Sciatica: When Symptoms and Imaging Disagree

Jan 6

Reading time: 4 minutes

Imagine a patient in severe pain extending down their right leg, but they have an MRI with no disc bulges or foraminal encroachment. Your patient is confused, and you must educate them on the cause of their symptoms.

Irritation or inflammation of a spinal nerve root is called radiculitis. Direct compression of a nerve and chemical irritation are the two most common causes of radiculitis. One less common etiology of radicular symptoms may be friction radiculitis. While less common, your knowledge of this phenomenon will assist in treating patients with confirmed disc herniations that don't correspond to the side of symptoms.

What is Friction Radiculitis

One possible cause of radiculitis is friction radiculitis, resulting from abnormal traction on a nerve root due to a lumbar disc herniation (LDH) on the opposite side of the body. Tractioning a nerve root leads to an inflammatory reaction and radicular pain. (1)

Friction radiculitis causes an acute inflammatory process at the exiting inferior nerve root. Inflamed nerve roots are hyperexcitable, leading to the clinical symptoms presenting to your office, such as pain, burning, tingling, electric shocks, etc.

Lumbar disc herniations causing mechanical or chemical compression of a nerve root can affect treatment and rehabilitation options. If the compression is chemical, it may be possible to use anti-inflammatory medications or time to address the issue. However, if the compression is mechanical, it may be necessary to use techniques such as foramen opening, nerve flossing, or nerve tensioning to reduce inflammation.

How can you differentiate between mechanical and chemical pain?

A recent study identified four clinical features that can help differentiate between chemical or inflammatory pain and mechanical/compressive pain. (2) These features are:

Back pain less than 5/10 in severity
Symptoms that get worse the next day after injury
Lumbar flexion range between 0 and 30 degrees
Positive clinical inflammation score includes at least three of the following: constant symptoms, morning pain or stiffness lasting more than 60 minutes, short walks not easing symptoms, and significant night-time symptoms.

The study found that this model had a high sensitivity, specificity, and predictive accuracy for histologically confirmed inflammation.

Treating Sciatica

Initially, treatment of friction radiculitis requires you to calm down your patient’s symptoms. Then you may transition a patient to a multimodal treatment plan to achieve the best clinical result. Many evidence-based chiropractors will initially opt for nerve mobilization techniques for patients with sciatica. However, a patient suffering from friction radiculitis may get worse performing nerve flossing. The active nerve mobilization may increase the amount of friction and resultant inflammation. These patients should opt for a static opener.

How To Reduce Sciatic Pain

One technique effective for friction radiculitis is the static opener, which involves lying on the unaffected side and flexing the hips and knees to 90 degrees while allowing the lower legs to hang off the edge of a table or bed. The patient holds this position for one minute before returning to the starting position and repeating the process five times. The hold time gradually increases until the technique can be performed five times a day or as directed. The Foramen Opener is an excellent initial exercise for those patients with suspected friction radiculitis.

It's important to note that not all patients with radiculitis will require active rehabilitation, and some may benefit more from rest and posture modifications. It's essential to determine the best course of treatment and rehabilitation for each patient.

*The Foramen Opener exercise is often used to reduce acute compression of the affected nerve root. Consider this: “Twenty lumbar radiculopathy patients presented to an emergency department with moderate or large disc herniations (via MRI). Half were randomized into a Foramen Opening self-treatment group. Compared to controls, the patients performing the Foramen Opening exercise demonstrated "significant improvements" in VAS back and leg pain, Oswestry disability scores, and straight leg raise. And "patients in the experimental group consumed less medication than control patients (21% versus 79%), including less than half the opioids (tramadol). No adverse responses occurred." (3)

How To Treat Sciatica Fast

Patients can advance their rehabilitation program to include flossing and tensioning exercises. The nerves in our bodies are flexible and able to stretch. However, swelling and scar tissue can inhibit this normal movement and cause neuropathic issues like sciatica. To address this, a technique called "sciatic nerve flossing" can be used. This treatment involves applying tension to one end of the nerve and then releasing it, repeating the process to glide the nerve back and forth and potentially release any adhesions that have formed. This technique can be performed in a chiropractic office and included in a home-based treatment program.

Sciatica Home Exercises

Once the patient is no longer exhibiting chemical radiculitis, clinicians can complement their in-office care by prescribing three variations of the sciatic nerve floss. Patients can perform home-based sciatic nerve flossing in any one of three positions.

ChiroUp subscribers can review home exercise videos from the links below or via their Clinical Skills/Treatment Techniques tab 24/7. Then, rest assured that your condition reports already include nerve flossing for your sciatica patients.

Do you want to prescribe the best exercises for patients? Do you want to prescribe the best exercises for patients quickly? Do you want to confidently prescribe the best exercises for patients quickly? Well, you can do all of that with ChiroUp. And, there is no better time than now to get started with us.

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BONUS MATERIAL

Do Herniated Discs Heal?

The mechanical obstruction of the nerve will resolve with time, manipulation, and manual therapy. Remember these eight facts while treating your next patient with a disc condition. (4,5)

You may successfully manage disc herniation with radiculopathy via conservative treatment.
The majority of disc herniations will reduce over time with nonsurgical care.
The size of the herniation has no predictive value regarding the failure of conservative management or the likelihood of requiring surgery.
Large “herniations” trigger a significant inflammatory response and generally regress more quickly when compared to contained “bulges” that do not benefit from reabsorption. The relatively avascular anatomy of the intervertebral disc may prolong recovery times.
Outcomes for nonsurgical management of LDL are similar, regardless of age.
The goal of conservative management should be to centralize symptoms, reduce pain & inflammation, decrease mechanical compression and improve functional core stability.
Lumbar disc herniation patients experience long-term LBP compared to the general population (46.2% vs. 11.9%).
Radiological findings and the degree of LBP do not always correlate to symptoms.

1. Hayashi N, Iba H, Ohnaru K, Nakanishi K, Hasegawa T. Radiculopathy contralateral to the side of disc herniation-microendoscopic observation. Spine Surgery and Related Research. 2018:2017-0062.
2. Ford JJ, Kaddour O, Gonzales M, Page P, Hahne AJ. Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy. BMC Musculoskeletal Disorders. 2020 Dec;21(1):1-9.
3. Shacklock M, Rade M, Poznic S, Mar?inko A, Fredericson M, Kröger H, Kankaanpää M, Airaksinen O. Treatment of Sciatica and Lumbar Radiculopathy with an Intervertebral Foramen Opening Protocol: Pilot Study in a Hospital Emergency and In-patient Setting. Physiotherapy Theory and Practice. 2022 Mar 8:1-1
4. Bertelsman T and Steele, B. www.ChiroUp.com Accessed 1/2/23. https://app.chiroup.com/clinical-skills/conditions/4021698
5. Wong T, Patel A, Golub D, Kirnaz S, Goldberg JL, Sommer F, Schmidt FA, Nangunoori R, Hussain I, Härtl R. Prevalence of Long-term Low Back Pain After Symptomatic Lumbar Disc Herniation. World Neurosurg. 2022 Nov 10:S1878-8750(22)01571-6. doi: 10.1016/j.wneu.2022.11.029. Link

Brandon Steele

Dr. Steele is currently in private practice at Premier Rehab in the greater St. Louis area. He began his career with a post-graduate residency at The Central Institute for Human Performance. During this unique opportunity, he was able to create and implement rehabilitation programs for members of the St. Louis Cardinals, Rams, and Blues. Dr. Steele currently lectures extensively on evidence-based treatment of musculoskeletal disorders for the University of Bridgeport’s diplomate in orthopedics program. He serves on the executive board of the Illinois Chiropractic Society. He is also a Diplomate and Fellow of the Academy of Chiropractic Orthopedists (FACO).