How to manage severe sciatic nerve pain, which has progressively worsened even with rest?

Question

Hello doctor,

I am a 28-year-old female. I have had severe sciatic nerve pain for the last six weeks, which has progressively worsened even with rest. Pain has made it difficult to get out of bed, stand up from a sitting position, and sit down. I have a history of L5-S1 laminectomy and discectomy, persistent moderate bilateral neural foraminal stenosis at L5-S1. I cannot do most activities without severe leg and back pain developing.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and saw your attached files (attachments removed to protect the patient's identity). First of all, I am so sorry for the degree of pain and limitation in daily activity you are experiencing at such a young age. Considering your explanation regarding your physician's clinical examination notes and your old lumbar MRI (magnetic resonance imaging), it is evident that you are suffering from bilateral S1 and L5 radiculopathies to the degree that has caused a minor weakness in your first toes. Such kind of pain cannot be managed by Ibuprofen exclusively.

If you were my patient, I would conduct the following measures:

1- An electrodiagnostic study (EMG-NCS study) to quantitatively evaluate the degree of insult to your lower limb nerves. It helps in decision-making for your treatment. In severe insult with ongoing denervation, surgical intervention is necessary. In a moderate degree of insult with ongoing denervation, medical treatment plus rehabilitation and lumbar steroid injection nerve block would be beneficial. In mild insults with or without ongoing denervation, medical treatment plus rehabilitation are the mainstays of treatment.

2- A new lumbar MRI (magnetic resonance imaging).

3- Boost your medical treatment with additional drugs such as Pregabalin or Gabapentin, or Duloxetine.

4- Prescribing rehabilitation and water treatment (including walking in a pool in the section where the water level reaches your upper sternum edge in a straight standing position).

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

It is easier to say with a new MRI (magnetic resonance imaging) and EMG-NCS (electromyography and nerve conduction studies). Nearly six years have passed since your previous surgery. You should consider that after a discectomy/laminectomy, the dynamic of the lumbosacral spine changes. Imagine a column of bricks under heavy pressure; due to some lesions, one has to pick some bricks from the bottom. Then, inevitably, the stability of the column would be affected. Some deviation and more insults to other parts may occur. A similar process may occur after any alteration in the spinal column. Therefore, any neurologist needs the mentioned workups to tell you what has happened. What is evident now is that your medication should be changed to overcome your pain, and I encourage you to do the water treatment rehab.

Thank you.

Answer 3

Hello,

Welcome back to icliniq.com.

The uploaded MRI (magnetic resonance imaging) images (attachments removed to protect the patient's identity) show a central herniation of the L5-S1 disc with mild canal stenosis at that level and bilateral foraminal stenosis (right>left). It means there is bilaterally stenosis in the foramina of your S1 roots (right a bit more than left). The S1 root is one of the primary roots of the sciatic nerve, and pressure on it can cause sciatica.

Thank you.

Answer 4

To give a relatively accurate answer to this question, the result of the EMG-NCS study is crucial. If that study shows notable damage to your leg nerves or significant evidence of ongoing denervation, then the surgical intervention would be necessary. If EMG-NCS shows no damage to the nerves, a combination of medical treatments including a good drug regimen, physical therapy and water treatment, with or without lumbosacral nerve block injection may solve the problem. In any case, if medical treatments fails (it means that pain and limitation remain after good drug+at least 30 sessions of physical therapy) then again surgical intervention is the choice of treatment.