Sciatica Pain

Episode 29 - Sciatica Pain

[00:00:00] Juliette Dassinger, PT, DPT: Hello, everyone. Welcome to IBJI's OrthoInform podcast, where we talk about all things orthopedics to help you move better and live better. I am your host, Dr. Julia Dasinger, physical therapist. Our goal is to provide you with an in depth resource about common orthopedic services that we provide every day.

Today, for this episode, I have the pleasure of talking with Dr. Gary Shapiro about sciatica pain. Dr. Shapiro is a board certified orthopedic surgeon who specializes in treating spinal conditions and pain in adults and children. He has a particular interest in sports related injuries and has treated professional athletes including the Chicago Bears.

He is a clinical assistant professor of orthopedics at the University of Chicago's Pritzker School of Medicine and conducts research in the effectiveness of lumbar spinal fusion. Please welcome Dr. Gary Shapiro. Dr. Shapiro, I know you and I talked right before this episode and I just want to say thank you so much for the care that you provide your patients.

[00:00:58] Gary Shapiro, M.D.: Oh, thank you very much and it's great to be here.

[00:01:00] Juliette Dassinger, PT, DPT: I see a few of your patients at the Highland Park location where I treat and they've all only told me great experiences working with you. So I like to say it from a physical therapist, thank you.

[00:01:09] Gary Shapiro, M.D.: Thank you.

[00:01:10] Juliette Dassinger, PT, DPT: , I actually want to start, , this episode with a quote that I found from you on our IBGI website.

If anyone's curious about the quote, , I took little snippets of it, but if you go to ibji. com, look up Dr. Gary Shapiro, you'll find this quote. You said, I believe it is very important to place the patient at the first priority. I have the ability to tailor both non surgical and surgical options to the patient's specific needs and will work with the patient to determine the proper course of treatment.

Here we also have an IBGI blog that we'll make sure that we post that link in those episode notes for you to be able to access. But I think this quote is a great example. and this patient's story in this blog on what we're going to be discussing today. So if I'm to describe this blog in a very short amount of time, I'm going to say four sentences.

This is what this blog is about. You had a patient that we're going to call Pat, who is an 83 year old female with left sciatica pain. Initially, she saw you in 2013. decided to go elsewhere to have a procedure done, which she found unsuccessful. Then she returned back to you in 2020. She did trial some interventions.

She did have injections, went to see Dr. Kelly Gates, um, who's also at IBGI, but still she didn't find success. So then what she did in later 2020 was underwent that double fusion spinal surgery with you and hasn't had problems any since. So when we talk about this episode related to sciatica pain, we'll start with if someone comes to you with symptoms of sciatica pain, what do they initially report to you?

[00:02:51] Gary Shapiro, M.D.: That's an excellent question. Most patients will present with complaints of low back pain and oftentimes pain into the leg. Sometimes there's a specific event or accident, but oftentimes it starts without a particular injury. Severity of symptoms can range from an annoyance or it can be much more limiting to a patient.

And we see these types of complaints in patients of all ages, including teenagers.

[00:03:15] Juliette Dassinger, PT, DPT: What are those initial tests? that you like to try right away in clinic to determine if they're experiencing sciatica type pain?

[00:03:26] Gary Shapiro, M.D.: So I'd say the most important from training is just someone's history and the story that they tell.

Very often you can immediately know what the source of their problem is, but in terms of a physical exam, it's important to be very thorough in terms of all the different neurologic tests That we will do starting with watching someone walk, testing their strength, and all the other important physical findings that can help a provider, you know, truly figure out what's wrong.

[00:03:54] Juliette Dassinger, PT, DPT: Of course. So when you have gathered those findings with the tests and measures that you've provided in clinic, with someone who is experiencing this pain, what are a couple treatment options you like to provide to them? in that first visit.

[00:04:10] Gary Shapiro, M.D.: So most patients respond very well to a course of physical therapy, as well as the use of anti inflammatories.

The studies that have been done looking at this topic is that 80 percent of patients will get better within three months without surgery, which is very encouraging. If they have already tried these options, when I'm seeing them potentially that first time, the next step usually will be cortisone injections into the spine, referred to as epidural steroid injections.

[00:04:37] Juliette Dassinger, PT, DPT: How do you know, coming from a physical therapist, how do you know if a patient is appropriate or not appropriate for physical therapy? interventions, even at that first appointment.

[00:04:47] Gary Shapiro, M.D.: So it's very important to listen to the history provided by the patient. Most patients can be treated safely with a non surgical approach, including physical therapy and over the counter medicines.

Um, there are certain situations, though, that are important to take a good history, , such as changes in someone's ability to use the restroom, , properly or normally, , or, , weakness that can develop into the legs, which can, very often, force us to change gears and, and potentially look at surgery sooner rather than later.

Okay.

[00:05:18] Juliette Dassinger, PT, DPT: When a patient comes in to see you, when do you find it appropriate to use imaging?

[00:05:24] Gary Shapiro, M.D.: So oftentimes, plain x rays will suffice initially to get an idea structurally of how the spine looks, and then depending on the The individual patient, very often MRI scans will be obtained at some point, though often it can be, , not anything initially, and many times if someone gets better, it won't even be obtained.

[00:05:45] Juliette Dassinger, PT, DPT: It's interesting. Sometimes when I work with my patients, , in the clinic, they will obtain imaging. Sometimes the imaging may find something, sometimes it may not, but then I get the question at times where, why am I still experiencing this pain? Even though my imaging looks clear, or even the other way around, it's interesting.

Some patients may have findings on imaging, but not experience pain. So I know how you and I like to go about talking to our patients is it's based off of what you're experiencing, your history, and what you're telling me. Right now we're just trying to rule it and rule out to see what is involved.

[00:06:22] Gary Shapiro, M.D.: I would agree.

The um, root cause of why patients will describe pain is inflammation. So people can have various degenerative conditions and be unaffected by them and one day it can just become a problem. And every option that we have is geared towards reducing inflammation. Even someone that might still have an underlying degenerative condition.

We just want them to get better and it's really treating the inflammation.

[00:06:47] Juliette Dassinger, PT, DPT: Of course, and then some patients will say, how did I develop this degenerative condition? And I always like to say it's how you just use your body your whole life, the demands you put on your body.

[00:06:57] Gary Shapiro, M.D.: I would agree.

[00:06:59] Juliette Dassinger, PT, DPT: What conditions are present with sciatic pain?

I know sciatic pain we say is a symptom, so are there certain conditions that can also have sciatic pain?

[00:07:09] Gary Shapiro, M.D.: Patients that present with quote unquote sciatic pain can be a range. People can sometimes just throw their back out. would consider a sprain or a strain and sometimes one can have referred pain into the leg.

Other patients can have herniated discs would be a very common cause of like a pinching of a nerve giving someone sciatica. And then patients of all ages sometimes as we get a little older people can have stenosis where the canal is just getting narrowed by arthritic material. I'm People sometimes can have traumatic injuries of their spine and also people can have like what we call instability where if the the bones are sliding on one another sometimes that can irritate nerves causing the leg to hurt.

[00:07:49] Juliette Dassinger, PT, DPT: And would you say imaging is what determines each of these different conditions? So I know you've named a few that have sciatic pain, so then how do you determine which one it is with your diagnosis?

[00:08:00] Gary Shapiro, M.D.: The imaging can be very important, starting with a plain x ray or sometimes an MRI or sometimes CAT scans.

Okay.

[00:08:08] Juliette Dassinger, PT, DPT: I know we discussed the deciding factors of surgical and non surgical interventions. Um, do you ever find a time where you need to refer to any of a, to any colleague of yours?

[00:08:19] Gary Shapiro, M.D.: There are times where if someone presents, , with a condition that, , something seems off where the diagnosis is not entirely clear, , we, um, can refer sometimes to specialists such as a rheumatologist or a neurologist, but I would say more common would be someone that might not be responding to therapy where we would refer to like a pain management specialist and they have a lot of different tools including medicines and different injections that can help patients.

[00:08:45] Juliette Dassinger, PT, DPT: That's excellent. That's excellent to know that there, there are still options even maybe the first line of treatment is not effective. So that's going then to our next point. We have someone who may have gone through therapy, didn't find successful, may have tried epidural injections. may have not find successful.

What would be that next step or what would be your next test to determine what that next treatment would be?

[00:09:08] Gary Shapiro, M.D.: So for someone that didn't respond to the basic conservative measures like therapy, medicines, injections, that patient would oftentimes come back and we would again talk about what is limiting them day to day, what the What their physical exam findings are, what their imaging studies show, and then talk about potential surgical options.

And oftentimes, things can be helped with a very small surgery. It kind of depends on the circumstance, and we try to really just, you know, Find the least invasive option to help someone's condition.

[00:09:37] Juliette Dassinger, PT, DPT: Of course. How about, uh, we can talk about some of those conditions that we mentioned, either that herniated disc or spinal stenosis.

What are surgical options for a herniated disc?

[00:09:48] Gary Shapiro, M.D.: So for a herniated disc, most patients would, uh, pursue what's called a microdiscectomy, and that would be an outpatient procedure, very often at one of the surgery centers that IBJI has, where under a small general anesthetic procedure, one can remove the herniated disc and the patient generally would be home in about an hour, and very often that's night and day better from moment one.

 If someone has stenosis, sometimes the procedures could be a little larger. We oftentimes can do minimally invasive outpatient surgeries, but some other patients that have more complex problems might require what are called fusions where we have to put hardware and different bone graft products into the spine and those usually would be done in a hospital and maybe have one or two days in the hospital.

[00:10:31] Juliette Dassinger, PT, DPT: Of course. And coming from a physical therapist, I always like to think, okay, someone may have gone through some of these procedures. So then going back to those spinal procedures, what would be then that next step? Um, they have the surgery. Would you recommend outpatient physical therapy? Is there other, other interventions needed after surgery?

[00:10:55] Gary Shapiro, M.D.: So I'm a big proponent. on physical therapy, whether it's before or after surgery. In terms of how we handle our practice and post op protocols, for smaller procedures, usually at that first visit, which would be about seven days after surgery, they would be encouraged to start physical therapy. For some of the larger surgeries, such as the fusions, we normally have patients walk and let everything heal until about six weeks.

That way they can feel comfortable that There's no, um, risk of like anything being done wrong to somehow affect their recovery. So anywhere from one week to six weeks in terms of when people would start therapy.

[00:11:33] Juliette Dassinger, PT, DPT: Okay. And just, just to let any of the listeners know, are there any other conditions or surgeries that you perform that someone could be nodding, say, I have, I'm experiencing these symptoms, I'm even having some neck pain.

, what, I would say what are the conditions that you see that are familiar to that sciatic pain or even just nerve pain and just other surgeries overall that you perform?

[00:11:57] Gary Shapiro, M.D.: So my career here at IBJI, lower back is a very common area that people have problems, but similarly the neck can be a problem. And so with respect to cervical spine or neck problems, we routinely are treating patients with IBJI.

both without and with surgery, depending on the circumstance. And when it comes to surgery, it's usually either a cervical fusion or a cervical disc replacement.

[00:12:21] Juliette Dassinger, PT, DPT: Would you say it's similar to then the lumbar spine?

[00:12:23] Gary Shapiro, M.D.: It is fairly similar. The recovery is usually faster for the cervical spine, just in terms of the anatomy and how we are able to approach it.

But it is fairly similar.

[00:12:33] Juliette Dassinger, PT, DPT: Similar. All right. How about this? Let's say someone right now is listening and they probably have nodded through this episode saying, I may be experiencing this or I know someone who has experienced this. What advice would you provide that person in listening?

[00:12:49] Gary Shapiro, M.D.: I think if someone has an ongoing problem, it would be helpful to see someone with a focus on the spine as part of their practice, someone that has a comprehensive view as to the treatment of spine disorders.

And, um, I think that would be a good first step so that they are getting all of the appropriate options laid out in front of them.

[00:13:10] Juliette Dassinger, PT, DPT: That's excellent. How can a patient communicate to the team for further follow up or evaluation?

[00:13:16] Gary Shapiro, M.D.: If someone needs to communicate, some patients like to use the phone, others like to use the electronic medical record that we have at High Beach AI called EPIC.

It makes it very easy for patients to have communication back and forth without a problem.

[00:13:32] Juliette Dassinger, PT, DPT: I also find as a physical therapist, patients really enjoy knowing they have a team behind them. And this is where even myself as a physical therapist can communicate with the doctor and communicate with you about their care as well.

[00:13:45] Gary Shapiro, M.D.: I agree. The team approach is very important for education and for people that are going to choose surgery. The steps leading up to surgery, the surgery itself, the expected recovery, all of that is covered by the team.

[00:13:58] Juliette Dassinger, PT, DPT: And for anyone listening, Dr. Shapiro does work out of our Desplaines, Glenview, and Wilmette locations.

If you are wanting to know more information, you can head over also to ibji. com. Thank you, Dr. Shapiro. It was a pleasure to have you on this OrthoINFORM episode talking about sciatica pain.

[00:14:14] Gary Shapiro, M.D.: Thank you so much. This was fun.