Date: 26th January 2012
Management of Sciatica and Brachialgia - Risks and Pitfalls
Management of sciatica and brachial neuralgia -the risks and pitfalls
Sciatica and brachial neuralgia are relatively common presentations in a neurosurgeon's office. Sciatica is usually due to nerve root compression in the lumbar region, or lower back, causing varying degrees of severe leg pain travelling down the back of the thigh and below the knee('true" sciatica-below the knee and not 'referred' pain in the posterior thigh only). It may be accompanied by neurological symptoms such as numbness, paraesthesiae ('pins and needles") and weakness, or in severe cases paralysis.Glutalgia (buttock pain) often accompanies sciatica, but may also be due to primary local gluteal pathology e.g. gluteus muscle tears etc..Femoralgia involves anterior thigh pain due to upper lumbar nerve root compression-it is strictly speaking not sciatica,as it involves the roots that constitute a different nerve-the femoral nerve-hence "femoralgia".The equivalent condition of nerve root compression (or "painful radiculopathy") in the cervical region, or the neck, causes again, varying degrees of severe arm pain not leg pain. It is termed brachialgia or "brachial neuralgia'. Patients present with neck, scapular and arm pain. They may prefer to place their arms above their heads, or tightly clutched against their chest. They too may experience neurological symptoms, usually in the arm, or upper limb. The cause for nerve compression is usually a disc bulge (degeneration), disc protrusion (degeneration and/or trauma) or narrowing of the spinal canal termed "stenosis". CT, MRI or myelogram with detailed neurological examination is required.Femoralgia refers to anterior thigh pain due to upper, not lower painful radiculopathy.
The management is complex. About 90% of first attacks resolve, or settle with rest, time and simple measures. It is the intensity of pain, or appearance of paralysis that leads to abandonment of conservative treatment in some cases in the first few weeks. Interventions such as drugs with risks, e.g. steroids, anti-inflammatories, narcotics may be an option-but not without risk. Physical therapy is unlikely to help true sciatica or brachialgia. The next options are CT steroid injections such as nerve root or epidural procedures in the radiology department. These carry about 1% 'minor risk and produce improvement, or resolution in about 40% of cases. Surgery is the so called final' option- even though it is the most successful-around 90%medium to long term relief, because it carries the highest risk. There is generally a 1-2 % risk of a major complication and 2-5% risk of a more minor complication-even in the best hands and hospitals. The risks include infection,DVT-pumonary thrombo-embolism, bleeding, nerve damage and scarring,incorrect level surgey,inadvertent intra-abdominal major vessel/organ injury,dural tear with cerebro-spinal fluid(CSF) leak with potential meningitis/ventriculitis/abscess/osteomyelitis/discitis, adjacent level degeneration and paralysis ranging from the fingers and toes to complete paraplegia and quadriplegia. Sobering risks-both to the patient, their families and the neurosurgeon who performed the surgery.
There is an ever increasing tendency for patients and surgeons to approach the surgical option, in my opinion more lightly nowadays. In other countries spinal surgery does not figure as prominently as it does on Australian and American operating lists-even adjusted per capita. Why is this so? Are patients unaware of the risks or are they not willing to persevere with non-operative, conservative treatments? Perhaps surgeons are proceeding with surgery earlier, and more frequently because of an expectation that they need to intervene to stop the pain. Or are there other non-medical factors in play such as fear of litigation for failing to operate, especially if a colleague takes over and operates with a good result. Maybe there are other financial motivators to operate-it is very difficult for the surgeon, also a human! His or her patient continues to report pain. Regrettably, however some patients of course rarely have a total non-clinical agenda which totally confounds the good faith being offered by the surgeon. These issues include compensation goals of never returning to any work, the surgical booking then patient cancelling of surgery and litigating the surgeon anyway.
The most important advice is that the surgeon MUST fully discuss diagnosis, options, expectations and risks in a frank manner with the patient, family and any insurers or lawyers on the sidelines BEFORE surgery.. .. the patient, his/her family and insurers and lawyers in the wings MUST also expect this before, not after the operation! Neurosurgery is a tough business!
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