Joey Wahler (Host): It's a common leg pain that has a connection to the lower back, so we're discussing sciatica. Our guest, Dr. Esteban Cuartas, he's an orthopedic surgeon with Montefiore St. Luke's Cornwall.

This is DocTalk presented by Montefiore St. Luke's Cornwall. Thanks for listening. I'm Joey Waller. Hi there, Dr. Cuartas. Thanks for joining us.

Dr Esteban Cuartas: Hi, good afternoon.

Host: So first, what exactly in a nutshell is sciatica and what are its typical symptoms?

Dr Esteban Cuartas: Sciatica refers to the sciatic nerve, which is a large nerve that courses down the back of the leg. It starts at the lower back, traverses the buttock area and goes down the leg. And typically, it refers to pain that's radiating in that distribution down the posterior aspect of the leg.

Host: And as mentioned, there's a connection between sciatica and the lower back. What is that and how surprised are patients to find out that there is this link?

Dr Esteban Cuartas: So, I would say that probably the vast majority of pains in that distribution originate in the lower back. There are a few exceptions, but the vast majority originate in the lower back. And we often find that patients come in for "hip pain," when in fact, it's really this type of pain or sciatica, which sometimes we'll rebrand as buttock pain, because it's located posteriorly. As orthopedic surgeons, we refer to the hip joint as the ball and socket joint that we walk on. And that one typically will give you pain more in the groin, sometimes in the front of the thigh and radiating downwards in the front.

Host: And so, what is it typically that's happening in that lower back area that's sending this pain traveling elsewhere?

Dr Esteban Cuartas: So usually, there's some pathology in the lower back in the spine that is causing some type of noxious effect on the nerve rootlets or the nerve roots in the lower back. So, we can subdivide by etiology, which is to say by a cause, the different types of stimuli that can cause this pain. On the one hand, a lot of patients suffer from degenerative causes, which is the process of aging of the spine and the joints in the spine, and that can cause physical pressure, mechanical pressure on the rootlets, and that begins the process of sciatic or radiating nerve pain.

Another cause would be perhaps what we call traumatic causes. For example, fractures can cause that, as well as sometimes I place in that category, lumbar disc herniations, which is more described as a ruptured disc or a herniated disc. And there's other causes, for example, anything such as cancer or tumors, be they benign or malignant tumors can also cause sciatic pain. Finally, one important cause is infection. That is another possible cause.

Host: So, this obviously can come from a variety of origins. How about sciatica usually affects one side of the body or the other, right?

Dr Esteban Cuartas: Correct. It usually is unilateral, although sometimes what we do when we're evaluating patients is we have the patient draw on a figure of a patient where they feel the pain. And more often, some patients do feel some degree of symptoms on the contralateral side, but there is usually a dominant side.

Host: And unlike many other orthopedic pain scenario, sciatica can strike younger people, even in their 20s, correct?

Dr Esteban Cuartas: Yeah. So based on the age of the patient and the history, and other past medical problems, we sort of can clinically arrive at a differential of what the possible cause is. So, yes, young patients in their 20s and 30s can develop sciatica. And in those patients, it's very commonly caused by a disc herniation or a mechanical failure of a disc, be it through some type of sports injury or lifting injury, or sometimes just from something as simple as sneezing or some unusual movement.

Host: So before we go on, just to be clear here, therefore you could be an athlete or athletic you're saying, and have a pain or actually a numbness too in your leg, and it's actually coming from an injury that happened in your back.

Dr Esteban Cuartas: Correct. And that's an important point. Anything that a nerve can do can accompany the sciatic pain. So, there can be numbness. there can be sometimes pins and needle sensations. There can be dysesthesia or hyperesthesia, which is just unpleasant or painful, sensory aspect to it on the skin. And finally, there can be weakness, which is often overlooked by the patients when they come in for the actual pain.

Host: And so, it begs the question, doctor, if you have sciatica, are you also experiencing symptoms like pain in your back as well?

Dr Esteban Cuartas: Some patients experience pain both in their back and their leg. Other patients come in just with the leg pain. So, there is definitely a variety of presentations.

Host: Interesting. It reminds me of years ago when I was diagnosed with tennis elbow, and it turns out I had pain all up and down my arm and hand everywhere, but In my elbow.

Dr Esteban Cuartas: That's correct. Oftentimes actually patients will come in, especially young patients with a disc herniation, they will come in with a previous history or what we call a prodrome of back pain that is pretty much limited to the lower back. And then once the disc actually ruptures and gets pushed out of its location, and starts bothering the nerve, then all of the pain moves into the leg and becomes a sciatic pain and the back pain actually resolves.

Host: Interesting. Very interesting. So, some exercises from what I understand will help ward off sciatica. So, what are some of those?

Dr Esteban Cuartas: I think it's always important, especially if you're involved in sports or working out athletics, to maintain a healthy core. The core is the group of muscles that stabilize the spine and, in that way, protect the spine from extreme overloads or extreme ranges of motion and protect it from injury in general.

Host: And then, what would be maybe some basic exercises you could suggest that would help to promote that?

Dr Esteban Cuartas: So, basically, one of the most important groups is everything that's anterior to the spine, which includes the abdominal muscles. And for that, we have the rectus abdominal muscles, which are involved in, for example, for a straightforward sit up. Then, we have the oblique abdominal muscles, and those are involved more for in a crisscrossing type of setup or rotation. And posteriorly, we have other stabilizers like the paraspinal muscles that would be involved in, for example, doing what we call like supermans. And finally, we have the hip flexors, the muscles that lift the leg up at the hip, are based in the spine actually. So, they stabilize the spine as well.

Host: Gotcha. A couple of other things. Once a patient does see you for possible sciatica, basically, how do you typically diagnose it?

Dr Esteban Cuartas: So oftentimes, the history is very helpful. And other times the physical exam is quite helpful. For example, when a young patient has a lot of sciatic pain, and they have what's called a stretch sign, which means they can't really straighten the leg out when they're in a sitting position, that's very helpful. That usually means that there's an acute problem like a disc herniation. And then, otherwise, sometimes we can tell by examining the muscle strength. Depending on where we find weakness in some patients, that can give us some information as to where the likely problem is in the spine.

The physical exam and the history are just not specific enough to help us diagnose it. So, oftentimes we do have to move on to obtain advanced imaging, which for the spine is x-rays and MRI. And that sometimes is what helps us finally figure out where the problem is.

Host: And so, what are the most common and best treatment options for sciatica?

Dr Esteban Cuartas: Then as for treatment options, I think the usual treatment algorithm, as for other problems, is first we can attempt to manage the symptoms with over-the-counter anti-inflammatories, rest, physical therapy. Then, you know, occasionally, when patients are still not improving, we can consider the use of steroid anti-inflammatory medication, like corticosteroids or prednisone and such.

Host: Is surgery ever an option?

Dr Esteban Cuartas: Yes, we usually consider surgery, something that's indicated once the conservative or non-surgical treatment methods have failed to provide relief. And for a lot of problems, that involves a trial of approximately six to eight weeks or so of conservative care.

Host: Gotcha. Well, folks, we trust you're now more familiar with sciatica. Dr. Esteban Cuartas, thanks so much again.

Dr Esteban Cuartas: Thank you.

Host: And for more information about their orthopedic services, please visit montefioreslc.org. Again, that's montefioreslc.org. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. And thanks again for listening to DocTalk, presented by Montefiore St. Luke's Cornwall.