, they can cause a condition called spinal stenosis. If they squeeze the nerves leaving the spinal cord that go to your arms and legs, they can cause a condition called radiculopathy.

What causes spinal bone spurs?

By far, the most common cause of spinal bone spurs is osteoarthritis. Osteoarthritis is the most common cause of joint pain, stiffness, and swelling. It is often called “wear and tear” arthritis because it occurs over time. Joints are protected at their ends by cartilage. As cartilage wear down and thins out over years of use, bones start to rub on bones. The bones try to make more cartilage for protection, but this often results in overgrowth of bone called an osteophyte or bone spur.

Because osteoarthritis occurs over many years, it is most common in people over age 60. An injury to the spine can speed up the process. Other risk factors include being overweight, not getting enough exercise, and having bad posture. Having a job that requires years of lifting and bending may also be a risk.

What are the symptoms of spinal bone spurs?

Spinal bone spurs are common and most people do not have any symptoms, although they may show up on an x-ray. If they get large enough and cause spinal stenosis or radiculopathy symptoms occur. The most common areas for symptoms are the neck and lower back.

• Spinal stenosis of the lower back causes burning pain and aching in the lower back and buttocks. Pain may extend down into the legs and get worse with walking or standing. There may also be weakness and numbness in the legs. Spinal stenosis of the neck causes similar pain, but the weakness and numbness occur in the arms, hands, and fingers.
• Radiculopathy causes symptoms in the areas supplied by the nerves leaving the spine that become compressed by spinal bone spurs. Symptoms include sharp pain in the neck, shoulders, back, or legs. Pain gets worse with activity. There may also be weakness, numbness, or “pins and needles” sensations.

What is the treatment for bone spurs on the spine?

Home care may include ice, rest, and over-the-counter pain and inflammation medications called NSAIDs, like Advil or Motrin. Losing weight and staying active are also important. Physical therapy may be prescribed by a health care provider. When OTC meds and home care are not helping, injections of numbing and anti-inflammatory medications into the vertebral spaces may help. As a last resort, spinal bone spurs may be removed surgically.

Learn more about bone spurs on your feet.

Exercises for spinal bone spurs

Exercises that strengthen the spinal muscles and increase flexibility may reduce bone spur symptoms. These stretching and strengthening exercises can be started safely in physical therapy and continued at home. Losing weight, maintaining a healthy weight, maintaining good posture, and staying fit and active are the best ways to prevent spinal bone spur symptoms.

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Preventing Pain

A healthy lifestyle can go a long way in preventing lower back pain.

“Obesity plays a role. Every extra pound of weight in the abdomen places an additional five to 10 pounds of pressure on the lumbar spine, increasing the chances of lower back pain,” says Jaspal “Ricky” Singh, MD, assistant professor of clinical rehabilitation medicine and director of the Interventional Spine Program at Weill Cornell. “Smoking also plays a role; smoking has been shown to increase the prevalence of back pain due to the obstruction of blood vessels.”

Maintaining an active lifestyle is one of the most effective ways of preventing back pain: Regular physical activity will help you lose weight or remain at a healthy weight, and strengthening your core muscles with exercise will help support your spine.

“Based on the Physical Activity Guidelines for Americans, I tell every patient to get 30 minutes of moderateintensity exercise five times a week for a total of 150 minutes,” says Dr. Singh.

Causes of Chronic Pain

Most episodes of lower back pain get better within two to six weeks, with or without treatment, but some people have chronic pain that lasts for three months or longer. Common causes of chronic lower back pain include osteoarthritis (OA), spinal stenosis (narrowing of the spinal canal), and degenerative disc disease.

OA wears away the protective layer of cartilage on the vertebrae and may be accompanied by bone overgrowth or the formation of bone spurs. “OA typically causes pain with standing, walking, and sometimes lying down, while sitting and leaning forward often provide relief,” says Dr. Singh.

With spinal stenosis, the spinal canal has narrowed due to thickening of ligaments or membranes and/or bone spurs, all of which may press on the nerves that run through the canal.

The intervertebral discs are the flexible donut-shaped structures located between the vertebrae. They function as shock absorbers and cushion the spine during motion. With age, these discs begin to dehydrate and become less flexible. This phenomenon is commonly referred to as degenerative disc disease.

When Testing Is Needed

If lower back pain does not subside or is accompanied by other symptoms, such as numbness, tingling, or weakness, diagnostic tests may be ordered.

“Depending on the patient’s history and physical exam, imaging may be necessary to rule out any potentially harmful conditions. X-rays can provide a view of the bony structure to determine if OA is present in the spine,” says Dr. Singh.

He adds that if a patient has neurologic deficits, such as weakness, balance issues, or loss of bladder/bowel control, magnetic resonance imaging (MRI) is useful in evaluating the spinal cord and soft tissues.

Treatment Options

Dr. Singh recommends physical therapy and exercise as the first line of treatment for patients with lower back pain. Having a strong core, which includes the muscles above, below, and around the abdominal area, is imperative for a healthy spine. If these muscles are strong, the spine’s structures will undergo less wear and tear.

Medications for low back pain may include acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve). Low doses of some types of antidepressants, such as amitriptyline (Elavil), have been shown to relieve back pain.

“In some patients, acupuncture, chiropractic care, and even spinal injections might be used if the initial treatment program does not provide significant relief,” says Dr. Singh.

If standard treatments aren’t successful, the next step is referral to a pain management specialist, who can provide interventions to localize and isolate the structures causing pain. These include epidural steroid injections, facet and sacroiliac joint injections, and ablation, which uses radiofrequency waves to disrupt pain signals.

For lower back pain, surgery is a last resort. There are many types of surgery, but typically, they have one of two purposes: decompression for patients who have a disc or bone pressing on a nerve, and fusion surgery, which stabilizes a weak area in the spine. Dr. Singh notes that there are no guarantees that surgical intervention will provide lasting pain relief.

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What’s Bothering Your Back?

The spine is a complex interplay of vertebrae (the spinal bones), muscles, ligaments (bands of tissue that attach cartilage to bone), tendons (the fibrous tissue that attaches muscle to bones) and disks (the soft, elastic material that forms a shock-absorbing cushion between the spinal vertebrae). Dr. Sheth says the sheer number of component parts is what makes the back vulnerable. “Walking upright also is a factor,” he adds, “since it means that the weight of the upper body has to be transferred down through the relatively small bony surface of the spinal vertebrae.”

It’s wear and tear that underpins most back pain. Degenerative disk disease occurs naturally as we age, and causes the spinal disks that form a shock-absorbing cushion between each vertebra to break down. “This can put older adults at higher risk of developing arthritis of the spine—called spondylosis—which causes the cartilage between the bones to wear away, so that bone grinds on bone,” Dr. Sheth explains. “This causes pain and stiffness that limits range of movement.”

Degenerative disk disease also makes older adults vulnerable to spinal stenosis, in which the bony channel that houses the spinal cord narrows. “The body attempts to compensate for the lack of padding between the vertebrae by forming bony growths called bone spurs,” Dr. Sheth says. “As well as obstructing the spinal canal, these spurs can press on the spinal nerves, causing pain in the back and legs.” Older women also are particularly at risk of osteoporosis (loss of bone density), which make the spinal bones vulnerable to fractures and collapse.

Mix Muscle Strength with Better Body Mechanics

Lack of muscle strength may contribute to back pain, Dr. Sheth notes. “The abdominal and lower back muscles support the spine, but in older adults these often are weak,” he explains. “Many patients see improvement in their pain by beginning a backstrengthening exercise program.” Dr. Sheth recommends you focus on strengthening your “core” muscles—the transversus abdominus and multifidi (the deepest layer of abdominal and back muscles, respectively)—in the abdominal area and the lower back. “These muscles stabilize and support the spine, restoring function and reducing pain,” he says. “A physical therapist can show you the most effective exercises.” He also recommends swimming in a heated pool. “Water is weight bearing and helps alleviate pressure on the back and other potentially painful joints.”

Dr. Sheth says that body mechanics also are important. “Body mechanics essentially involve using your body to produce motion that is safe, energy-efficient, and effective,” he explains. In the case of your back, using the correct lifting technique is a good example of better body mechanics—bend at the knees, not the waist, and carry heavy objects close to your body. “It’s also important to avoid spending long periods of time sitting in slumped positions that place stress on the back,” Dr. Sheth adds.

Alternative Approaches

Research shows that people who regularly practice yoga report decreased pain and need for pain medications, as well as an improvement in their ability to perform daily functions. Ask about yoga sessions at your local senior center or gym, and let the instructor know that you have back pain so that poses can be modified if necessary to avoid exacerbating the problem. “Cat” and “Cow,” two yoga positions recommended for easing back pain, are described below. Pilates is another option you may want to consider—like yoga, it involves slow, controlled movements that strengthen muscles. It also promotes body awareness that can help you avoid further injury. Your local senior center or gym may offer sessions.

Massage also may help—one 2011 study showed that people with chronic low back pain have improved symptoms, better function, and few side effects with massage therapy. Consider acupuncture too. This form of traditional Chinese medicine involves the insertion of very fine needles in certain areas of the body. “The theory is that the needles clear blockages in the body, restoring its energy balance and alleviating pain,” says Dr. Sheth. “However it has been suggested that acupuncture relieves pain because the needles stimulate the body to secrete natural pain-relieving substances, such as endorphins.” Very few risks are associated with acupuncture, although you may experience a slight burning or stinging sensation when the needles are inserted.

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© Stephane Noiret |Getty Images
Back pain that doesn’t resolve within a few weeks requires imaging to determine next steps.

struggle with chronic pain for months and even years. If you suffer from such ongoing pain, you likely know that surgery is the last resort, after noninvasive treatments have been exhausted. These typically include physical therapy, heat/ice treatments, massage therapy, acupuncture, topical analgesics, steroid injections, and medications for pain and inflammation. If these treatments have failed or back pain has worsened after six to 12 months, then surgery may be a viable option.

Defining Minimally Invasive

Minimally invasive surgery (MIS) is an umbrella term for any surgical procedure that involves using specialized surgical tools and instruments to visualize internal structures and to perform surgery with small incisions. This includes using tubular retractors (used to hold an incision open, hold back tissues, or other objects to maintain a clear surgical view), micro instruments, endoscopy (specialized miniature cameras that can be threaded through catheters) and imaging technology such as biplanar fluoroscopy (X-rays taken from two angles that simultaneously capture images) to help visualize the spinal anatomy without completely exposing it. These tools enable highly skilled surgeons to perform precision spine surgeries through incredibly small openings.

© Kamil Macniak | Dreamstime

“With the minimally invasive approach, there is less muscle retraction and less tissue damage because we avoid detaching muscle. Instead, we split the muscle fibers and go between the fibers to reach the target anatomy,” says Don Young Park, MD, Vice Chair, Quality and Safety, UCLA Department of Orthopedic Surgery.

Minimally invasive spine surgery (MIS) has been a welcome evolution. The incisions are much smaller, about quarter inch, compared to traditional or “open” back surgery with incisions that range from 4 to 6 inches. Smaller incisions result in less blood loss, less pain, and faster recovery compared to traditional back surgery. Though minimally invasive, make no mistake that it is still very serious surgery, carrying potential risks and complications. Deciding to undergo any surgery is best done knowing the risks, benefits, and realities of what the surgery can do for you.

According to Dr. Park, patients tend to think one procedure will cure them, but that’s not necessarily the case when it comes to spine surgery. “Back pain is complicated, and often more than one part of the spine has significant pathology,” he explains. “Though we try to get patients as close to no pain as possible, the goal of surgery is not the complete elimination of pain. It’s about reducing pain and improving function.”

MIS can be an optimal choice for many people, but it is not always the right and only choice.

“It depends on the patient’s pathology,” explains Dr. Park. “Sometimes I use minimally-invasive techniques in addition to and in conjunction with open techniques.”

The Cause Informs the Approach

Ideal candidates for minimally invasive spine surgery are people who have back pain along with nerve-related pain due to compression, which could be caused by a bulging (herniated) disc, lumbar stenosis (narrowing of the spinal canal), an instability of the spine, or other structural problem. Symptoms from these issues usually include back pain and radiating pain, for example the shooting leg pain from sciatica.

More complex problems such as severe scoliosis, tumors, excessive scar tissue from previous surgeries, or pathologies that involve several levels of the spine are typically better served by traditional open techniques or a combination of open and MIS.

If you are considering back surgery, ask surgeons a lot of questions to make sure you understand what’s involved and what outcomes can be expected (see the What You Can Do box on page 5).

Common Causes of Back Pain

The complexity of the spine makes diagnosis and treatment of back pain time consuming, challenging, and sometimes quite elusive. Consultations with several experts may be warranted. The most common causes of back pain fall into five basic categories:

• Mechanical pain results from injuries to the spine, intervertebral disks, or soft tissues (muscles, tendons, ligaments). Fractures and bulging (herniated disks) are also considered mechanical issues.
• Degenerative diseases include osteoarthritis of the spine, which can result in spinal stenosis, and degenerative disk disease, which can result in compression fractures.
• Inflammation can be acute, due to a sudden injury, or it can be chronic, such as with sacroiliitis (inflammation of either or both joints of the sacrum). Ankylosing spondylitis is an inflammatory disease that causes the vertebrae to fuse.
• Oncologic causes include cancer-causing back pain from conditions such as cancer of the bone marrow or tumors on the spine.
• Infections can occur in the vertebrae, disks, muscle, or other soft tissues.

Diagnosis begins with a thorough history and physical exam, where physicians evaluate pain intensity, location, duration, degree of the pain, and impact on daily life. Imaging (magnetic resonance imaging, MRI, or computed tomography, CT) reveal soft tissue damage or abnormalities, nerve root/spinal cord compression from a bulging disk, malignancy, and inflammatory conditions of the spine and surrounding tissues.

MIS can treat a wide variety of the aforementioned spine disorders. It’s worth noting that while a herniated disk is a common cause of back pain, not all herniated disks cause pain. A herniated disk is when the soft center of the shock-absorbing disk pushes through a crack in the disk’s tough outer ring. Herniated disks are often seen on MRIs of asymptomatic patients who have scans for other purposes. If imaging reveals a bulging vertebral disk but the bulge isn’t pressing on a nerve or the spinal cord, it’s not a source of back pain.

Minimally Invasive Procedures

The general goal of MIS is to stabilize the spine or relieve pressure from trapped nerves. MIS can include the following procedures:

• Diskectomy removes all or part of a bulging disk to relieve pressure on nerves.
• Foraminotomy widens the opening in the spine where nerve roots leave the spinal canal to relieve pressure off those nerves.
• Laminectomy involves removing some vertebral bone (the lamina) to create more space for spinal nerves and/or the spinal cord.
• Spinal fusion permanently joins together two or more bones to stabilize the spine.

MIS can be performed using a variety of techniques. The most common is tubular surgery, in which a tubular retractor is inserted into the back that measures approximately 2 cm in length. A newer form of MIS is spinal endoscopy, which consists of two main types. The first is the “uniportal” technique, which consists of a single 1 centimeter (cm) incision video-assisted technique, where a single port is introduced into the back and integrated with the endoscopic camera. Ports are devices (e.g., a camera and specialized endoscopic equipment) placed into the body to visualize and affect the target areas. Uniportal spinal endoscopy can only affect the spinal anatomy that is directly in front of the camera, which can be limiting and difficult.

The latest MIS advancement is a “bi-portal” endoscopic technique, which enables surgeons to have better views of the surgical area. Biportal spinal endoscopy uses two small incisions that are several centimeters apart, the first being a 3-millimeter (mm) incision for the camera and the second being a 7-mm incision for the instruments. “Having two portals effectively decouples the camera and the instruments, allowing for greater flexibility, versatility, and control over the surgical instruments,” says Dr. Park. “The camera can be moved independently from the surgical instruments, allowing greater freedom to perform the surgery. Most of all, the visualization is enhanced and the spinal anatomy can be visualized to a greater degree than ever before.” All these benefits allow the surgeon to perform the surgery more effectively with a greater degree of safety while still reducing the injury to the soft tissues. As such, these surgeries can now be more commonly performed in the outpatient setting instead of the inpatient hospital, as they were done in the past.

Preparing for any elective surgery includes being in the best possible physical and mental condition. Obviously, pain may prohibit a strenuous workout, but a physical therapist may be able to help you strengthen your core muscles in ways that don’t exacerbate the pain. Some physicians may also recommend a mental health screening prior to surgery to assess for depression and anxiety. These conditions may decrease the response to surgery as well as interfere with recovery time. Recognizing and treating them may help speed healing and increase post-surgical satisfaction.

“Performing minimally invasive surgery has a steep learning curve because it is so highly technical, and it’s continually evolving. Surgeons who have had training and fellowships in minimally invasive techniques and membership in societies such as the Society of Minimally Invasive Spine Surgery can help distinguish those who have been properly trained.”

­—Don Young Park, MD,
Vice Chair, Quality and Safety,
UCLA Department of Orthopedic Surgery

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“The correct terminology for this condition is actually ‘radiculopathy,’ or radicular pain,” explains Jaspal Ricky Singh, MD, vice chair and associate professor in the department of rehabilitation at Weill Cornell Medicine.

Causes of Sciatic Pain

The sciatic nerves are the longest nerves in the body; they begin in the lumbar (lower back) area and extend through the buttocks down each leg to the feet. Sciatica can be acute, lasting a few weeks, or chronic, persisting for more than three months. Often, the pain resolves without treatment within a few weeks or months.

Some medical conditions that can cause these symptoms include herniated discs, lumbar spinal stenosis, and degenerative disc disease.

Often, sciatica is a result of a bulging or herniated disc in the lumbar spine. Intervertebral discs are gel- and fiber-filled structures that act as shock absorbers and prevent your vertebrae from rubbing together when you move your upper body.

“Think of the disc as a jelly donut; if the donut is squeezed or compressed, the ‘jelly’ squirts out and can come into contact with a nerve. When a bulging disc presses on one of these exiting nerves in the lower back, the patient often reports shooting pain down the leg,” explains Dr. Singh.

Symptoms and Diagnosis

A patient who has radiculopathy usually reports sharp, stabbing pain starting in the lower back and radiating down the buttock and leg. If the nerve compression is severe, the patient may report weakness in the leg. The pain can vary from mild to debilitating, depending on the degree of pressure exerted on the sciatic nerve. Other symptoms include:

• Numbness or a burning or tingling sensation in the leg or foot
• Weakness of the leg or foot
• Pain in the buttock area and leg that increases with coughing, sneezing, or straining
• Pain that increases with bending backward and with prolonged sitting or standing

An evaluation for sciatica includes a complete medical history, a physical examination, and an assessment of neuromuscular function. Imaging procedures, such as X-ray, MRI, CT scan, and electromyogram, and/or nerve conduction tests may be necessary to confirm the diagnosis and/or identify the exact location of the nerve impingement.

Treatment Options

“The first goal of treatment is to minimize the inflammation of the nerve; this may require an oral medication, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or an oral steroid. In addition, it is critical to take the compression off the disc and the nerve, which can sometimes be accomplished with physical therapy and core-strengthening exercises,” says Dr. Singh. Applying ice or heat, massage, and manual manipulation may also help relieve the pain.

If conservative options do not provide relief, epidural steroid injections usually are effective in alleviating symptoms.

If symptoms persist and the patient reports any neurological problems, such as weakness or numbness, surgical intervention should be considered. Conditions that may be treated with surgery include herniated discs, lumbar spinal stenosis, spondylolisthesis, and degenerative disc disease.

Finally, Dr. Singh emphasizes the importance of doing exercises that strengthen your core muscles.

“To prevent sciatic pain or to keep it from returning once you’ve had it, keep your core strong; this will minimize the compressive forces on the discs and prevent pressure on the sciatic nerve.”

Ask your doctor for a referral to a physical therapist or other health-care provider who can teach you core exercises that are safe and effective.

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Osteoarthritis a Common Cause

Stenosis develops when the spinal canal (the space around the spinal cord) narrows, putting pressure on the spinal cord. The most common cause is osteoarthritis, a condition in which the cartilage that covers and protects the ends of the bones in a joint wears away. If this process takes place in the spine, the body may respond by forming bony growths called spurs. Bone spurs narrow the space the spinal nerves pass through and may pinch the nerves that travel down to the legs. “This results in pain, numbness and/or weakness in the legs, groin, hips, buttocks, and lower back,” Dr. Cho says. “The symptoms are worse when you’re walking or standing, and decrease when you’re lying down or sitting, particularly if you lean forward, since this increases the space available for the nerves.”

Maintaining Mobility and Flexibility

There is no cure for spinal stenosis, but there are strategies you can use to manage it. “If your condition is mild, staying as active as possible may help prevent it from progressing to severe,” Dr. Cho says, “and physical therapy incorporating stretching exercises, and exercises that strengthen the muscles of the lower back and abdominal area, can help you maintain flexibility.”

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil®, Motrin®) and naproxen (Aleve®, Naprosyn ®) can help alleviate pain from stenosis, as well as reduce inflammation around pinched nerves. However, if you are taking these drugs regularly, keep in mind that they have been associated with serious side effects, such as gastrointestinal bleeding, in seniors. This increased risk can be reduced by taking medications called proton pump inhibitors (PPIs), so discuss your NSAID use with your doctor to see if a PPI might be indicated. Another treatment option is corticosteroid injections into the space around the spinal nerves. This relieves pressure on the nerves by reducing inflammation. However, the injections can be given only a few times a year, since repeated steroid injections may weaken nearby bones and connective tissue.

Surgery vs. Conservative Treatment

Studies have suggested that surgery may help to restore mobility in people with progressive, severe spinal stenosis that is not eased by conservative therapies. “One option is laminectomy, which enlarges the spinal canal by removing bone spurs that may be pressing on the spinal nerves,” Dr. Cho explains. “If there is instability between the vertebrae, spinal fusion—which permanently joins two or more of the vertebrae to restrict movement in painful areas—also may be performed.”

While some research has indicated that surgical treatment for stenosis can benefit even the oldest old, other studies suggest that long-term outcomes from surgery may be comparable to those seen with conservative treatment. “The data highlight the importance of discussing the pros and cons of various treatments, including surgery, to achieve the best outcome for individual patients who are affected by lumbar spinal stenosis,” Dr. Cho concludes.

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A: A variety of problems can put the squeeze on your sciatic nerve. Some of the more common culprits include:

• Herniated (slipped) discs between the vertebrae pressing on the sciatic nerve.
• Spinal stenosis, or narrowing of the spinal canal.
• Spondylolisthesis, when one of the vertebrae slips out of place.
• Piriformis syndrome, which occurs when the piriformis muscle deep in the derriere becomes tight or starts having spasms.

Don’t overdo it. Overuse of your back, such as lifting something that is too heavy, an injury from a fall, or having something hit your back, can also bring about an episode of sciatica. It can also be the result of excess body weight that increases stress on the spine, which can contribute to bone spurs and herniated discs. Other causes include a sedentary lifestyle or a job that forces you to sit for long hours.

A flare-up of sciatica differs from other types of back pain. Instead of a throbbing in one place, it can range from a mild ache to a sharp, shooting pain, or a burning sensation to an electric shock. Aside from pain, some people develop numbness, tingling, or weakness in a leg or foot, or multiple symptoms in different parts of the leg. Typically, though, people experience symptoms only on one side of their body.

Conservative Management. The good news is that mild sciatica usually dissipates over time with conservative management such as pain relievers, alternating heat and ice, avoiding lifting or bending, and physical therapy. Surgery is recommended in a small minority of cases.

To reduce your chances of flare-ups:

• Lose weight if you are overweight.
• Do warm-up stretches before participating in activities.
• Do regular aerobic exercises to strengthen your back and abdominal muscles.
• Lift properly, bending your knees and hips and keeping your back straight.
• Practice good posture.

If you experience a bout of sciatica that lasts more than a week or two, or becomes severe or progressively worse, it is time to seek out help from a physician.

Q: Since the start of the pandemic, my doctors have given me the option of scheduling tele-medicine appointments. I’m happy to use my computer to visit with friends, but I don’t feel fully comfortable with online health care. Should I?

A: Telemedicine has been around for a very long time. When it was first introduced, it referred to telephone appointments, which were particularly useful in rural areas where patients sometimes would have to travel hundreds of miles to see a specialist. Telemedicine has come a long way since then as a result of software technology that makes it safe to visit with your doctor in the privacy of your home via smartphone or computer.

Oftentimes, doctors will conduct the initial consultation visit in-person and use telemedicine only for follow-up visits. There are two benefits to this system: One is the ability to use hands-on exams to establish a diagnosis, and the other one is to establish a doctor-patient relationship prior to conducting visits by telehealth.

The short answer to your question is: Yes. You should be comfortable with virtual doctor visits and you should get on board with telemedicine because it’s here to stay. Doctors are doing everything possible to have fewer patients physically in their waiting rooms, in an effort to enforce social distancing. Virtual appointments are key to enforcing safety protocols. And many patients have embraced the convenience of seeing their doctor without leaving their home.

If you agree to a virtual visit, remember to check with your insurance provider about coverage. Insurance payments for telehealth services, especially at full cost, may only be temporary. Medicare’s coverage of a broad range of services may end when the novel coronavirus no longer poses a public health emergency.

The post Q&A: Sciatic Nerve Pain; Telemedicine Appointments appeared first on University Health News.

What Causes Sciatica? Sciatica is caused by compression of the sciatic nerve, which starts in the lower spine and branches out through the lower back and down the legs. If any part of the nerve is squeezed or pinched, you may experience what many people describe as a “lightning bolt of pain” that shoots from your lower back as far as your foot, along with tingling or numbness in the affected leg.

Houman Danesh, MD, associate professor of rehabilitation and physical medicine at Mount Sinai, says that in seniors sciatica often is caused by spinal stenosis (a narrowing of the space the spinal nerves pass through) in the lower back. Stenosis typically occurs due to osteoarthritis, which can cause bone spurs (bony outgrowths) to form on the vertebrae. “These spurs may compress the sciatic nerve roots,” Dr. Danesh explains. Another possible cause of sciatica is a herniated (also known as slipped) spinal disc. “These discs degenerate as you age,” Dr. Danesh says. “As this happens, the discs may bulge and compress or irritate the roots of the sciatic nerve.”

Comorbidities Common The study we reference (Journal of the American Academy of Orthopaedic Surgeons, May) looked at data on about 1 million Medicare recipients. Compared to people without sciatica, those with the condition were more likely to be obese, and to have heart disease, high blood pressure, a history of heart attack and stroke, and diabetes, among others.

The study doesn’t prove that sciatica caused these conditions, but Dr. Danesh notes that sciatica pain can cause people to reduce their physical activity levels, and that lack of exercise is associated with a greater risk for cardiovascular disease, diabetes, stroke, and obesity. “Sciatica also can disturb your sleep, which may decrease your immune response as well as worsen comorbidities,” he adds.

Managing the Pain Ice packs can help ease sciatica pain, and Dr. Danesh recommends you also adopt an exercise regimen to strengthen the muscles that support your lower back. Don’t forget your glutes (the muscles in the buttocks and sides of the hips), either. “Many people with sciatica have an underlying weakness in these muscles,” Dr. Danesh says. “If you have to push off from your knees or the armrests of a chair to get up from a seated position, you likely would benefit from strengthening your glutes.” Doing so may help you avoid exerting further strain on the muscles of your lower back. A physical therapist can help design an exercise program that suits you—if you use a fitness instructor, be sure to check that he or she has experience working with older adults and people who have lower back problems.

If non-drug approaches don’t bring adequate relief from sciatica pain, try acetaminophen (Tylenol®) before nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil®, Motrin®) or naproxen (Aleve®, Naprosyn®), since the latter are associated with bleeding in older adults, and also have been linked with a greater risk of heart attack and stroke. Your doctor also may prescribe muscle relaxants and/or anti-seizure drugs, such as gabapentin (Neurontin®), and pregabalin (Lyrica®). Beware that muscle relaxants may cause drowsiness and dizziness that can raise your risk of falls—anti-seizure drugs also may cause dizziness. Steroid injections are another option, and help reduce inflammation in the sciatic nerve, but the number of injections you can have is limited due to potentially serious side effects.

What About Surgery? Surgical options are available for severe sciatica, but Dr. Danesh recommends that surgery be seen as a last resort for people whose sciatica causes significant weakness of the leg, and/or interferes with bowel function. “If you are neurologically intact, start with conservative treatments and give them time to work,” he advises.

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