Lumbar Radiculopathy (Sciatica) - Justin Paquette, MD

Sechrest: Hello, I am Dr. Randale Sechrest your host for eOrthopodTV. Today I have with me as my guest Dr. Justin Paquette. Dr. Paquette is a neurosurgeon who practices complex spine surgery in Los Angeles, CA. Dr. Paquette did his medical training at Albany Medical College. He then went on to complete a residency in neurosurgery at the Harvard Tufts Combined Program in Boston, MA. From there he completed a fellowship in complex spine surgery in Los Angeles at Cedar Sinai. Good afternoon Dr. Paquette.

Paquette: Good afternoon.

Sechrest: Dr. Paquette today what I would like to discuss is a fairly common situation where people have what's called sciatica or lumbar radiculopathy. And that's where people come in, we see patient's who come in who are having some back pain but mainly it's pain into the leg and most folks understand that disease process is caused by either a herniated disc, that's the most common thing that people think about. But tell us a little bit about sciatica or lumbar radiculopathy. What's going on when we see that disease process?

Paquette: Sure. The most important thing to do to realize is that we need to separate back and leg pain. A lot of patient's think these are one in the same but actually they are rising from different processes. Back pain itself, we all have it, it's one of the most common problems in America. Back pain itself comes from either muscles or ligaments in the back being spasming up, inflamed and painful. Could be from a degenerated disc, could be from a bad joint in the back or bone spur in the back. But it's got something to do with a mechanical issue in the back itself. On the other hand are nerve problems. Now a nerve problem is what we feel from the buttocks and legs down. It could be pain, it could be numbness, it could be weakness. And in fact as a nerve gets pinched, whether it's pinched from the disc herniation, whether it's pinched from a little bone spur, whatever the cause, the initial symptoms that arise are pain. Usually it's described as a sharp, sometimes burning electric kind of pain which shoots down the legs within a particular distribution. That distribution depends upon which nerve in the back is actually getting pinched. But the pain is sometimes then followed eventually by numbness which can be kind of a numbness, pins and needles kind of sensation often times in the foot which is a sign that the nerves now are being pinched for a little bit longer period of time. Ultimately, if a nerve is really being squashed and has been squashed for quite some time, we will begin to see weakness. And weakness in particularly where that nerve travels. That's the most concerning level for us, it's kind of a Def Con One because that means that the nerve is effectively being strangled.

Sechrest: And there's a couple of common sort of misconceptions of folks who come down with sciatica. In the old days I think we always thought that that disease process came from pressure on the nerve. And now, more and more we're understanding that it's not always the pressure, there's also a considerable amount of chemical irritation that goes on in the early stages especially, so if you've got an annular tear, you've got something that has disrupted the disc that perhaps some of that pain down the leg is coming from chemical irritation. What's your position on that? What do you think is going on most of the time?

Paquette: I do agree with that and it's based upon the fact that the nerves as they leave the spine travel right by the edges of the disc. Now the disc as we know is essentially two parts of some very tough fiber outside and then a soft jelly-like inside. The jelly-like inside is very low oxygen which essentially makes it kind of a __????__ of toxic chemicals to the body. It's normally separated from the body by that tough outer shell but we know that as part of the degenerative disc disease and as the disc dries up you get a crack in the tube and part of that material can seep out along with those noxious chemicals that go along with it. The nerve just so happens to glide right by it and studies have shown that the chemicals an irritate the nerve. Even if there isn't any direct pressure being put on the nerve itself.

Sechrest: And when you see a patient, if the patient comes into your office with leg pain, maybe has some back pain, some leg pain. What signs and symptoms are you looking for to try to make a decision as to whether this person has sciatica or has a lumbar radiculopathy or some other disease process. What tips you off?

Paquette: Usually I'll come in and interview the patient before I even look at the x-rays and the important things to me are, number one, is history. When did the pain start? How did the pain start? Is it getting better? Is it getting worse? Where exactly does it travel? To find the exact character of the pain is very important in actually beginning to figure out where it may be coming from. Once I have the full history of this, I then do the examination which has also helped to elicit maybe the particular areas that are affected. And what I'll do is check for sensation throughout the whole body. Certain nerves as they're affected will lose sensation in very specific parts of the body, say in the front of the thigh. So, you check sensation, you also check reflexes. Reflexes in the knee, reflexes in the ankles and other places which also can be very specific to one particular nerve. If a nerve is being pinched, you may not find that reflex to be available. It may be gone, which is another indication for a pinched nerve. And then finally, we check the strength of every possible muscle group in the body, especially in the legs to see if there is any subtle weakness that might indicate which nerve is being pinched. So, for example when people raise up their feet or raise up their big toes, it's predominantly the L5 nerve that does that. When we press down on the foot as if we're pressing on the gas pedal, that's predominantly the S1 nerve and so by putting all those pieces of information together, we start to get a pretty good idea of what to expect when we then go on to look at the x-rays.

Sechrest: Now there's, I see a misconception amongst a lot of physicians who are not spine specialists, who have this concept that if a patient comes in and expresses sciatic pain, they say they have pain down, let's say into the calf, but they don't have any reflex changes, they don't have any numbness and they don't have any weakness, that a lot of physicians would consider that not a radiculopathy or not a radicular problem. My understanding is that pain itself in a radicular pattern that makes sense is the first stage like you said and we shouldn't discount the fact that that is an evolving radiculopathy in the early stages. Am I correct or what's your thoughts on that?

Paquette: Yeah, I believe you're absolutely correct. A radiculopathy refers to any change in sensory symptoms within the distribution of a nerve and that can refer to pain, can refer to numbness, can refer to weakness, can refer to loss of reflexes. All of those things mean that the nerve is being pinched. The problem is that if it is not recognized and ultimately goes on to weakness, it can be pretty significant because sometimes if weakness appears, it may not ultimately get 100% better. But if we can diagnose it at the earliest stages, visualize it on x-rays and decide how to take care of it, the pay is that they should have a much better overall outcome.

Sechrest: So in our practice in your office, if you have a patient who comes in and you're convinced that even if they just have pain in a radicular pattern, that you say that sounds like an L5 radiculopathy, or that sounds like an L4 radiculopathy that's evolving. How do you evaluate that patient next? What test do you order?

Paquette: Sure. It depends a little bit upon their overall symptomatology. If the patient's having a lot of back pain as well, what I'll do is I'll get special x-rays of the lumbar spine in the office right then and there, especially with flexion/extension films going back and forth so that I can rule out fractures, I can rule out spondylolistheses or slips, or abnormal positionings or curves of the spine. If they pretty much are good with their back but just have this particular leg pain, the next step then is to get an MRI scan. The only other possibility is if they have a pacemaker in and can't get an MRI, I would get a CT scan. But in general, the MRI is the best test looking at the soft tissues of the disc of the nerve and helping to completely determine where exactly the nerves are being pinched.

Sechrest: Do you find the electrical tests at all helpful like the EMG test? Do you routinely get that for patient's who has sciatica?

Paquette: I do not routinely get EMG tests for sciatic pain. The reason being is that they, to a certain degree can be subjective based upon the patient and based upon the person who's doing the test. The only reason I would get an EMG is if I am trying to distinguish between two problems that I'm unclear about. For example, if it seems like maybe a nerve is being pinched in the back, but also being pinched behind the knee, and it's hard to clear those two things out, sometimes an EMG can give you a decent idea of that. But, otherwise as just a standard test, I don't order an EMG.

Sechrest: Well, I think you raise an important point and that point is that the nervous system is a wiring harness just like in a car or anything else and we tend to focus on, well you don't have a herniated disc so you couldn't have some type of nerve problem or radiculopathy. You can have a radiculopathy from the back, but you can also have nerve compression anywhere between the back and where that nerve ends. Correct?

Paquette: Correct.

Sechrest: And what you're saying is that you rely on the EMG more to look at those extra spinal causes, those compressions for example maybe in the pelvis, or maybe behind the knee or in the areas of the lower extremity where we commonly see nerves get trapped and get too much irritation or too much pressure. That's correct. The nerve as it travels from the spine to say the tip of the toe or to the feet, there's many different spots where they can get assaulted. Various muscles can actually contract along a nerve and cause a problem with it. Certain ligaments can narrow down tunnels that the nerves can get trapped at. Somebody can have an injury where they actually get hit in the leg or something like that years ago, but then develop scar tissue that then traps a nerve also. And so, sometimes when there's not a clear cut obvious answer in the spine, we now have to use these other supplementary tests to try to figure it out.

Sechrest: Okay. If you get to the point to where you're convinced that the patient has a radicular pain, either a radiculopathy or radiculitis from some type of irritation or pressure on the nerve in the spine and you're convinced that the spine is stable, it does not have any instability that's causing that problem. Where are you going to go at that point? At that point I'm assuming that you're ready to recommend some treatment and you're sure that this person, or you're convinced this person has nerve pain coming from the spine. Is there any place for conservative care or is that something that is only amenable to surgery?

Paquette: I think that conservative therapy, absolutely is the way to go in 99% of people that come in with radiculopathies. Unless they've developed an overt weakness secondary to the compression, I always try the conservative things first. And that's going to include kind of a multipronged approach. Starting off with the least evasive is just going to be medication management, so anti-inflammatory Sometimes a dose of oral steroids, muscle relaxers and if necessary, narcotics for a short period of time to help to ease the pain until it starts to improve on its own. A little more invasive technique would be to do an injection, a so called epidural injection where they put a drop of steroid directly onto the nerve that's being pinched. And all these things can help to decrease inflammation and hopefully to improve the patient's pain. We've actually done studies where if you look at all kinds of disc herniations, and you follow them out for a couple of years, 85% of people will get better on their own whiteout any kind of intervention, which is a great number. That means that most people will do better on their own. The problem, of course, is that means 15% of people will not get better on their own and what we have tried to do is determine what are those variables that point towards those people that may need to have surgery earlier because they're not going to get better on their own. And some of those variables include:
1. The size of the disc, so a very large disc herniation is less likely to get better on their own.
2. Are the so called free fragments which are disc pieces that have broken completely and totally out of the disc space itself, are now in the nerve tunnel. It's very unlikely that they'll find their way back into the disc.
3. Those that have had pain for more than 6-8 weeks becomes less likely they'll get better on their own as well and so those people I start having discussions of surgery a little bit sooner.

Sechrest: Now, is there a time frame when you would tell a patient that they may not get better if they elect surgery at this point? I mean, do we have a window of opportunity where if you're going to do surgery, it's more successful or if I've put up with this for six months, am I just as likely to get pain relief if I have surgery at six months than I was at six weeks? Is there a difference?

Paquette: I think that if you're just dealing with pain, I think an individual probably stands the same chance of improvement whether it's done right out of the box, or you give it some time to improve on it's own. Where I think it becomes different is if there's numbness or weakness present, because again, those two symptoms don't come around until the nerves are really being pinched and we know for a fact that after surgery, those get better in a reverse order. So, in other words, you operate the pain gets better pretty quickly, the radicular pain of the nerve, but numbness and weakness can be kind of dark horses. They may take quite some time to get better, sometimes they don't get better 100% and we know that the longer you persist with numbness and weakness before surgery, the longer it can take to get better and sometimes the less of a chance of 100% recovery. And so when those symptoms are present, I'm a little bit more concerned about waiting.

Sechrest: Okay. And you know, I think there is one thing we should mention, and that is the cauda equina syndrome, which is a special case of a very large disc herniation that's not only affecting the pain down the leg or the nerves down the leg, but also the nerves that go to the bowels and the bladder. So, tell us a little bit about cauda equina syndrome and tell my why we worry so much about it.

Paquette: Sure. Well, the cauda equina syndrome develops based upon the fact, and most patient's don't realize this, that the spinal cord itself ends at either the twelfth thoracic or the first lumbar vertebrae. That's where the bottom of the spinal cord is and then from that point on there's just peripheral nerves that are going down into your legs. When there's actually no spinal cord per se in the lumbar spine. At that level of T12-L1, we sometimes call this the thoracolumbar junction because of the thoracic spine and the lumbar spine join right there. Right at that level there's lots of stress on the discs because they're right at the area of a major spot of motion. Sometimes you can get a very significant or very large disc herniation or sometimes even a fracture there that closed down the space on the nerve tunnel. Now the problem is that that's where the tip of the spinal cord is and within the tip of the spinal cord are very special sensitive nerves that control the bowel and the bladder. If this becomes compressed too tightly, we can develop a multitude of symptoms including numbness and pain in the legs, weakness in the legs, but also incontinence and loss of control and sensation in the bowel and the bladder.

Sechrest: And that's an emergency I'm assuming.

Paquette: This is absolutely a true spinal emergency.

Sechrest: So patient's that have that should not make an appointment with their doctor they should basically go to the Emergency Room and say, I have a problem

Paquette: No, this is one of those situations where the patient needs to be brought to the Emergency Room immediately and surgery needs to be addressed and performed immediately.

Sechrest: Okay. Let's move on a little bit to surgical planning. When you've decided with a patient that it's best to have surgery for their radiculopathy, what are their options? What sort of things can be done today to alleviate that radiculopathy?

Paquette: With regards to the types of surgery available for radiculopathy, and we're going to discount from this topic anybody who also has very poorly degenerative back, lots of back pain, other issues like that. All this person has is, let's say a herniated disc or a little bone spur, one nerve's being pinched, everything else in the spine looks pretty good. The key concepts to the approach to this needs to be minimally invasive. You really want to cause as little damage to all the normal structures in the spine as possible. This refers to the normal bone, the normal ligament, the muscles, the areas where the muscles attach to the ligament, etc. What used to be done in the past was that surgeons would go in and remove the entire back of the spine. A so called laminectomy, which would be very affective in decompressing the nerves. The problem is, is that those lamina are where all the muscles attach to, and when the bone is gone and the muscle can't attach to it, the structural integrity of the spine has now been compromised. And what we see over time is that people now start to bend forward and forward and forward and we get what we spoke about earlier which is flat back syndrome. So the key thing to decompressing a radiculopathy is to leave everything else alone and so my personal approach is to do this under microscopic visualization a few different ways. It either can be done through a small incision with a small little retractor that we put in there, or we can also do it through a small little tubes where we take a needle down through the skin onto the right spot that we want and through successively larger dilators, we open up a small little tunnel that we can then attach to the bed. And through that small tunnel and a microscope we can see all the anatomy we need to see and take out the problem. With the advantage of which is that we don't do any kind of excessive manipulation of the patients normal muscle. We just move it to the side around the tubular retractor. Most individuals go home the same day or the next day after this kind of surgery and have very good positive results. The other way which is even less invasive, which we're starting to do now in the treatment of microdiscectomies or nerve decompressions, is using a purely endoscopic approach. And to do this, we actually keep the patient awake. The patient does not need to have general anesthesia as they do with the other procedures and with the complicated x-ray machines, we'll basically go down with a small, tiny, little needle through the skin, right to the spot where the disc is pinching on the nerve and then through the usage of a 5mm endoscope, we can actually put small little instruments through, manipulate things and pluck out the piece of disc that needs to come out. We can also use lasers or other types of machines there to seal off the disc space and to prevent any further disc from coming up and bothering the nerve.

Sechrest: Well, I think you've probably already answered this question but what's the advantage of that? I mean, what's the advantage of this minimally invasive approach?

Paquette: Sure. The advantages overall are basically less destruction to the muscles and to the tissues, faster recovery period, less blood loss, less problems down the line meaning the more you keep the spine intact, the less of a chance of that person developing instability with flat back syndrome. And, usually a fast recovery to work and to activities. The advantages of the endoscopic approach on top of what I just mentioned is that the patient's actually awake while you're doing the surgery, they can tell you when you've gotten the piece off the nerve because all of a sudden they give a big sigh of relief. And they're like, oh, that's it right there. And the patient goes home in about a half hour after surgery. So, it's truly an outpatient procedure. Not all patients are candidates for that, but that surely, I think, is the absolute gold standard of the ultimate in minimally invasive surgery.

Sechrest: Now is this only useful for a herniated disc? What if this patient has problems that are coming from bone spurs for example? What if it's a little more of an advanced problem and not just a herniated disc. No, I think actually the principle of minimally invasive surgery is applicable to many different problems and in fact I'll use those tubular retractors, the endoscopic system to remove discs, to remove bone spurs, to take off facet or joint arthrosis which is pinching on nerves. You can also actually put in instrumentation through these minimally invasive procedures whereas rather than making a big open hole and putting in screws, we put in the small little retractor with a little tube and through that tube, put in the screws that are necessary. There's also some available now that are truly percutaneous screws where we don't open the retractor at all, we just x-rays and then slide screws in just straight through the skin, connect them through a bar through the skin and put little band aides over the incisions.

Sechrest: So the concept of minimal invasive surgery holds for all surgery and I think what you're saying is that the less damage to normal tissue the better no matter what you're doing.

Paquette: Absolutely.

Sechrest: And the whole concept of doing this with a disc herniation in a young person is especially appealing.

Paquette: Especially like if you're operating on professional athletes or stunt individuals or people that really want to stress their body, you want to make sure that they heal up as close to as possible in the condition they were before because they're going to really go back and test their body.

Sechrest: So let's go through the post-op recovery from this minimally invasive surgery. Obviously they have less damage to normal tissue that has to heal, but the disc is still injured, I'm assuming if they've had a ruptured disc, so what's the normal course after surgery? I mean, does this stunt person going to go back to work the next day? Or do you still expect a healing process to occur and restrict them in any ways?

Paquette: Sure. The surgery itself usually takes less than an hour. The patient is up and about that day, either goes home that day or the next morning. The pain that they feel after surgery is from the muscle spasms in the back that will last for a few weeks. We give them medications to help to control that. Most individuals following this surgery could be driving within a week. Depending upon what they do for work, they could get back to work within a couple of weeks. If they're heavy laborers that require heavy lifting, I ask them to stay off maybe for a couple of months. The restrictions that I have on most individuals immediately after the operation are lifting no more than ten pounds, a gallon of milk being eight pounds and so I want them relatively to take it easy. Lots of walking is good but otherwise no major lifting, no major impact activities. At about 4-6 weeks out from surgery, everyone goes into an aggressive physical therapy program, core muscle strengthening, range of motion, flexibility, advancing their lifting and then by the end of their physical therapy course they've got no restrictions, they can do whatever they want to do.

Sechrest: And I'm assuming that you've encouraged them to continue with the physical therapy program just for preventative spine health, lifetime.

Paquette: It's actually a critical thing that everyone gets involved, if not doing it at the physical therapists, getting a home program they do every single day for the rest of their life.

Sechrest: Well, it definitely seems like this is a major advance to the old way of doing things where you made big incisions, destroyed a lot of tissue, but I'm assuming this still has some complications and perhaps some complications that aren't necessarily a part of the older way of doing it. What do you worry about as a spine surgeon when you're dealing with a patient with a lumbar radiculopathy and you've decided to treat them with a minimally invasive technique, what are the complications?

Paquette: The first complications are generic complications that can happen to any kind of surgery, so bleeding and infection, both of which are less than 1% but certainly those are possibilities. The biggest complication is avoiding what we have found happens with the larger surgeries, which means, if you go in there and you end up affecting one of the facet joints, or affecting too much of the local anatomy, you can set that patient up for further back pain, further problems down the line. So, you must adhere very strictly to the goals of minimally invasive which is, get in there, don't disturb anything normal and just get straight down to the problem. Now, sometimes because you're so focused on leaving everything else normal there may be a little higher risk of something like a CSF leak, a fluid leak, which means that because you're working through such tiny narrow spaces you can get a knick in one of the membranes that encloses the nerve or the nerve roots and some fluid may leak out because of that. A normal risk might, say be, 2-3% under one of these very micro minimally invasive surgeries, may be 3-5%.

Sechrest: And how is that treated if it occurs?

Paquette: It's usually treated very easily at the time of surgery. Sometimes you can put a little stitch through it and seal it off that way, otherwise we have little special glue that we can make and just glue over the side of it. It rarely becomes any kind of a persistent problem.

Sechrest: So, I'm assuming that you're a big proponent of the minimally invasive techniques for everything.

Paquette: Correct.

Sechrest: But it sounds, from your description, that this is clearly becoming the standard of care for lumbar herniated nucleus pulposus. Am I correct?

Paquette: Correct. And it's even broader than that and I think we're trying to develop minimally invasive approaches to everywhere in the spine. The front of the neck, back of the neck, thoracic spine and for sure the lumbar spine. Do you think we're going to see any big changes in the approach to the patient with a herniated disc? You know, the young person, maybe the 30-yera-old person with your typical herniated disc single injury. Do you think we're seeing even newer things more minimally invasive things coming down the pipe or is this as good as it gets. I think we will see some changes. You know, one of the exciting things about the field of spine is that there's always new technologies. Number one, I hope that the endoscopic approach really becomes more prevalent, I think it's a fantastic procedure, has excellent outcomes and the fact that it doesn't destroy any normal anatomy is certainly the best for the patient and it's a very technical surgery however and therefore it's use has been limited to only a few parts of the country because of that. The other thing that I think is going to really take of shortly is going to be stem cells and people right now are really working on trying to develop stem cells that can regenerate a bad disc and so if somebody has an annular tear or a herniated disc, either inject it and have it heal without requiring surgery or if you require surgery, then you can inject stem cells at the same time to regrow the disc to it's normal diameter and then to seal it down so that no further disc herniations occur.

Sechrest: That sounds exciting. As I think we know that once someone has a surgery for a herniated disc, it's not even the surgery, it's once they've injured that disc, that disc is at risk for accelerated degeneration and that's why we're forced to do these surgeries like the fusion and that sort of thing. Good information, but let me ask you, is there anything that we haven't covered in terms of the patient with a lumbar radiculopathy that you think patient's should know when they're faced with making this decision. The only thing that I would mention and I have seen this a few times now, are in very complicated patients. So we've just been talking about single disc herniations and one nerve pain. I've seen a few patient's that have had massive surgery, scoliosis surgery, degeneration surgeries, etc. that never got better after surgery and ultimately in the beginning, a so called spinal cord stimulator or morphine pump placed to try to control their persistent nonstop radiculopathy. And in those individuals, I consider those to be kind of an end gate. You basically have thrown your hands up and said that there's no way that we can help these patients anymore and certain individuals, if you do appropriate tests you may actually find that their nerves are still begin pinched. And if you can go in there and decompress those nerves, I've actually taken out all of their spinal cord simulators and there nerve pain has gotten better and so I would just caution people before they try to do very extreme situations for radiculopathies, be it a spinal cord stimulator or a morphine pump, make sure that you haven't missed some possible diagnoses that are causing an ongoing problem.

Sechrest: So, keep an open mind.

Paquette: Keep an open mind.

Sechrest: Always good advice, thanks a lot. Interesting stuff.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.