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Sciatica refers to pain that is coming from the sciatic nerve. The sciatic nerve is actually a conglomeration of numerous nerve roots that meet up after coming off from the remnant of the spinal cord. After the first lumbar level, the spinal cord ends and is referred to as the dural sac. It still looks like the spinal cord, but at that point it basically contains nerve filaments and emits a nerve root on each side at each level of the spine.

There are five lumbar vertebrae in a normal spine. At each of these levels a nerve root comes out on each side and is named according to that level. The nerve root, for example, that comes out at the 4th lumbar level is called L4. At the 5th lumbar spinal level, it’s referred to as L5.

The sacrum lies under these five lumbar vertebrae. The sacral bone is one structure, however there are holes on each side going down where the various nerve roots come out. S1 is the first sacral nerve root.

The sciatic nerve, as mentioned, is a nerve that combines multiple nerve roots. The roots involved on each side are L4, L5, and S1. The merging into the sciatic nerve results in a large structure which emanates from the pelvis, goes behind the hip joint area, and runs down the back side of both legs.

If there is an irritant or pinching to any portion of the sciatic nerve, the resultant pain is called sciatica pain. The various pain components can be broken down into:
1) Pinched nerves of a nerve root prior to the sciatic nerve formation (L4, L5, or S1 itself) or
2) The sciatic nerve itself is getting pinched with resulting pain after it has been formed.
3) The nerve itself has a problem inside it (intrinsic problem).

In the case of #1, the typical cause is a herniated disc that squeezes out and touches on a nerve root leading to inflammation and pain. It could be simply pain, or the person may also have numbness, tingling, and/or muscle weakness. The symptoms will typically correspond to the particular nerve root that is being compressed by the disk herniation (pinched nerve). For example, if a disk herniation is pushing on the 5th lumbar nerve root (L5) that individual may end up with a foot drop, which is difficulty lifting up the foot, along with numbness and pain radiating down the back of one’s leg into the foot.

Even though the pain is a result of a pinched nerve at L5, the term sciatica is commonly used to describe the painful symptoms since L5 comprises part of the sciatic nerve. It just sounds better than “L5ica”.

As in #2, Sciatica pain may also occur from sciatic nerve compression after the nerve roots combine together. This can be from a tumor, scar tissue, a tendon, basically anything that is compressing the sciatic nerve enough to cause the symptoms of pain and numbness or the signs of weakness.

The term intrinsic refers refers to a problem inside the sciatic nerve resulting in sciatica pain that is not a result of compression. This would be a disease like diabetic neuropathy where there is a problem inside the nerve as a result of disease complications. This is difficult to handle since fixing the problem is not as easy as removing something compressing the nerve.

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Pain doctors take on significant risk prescribing narcotics to individuals. Devoting one’s life to relieving pain is a humane and noble profession to participate in, however, the incidence of drug diversion among patients is rampant. Pain doctors need to be careful.

A 2005 study by Pembrook in Pain Medicine News displayed that 35% of patients failed to show the expected medication concentration in their urine screens.

So what are the methods pain doctors use to drug screen their patients for compliance?

1. Urine – this is the most common and widespread tool utilized for testing compliance. The window of detection spans from twelve to seventy two hours. It is also good for testing metabolites in drugs. Pain doctors can do a screen in the office that will give a positive or negative result for numerous drug classes. Then the sample can be tested with gas chromatography to check specific drug levels.
2. Sweat – Perspiration gives a window of detection of about a week. The collection method is inefficient – patients need to wear a patch for days to weeks. It’s not a widespread method of screening.
3. Hair – The time of detection for hair is significantly long – upwards of 6 weeks. The incidence of false negatives is substantial and the screening is onerous. There also is questionable racial bias with individual hair colors binding differentially to certain drugs. Similar to sweat, it is not efficient for screening.
4. Oral saliva – this screening method offers easy collection with the added benefit of actually being able to watch the patient produce the sample. It has a short detection window (up to 4 hours) and the drugs are generally found at lower levels than what one sees in urine. The percentage of positive drug screens in workers has been shown to have similar equality between saliva and urine testing. Oral saliva screening is growing in popularity for drug testing.
5. Blood – serum testing is very good at detecting even low drug levels. The window of detection is very short, just a few hours. Because of the need for office blood draws it is not a popular screening method.

Monitoring pain medication compliance with drug testing is an important part of the regimen pain management doctors use to ensure their patients are serious about their treatment and are properly participating in their care. It’s a 2 way street, and drug screening assists in making sure diversion is not occurring.

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Typical pain management treatment for musculoskeletal injuries is routinely provided according to the mnemonic RICE.

• Rest
• Ice
• Compression
• Elevation

The question is for a musculoskeletal injury and pain management, is ice better than heat? There is no hard and fast answer, as research has been unclear for a definitive answer.

The thinking is as follows. For an acute injury, such as an ankle or low back sprain/strain, ice is better. An injury sparks up increased blood flow to the area, which brings in inflammatory mediators and increases swelling. Ice can reduce the blood flow, and in addition to the elevation can minimize the resulting pain and swelling. In addition ice provides some numbing relief for pain control. Treatment with ice is also called cryotherapy.

Be cautious not to apply ice continuously, as it can hurt the skin. A good rule of thumb is 20 minutes on, 20 minutes off and to place a towel on top of the skin to prevent direct contact.

After the initial 48 to 72 hours of injury treatment with ice, the current recommendation is to switch over to heat. The first phase of healing is the inflammation phase, for which sufficient blood flow is needed to bring in those substances.

Plenty of pain management doctors recommend at that point alternating ice and heat for both pain control and assisting in the healing process. It can provide pain relief to assist with other treatments such as pain medication. After physical therapy, switching to ice is best to prevent excessive inflammation and throbbing along with pain. After a few hours, for instance when going to bed later on, heat may assist with relaxing the affected body part and allow one to fall asleep easier.

For a musculoskeletal injury, this is the current thinking with ice and heat treatment. When used in conjunction with physical therapy and possibly chiropractic treatment along with other pain management treatments, ice and heat can be very effective modalities.

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Pain that is in the groin or around the hip area could or could not be a result of a hip problem. The pain can also be coming from a low back spinal problem.

The potential generators of the pain can be:

1) Hip joint arthritis or a soft tissue problem inside the hip joint (labrum)

2) Intervertebral disc herniation

3) Spinal Stenosis

4) Soft tissue problem around the hip

5) Fracture in the spine

6) Hip Fracture

Hip arthritis pain or a labral tear may cause significant pain in the groin area on the affected side. Physical examination and x-rays will typically confirm the culprit as degenerative joint disease (DJD) in the hip. If the patient receives a hip injection as treatment and the pain is eliminated even for an hour, one can be certain the hip is in fact the problem with further treatments confined to the hip.

Groin pain can also be a result of a disc herniation. It’s not something typically seen in a textbook and it is an atypical presentation, but an L5-S1 disc herniation can in fact cause groin pain on the affected side. So if the exam and radiologic studies of the hip are not definitive for a hip problem, potentially obtain and MRI of the lumbar spine for the answer.

Pain that is around the hip joint may be coming from the spine. It is called radiating pain if it emanates from a spinal problem and then travels down into the buttock area or hip region. One such problem is called spinal stenosis, which represents nerve root compression at one or multiple levels from an arthritic process.

Spinal stenosis typically occurs in older individuals that may also be experiencing pain in the hip from arthritis. So the hip pain may be a mixture or pain radiating from spinal stenosis combined with the direct pain from degenerative arthritis in the hip. How does one make the diagnosis then.

The combination of a competent physical examination, thorough patient history, and imaging studies often clarifies the pain source. If there’s still a question mark, injections can give the answer. Here is an illustration. Betty is 74 and suffering from pain in the front and outside of her right hip daily. Activity exacerbates the pain, and often causes her to wake up during the night. Additionally it spreads down her thigh in the front a little.

She is convinced the pain is coming from her hip since she has no back pain at all. On physical examination while moving her right hip all over the place, however, she has minimal provocation of her pain. X-rays show moderate arthritis in her right hip, with the same degenerative joint disease existing on her left side as well.

The physician orders x-rays and an MRI of Betty’s lumbar spine which shows numerous nerve roots being compressed as they are trying to get out from the spine on the right side. So she has a condition called spinal stenosis.

As a diagnostic test, the physician performs a right hip injection under x-ray guidance. Betty’s pain reduced only by twenty percent over the following 3 days. So the physician sent Betty to a pain doctor the following week who performed an interventional pain management procedure called an epidural injection.

And you know what happened? Betty’s pain decreased another 50% after the first injection and another 20% with the second injection, adding up to a 90% pain reduction with the epidural injections. Both the spinal injections and the hip injection therefore served both a diagnostic and therapeutic purpose.

It is imperative to remember that pain around the hip can be a result partly or completely from a spine problem. This can be the difference between a frustrated patient still in pain versus one who shows dramatic improvement.

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