Management of Low Back Pain with special reference to Sciatica:
In modern medicine; for the management of sciatica various modalities are available such as –
- Conservative treatment
- Epidural steroid injection
- Peri-radicular infiltration
- Surgical treatment
All these are having their own complications and side effects. On the other hand, all these management tools are not affordable for the poor, particularly in developing countries.
In Ayurvedic texts, there are various methods used as a line of treatment, some of which are effective, simple, safe and cheap for the patients like –
- Siravyadha (Ayurvedic Venepuncture)
- Agnikarma (An Ayurvedic para-surgical procedure)
- Basti Karma (Medicated Enema under Panchkarma Therapy)
- Snehana (Massage with help of Ayurvedic herbal oils)
- Swedana (Hot fomentation by Ayurvedic way)
- Oral medication by Ayurvedic herbs.
Caring for Sciatica should be considered part of one’s daily living, not just something to add to the routine at the end of the day. The medical approach managing sciatica is to treat the symptoms. This may include using pain killers, muscle relaxers or anti-inflammatory drugs. Traction, physical therapy or injections directly into the nerve roots may also be used. In severe cases, even surgery may be tried. The chiropractic approach to treating sciatica is to find the source of nerve irritation and relieve the pressure causing the pain. By correcting the source of the problem the body can heal naturally without nerve interference. Treatments will vary according to the severity of the condition.
Whatever the cause of sciatica, it is important to seek treatment promptly. Too many people wait, hoping the pain will go away or get better by itself. However, it is usually easier to treat a problem when it is first noticed. Too many people wait until the pain becomes unbearable, suffering needlessly. Long term nerve damage may result from this delay in seeking treatment.
Absolute Bed Rest : Absolute bed rest is the treatment forlower backache.
NSAIDs : Non-steroidal anti-inflammatory drugs, Musclerelaxants, Anti-depressants are recommended.
Traction : Bucks extension skin traction and Pelvic traction, help to relive pain.
Belts : Back braces or belts are recommended in acute stages. They are discarded as soon as symptoms decrease otherwise muscle become weak and hasten the degeneration.
Local Fomentation : Local fomentation can be done by hot water bag.
For sub-acute and chronic cases :
Long-acting steroids + Local Anaesthetics :
Reduces dependence on narcotics : Effect lasts for 3 weeks :
Epidural steroid is a symptomatic method of treatment and consists of injecting a long-acting steroid and a local steroid. Its effect lasts for three weeks and is useful for sub-acute and chronic cases. It also reduces dependence on narcotics in chronic cases.
Done in Proper Indications :
Failed conservative management, Marked progressive weakness of muscles, Progressive neurological deficit, Cauda equina paralysis
Recurrent episodes of incapacitating sciatica, Pain unrelieved by complete rest from activity.
Different operative techniques :
- Laminectomy and disc excision : Earlier this was the surgery of choice but now it is no longer resorted to as it makes the spine unstable.
- Hemilaminectomy : Here part of the lamina is removed. It is considered by many as extended fenestration approach. If fenestration technique is properly done hemilaminectomy is not necessary.
- Fenestration surgery : Here the spine is approached unilaterally and the spine on the opposite side is not exposed. Here only the contiguous margin of upper and lower laminae are removed and medial facetectomy is done. The disc is now excised. This procedure requires that the affected disc is correctly located by M.R.I. and radiographic studies.
- Microscopic Lumbar Discetomy : Using an operating microscope the disc can be excised through a very small incision (<3.5 cm) with minimum damage to the structures and minimum blood loss. It is a technically damaging procedure and gives excellent results if done in properly indicated cases like a single level postero-lateral disc prolapse. The patient can be discharged home within 2 days and he/she can return back to his/her normal work faster. In short it can be described as a less invasive, less painful more specific procedure giving maximum comforts to the patient.
Principle of Surgery :
Spine surgery is only capable of correcting anatomical conditions that result in either instability or nerve pinching. If either of these is present on an imaging study and the patient’s symptoms fit with the clinical and radiographic picture, spine surgery may be indicated.
Indications : Same as for “Surgery”.
Limitations : Limited only to lumber spine.
Drug : Drug used is Chymopapain.
Active and passive physiotherapy.
Flexion and extension exercises :
Choice of exercise is based on the increase or decrease of pain by extension or flexion. If pain decreases by extension, extension exercises are recommended. On the other hand if the pain decreases by flexion, flexsion exercises are recommended. Improvements in symptoms with extension is indications of a good prognosis with conservative care.
Lower extremity exercises increases the strength and relieves the stress on the back, but they may increase the lower extremity arthritis. Thus, the true benefit of such treatment may be in the promotion of good posture and body mechanics than strength.
Recurrence Prevention :
This is the most important aspect of the management of sciatica. Like in all other diseases; in sciatica, prevention is better than cure.
Back education :
Adopting proper posture and creating an awareness that it is in the erect position, the back can withstanding strain the best.
Proper postural habits :
Stress on the back is less when it is properly used during sitting, walking etc. These proper habits have to be cultivated with practice.
Back exercises :
These aim to strengthen the abdominal, pelvic back and thigh muscles. Strong healthy muscles reduces load on the disc and other structures.
- Each exercise is done one to five times twice daily.
- The number of repetitions should be kept increasing to reach a minimum of ten repetitions twice daily.
- Exercises are to be done slowly and smoothly.
Avoid all sports :
To avoid all sports including the aerobic ones.
Swimming and walking are encouraged.