Episode 14 - Top 5 Non-Disc Causes of Low Back Pain and Sciatica
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Episode Summary
If you are experiencing lower back pain or sciatica, it’s important to determine its cause for proper treatment and better pain management. However, there are some cases where patients, who reported to have issues in this region, find out through medical diagnosis that the cause is not rooted in bulging or degenerative lumbar discs.
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia dives deep into the top 5 reasons behind your lower back pain. These are the piriformis syndrome, sacroiliitis, lumbar and gluteal trigger point syndrome, hamstring strains and lumbar facet referral pain patterns. Most of these are related to certain muscle groups in the lower region of the body and spinal joints. He discusses the causes behind each condition, common symptoms, ways to diagnose these and treatment options.
He also points out to thoracic myelopathy, a serious upper back condition that not only causes lumbar pain, but dysfunction of the spinal cord as well.
For Dr. Lakhia, it’s important that you always refer to a specialist or skilled practitioner to properly diagnose your pain. They are able to give you the best treatment and pain management options, which normally include physical therapy and medication.
Key Moments in the Episode
Every episode of Back Talk Doc includes a Health Matters segment intended to provide actionable health information you can immediately put into practice in your life. This week, Dr. Lakhia talks about active rest techniques and how you can incorporate these in your daily lifestyle. He refers to strategies outlined in the book The Power of Rest by sleep expert Dr. Matthew Edlund.
It’s essential that you engage in activities that rejuvenate your mind and that provide you with mental rest, social rest, spiritual rest and physical rest. He also encourages taking a nap about 3 hours before your normal bedtime for improved productivity during the day. Making social connections, deep breath work and mediation are other techniques you can incorporate to optimize your health through rest.
Links Mentioned in the Episode
Back Talk Booklet by Dr. Sanjiv Lakhia
Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual
The Power of Rest by Dr. Matthew Edlund
The Rest Doctor
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
If you are experiencing lower back pain or sciatica, it’s important to determine its cause for proper treatment and better pain management. However, there are some cases where patients, who reported to have issues in this region, find out through medical diagnosis that the cause is not rooted in bulging or degenerative lumbar discs.
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia dives deep into the top 5 reasons behind your lower back pain. These are the piriformis syndrome, sacroiliitis, lumbar and gluteal trigger point syndrome, hamstring strains and lumbar facet referral pain patterns. Most of these are related to certain muscle groups in the lower region of the body and spinal joints. He discusses the causes behind each condition, common symptoms, ways to diagnose these and treatment options.
He also points out to thoracic myelopathy, a serious upper back condition that not only causes lumbar pain, but dysfunction of the spinal cord as well.
For Dr. Lakhia, it’s important that you always refer to a specialist or skilled practitioner to properly diagnose your pain. They are able to give you the best treatment and pain management options, which normally include physical therapy and medication.
Key Moments in the Episode
- The importance of personal experience - 01:02
- Piriformis syndrome - 02:56
- Causes of piriformis syndrome - 04:01
- Treatment options for piriformis syndrome - 05:35
- Sacroiliitis - 08:14
- Factors that aggravate the sacroiliac joint - 09:07
- Diagnosing sacroiliitis - 10:08
- Lumbar and gluteal trigger point syndrome - 11:36
- Common trigger points that cause back pain - 12:57
- Treatment options for lumbar and gluteal point syndrome - 14:14
- Hamstring strains - 23:48
- Lumbar facet referral pain patterns - 25:51
- Treatment options for lumbar facet referral pain - 27:51
- Thoracic myelopathy - 28:52
Every episode of Back Talk Doc includes a Health Matters segment intended to provide actionable health information you can immediately put into practice in your life. This week, Dr. Lakhia talks about active rest techniques and how you can incorporate these in your daily lifestyle. He refers to strategies outlined in the book The Power of Rest by sleep expert Dr. Matthew Edlund.
It’s essential that you engage in activities that rejuvenate your mind and that provide you with mental rest, social rest, spiritual rest and physical rest. He also encourages taking a nap about 3 hours before your normal bedtime for improved productivity during the day. Making social connections, deep breath work and mediation are other techniques you can incorporate to optimize your health through rest.
Links Mentioned in the Episode
Back Talk Booklet by Dr. Sanjiv Lakhia
Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual
The Power of Rest by Dr. Matthew Edlund
The Rest Doctor
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Intro: 00:01
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health. Brought to you by Carolina Neurosurgery and Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 00:35
There's no substitute in life for personal experience. On this episode of Back Talk Doc, I want to review with you what I believe to be the top five non-disc causes of low back pain and sciatica. And as you know, I'm a board certified specialist in physical medicine and rehabilitation, so I treat back pain for a living. But I also have been blessed with my own personal challenges off and on with low back issues.
Sanjiv Lakhia: 01:02
This past weekend, as many of you are doing, getting outside more during this pandemic, I did go for a long bike ride and afterwards have dealt with some soreness and some pain going down my leg. Now my own history, I have a bulging disc. So if you have a history of a bulging disc and some nerve pain, I can understand and I can relate. And I do think it's made me a little better at understanding these issues and being more compassionate about them. And like I said, there's no substitute for personal experience. You certainly can have book experience, classroom experience. But then when you sprinkle in a little personal experience, I think you get a much clearer picture about what's going on.
Sanjiv Lakhia: 01:40
It got me thinking, talking with my wife about this, I think really that some of the discomfort I had from my bike ride is not necessarily disc-related pain. And to be honest, we speak often that about 80% of the patients that come to see us at Carolina Neurosurgery and Spine Associates don't really need back surgery. And I'll go a step further, at least half of the patients I see with back issues really have discomfort and injury coming from something other than their lumbar disc. We've talked about before, and I just discussed this in my book Back Talk, that there's a very high percentage of the population that's walking around with bulging disks or generative disc that have no pain.
Sanjiv Lakhia: 02:21
What does that mean? Well, essentially that on some level disc deterioration is a normal process of Father Time and Mother Nature, as I call it. Not all pain is disc-related pain. So what are the alternatives? Today, I want to break down for you, what I believe to be the top five non-disc related causes of back pain and sciatica. And then I'll have a kind of a plus one at the end, a bit of an outlier that you should consider as well. Without further ado, let's get going with today's list of the top five non-disc related causes of back pain and sciatica.
Sanjiv Lakhia: 02:56
Number one, piriformis syndrome. Now piriformis syndrome is very common and the piriformis muscle is a major muscle that's in your buttock or in your gluteal muscle complex. It's beneath the big gluteus maximus muscle, and essentially it runs from your sacrum to the side of your hip, what's known as the greater trochanter. Piriformis syndrome is often diagnosed by physical therapists. And let me describe it for you in brief.
Sanjiv Lakhia: 03:27
If you look at the anatomy of the piriformis muscle, in about 10 to 15% of the population, your sciatic nerve will actually split the muscle. In the remainder of us, the sciatic nerve runs underneath it. In any event, sciatic nerve is very close to this muscle. If you develop tightness in the muscle or irritation of the muscle, it can irritate the sciatic nerve. It can cause pain that shoots down your leg mimicking a pinched nerve in your low back, mimicking a herniated disc. Particularly at L5-S1, it can look very similar.
Sanjiv Lakhia: 04:01
What causes piriformis syndrome? A variety of things that we believe. It's not fully understood, but I think there are some common factors. Number one, I do tend to see this more in women. The dimensions of the female pelvis are wider, and that's for obvious reasons, for childbirth, labor and delivery. And that can put a little more strain on the muscle complex in the hips. Other factors can include just general weakness in your hip muscles, that can lead to overexertion of the piriformis muscle and irritation of your sciatic nerve.
Sanjiv Lakhia: 04:34
Now the piriformis muscle has multiple functions. One of them is to externally rotate or rotate out your hip and leg, and the other one is to extend the hip back so think about when you're walking. And there are many maneuvers that a physical therapist or a physician can use to try and diagnose this problem. And oftentimes it just comes down to if you push over the muscle and it's very sore and you're getting some referred pain down the leg, you may suspect piriformis syndrome.
Sanjiv Lakhia: 05:05
It's a challenging condition though to diagnose and treat. Why? Well, there's no specific test that can confirm the diagnosis. It's somewhat a diagnosis of exclusion, meaning we will typically look at your low back first and rule out a disc issue or a bone spur issue touching the nerve. And then if those are negative, we'll oftentimes have a presumed diagnosis of piriformis syndrome if there are some other conditions that point us in that direction.
Sanjiv Lakhia: 05:35
After you have a suspected diagnosis of piriformis syndrome, how do you get better? Well, we prescribe a lot of physical therapy for this. There's multiple factors that I believe play a role such as muscle tightness, muscle weakness, pelvic imbalance, gait imbalance, and overall a lack of flexibility. A good knowledgeable physical therapist can put together an exercise prescription that can address your specific problems.
Sanjiv Lakhia: 06:02
In terms of more direct techniques for pain control, as a physiatrist, we have performed injections for this problem. You can inject the piriformis muscle, but it needs to be done safely under some degree of guidance. And we typically use ultrasound imaging to visualize the muscle, identify the adjacent psychotic nerve so we can direct a needle into the muscle or around the muscle itself and not into the sciatic. nerve.
Sanjiv Lakhia: 06:27
Now there's debate in the literature about does the injection really work and what do you inject? Well, there are several options. You can inject a mixture of an anesthetic, such as lidocaine and a steroid around the muscle just to reduce inflammation. There's also some research being done that shows a benefit of injecting the area with a small amount of Botox. You may know that Botox is often used for wrinkles, but also it's used for what's called spasticity, which has over tight muscles from neurologic conditions. If you inject the piriformis with a little bit of Botox, it can relax a chronic muscle spasm and promote healing.
Sanjiv Lakhia: 07:05
In any event, make sure you speak with your physician regarding any of these possibilities. And again, this is more for informational purposes. I'm not making any specific recommendations for your condition. Medications typically are used as well to manage symptoms. These are typically over-the-counter medications and I don't personally believe medications have a role of long-term management of this issue.
Sanjiv Lakhia: 07:24
A few other considerations. I often see piriformis syndrome develop in individuals who do yoga. There are multiple postures, particularly the pigeon pose, which are done to target the piriformis. And I've seen almost an over exertion or overstretched syndrome develop that can irritate the muscle-tendon complex, so be careful when you're doing yoga and make sure you're only going to your limits and not trying to compete with others. And typically, you can stay out of trouble that way.
Sanjiv Lakhia: 07:50
Lastly, there are some individuals who believe you can diagnose piriformis syndrome with EMG testing. EMG testing is a way to look at the electrical health of your sciatic nerve. And in some cases, there are some utility with that test as well. Again, speak with your physiatrist about this if you're concerned. That's piriformis syndrome in a nutshell. It's very common, and I wanted you to understand a little bit about it.
Sanjiv Lakhia: 08:14
Let's move on to number two in our list of top non-disc related causes of back pain and sciatica. Number two would be sacroiliitis. Sacroiliitis is inflammation of the sacroiliac joint. The sacroiliac joint is a joint between your sacrum and your ilium, and it's really in the back, near the buttock. It's kind of where your tailbone meets your hip.
Sanjiv Lakhia: 08:37
Now the sacroiliac joint bears a tremendous amount of weight when you're walking, but there's not much movement in the joint. Particularly as you get older, movement in the joint becomes much less. It's a very small joint and can only really be visualized under direct imaging studies. The joint itself can become inflamed. And when it does, it can create pain in the buttock area and can also mimic pain going down the back of your leg, very similar to sciatica. Let's talk about the joint a little more.
Sanjiv Lakhia: 09:07
What tends to aggravate the sacroiliac joint? Very similar, you're going to find that in all these conditions excessive weight bearing on the joint, prolonged sitting, muscle imbalances around the joint can trigger pain. More commonly, the sacroiliac joint is often aggravated and inflamed during pregnancy, just through the changes that develop in the pelvis and the ongoing pressure and weight of the developing fetus. Women often are familiar with sacroiliitis as we call it, and many times in that situation it'll resolve after the child is delivered.
Sanjiv Lakhia: 09:40
But trauma to the joint, so a fall on your hip, can aggravate the joint and simple things like leg length inequalities and muscle imbalance can trigger what we call mechanical sacroiliitis. Now there are medical conditions that can actually attack and inflame the joint. There are inflammatory arthritis-type conditions. If you do have actual x-ray evidence of destruction of your joint or erosion of your joint, then you should be tested for some of these other conditions.
Sanjiv Lakhia: 10:08
How do you diagnose sacroiliitis? Typically, again, it's mostly done by a physical exam and history. There are some maneuvers where we can mobilize and manipulate your hip and see if we can provoke the pain. But largely, literature shows there's not a real reliable physical exam maneuver to clearly diagnose sacroiliitis. The more definitive way to diagnose the condition is to inject the joint under x-ray guidance with an anesthetic agent to numb it up and then document your pain score. Oftentimes, we perform a fair number of sacroiliac injections under fluoroscopic guidance to diagnose and treat the condition. Additionally, physical therapy is critical, to again identifying some of these mechanical factors that could be driving pain in the joint and hopefully eliminate them through a proper exercise prescription.
Sanjiv Lakhia: 11:01
The sacroiliac joint can definitely refer pain down the back of the leg. In fact, I was just doing an injection this week and right during the injection when I put the medicine in, she complained of a little bit of achiness going down the back of her leg. It is well-documented that sacroiliac joint has a referral pain distribution, so keep that in mind as well. It's often a undiagnosed or misdiagnosed cause of low back pain. And it's one that skilled practitioners are always on the lookout for. If you have an MRI, that's unimpressive with regards to your low back and you're having persistent back and buttock pain, consider sacroiliitis.
Sanjiv Lakhia: 11:36
Moving on to number three in our top five non-disc related causes of back and leg pain or back pain and sciatica are lumbar and gluteal trigger point syndrome. Trigger points are tender spots in the muscles that can develop through chronic strain. And when you push on them, it can trigger pain in another part of the body.
Sanjiv Lakhia: 12:04
For example, if you've ever had a massage and you get deep pressure on your shoulder muscles or your upper trap muscles, you might feel some achiness in your jaw or down your arm. That's called a referral pain pattern. A classic example of a referral pain pattern is cardiac events where individuals may suffer a heart attack and they can feel it in their jaw or down their arm. The body will refer symptoms to other regions even though the source of the pain may be in a different location.
Sanjiv Lakhia: 12:37
If you look at the classic trigger point referral pain maps that were authored by Janet Travell, there are multiple trigger points that can be determined through physical examination that exist in your low back and pelvis and buttocks, that can cause back pain and referred pain down your leg. Let me name a few.
Sanjiv Lakhia: 12:57
Probably the most common one that I see is a gluteus medius muscle. Now, the gluteus medius muscle is on the side of your hip and is very critical for helping to extend and move your leg out to the side. Tenderness in that area can mimic sciatic pain and cause radiating pain down your leg, but it's not just the gluteus medius muscle. The gluteus maximus muscle can do it. Some of the deep external rotators of the hip can do it. A knowledgeable and skilled physician or physical therapist can rather easily identify these trigger points through direct pressure.
Sanjiv Lakhia: 13:32
Other areas to consider would be muscle complex, such as the quadratus lumborum muscle or the iliopsoas muscle. These muscles are deeper in the pelvis and a little bit higher up in the lumbar spine, and can radiate symptoms more into the front of your leg and thigh. And I will often see these activated in individuals who sit all day at work doing desk and computer work. Again, a knowledgeable physical therapist can identify these and treat these. These again are diagnosis of exclusion. You want to have a full, complete workup of your spine before you have a presumed diagnosis of trigger point referral patterns, but I would say they're very, very common and we've had great success treating them.
Sanjiv Lakhia: 14:14
What's the treatment? It can be any number of things. There's certainly an exercise component of focused stretching and strengthening, and then you can utilize direct treatment techniques such as dry needling, acupuncture or trigger point injections. Let's talk about these briefly.
Sanjiv Lakhia: 14:32
Trigger point injections can be done where you inject an anesthetic agent into the muscle itself. The goal of this is to essentially allow the muscle to release, and that's mostly accomplished through the mechanical irritation with a needle. Now there are some individuals who inject with a little bit of corticosteroid, mostly it's done with anesthetic agent.
Sanjiv Lakhia: 14:52
Alternative to that would be dry needling physical therapist at Carolina Neurosurgery and Spine Associates are trained and skilled in dry needling technique. This technique utilizes a very fine needle. It's essentially an acupuncture needle. It's the same needles that I use when I treat patients with acupuncture. You identify the trigger point through manual palpation, and then essentially you take the needle and you insert it into the muscle trigger point and you gently move it back and forth. This eventually allows the muscle to relax. It's largely painless. Although, there can be some trigger points that are very sensitive. Again, you want to have someone who's certified in this technique perform it to remain safe.
Sanjiv Lakhia: 15:28
Acupuncture is another technique that can help calm down trigger points. Now, it's not geared directly towards trigger point deactivation. There's other mechanisms that are utilized in acupuncture, and is a topic that I'll likely discuss in a future episode as I've been practicing acupuncture for almost 15 years.
Sanjiv Lakhia: 15:45
But those are some treatments that can be offered for trigger point pain syndrome. And the key take home there is you want to have a practitioner who is aware of these syndromes and knows how to evaluate and treat them, but there's certainly progress that can be made. That's the top three and we have a few more in our list of top five non-descriptive causes of back pain and sciatica. And we're going to get to the final few items after this break.
Sanjiv Lakhia: 16:16
On today's Health Matters segment, I want to do a book review on a very interesting and powerful book that I've recently gone through called The Power of Rest. Now, The Power of rest is written by Dr. Matthew Edlund and he is known as the "Rest Doctor" and can be found at the restdoctor.com. He's the director of the Center for Circadian Medicine in Sarasota, Florida, and really an award-winning expert on circadian rhythms, sleep, body clocks, and general health. The book I think is extremely powerful and there are some concepts in here that I want to share with you, and then elaborate on with my own spin.
Sanjiv Lakhia: 17:00
The general idea here is that Dr. Edlund believes sleep, while essential for our health, is not enough. That we need to build into our daily lifestyle, what he terms as active rest techniques, to just restore our normal physiology and the rhythm of life. He feels like active rest is under our control and it can allow us to restore our general health.
Sanjiv Lakhia: 17:28
Let me define for you or explain for you how he defines active rest. He kind of breaks it down into several categories. One is mental rest. He highly recommends engaging in activities that are rejuvenating for your mind. And he talks about social rests, spiritual rests and physical rest. One of the things he likes and really promotes, which I'm a big fan of, is naps. Taking a nap during the day is really not taboo, and the old thinking of taking a nap is lazy or counterproductive has really been debunked by science.
Sanjiv Lakhia: 18:02
Research has clearly demonstrated that if you take a nap in the early afternoon, that you're going to benefit with better productivity throughout your day and you're actually going to sleep better at nighttime. Now you want to make sure the nap is at least three hours removed from bedtime. The best and ideal time to take a nap is typically between one and three o'clock. Okay, I can already hear all of you out there saying, who can do that? We're all working. And I understand that. Weekends might be an opportunity. That's when I tend to take my nap is on Saturdays and Sundays, if the kids and life allow. And I find myself always to be more productive on the weekends when I sprinkle in a nap.
Sanjiv Lakhia: 18:38
In his book, he outlined that Winston Churchill was a big believer in the power of naps. And I want to read a quote for you. He said, "That you must sleep sometimes between lunch and dinner and no half-way measures. Take off your clothes and get into bed. That's what I always do. Don't think you will be doing less work because you sleep during the day. That's a foolish notion held by people who have no imagination. You will be able to accomplish more. You get two days instead of one. Well, at least one and a half, I'm sure. When the war started, I had to sleep during the day because that was the only way I could cope with my responsibilities." That's a quote from Winston Churchill.
Sanjiv Lakhia: 19:17
Really look to see, do you have opportunities during your day to integrate a nap? Outside of naps, he's really a big believer in social rest. And by social rest, I think really what he means is rejuvenating rest, where you're enjoying time with people making social connections. We know through research that social connections are critical to our overall health and wellbeing. And that's why I'm somewhat concerned during our current pandemic where we're all isolated, particularly our seniors who really thrive on connection with family and grandkids and friends, there are real physiologic health benefits that come with social rest.
Sanjiv Lakhia: 19:52
Simple examples that he gives in the book are to walk with a coworker at lunch, invite a friend to walk and converse with in the park, visit a neighbor or a coworker that you'd like to know better and just reach out to people you love. I think that's a great tip.
Sanjiv Lakhia: 20:08
Another tip that he talks about in terms of active rest is breathing. It sounds simple, right? Those who listen to Back Talk Doc understand how valuable I believe meditation is. And I consider deep breath work to be somewhat of an offshoot of meditation. Folks, there's real physiologic benefits with simple deep breathing. Most of us will breathe anywhere from 12 to 16 times per minute and research shows if you can get your breath cycle, your respiratory cycle, somewhere between five and 10 breaths per minute that you're going to have a relaxing, positive effect on your daily activities.
Sanjiv Lakhia: 20:45
How do you do that? Well, it typically involves expanding your inhalation and your exhalation, and I like to make the exhalation slightly longer than the inhalation. There's good data that shows that type of breathing pattern can shift your nervous system into more of a relaxed state. Let me give you an example and maybe you can follow along with me.
Sanjiv Lakhia: 21:05
During my coursework as a fellow at the Andrew Weil Center for Integrative Medicine, we've talked about the 4-7-8 breathing technique, and I want to go through that with you right now. if you're driving, I would just listen along. Certainly you can't follow along and do this technique while you're driving. You'd want to pull over and come back to this when you're sitting down. But if you're sitting down, go ahead and sit straight and kind of relax your jaw. Relax your shoulders and neck. And the 4-7-8 breath is essentially you inhale for a count of four, you hold the breath for a count of seven and then you exhale for a count of eight. Let's try it.
Sanjiv Lakhia: 21:43
Okay, go ahead and breathe in for a count of four. One, two, three, four. Now, hold the breath. Two, three, four, five, six, seven. Now exhale out your mouth, two, three, four, five, six seven, eight. And now relax. That's a very powerful technique, 4-7-8 breath, and I'll put a link in our show notes to a handout that can help explain that further. But if you go through two or three cycles of that a couple of times per day, you'll really find a different outlook on your day. It's a technique that I use at my bedtime.
Sanjiv Lakhia: 22:28
There are other techniques like that. There's box breathing, where you inhale for a count of four, you hold the breath for a count of four, you exhale for a count of four, you hold a breath for a count of four, and then you repeat. Find something that works for you, but really add breathing techniques as a form of active rest throughout your day.
Sanjiv Lakhia: 22:48
Lastly, he talks about physical rest, and physical rest really is meditation. It's probably the most powerful form of physical rest, and there are multiple versions of meditation out there we've talked about in previous episodes. And I think I'm going to do a whole episode on the benefits of meditation in the future. Anyway, I hope you find this to be interesting. Check the book out. We'll put a link to it in the show notes. It's called The Power of Rest by Matthew Edlund, MD. I think you'll find some great tips to help you stay healthy and calm during these stressful times.
Sanjiv Lakhia: 23:21
Okay, let's finish out our list of the top five non-disc related causes of back and leg pain and sciatica. We've covered three so far, and the first one was piriformis syndrome. The second one was sacroiliitis or sacroiliac joint pain. The third one was trigger point referral patterns. Moving on to number four. Number four on the list today, muscle strain, in particular hamstring strains.
Sanjiv Lakhia: 23:48
I'd say about two or three times a year. I get patients referred to my clinic evaluated of possible sciatica or a herniated disc in their back, and it turns out that pulled their hamstring muscle. Now, I would also say I get referrals in reverse where individuals were diagnosed with hamstring strains that turned out to be herniated disc in the back. It's one to consider. Particularly if you're an athlete, the hamstring muscle complex is a very large muscle group in the back of your leg. Pain in that area can follow the same distribution of the sciatic nerve and it can even irritate the sciatic nerve some and cause some paresthesia or nerve sensations in your leg.
Sanjiv Lakhia: 24:24
Typically, though the hamstring injury is easy to diagnose in terms of the history. Most of the time, it occurs in athletes and runners. Many times it's an acute injury where you'll feel a pull or even a pop and grab your buttock area or your hamstring area. I'm from the Cincinnati area, and growing up, watching the Cincinnati Reds, got to watch Ken Griffey Jr., who's one of the top baseball players of all time. He suffered with really severe hamstring injuries when he was with the Reds, and I have a really good recollection of that.
Sanjiv Lakhia: 24:57
Hamstring injuries can be very, very serious if not diagnosed correctly, and treated and a rehabilitated correctly. Now the diagnosis of a hamstring strain can be simply clinical based upon the history. And as long as a good physical exam is done to make sure you haven't actually torn the tendon, you can typically start rehabilitation immediately. Proper PT or physical therapy is essential to getting back to your activities and your athletics. And this may involve a degree of rest followed by active rehab with stretching and exercise strength training, along with modality treatment.
Sanjiv Lakhia: 25:31
If you're having pain, particularly in your leg and the back of the leg from the buttock to the knee, consider a hamstring strain. Now in severe cases, we can order MRI imaging to look at the structure and integrity of the hamstring muscle, as well as the tendon where asserts in the pelvis. But most of the time, this can be diagnosed through physical examination and history.
Sanjiv Lakhia: 25:51
That brings me to number five on our list of top five non-disc related causes of back pain and sciatica, and number five, lumbar facet referral pain patterns. Okay, so that's a lot. Let me break that down. Essentially, if we were to look at a spine model, on the back of the low spine or lumbar facet joints, these are the tiny joints of our spine that allow for degrees of movement. Just like you have joints in your knees and hips, there are joints all up and down your spine called facet joints.
Sanjiv Lakhia: 26:22
Now, the facet joints can degenerate over time. And very similar to how you can have false positive findings on MRIs for disc issues, you can also have the same thing for facet joints. What I mean by that is, facet joints will change over the course of our life. It's an aging process. And not all imaging abnormalities, x-ray and MRI abnormalities of your facet joints are sources of pain. And in fact, most are not. However, there are cases where you can have extensive wear and tear on your facet joints and it can cause both low back pain, but can also radiate down the back of your legs some. This can mimic a sciatic nerve irritation, mimic a disc bulge and nerve irritation.
Sanjiv Lakhia: 27:08
There are lumbar facet referral pain maps that have been developed. They're not quite as specific as the maps that we have for the cervical spine, but they do exist. And I have seen cases where individuals get treatment for the lumbar facets and some of the pain down their leg resolves. Lumbar facet referral pain patterns can be diagnosed through physical exam and also somewhat through imaging, but it's largely a diagnosis of exclusion. And really the main way to diagnose is to perform what's called medial branch blocks. And this is where you inject a small amount of a numbing medicine to numb up the nerves that go into the joints and then determine is that where the pain is coming from.
Sanjiv Lakhia: 27:51
What are the treatments for lumbar facet disease or lumbar facet referral pain? Again, you start with the basics of movement and exercise, weight reduction, optimizing nutrition and health. If that's ineffective, then there are more targeted treatments such as radiofrequency ablation or radiofrequency neurotomy. And this is a technique where you can essentially take a heated needle tip and burn the nerves that innovate those joints to block the pain for up to a year. It's a great alternative to surgery and can eliminate your back pain and buttock pain.
Sanjiv Lakhia: 28:22
Those are the top five causes, in my opinion, of non-disc related causes of back pain and sciatica. Beyond this, I'd like to add what I call a plus one. It's something to look out for. It's not very common, but is something to consider if you're really struggling with pain on the back of your leg. Particularly for having your neurologic symptoms such as numbness, burning and tingling, and your lumbar MRI really isn't showing much and these other causes have been ruled out, consider a condition called thoracic myelopathy.
Sanjiv Lakhia: 28:52
Now, the thoracic spine is your upper back and it's above the lumbar spine and the spinal cord runs through that area. Now myelopathy is a very serious issue where you can have some sort of dysfunction of the spinal cord as it runs through the area. For example, a bulging disc or a bone spur can irritate the spinal cord and cause a radiating pain down your leg. Now this condition is often accompanied by more serious symptoms as well, such as weakness in the leg, gait disturbance, and even possibly dysfunction of your bowel or bladder function. Certainly, if you have any suspicion for this, you should be evaluated by a physician.
Sanjiv Lakhia: 29:29
But there are cases where individuals will suspect that they have pain coming from a bulging disc in their low back, and it turns out that the issue was in the upper back. Again, you need a skilled clinician to have this on their radar and perform a proper physical examination and workup. But it's just something I want to plant the seed for if you're really struggling. You can ask the question, "Has anyone looked at my upper back as a potential source for the discomfort in my low back and leg?"
Sanjiv Lakhia: 29:55
There you have it folks. These are the top five causes in my opinion of low back pain and sciatic pain. Again remember, not all sciatica is disc related, not all back pain is a disc problem. There are multiple conditions that can be evaluated. Oftentimes, a good physical therapist can diagnose most of these. At our group, we're fortunate to have skilled physiatrists and neurosurgeons that can also help in your assessment. I hope you found these useful, and take care of yourself. Remember exercise, diet, and sleep are the key. And I look forward to speaking with you on our next episode.
Outro: 30:31
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health. Brought to you by Carolina Neurosurgery and Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 00:35
There's no substitute in life for personal experience. On this episode of Back Talk Doc, I want to review with you what I believe to be the top five non-disc causes of low back pain and sciatica. And as you know, I'm a board certified specialist in physical medicine and rehabilitation, so I treat back pain for a living. But I also have been blessed with my own personal challenges off and on with low back issues.
Sanjiv Lakhia: 01:02
This past weekend, as many of you are doing, getting outside more during this pandemic, I did go for a long bike ride and afterwards have dealt with some soreness and some pain going down my leg. Now my own history, I have a bulging disc. So if you have a history of a bulging disc and some nerve pain, I can understand and I can relate. And I do think it's made me a little better at understanding these issues and being more compassionate about them. And like I said, there's no substitute for personal experience. You certainly can have book experience, classroom experience. But then when you sprinkle in a little personal experience, I think you get a much clearer picture about what's going on.
Sanjiv Lakhia: 01:40
It got me thinking, talking with my wife about this, I think really that some of the discomfort I had from my bike ride is not necessarily disc-related pain. And to be honest, we speak often that about 80% of the patients that come to see us at Carolina Neurosurgery and Spine Associates don't really need back surgery. And I'll go a step further, at least half of the patients I see with back issues really have discomfort and injury coming from something other than their lumbar disc. We've talked about before, and I just discussed this in my book Back Talk, that there's a very high percentage of the population that's walking around with bulging disks or generative disc that have no pain.
Sanjiv Lakhia: 02:21
What does that mean? Well, essentially that on some level disc deterioration is a normal process of Father Time and Mother Nature, as I call it. Not all pain is disc-related pain. So what are the alternatives? Today, I want to break down for you, what I believe to be the top five non-disc related causes of back pain and sciatica. And then I'll have a kind of a plus one at the end, a bit of an outlier that you should consider as well. Without further ado, let's get going with today's list of the top five non-disc related causes of back pain and sciatica.
Sanjiv Lakhia: 02:56
Number one, piriformis syndrome. Now piriformis syndrome is very common and the piriformis muscle is a major muscle that's in your buttock or in your gluteal muscle complex. It's beneath the big gluteus maximus muscle, and essentially it runs from your sacrum to the side of your hip, what's known as the greater trochanter. Piriformis syndrome is often diagnosed by physical therapists. And let me describe it for you in brief.
Sanjiv Lakhia: 03:27
If you look at the anatomy of the piriformis muscle, in about 10 to 15% of the population, your sciatic nerve will actually split the muscle. In the remainder of us, the sciatic nerve runs underneath it. In any event, sciatic nerve is very close to this muscle. If you develop tightness in the muscle or irritation of the muscle, it can irritate the sciatic nerve. It can cause pain that shoots down your leg mimicking a pinched nerve in your low back, mimicking a herniated disc. Particularly at L5-S1, it can look very similar.
Sanjiv Lakhia: 04:01
What causes piriformis syndrome? A variety of things that we believe. It's not fully understood, but I think there are some common factors. Number one, I do tend to see this more in women. The dimensions of the female pelvis are wider, and that's for obvious reasons, for childbirth, labor and delivery. And that can put a little more strain on the muscle complex in the hips. Other factors can include just general weakness in your hip muscles, that can lead to overexertion of the piriformis muscle and irritation of your sciatic nerve.
Sanjiv Lakhia: 04:34
Now the piriformis muscle has multiple functions. One of them is to externally rotate or rotate out your hip and leg, and the other one is to extend the hip back so think about when you're walking. And there are many maneuvers that a physical therapist or a physician can use to try and diagnose this problem. And oftentimes it just comes down to if you push over the muscle and it's very sore and you're getting some referred pain down the leg, you may suspect piriformis syndrome.
Sanjiv Lakhia: 05:05
It's a challenging condition though to diagnose and treat. Why? Well, there's no specific test that can confirm the diagnosis. It's somewhat a diagnosis of exclusion, meaning we will typically look at your low back first and rule out a disc issue or a bone spur issue touching the nerve. And then if those are negative, we'll oftentimes have a presumed diagnosis of piriformis syndrome if there are some other conditions that point us in that direction.
Sanjiv Lakhia: 05:35
After you have a suspected diagnosis of piriformis syndrome, how do you get better? Well, we prescribe a lot of physical therapy for this. There's multiple factors that I believe play a role such as muscle tightness, muscle weakness, pelvic imbalance, gait imbalance, and overall a lack of flexibility. A good knowledgeable physical therapist can put together an exercise prescription that can address your specific problems.
Sanjiv Lakhia: 06:02
In terms of more direct techniques for pain control, as a physiatrist, we have performed injections for this problem. You can inject the piriformis muscle, but it needs to be done safely under some degree of guidance. And we typically use ultrasound imaging to visualize the muscle, identify the adjacent psychotic nerve so we can direct a needle into the muscle or around the muscle itself and not into the sciatic. nerve.
Sanjiv Lakhia: 06:27
Now there's debate in the literature about does the injection really work and what do you inject? Well, there are several options. You can inject a mixture of an anesthetic, such as lidocaine and a steroid around the muscle just to reduce inflammation. There's also some research being done that shows a benefit of injecting the area with a small amount of Botox. You may know that Botox is often used for wrinkles, but also it's used for what's called spasticity, which has over tight muscles from neurologic conditions. If you inject the piriformis with a little bit of Botox, it can relax a chronic muscle spasm and promote healing.
Sanjiv Lakhia: 07:05
In any event, make sure you speak with your physician regarding any of these possibilities. And again, this is more for informational purposes. I'm not making any specific recommendations for your condition. Medications typically are used as well to manage symptoms. These are typically over-the-counter medications and I don't personally believe medications have a role of long-term management of this issue.
Sanjiv Lakhia: 07:24
A few other considerations. I often see piriformis syndrome develop in individuals who do yoga. There are multiple postures, particularly the pigeon pose, which are done to target the piriformis. And I've seen almost an over exertion or overstretched syndrome develop that can irritate the muscle-tendon complex, so be careful when you're doing yoga and make sure you're only going to your limits and not trying to compete with others. And typically, you can stay out of trouble that way.
Sanjiv Lakhia: 07:50
Lastly, there are some individuals who believe you can diagnose piriformis syndrome with EMG testing. EMG testing is a way to look at the electrical health of your sciatic nerve. And in some cases, there are some utility with that test as well. Again, speak with your physiatrist about this if you're concerned. That's piriformis syndrome in a nutshell. It's very common, and I wanted you to understand a little bit about it.
Sanjiv Lakhia: 08:14
Let's move on to number two in our list of top non-disc related causes of back pain and sciatica. Number two would be sacroiliitis. Sacroiliitis is inflammation of the sacroiliac joint. The sacroiliac joint is a joint between your sacrum and your ilium, and it's really in the back, near the buttock. It's kind of where your tailbone meets your hip.
Sanjiv Lakhia: 08:37
Now the sacroiliac joint bears a tremendous amount of weight when you're walking, but there's not much movement in the joint. Particularly as you get older, movement in the joint becomes much less. It's a very small joint and can only really be visualized under direct imaging studies. The joint itself can become inflamed. And when it does, it can create pain in the buttock area and can also mimic pain going down the back of your leg, very similar to sciatica. Let's talk about the joint a little more.
Sanjiv Lakhia: 09:07
What tends to aggravate the sacroiliac joint? Very similar, you're going to find that in all these conditions excessive weight bearing on the joint, prolonged sitting, muscle imbalances around the joint can trigger pain. More commonly, the sacroiliac joint is often aggravated and inflamed during pregnancy, just through the changes that develop in the pelvis and the ongoing pressure and weight of the developing fetus. Women often are familiar with sacroiliitis as we call it, and many times in that situation it'll resolve after the child is delivered.
Sanjiv Lakhia: 09:40
But trauma to the joint, so a fall on your hip, can aggravate the joint and simple things like leg length inequalities and muscle imbalance can trigger what we call mechanical sacroiliitis. Now there are medical conditions that can actually attack and inflame the joint. There are inflammatory arthritis-type conditions. If you do have actual x-ray evidence of destruction of your joint or erosion of your joint, then you should be tested for some of these other conditions.
Sanjiv Lakhia: 10:08
How do you diagnose sacroiliitis? Typically, again, it's mostly done by a physical exam and history. There are some maneuvers where we can mobilize and manipulate your hip and see if we can provoke the pain. But largely, literature shows there's not a real reliable physical exam maneuver to clearly diagnose sacroiliitis. The more definitive way to diagnose the condition is to inject the joint under x-ray guidance with an anesthetic agent to numb it up and then document your pain score. Oftentimes, we perform a fair number of sacroiliac injections under fluoroscopic guidance to diagnose and treat the condition. Additionally, physical therapy is critical, to again identifying some of these mechanical factors that could be driving pain in the joint and hopefully eliminate them through a proper exercise prescription.
Sanjiv Lakhia: 11:01
The sacroiliac joint can definitely refer pain down the back of the leg. In fact, I was just doing an injection this week and right during the injection when I put the medicine in, she complained of a little bit of achiness going down the back of her leg. It is well-documented that sacroiliac joint has a referral pain distribution, so keep that in mind as well. It's often a undiagnosed or misdiagnosed cause of low back pain. And it's one that skilled practitioners are always on the lookout for. If you have an MRI, that's unimpressive with regards to your low back and you're having persistent back and buttock pain, consider sacroiliitis.
Sanjiv Lakhia: 11:36
Moving on to number three in our top five non-disc related causes of back and leg pain or back pain and sciatica are lumbar and gluteal trigger point syndrome. Trigger points are tender spots in the muscles that can develop through chronic strain. And when you push on them, it can trigger pain in another part of the body.
Sanjiv Lakhia: 12:04
For example, if you've ever had a massage and you get deep pressure on your shoulder muscles or your upper trap muscles, you might feel some achiness in your jaw or down your arm. That's called a referral pain pattern. A classic example of a referral pain pattern is cardiac events where individuals may suffer a heart attack and they can feel it in their jaw or down their arm. The body will refer symptoms to other regions even though the source of the pain may be in a different location.
Sanjiv Lakhia: 12:37
If you look at the classic trigger point referral pain maps that were authored by Janet Travell, there are multiple trigger points that can be determined through physical examination that exist in your low back and pelvis and buttocks, that can cause back pain and referred pain down your leg. Let me name a few.
Sanjiv Lakhia: 12:57
Probably the most common one that I see is a gluteus medius muscle. Now, the gluteus medius muscle is on the side of your hip and is very critical for helping to extend and move your leg out to the side. Tenderness in that area can mimic sciatic pain and cause radiating pain down your leg, but it's not just the gluteus medius muscle. The gluteus maximus muscle can do it. Some of the deep external rotators of the hip can do it. A knowledgeable and skilled physician or physical therapist can rather easily identify these trigger points through direct pressure.
Sanjiv Lakhia: 13:32
Other areas to consider would be muscle complex, such as the quadratus lumborum muscle or the iliopsoas muscle. These muscles are deeper in the pelvis and a little bit higher up in the lumbar spine, and can radiate symptoms more into the front of your leg and thigh. And I will often see these activated in individuals who sit all day at work doing desk and computer work. Again, a knowledgeable physical therapist can identify these and treat these. These again are diagnosis of exclusion. You want to have a full, complete workup of your spine before you have a presumed diagnosis of trigger point referral patterns, but I would say they're very, very common and we've had great success treating them.
Sanjiv Lakhia: 14:14
What's the treatment? It can be any number of things. There's certainly an exercise component of focused stretching and strengthening, and then you can utilize direct treatment techniques such as dry needling, acupuncture or trigger point injections. Let's talk about these briefly.
Sanjiv Lakhia: 14:32
Trigger point injections can be done where you inject an anesthetic agent into the muscle itself. The goal of this is to essentially allow the muscle to release, and that's mostly accomplished through the mechanical irritation with a needle. Now there are some individuals who inject with a little bit of corticosteroid, mostly it's done with anesthetic agent.
Sanjiv Lakhia: 14:52
Alternative to that would be dry needling physical therapist at Carolina Neurosurgery and Spine Associates are trained and skilled in dry needling technique. This technique utilizes a very fine needle. It's essentially an acupuncture needle. It's the same needles that I use when I treat patients with acupuncture. You identify the trigger point through manual palpation, and then essentially you take the needle and you insert it into the muscle trigger point and you gently move it back and forth. This eventually allows the muscle to relax. It's largely painless. Although, there can be some trigger points that are very sensitive. Again, you want to have someone who's certified in this technique perform it to remain safe.
Sanjiv Lakhia: 15:28
Acupuncture is another technique that can help calm down trigger points. Now, it's not geared directly towards trigger point deactivation. There's other mechanisms that are utilized in acupuncture, and is a topic that I'll likely discuss in a future episode as I've been practicing acupuncture for almost 15 years.
Sanjiv Lakhia: 15:45
But those are some treatments that can be offered for trigger point pain syndrome. And the key take home there is you want to have a practitioner who is aware of these syndromes and knows how to evaluate and treat them, but there's certainly progress that can be made. That's the top three and we have a few more in our list of top five non-descriptive causes of back pain and sciatica. And we're going to get to the final few items after this break.
Sanjiv Lakhia: 16:16
On today's Health Matters segment, I want to do a book review on a very interesting and powerful book that I've recently gone through called The Power of Rest. Now, The Power of rest is written by Dr. Matthew Edlund and he is known as the "Rest Doctor" and can be found at the restdoctor.com. He's the director of the Center for Circadian Medicine in Sarasota, Florida, and really an award-winning expert on circadian rhythms, sleep, body clocks, and general health. The book I think is extremely powerful and there are some concepts in here that I want to share with you, and then elaborate on with my own spin.
Sanjiv Lakhia: 17:00
The general idea here is that Dr. Edlund believes sleep, while essential for our health, is not enough. That we need to build into our daily lifestyle, what he terms as active rest techniques, to just restore our normal physiology and the rhythm of life. He feels like active rest is under our control and it can allow us to restore our general health.
Sanjiv Lakhia: 17:28
Let me define for you or explain for you how he defines active rest. He kind of breaks it down into several categories. One is mental rest. He highly recommends engaging in activities that are rejuvenating for your mind. And he talks about social rests, spiritual rests and physical rest. One of the things he likes and really promotes, which I'm a big fan of, is naps. Taking a nap during the day is really not taboo, and the old thinking of taking a nap is lazy or counterproductive has really been debunked by science.
Sanjiv Lakhia: 18:02
Research has clearly demonstrated that if you take a nap in the early afternoon, that you're going to benefit with better productivity throughout your day and you're actually going to sleep better at nighttime. Now you want to make sure the nap is at least three hours removed from bedtime. The best and ideal time to take a nap is typically between one and three o'clock. Okay, I can already hear all of you out there saying, who can do that? We're all working. And I understand that. Weekends might be an opportunity. That's when I tend to take my nap is on Saturdays and Sundays, if the kids and life allow. And I find myself always to be more productive on the weekends when I sprinkle in a nap.
Sanjiv Lakhia: 18:38
In his book, he outlined that Winston Churchill was a big believer in the power of naps. And I want to read a quote for you. He said, "That you must sleep sometimes between lunch and dinner and no half-way measures. Take off your clothes and get into bed. That's what I always do. Don't think you will be doing less work because you sleep during the day. That's a foolish notion held by people who have no imagination. You will be able to accomplish more. You get two days instead of one. Well, at least one and a half, I'm sure. When the war started, I had to sleep during the day because that was the only way I could cope with my responsibilities." That's a quote from Winston Churchill.
Sanjiv Lakhia: 19:17
Really look to see, do you have opportunities during your day to integrate a nap? Outside of naps, he's really a big believer in social rest. And by social rest, I think really what he means is rejuvenating rest, where you're enjoying time with people making social connections. We know through research that social connections are critical to our overall health and wellbeing. And that's why I'm somewhat concerned during our current pandemic where we're all isolated, particularly our seniors who really thrive on connection with family and grandkids and friends, there are real physiologic health benefits that come with social rest.
Sanjiv Lakhia: 19:52
Simple examples that he gives in the book are to walk with a coworker at lunch, invite a friend to walk and converse with in the park, visit a neighbor or a coworker that you'd like to know better and just reach out to people you love. I think that's a great tip.
Sanjiv Lakhia: 20:08
Another tip that he talks about in terms of active rest is breathing. It sounds simple, right? Those who listen to Back Talk Doc understand how valuable I believe meditation is. And I consider deep breath work to be somewhat of an offshoot of meditation. Folks, there's real physiologic benefits with simple deep breathing. Most of us will breathe anywhere from 12 to 16 times per minute and research shows if you can get your breath cycle, your respiratory cycle, somewhere between five and 10 breaths per minute that you're going to have a relaxing, positive effect on your daily activities.
Sanjiv Lakhia: 20:45
How do you do that? Well, it typically involves expanding your inhalation and your exhalation, and I like to make the exhalation slightly longer than the inhalation. There's good data that shows that type of breathing pattern can shift your nervous system into more of a relaxed state. Let me give you an example and maybe you can follow along with me.
Sanjiv Lakhia: 21:05
During my coursework as a fellow at the Andrew Weil Center for Integrative Medicine, we've talked about the 4-7-8 breathing technique, and I want to go through that with you right now. if you're driving, I would just listen along. Certainly you can't follow along and do this technique while you're driving. You'd want to pull over and come back to this when you're sitting down. But if you're sitting down, go ahead and sit straight and kind of relax your jaw. Relax your shoulders and neck. And the 4-7-8 breath is essentially you inhale for a count of four, you hold the breath for a count of seven and then you exhale for a count of eight. Let's try it.
Sanjiv Lakhia: 21:43
Okay, go ahead and breathe in for a count of four. One, two, three, four. Now, hold the breath. Two, three, four, five, six, seven. Now exhale out your mouth, two, three, four, five, six seven, eight. And now relax. That's a very powerful technique, 4-7-8 breath, and I'll put a link in our show notes to a handout that can help explain that further. But if you go through two or three cycles of that a couple of times per day, you'll really find a different outlook on your day. It's a technique that I use at my bedtime.
Sanjiv Lakhia: 22:28
There are other techniques like that. There's box breathing, where you inhale for a count of four, you hold the breath for a count of four, you exhale for a count of four, you hold a breath for a count of four, and then you repeat. Find something that works for you, but really add breathing techniques as a form of active rest throughout your day.
Sanjiv Lakhia: 22:48
Lastly, he talks about physical rest, and physical rest really is meditation. It's probably the most powerful form of physical rest, and there are multiple versions of meditation out there we've talked about in previous episodes. And I think I'm going to do a whole episode on the benefits of meditation in the future. Anyway, I hope you find this to be interesting. Check the book out. We'll put a link to it in the show notes. It's called The Power of Rest by Matthew Edlund, MD. I think you'll find some great tips to help you stay healthy and calm during these stressful times.
Sanjiv Lakhia: 23:21
Okay, let's finish out our list of the top five non-disc related causes of back and leg pain and sciatica. We've covered three so far, and the first one was piriformis syndrome. The second one was sacroiliitis or sacroiliac joint pain. The third one was trigger point referral patterns. Moving on to number four. Number four on the list today, muscle strain, in particular hamstring strains.
Sanjiv Lakhia: 23:48
I'd say about two or three times a year. I get patients referred to my clinic evaluated of possible sciatica or a herniated disc in their back, and it turns out that pulled their hamstring muscle. Now, I would also say I get referrals in reverse where individuals were diagnosed with hamstring strains that turned out to be herniated disc in the back. It's one to consider. Particularly if you're an athlete, the hamstring muscle complex is a very large muscle group in the back of your leg. Pain in that area can follow the same distribution of the sciatic nerve and it can even irritate the sciatic nerve some and cause some paresthesia or nerve sensations in your leg.
Sanjiv Lakhia: 24:24
Typically, though the hamstring injury is easy to diagnose in terms of the history. Most of the time, it occurs in athletes and runners. Many times it's an acute injury where you'll feel a pull or even a pop and grab your buttock area or your hamstring area. I'm from the Cincinnati area, and growing up, watching the Cincinnati Reds, got to watch Ken Griffey Jr., who's one of the top baseball players of all time. He suffered with really severe hamstring injuries when he was with the Reds, and I have a really good recollection of that.
Sanjiv Lakhia: 24:57
Hamstring injuries can be very, very serious if not diagnosed correctly, and treated and a rehabilitated correctly. Now the diagnosis of a hamstring strain can be simply clinical based upon the history. And as long as a good physical exam is done to make sure you haven't actually torn the tendon, you can typically start rehabilitation immediately. Proper PT or physical therapy is essential to getting back to your activities and your athletics. And this may involve a degree of rest followed by active rehab with stretching and exercise strength training, along with modality treatment.
Sanjiv Lakhia: 25:31
If you're having pain, particularly in your leg and the back of the leg from the buttock to the knee, consider a hamstring strain. Now in severe cases, we can order MRI imaging to look at the structure and integrity of the hamstring muscle, as well as the tendon where asserts in the pelvis. But most of the time, this can be diagnosed through physical examination and history.
Sanjiv Lakhia: 25:51
That brings me to number five on our list of top five non-disc related causes of back pain and sciatica, and number five, lumbar facet referral pain patterns. Okay, so that's a lot. Let me break that down. Essentially, if we were to look at a spine model, on the back of the low spine or lumbar facet joints, these are the tiny joints of our spine that allow for degrees of movement. Just like you have joints in your knees and hips, there are joints all up and down your spine called facet joints.
Sanjiv Lakhia: 26:22
Now, the facet joints can degenerate over time. And very similar to how you can have false positive findings on MRIs for disc issues, you can also have the same thing for facet joints. What I mean by that is, facet joints will change over the course of our life. It's an aging process. And not all imaging abnormalities, x-ray and MRI abnormalities of your facet joints are sources of pain. And in fact, most are not. However, there are cases where you can have extensive wear and tear on your facet joints and it can cause both low back pain, but can also radiate down the back of your legs some. This can mimic a sciatic nerve irritation, mimic a disc bulge and nerve irritation.
Sanjiv Lakhia: 27:08
There are lumbar facet referral pain maps that have been developed. They're not quite as specific as the maps that we have for the cervical spine, but they do exist. And I have seen cases where individuals get treatment for the lumbar facets and some of the pain down their leg resolves. Lumbar facet referral pain patterns can be diagnosed through physical exam and also somewhat through imaging, but it's largely a diagnosis of exclusion. And really the main way to diagnose is to perform what's called medial branch blocks. And this is where you inject a small amount of a numbing medicine to numb up the nerves that go into the joints and then determine is that where the pain is coming from.
Sanjiv Lakhia: 27:51
What are the treatments for lumbar facet disease or lumbar facet referral pain? Again, you start with the basics of movement and exercise, weight reduction, optimizing nutrition and health. If that's ineffective, then there are more targeted treatments such as radiofrequency ablation or radiofrequency neurotomy. And this is a technique where you can essentially take a heated needle tip and burn the nerves that innovate those joints to block the pain for up to a year. It's a great alternative to surgery and can eliminate your back pain and buttock pain.
Sanjiv Lakhia: 28:22
Those are the top five causes, in my opinion, of non-disc related causes of back pain and sciatica. Beyond this, I'd like to add what I call a plus one. It's something to look out for. It's not very common, but is something to consider if you're really struggling with pain on the back of your leg. Particularly for having your neurologic symptoms such as numbness, burning and tingling, and your lumbar MRI really isn't showing much and these other causes have been ruled out, consider a condition called thoracic myelopathy.
Sanjiv Lakhia: 28:52
Now, the thoracic spine is your upper back and it's above the lumbar spine and the spinal cord runs through that area. Now myelopathy is a very serious issue where you can have some sort of dysfunction of the spinal cord as it runs through the area. For example, a bulging disc or a bone spur can irritate the spinal cord and cause a radiating pain down your leg. Now this condition is often accompanied by more serious symptoms as well, such as weakness in the leg, gait disturbance, and even possibly dysfunction of your bowel or bladder function. Certainly, if you have any suspicion for this, you should be evaluated by a physician.
Sanjiv Lakhia: 29:29
But there are cases where individuals will suspect that they have pain coming from a bulging disc in their low back, and it turns out that the issue was in the upper back. Again, you need a skilled clinician to have this on their radar and perform a proper physical examination and workup. But it's just something I want to plant the seed for if you're really struggling. You can ask the question, "Has anyone looked at my upper back as a potential source for the discomfort in my low back and leg?"
Sanjiv Lakhia: 29:55
There you have it folks. These are the top five causes in my opinion of low back pain and sciatic pain. Again remember, not all sciatica is disc related, not all back pain is a disc problem. There are multiple conditions that can be evaluated. Oftentimes, a good physical therapist can diagnose most of these. At our group, we're fortunate to have skilled physiatrists and neurosurgeons that can also help in your assessment. I hope you found these useful, and take care of yourself. Remember exercise, diet, and sleep are the key. And I look forward to speaking with you on our next episode.
Outro: 30:31
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
