Sciatica and lumbar radiculopathy Prolotherapy

treatments
caringmedical.com/prolotherapy-news/sciatica-treatment

Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort
Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak
Park, Illinois

You have been diagnosed with sciatica

You went to the doctor concerned about a burning pain and numbness sensation in your
buttocks, legs and feet. Often the pain will wake you up in the middle of the night. You are
at the doctor now because your own pain management plan of aspirin, anti-inflammatories,
heat, ice, yoga, stretching, resting and back braces have not helped. Your problems have
probably gone on for some time and now worse, you are getting worse as you began to
suffer from severe spasms in the lower leg and calf muscles.

A friend may have recommended a great chiropractor, who has centered your treatment on
nerve impingement happening in your L4/L5 lumbar region. You were told that a few
adjustments should relieve the pressure on the sciatic nerve bundle and your symptoms
should be gone. For many, possibly like yourself, unfortunately after a few adjustments you
did not respond well enough to call yourself healed or cured.

At the doctor’s, after an examination, the doctor may suspect sciatica symptoms and will
be looking at the possibility of a herniated, slipped, bulging disc in the lumbar spine
causing an inflammation of the sciatic nerve or a lumbar radiculopathy and need a
sciatica treatment plan.

Sciatica is not a disease, Sciatica is a symptom of Lumbar Radiculopathy. Radiculopathy is

a disease of the nerve root causing an inflammation on the nerve. If you are reading this
article you have likely been diagnosed with sciatica and it has been described to you as an
inflammation of the sciatica nerve caused by pressure from a bulging or herniated disc
pressing down on the sciatic nerve. For this reason a diagnosis of lumbar radiculopathy
and sciatica are terms often used interchangeably.

Your doctor may recommend a pain relief plan and tell you about an epidural
injection or nerve block for sciatica nerve pain, pain-killers, NSAIDs anti-
inflammatory therapy or corticosteroids. Your doctor will likely issue warnings to you
about the realistic expectations of pain relief you may achieve and what type
of herniated disc sciatica recovery time you may expect.
Recommendations to reduce physical activity is generally made, heavy lifting is to be
avoided. Hamstring stretches and abdominal strengthening or low back exercises
1/12
 may be encouraged to strengthen the spine. A physical therapy plan may be
encouraged.

If you are reading this article, you should not be at all surprised that research has called
into question all of these “remedies,” as not being particularly effective for sciatica
patients. If you are reading this article you may be near the point of exhausting all
conservative care options and surgery may be indicated. You are likely researching the
avoidance of having to make a choice between constant medical and a spinal surgery.

Trying to solve the sciatica riddle by focusing on difficult to

treat patients
If you are reading this article you are likely a patient who doctors describe as having
refractory sciatica, a difficult to treat problem that stubbornly refuses to respond to
conventional treatments. Doctors have seen many patients respond to anti-inflammatories,
physical therapy, even cortisone and epidural. This is why they stubbornly hold onto these
conventional treatments as primary interventions following a sciatica determination. When
these treatments do not help you, despite increasing doses or a trial and error medication
plan that looks to see which one works best if any, your doctors may have become
perplexed when you did not respond. This is when surgical discussion typically begins.

Difficult to treat patients get more drugs with no evidence that

they are helpful. Researchers call these treatments “over
used” and tell doctors they have “no use” for patients. Some
of you get them prescribed anyway.
Once you progress past the ineffectiveness of aspirin or ibuprofen, you may be managed
with stronger medications, these painkillers include oxycodone, antidepressants, and
anticonvulsants.

Doctors writing in the Canadian Medical Association journal wrote in July 2018 ( 1) that:
“There is moderate- to high-quality evidence that anticonvulsants are ineffective for
treatment of low back pain or lumbar radicular pain. There is high-quality evidence that
gabapentinoids (one of the classes of anticonvulsants including pregabalin (Lyrica) and
gabapentin (Neurontin)) have a higher risk for adverse events.”

You can get a second opinion on that from another group of Canadian researchers wring in
the journal Public Library of Science medicine (PLOS).(2)

“Existing evidence on the use of gabapentinoids in chronic low back pain is limited
and demonstrates significant risk of adverse effects without any demonstrated
benefit. Given the lack of efficacy, risks, and costs associated, the use of
gabapentinoids for chronic low back pain merits caution.”

In the Journal of the American Medical Association (JAMA) December 8, 2018 issue (3),
editors provided a 2018 update of “medical overuse”, that is medical treatments that have
“no use,” and in fact are potential harmful to patients.

2/12
One of the top problems was the use of the drug pregabalin. To quote: “pregabalin does not
improve symptoms of sciatica but frequently has adverse effects (40% of patients
experienced dizziness).” Yet the drug is still sometimes prescribed for sciatica nerve
related inflammation

In the British Medical Journal,(4) researchers also found that pain medications were really
not that helpful. Paralleling the findings of the two studies above, the British researchers
found that most sciatic related pain resolves on its own, however they cited supportive
research that suggested 30% of people will continue to have after one year.

The highlights of this study:

“The most effective pain medication to treat patients with sciatica or radicular leg
pain is unclear“
“Medications used for the treatment of sciatica can have considerable side effects .”
Acute sciatica will usually clear within two weeks, and about three quarters of
patients reported any improvement within 12 weeks.
Thirty percent of patients will report persistent and disabling symptoms after one
year.

Researchers in Sweden had a difficult time assessing the effectiveness of Non-Steroidal

Anti-Inflammatory medications (NSAIDs). Writing in The Cochrane database of systematic
reviews (5) they could not make clear recommendation for NSAIDs usage in sciatica
patients.

“This updated systematic review including 10 trials evaluating the efficacy of NSAIDs
versus placebo or other drugs in people with sciatica reports low- to very low-level evidence
using the GRADE criteria (the GRADE criteria is exactly what is sounds to be a grading
system of evidence. In this case low grades).

The efficacy of NSAIDs for pain reduction was not significant.

NSAIDs were better than placebo.
While the trials included in the analysis were not powered to detect potential rare side
effects, we found an increased risk for side effects in the short-term NSAIDs use.
As NSAIDs are frequently prescribed, the risk-benefit ratio of prescribing the drug
needs to be considered.

Researchers in Australia at the University of Sydney wrote in the journal Drugs and Aging
(6) of their questioning pharmacological management, including paracetamol (Tylenol),
in older patients with sciatica. “There is overall very limited information on the efficacy,
safety, and tolerability of these medicines in older patients.”

Epidural corticosteroid injections and pain management

: Epidural corticosteroid injections have no demonstrated
benefit beyond the placebo effect

3/12
Epidural steroid injections ease pain temporarily by reducing the size of stressed nerve
roots. However concerns over short-term gain long-term costs in the use of epidural steroid
injection side-effects have been noted. Although many patients initially respond well to the
injections, they still remain a temporary fix.

2014: In the French medical journal Prescrire international (Prescribe), (7) this
editorial appeared in late 2014: “Sciatica and epidural corticosteroid injections.”
According to trials conducted in hundreds of patients with sciatica, epidural
corticosteroid injections have no demonstrated efficacy beyond the placebo
effect, either in the short term or the long term. However, they expose patients
to a risk of sometimes serious neurological adverse effects.
However some patients do get relief from Epidural Steroid Injections. In a November
2017 study in the journal World Neurosurgery, (8) doctors in Switzerland wanted to
see how long that pain relief lasted.
Fifty-seven patients who underwent a transforaminal epidural steroid injection
for sciatica secondary to a lumbar disc herniation were followed for 24
months.
Leg and back pain, health-related quality of life were measured using various
scoring systems. Patients who underwent a second injection or surgery were
defined as treatment failures (nonresponders).
At 24 months, 31 (54.4%) patients were responders, and 26 (45.6%) were
nonresponders.
Further, research in the Journal of the American Medical Association, JAMA said that
oral steroids as compared to placebo, offered minor improvement in function but did
not improve pain conditions.(9)

A review of the treatments to see why you are now going to

surgery
Doctors at the Arthritis Research UK Primary Care Centre at Keele University and the
University of Nottingham in the United Kingdom attempted to categorize a patient’s one
year trajectory, or treatment/improvement path with their sciatica related pain. In part this
would help perplexed doctors understand their sciatica patients better.

The study was published, December 2018, in the journal Arthritis care & research.(10)

Four patient types were identified from 609 study participants with back and leg pain still in
primary care.

Patients with improving mild pain (58%) where the pain is associated and seemingly
from back pain problems
Persistent moderate pain (26%) where the pain is associated and seemingly from
back pain problems
Persistent severe pain (13%) where the pain is associated and seemingly from back
pain problems
Improving severe pain (3%) where it is unclear where the original pain was coming
from. See below for a discussion on spinal ligaments.

4/12
What we see in this study is that 61% of the participants, after one year of follow up, were
getting better, so there is some degree of confidence that the traditional pathways of
treatment, medication, rest, therapy, stretching, is slowly but positively helping people
manage their sciatica.

However, 39% of the study participants continued or persisted with moderate to severe
pain after one year. If you are reading this article, you are likely in the 39% and you are now
being recommended to a surgery.

Doctors writing in the Swiss Medical Review (Revue médicale suisse) suggest not even
waiting a year, if these treatments are not working, better to decide on surgery sooner:

“(If symptoms worsen) under conservative treatment or if pain is poorly controlled by well-
conducted conservative treatment performed during four to six months, surgery is then
recommended.(11)

The best conventional medicine has to offer for lumbar disc

herniation and associated lumbar radiculopathy and sciatica
are surgeries that do not work that well.
So your journey now has come to a surgical recommendation. Up until this time you may
have spent years looking for some type of relief to a problem that has become significantly
worse and there seems to be little else for you to consider beyond getting the surgery. But
you may have seen the commercials on TV and the ads on the internet for minimally
invasive surgery. This has peaked your interest.

Minimally invasive spinal surgery procedures

We have published a much broader article on this subject on this website: In that article we
discuss

Is Minimally invasive spine surgery really less complicated, less risky, less painful?
Toronto Western Hospital, University of Toronto surgeons questions this.
Is Minimally invasive spine surgery less complicated, less risky, less painful? New
York University Langone Medical Center Study questions this.
Is Minimally invasive spine surgery less complicated, less risky, less painful? A study
in the British Journal of Neurosurgery questions this.

You can read the entire article here: Minimally invasive spinal surgery

Writing in the European Journal of Pain, doctors found that some patients with
sciatica still experience pain and disability 5 years after surgery. They wrote in their
conclusion “Although surgery is followed by a rapid decrease in pain and disability by
3 months, patients still experience mild to moderate pain and disability 5 years after
surgery. “(12)

Another path to treatment – Prolotherapy and spinal ligament

damage
5/12
In the above research we presented the typical paths of treatments patients may take in the
treatment of their sciatica. Some of the treatments worked, some of the treatments
provided some relief, some of the treatments did not work at all. We will focus now on the
treatments that did not work and why.

Maybe you did not have lumbar radiculopathy and the burning
sensations in your hip and leg are not really sciatica. Many
patients are diagnosed with “sciatica” when, in fact, their
sciatic nerve is not getting pinched. How can this be?
The term sciatica is thrown around loosely and is often used for any pain traveling down
the leg. In fact some patients come in asking for sciatic nerve treatment. True sciatica is a
nerve injury that causes extreme pain and is caused by the sciatic nerve being pinched due
to a herniated disc, spondylolisthesis, or foraminal or lumbar stenosis commonly referred
to as spinal narrowing.

However, many patients are diagnosed with “sciatica” when, in fact, their sciatic nerve is
not getting pinched.

In our experience, many individuals who are diagnosed with sciatica or lumbar
radiculopathy, are more likely to have a “pseudo” sciatica and a “pseudo” radiculopathy.
This is a condition where radicular or sciatica pain comes and goes with changes in activity
or changes in position, pinching the nerve intermittently.

Indications the symptoms are caused by a “pseudo sciatica”

ligament injury rather than nerve injury
You can sit in a chair and raise your leg straight out in front of you without
reproducing your pain.
Your low back pain is greater than your leg pain. Leg pain is 25% or less of the pain.
The pain isn’t to the point of causing you to sweat.
No numbness in your leg or foot.
You experience numbness, but can touch the area and have sensation of touch there.
This is a referral sensation, generally from a ligament injury, not a nerve injury.

It is important to note that many people have herniated disks or bone spurs that will show
up on MRI’s and other imaging tests but cause no symptoms. So a herniated disc
according to MRI does not cause sciatica in all patients.

The sciatica complaint very possibly is a simple ligament problem in the sacroiliac
joint. For the majority of people who experience pain radiating down the leg, even in
cases where numbness is present, the cause of the problem is not a pinched nerve
but sacroiliac ligament weakness.

Sciatica may be due to ligament laxity in the sacroiliac joint, which can cause radiating
pain down the side of the leg, as well as numbness, a symptom that has traditionally been
attributed only to nerve injury.
6/12
 https://youtu.be/LExrGa0NFCY

Comprehensive Prolotherapy for sciatic pain involves treating all of the affected areas,
such as the sacroiliac ligament attachments and the lumbosacral area as necessary.
Prolotherapy injections stimulate the body’s own natural healing process which is through
inflammation. The inflammation causes the blood supply to dramatically increase in the
injured areas, alerting the body to send reparative cells to the ligament site. Ligaments,
such as the sacroiliac ligament are made of collagen. In this healing process, the body
deposits new collagen. The sacroiliac ligament will then be strengthened and tightened as
this new collagen matures. The sacroiliac joint which was unstable, will then become
strong and stabilized, and the symptoms will abate.

Our research: Published research from Caring Medical and

Rehabilitation Services
In addition to the in-house data analyzed from consecutive cervical and lumbar
radiculopathy cases, Caring Medical published research in the Journal of
Prolotherapy demonstrating the effectiveness of Prolotherapy for unresolved back pain.

In our research, we reported on 145 patients who experienced low back pain an average of
58 months, who were treated on average with four sessions of dextrose (12.5%)
Prolotherapy, quarterly, at a charity clinic.

The patients were contacted on average 12 months after their last Prolotherapy session.In
these patients:

pain levels decreased from 5.6 to 2.7 (numerical rating scale NRS , 1-10 scale);
89% experienced more than 50% pain relief

7/12
Results were similar in the patients who were told by at least one medical doctor that there
was no other treatment option (55 patients) or that surgery was the only option (26
patients).(7)

The approach to back pain used in these studies was the foundation used in our clinics
today. You can read more about the regenerative methods to treating spine pain conditions
here.

Back to Pseudo-Radiculopathy | Structural radiculopathy

vs intermittent or transient radiculopathy | Realistic treatment
options with Prolotherapy
Testing for Radiculopathy: An EMG or nerve conduction study seeks to determine if
the nerves are getting pinched. If the nerve is getting pinched then we have to figure
out is it a structural radiculopathy (constant pain) or is it a radiculopathy that’s
intermittent (pain and numbness comes and goes).

In utilizing Prolotherapy as a treatment, diagnosing lumbar radiculopathy as an intermittent

of transient pain, as mentioned above, requires a physical examination, manipulation, and
8/12
palpitation of the suspect area. During the physical examination we are looking for
underlying ligament injury to the lumbar spine . When the ligaments become weaker and
allow for more movement than normal the vertebrae then move excessively, rotate, and the
nerve can get pinched. This pinching causes extreme pain down the legs and feet. If the
lumbar radiculopathy is intermittent, then this pain will be occasional or intermittent.
Prolotherapy to the injured and weakened areas will stabilize the lumbar vertebrae.
Intermittent radiculopathy generally responds very well to Prolotherapy. Three to six
Prolotherapy sessions and the majority of these pains subside.

For the people who have a true radiculopathy the following is typically present:

Crippling pain.
The MRI shows an acute herniated disc
The MRI finding is consistent with the person’s symptoms and exams
The EMG collaborates the MRI

9/12
In our office when a person with structural or true radiculopathy comes in, and we think we
can help, we may offer nerve blocks with steroids along with the Prolotherapy. If the
vertebrae is rotated and that is what is causing the problems of pinched or compressed
nerves, and we are going to try to rotate it back with Prolotherapy, we may offer nerve
blocks because Prolotherapy to work effectively will need time. Certainly a lot less time
than surgical repair recovery. The person with a true radiculopathy needs to decrease the
inflammation of the disc material pressing on the nerve while the Prolotherapy helps
stabilize the herniated areas.

The key is time. When there is the presence of bone spurs and they are pinching on the
nerves a person may be tempted try decompressive laminectomy or other surgical
procedure.

In the case of a true pinched nerve, most Prolotherapists will get the person some pain
control while the Prolotherapy is working.

A nerve block can be performed where the disc is herniated.

Sometimes an epidural is done, but we like putting the medication directly where the
problem is located.
The person is also prescribed muscle relaxers and rarely oral steroids. These steps
are only immediate-level treatments.
Simultaneously, Prolotherapy works on the long-term cure. Yes, the steroids may
block some of the Prolotherapy effect, but the person needs immediate pain relief.
A medication to help sleep is also warranted sometimes.

Obviously, the person gets Prolotherapy to the areas.

The person is seen in follow-up in one week. At this time if they still have a lot of pain,
then another steroid injection is given to the painful area.
At the two-week point, sometimes another Prolotherapy session is done.

Four to six Prolotherapy sessions are sometimes needed. The above approach has been
used at Caring Medical for years. It has kept a lot of people out of surgery.

In our experience, the above approach even with herniated discs is around 90% successful.
Of course, we have our handful of cases that have needed surgical consultation and
surgery. We are grateful the surgeons are there for back-up. Even for an acute herniated
disc, the surgeon is second-line therapy, or the person with a pseudo- or true radiculopathy
the treatment of choice is Prolotherapy.

Do you have a question about Prolotherapy Sciatica and

lumbar radiculopathy treatments or need help?
Get help and Information from our Caring Medical staff

10/12
1 Enke O, New HA, New CH, Mathieson S, McLachlan AJ, Latimer J, Maher CG, Lin CW.
Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic
review and meta-analysis. CMAJ. 2018 Jul 3;190(26):E786-93. [Google Scholar]
2 Shanthanna H, Gilron I, Rajarathinam M, AlAmri R, Kamath S, Thabane L, Devereaux PJ,
Bhandari M. Benefits and safety of gabapentinoids in chronic low back pain: A systematic
review and meta-analysis of randomized controlled trials. PLoS medicine. 2017 Aug
15;14(8):e1002369. [Google Scholar]
3 Morgan DJ, Dhruva SS, Coon ER, Wright SM, Korenstein D. 2018 Update on Medical
Overuse. JAMA internal medicine. 2018 Dec 3. [JAMA]
4 Pinto RZ, Verwoerd AJ, Koes BW. Which pain medications are effective for sciatica
(radicular leg pain)?. BMJ. 2017 Oct 12;359:j4248. [Google Scholar]
5 Rasmussen-Barr E, Held U, Grooten WJ, Roelofs PD, Koes BW, van Tulder MW, Wertli MM.
Non-steroidal anti-inflammatory drugs for sciatica. Cochrane Database Syst Rev. 2016 Oct
15;10:CD012382. [Google Scholar]
6 Ferreira ML, McLachlan A. The Challenges of Treating Sciatica Pain in Older Adults. Drugs
Aging. 2016 Oct 13. [Google Scholar]
7 Sciatica and epidural corticosteroid injections. Prescrire Int. 2015 Feb;24(157):49.
8 Joswig H, Neff A, Ruppert C, Hildebrandt G, Stienen MN. The Value of Short-Term Pain
Relief in Predicting the Long-term Outcome of Lumbar Transforaminal Epidural Steroid
Injections. World Neurosurgery. 2017 Aug 23. [Google Scholar]
9 Goldberg H, Firtch W, Tyburski M, Pressman A, Ackerson L, Hamilton L, Smith W, Carver R,
Maratukulam A, Won LA, Carragee E, Avins AL. Oral steroids for acute radiculopathy due to
a herniated lumbar disk: a randomized clinical trial. JAMA. 2015 May 19;313(19):1915-23.
doi: 10.1001/jama.2015.4468. [Google Scholar]
10 Ogollah RO, Konstantinou K, Stynes S, Dunn KM. Determining one‐year trajectories of
low back related leg pain in primary care patients: growth mixture modelling of a
prospective cohort study. Arthritis care & research. 2018 Mar 25. [Google Scholar]
11 Corniola MV, Tessitore E, Schaller K, Gautschi OP. Lumbar disc herniation–diagnosis
and treatment. Rev Med Suisse. 2014 Dec 10;10(454):2376-82. [Google Scholar]
12 Machado GC, Witzleb AJ, Fritsch C, Maher CG, Ferreira PH, Ferreira ML. Patients with
sciatica still experience pain and disability 5 years after surgery: A systematic review with

11/12
meta-analysis of cohort studies. Eur J Pain. 2016 May 12.[Google Scholar]
13 Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a
retrospective case series study. Journal of Prolotherapy. 2009;1:145-155.

3708

12/12