Sciatica refers to pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg. The pain typically feels like a shooting, shocking or burning sensation. Sometimes it’s accompanied by tingling, numbness or muscle weakness in the affected leg. Sciatic pain often starts gradually and intensifies over time. It’s caused by injury to or pressure on the sciatic nerve.
The most common cause of sciatica is a herniated disk in the spine that presses on the nerve roots. Other causes include spinal stenosis, isthmic spondylolisthesis, piriformis syndrome, pregnancy, trauma, tumors and infection.
For most people, sciatica responds well to self-care measures and non-surgical treatments like rest, over-the-counter pain relievers, ice packs, physical therapy and stretching exercises. But for some, the leg pain is severe and debilitating, and nonsurgical treatment options fail to provide lasting relief. In these cases, surgery may be considered.
There are several surgical options for treating chronic sciatica, depending on the underlying cause. The main types of surgery are:
| Discectomy (Microdiscectomy) | Removes a herniated disc that’s pressing on a nerve root. |
| Laminectomy | Removes bone and ligaments to relieve pressure on the spinal nerve roots. |
| Foraminotomy | Widens the neural foramen to relieve pinched nerve roots. |
| Spinal fusion | Fuses two or more vertebrae together to stabilize the spine. |
Surgery for sciatica is only considered if:
– Non-surgical treatments have failed to provide lasting relief after several months
– The pain severely impacts your quality of life
– You have progressive nerve damage or weakness in your leg
Candidates for surgery tend to have severe sciatica caused by a lumbar herniated disc, spinal stenosis, spondylolisthesis or piriformis syndrome.
Let’s discuss the surgical options for sciatica and what’s involved in more detail.
Discectomy (Microdiscectomy)
A discectomy, also called a microdiscectomy, is one of the most common surgeries for sciatica. It’s used to treat a herniated or “slipped” disc that’s pressing on one of the nerve roots exiting the lumbar spine.
A herniated lumbar disc is a very frequent cause of sciatica. It occurs when the jelly-like center of a spinal disc ruptures through a weak area in the tough outer layer. This allows the disc material to bulge outward, pressing on the adjacent spinal nerve root.
Symptoms of a herniated lumbar disc often come on suddenly after lifting a heavy object, bending awkwardly or suffering a trauma like a fall. The hallmark symptom is sciatica or radiating leg pain, which occurs when the protruding disc compresses the nerve root.
A discectomy surgery aims to relieve the pressure on the nerve by removing the protruding portion of the disc. The standard procedure is performed through a 1-2 inch incision in the middle of the lower back.
The steps include:
– The surgeon retracts muscles to access the spine.
– X-ray guidance is used to locate the problematic disc level.
– A small amount of bone and ligament are removed to expose the nerve root and disc. This is called a laminotomy.
– The surgeon removes the fragment of the disc that’s compressing the nerve.
– The wound is closed with sutures.
Patients may go home the same day or stay one night in the hospital. Recovery time averages around 2-4 weeks. Light activity can resume after 2 weeks, but it takes about 6 weeks for the tissues to fully heal. Avoiding re-injury and maintaining proper spine alignment are important during recovery.
The success rate of discectomies is over 90%. Most patients experience significant relief from leg pain after surgery. Recurrence rates are low at around 5-15%.
When is Discectomy Recommended?
Discectomy is generally recommended for sciatica when:
– There’s clear evidence of a herniated disc correlating with symptoms
– Leg pain persists for over 3 months despite conservative treatment
– The leg pain is severe or disabling
– Nerve damage or weakness progresses
Studies show discectomy provides faster relief from sciatica than prolonged conservative treatment in patients with lumbar disc herniations. Patients report greater satisfaction and return to work sooner after surgery.
Risks and Complications
Discectomy is considered safe with few complications. But as with any surgery, there are some risks including:
– Infection
– Blood clots
– Bleeding
– Nerve injury
– Worsening leg or back pain
– Recurrent disc herniation
Proper precautions reduce surgical risks. Choosing an experienced spine surgeon also improves results. Overall, less than 10% of patients have complications from discectomy surgery and the majority make a full recovery.
Laminectomy
A laminectomy surgery removes bone and ligaments to relieve pressure on spinal nerve roots. It’s done to treat spinal stenosis, a narrowing of the spinal canal that compresses nerves in the lower back.
Spinal stenosis occurs when the hollow spinal canal gradually narrows due to arthritis, bulging discs, enlarged facet joints or thickened ligaments. This compresses and pinches the spinal nerve roots, leading to sciatica symptoms down the legs. The condition tends to develop slowly over time.
Laminectomy surgery tries to take pressure off the nerves by creating more space in the spinal canal. The lamina is a plate-like part of the vertebrae that forms the back wall of the canal. Removing the lamina on one or both sides gives the nerves more room.
There are a few techniques:
– Unilateral laminectomy removes lamina on one side to access an affected nerve root. This is done for one-sided sciatica.
– Bilateral laminectomy removes lamina on both sides to decompress multiple nerve roots. This provides more space if there’s narrowing across the canal.
– Laminotomy is a partial removal to access the canal while leaving more of the structure intact.
The steps involve:
– Making an incision down the center of the low back
– Cutting through muscles to access the bony lamina
– Removing all or part of the lamina on one or both sides
– Trimming ligaments and soft tissues pressing on the nerves
– Closing the incision
Recovery time is around 4-6 weeks but slower for older adults. Avoidance of re-injury is key during healing. Physical therapy helps strengthen back muscles for support.
Laminectomy is often combined with a spinal fusion procedure for added stability. Overall, about 80-90% of patients report significant relief of leg pain after surgery. Recurrence rates are up to 10% after 2 years.
When is Laminectomy Recommended?
Laminectomy tends to be recommended when:
– There’s evidence of lumbar spinal stenosis correlating with symptoms
– Persistent sciatica after 6 months of conservative treatment
– Leg pain worsens and limits mobility
– Bowel/bladder changes signal advancing nerve damage
The surgery aims to halt progression of weakness and nerve damage. Studies show laminectomy provides lasting relief of leg pain and disability in most patients with lumbar spinal stenosis.
Risks and Complications
Laminectomy risks include:
– Infection
– Bleeding
– Spinal fluid leak
– Nerve injury
– Instability of the spine
– Failure to relieve symptoms
Proper techniques reduce risks. A short hospital stay and physical therapy aid recovery. For older adults, risks tend to be higher due to age-related factors. Overall complication rates are around 10-15%.
Foraminotomy
A foraminotomy surgery enlarges the neural foramen to relieve pinched nerve roots exiting the spine. The foramen is the small opening between vertebrae where nerves pass through.
Foraminal stenosis, or narrowing of these openings, frequently causes sciatica. Enlarging the foramen takes pressure off the nerve root and can relieve symptoms.
Causes of foraminal stenosis include:
– Herniated discs
– Bone spurs
– Enlarged facet joints
– Degenerative disc disease
Often foraminal stenosis develops on one side, affecting just one nerve root. This leads to one-sided sciatica symptoms.
Foraminotomy surgeries are minimally invasive, requiring only small incisions. There are a few techniques:
– Keyhole foraminotomy uses an endoscope and microtools through a half-inch incision.
– Microforaminotomy removes bone through a 1-inch incision under a microscope.
– Open foraminotomy makes a larger 2-4 inch incision to access the foramen.
The basic steps include:
– Making a small incision off-center of the spine
– Accessing the vertebrae, nerve root and foramen
– Removing bone/tissue enlarging the opening
– Closing the incision
Foraminotomy often provides immediate pain relief by decompressing the nerve root. Recovery may take only 1-2 weeks. However, good spine alignment and avoiding re-injury during healing are important. Physical therapy builds strength to help stabilize the spine.
Success rates are upwards of 90%. Sciatica recurrence is rare, but some may still have mild back pain from underlying conditions. Overall risks and complications are minimal given the minimally invasive techniques.
When is Foraminotomy Recommended?
Foraminotomy is generally recommended when:
– There’s clear foraminal stenosis correlating with sciatica symptoms
– Leg pain continues for over 6 weeks with unsuccessful conservative treatment
– Leg pain and function are significantly impacted
– Other conditions like herniated discs are ruled out
Studies indicate foraminotomy provides significant relief from one-sided sciatica caused by foraminal stenosis. Pain reduction and improved function are similar to laminectomy but with quicker recovery.
Risks and Complications
Possible risks of foraminotomy include:
– Infection
– Bleeding
– Spinal fluid leak
– Nerve injury
– Recurrent sciatica
Minimally invasive techniques reduce risks. Choosing an experienced surgeon also improves outcomes. Overall complication rates are low, around 5% or less.
Spinal Fusion
Spinal fusion surgery joins two or more vertebrae together using bone grafts and implants. It helps stabilize the lumbar spine in cases of instability, severe slippage or recurring disc herniations.
Fusion stops movement between the vertebral bones to prevent further nerve compression. Recovery takes 3-6 months for the bones to fully fuse.
There are two main techniques:
– Posterior lumbar interbody fusion (PLIF) accesses the disc space from the back of the spine. This places bone graft material to stimulate fusion.
– Transforaminal lumbar interbody fusion (TLIF) enters through the neural foramen to insert bone grafts between vertebrae.
The basic steps include:
– Accessing the spine from the back or side
– Removing disc material between vertebrae
– Inserting bone grafts or spacers
– Securing vertebrae with plates, rods and screws
– Closing up the incisions
The hardware holds vertebrae steady while fusion occurs. Braces may be worn for around 3 months post-surgery to help limit activity. Physical therapy thereafter focuses on core strength.
Spinal fusion takes pressure off nerves by correcting underlying instability or misalignment of vertebrae. Over 90% of patients have significant relief of back and leg pain after fusion. Complete pain relief is less likely if there’s permanent nerve damage before surgery.
When is Spinal Fusion Recommended?
Fusion may be recommended for sciatica when:
– There’s spinal instability from conditions like spondylolisthesis
– Multiple lumbar discs are severely degenerated
– Other surgeries like laminectomy fail to relieve symptoms
– Recurrent disc protrusions or scoliosis cause ongoing nerve compression
The goal is to correct spine alignment and prevent further nerve compression. By fusing unstable segments, pain signals transmitting through the nerves are calmed.
Studies show spinal fusion has good long-term outcomes for pain relief if strict criteria are met. Candidates with clear indications tend to have a 95% success rate after surgery.
Risks and Complications
Possible risks of spinal fusion include:
– Infection
– Bleeding
– Nerve damage
– Issue with bone graft incorporation
– Hardware failure
– Adjacent segment disease
– Limited mobility
Meticulous surgical techniques reduce risks. But fusion does limit some spine motion. Rehabilitation is key to maintain strength and prevent complications. Overall, complication rates are around 10-15% depending on complexity.
Conclusion
Surgery for sciatica is considered when conservative treatments fail to provide lasting relief after several months. Discectomy, laminectomy, foraminotomy and spinal fusion are common procedures to relieve compression on the sciatic nerve and its roots.
Discectomy removes part of a herniated lumbar disc pressing on a nerve. Laminectomy creates more space by trimming bone/ligaments constricting the spinal canal. Foraminotomy enlarges the neural foramen openings in the spine. Spinal fusion stabilizes vertebrae to take pressure off pinched nerves.
These surgeries relieve sciatica symptoms by directly decompressing the compromised nerves. Success rates are over 90% when strict criteria are met. Risks and recovery times vary based on the type of surgery. Working with an experienced spine specialist improves outcomes.
For the minority with debilitating, long-term sciatica, surgery can provide lasting pain relief and restoration of function. This allows return to a more active lifestyle. However, maintaining proper spine health through everyday preventive care remains important even after surgery.