Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And joining me today to help us understand herniated discs and sciatica is Dr. Daniel Pak. He's an attending anesthesiologist at New York Presbyterian Hospital Weill Cornell Medical Center, and an Assistant Professor of Clinical Anesthesiology at Weill Cornell Medical College Cornell University.

Dr. Pak, thank you so much for joining us today. I'd like you to start by telling people what is sciatica. We've heard that term bandied about. What is it?

Dr Daniel Pak: Yeah. You know, sciatica is a very common term that people are mostly aware of, and it refers to pain that travels along the path of the sciatic nerve. Now, the sciatic nerve travels from essentially the buttocks down the leg, and it most often happens when something like a herniated disc, or an overgrowth of bone puts a little bit of pressure on the lumbar spine nerve roots that then recreates that pain. In a lot of ways, sciatica, or this term, is a misnomer in that it refers to pain in the distribution of the sciatic nerve, as I mentioned, which essentially goes down the back of the leg. However, you can have leg pain that goes in a different pattern or a different distribution as well. So, a lot of times when people are talking about sciatica, they're just referring to pain that goes down the leg, regardless of the source.

Melanie Cole, MS: I agree with you there because people always say, "Oh, it's my sciatica," and it's pain down their leg, which could be from other situations. Now, tell us, because you mentioned herniated disc, what is that and how are they related?

Dr Daniel Pak: So, I think before we talk about that, you have to understand what a disc does. And if you look at the anatomy of the spine, there are discs that essentially serves as shock absorbers for the spine or cushions. And over time, those discs can lose its integrity. And that's a natural process for most people. So, it can get dehydrated, gets desiccated. And when it protrudes, then you can develop something called a herniated disc. Now, there are different morphologies of how that looks. But when it then compresses or hits a nerve root among other things, that's when it can usually present as kind of the sciatica picture.

Melanie Cole, MS: So, on x-ray or MRI or whatever you would do, if someone comes to you, do we see that disc actually bulging, herniated? Does it show, Dr. Pak? Because I think there's been various incarnations of herniated disc, bulging disc, weight trainers, and people that lift weights are always talking about these things.

Dr Daniel Pak: So in addition to getting kind of the full history and physical, there are different exam maneuvers you can use to elicit the pain that then suggests that it is a herniated disc that's causing the problem. But imaging is really the diagnostic gold standard. And so, things like MRIs are oftentimes ordered in order to actually visualize what that disc looks like.

Melanie Cole, MS: What are people really feeling when you say that you're doing this full history? What are those symptoms that they're describing when they're thinking that they have sciatica or you're suspecting that the cause might be from a herniated disc?

Dr Daniel Pak: So obviously every patient is a little bit different, but classic symptoms that we look for people will describe is they'll say that the pain is a burning sensation, tingling, pins and needles going down the leg. Some people will even experience numbness in the distribution of pain and, when it's particularly severe or if the nerve compression is severe, will also describe weakness. That can be subjective, meaning did it just feel like the leg just isn't working like it's supposed to. But objectively when we do a physical exam, the strength is intact. But other times people will actually describe things like a dropped foot and actually have objective weakness of the leg, which sometimes can be concerning to a lot of people. But these things all can make walking in certain positions for patients very difficult.

Melanie Cole, MS: And as someone who has had it one time, and I hope that I never have it again, and it was literally true sciatica, the worst pain I've ever felt, and I've had babies. So, I would like you to speak about treatment. Because I was medicated until it went away. And at the time, it was quite a few years ago, we weren't looking to movement to really help make something like this help. And there wasn't pain management. Speak about what you do now, because it's really an exciting time in your field, and you can help so many people.

Dr Daniel Pak: You're right. It can be very, very uncomfortable and very painful for people. Treatments fall into a few buckets. Medications is one of them. So, these are different types of anti-inflammatory medications. People will take also different types of "nerve pain" medications that can help with the burning and the tingling sensations. When it's particularly severe, sometimes we'll recommend oral steroids, which is an anti-inflammatory medication, because oftentimes when people have sciatica, it's really an inflammatory issue that causes the pain. So, medications is certainly one option.

As you mentioned, physical therapy is what really helps patients long term and certainly we can talk more about the role of physical therapy, but among other things that helps to build core strengthening and also reinforce really a lot of the proper spinal alignment to offload some of the pressure off of these nerves, but that's more of a long-term solution. Then, you also have different types of interventions, things like spinal injections, some people will refer to these as corticosteroid injections, and that's oftentimes more of a directed, targeted therapy at the areas where there are herniated discs or, let's say, nerve impingement that can really help with pain relief. And then, the last option is something like surgery.

Melanie Cole, MS: Just expand for a minute when you talk about injections, and then possibly needing surgery. People have a lot of questions about injections, Dr. Pak. What does that entail?

Dr Daniel Pak: The most common injection that's offered for things like sciatica or any pain that comes from a herniated disc is a corticosteroid injection in that area. And that is a minimally invasive injection that we do usually under image guidance or something like x-ray. Now, without even going into the details of all the nuances of the procedure, it's actually a very common thing that we do and very routine for us. So, it's usually a 10-minute procedure where a patient's essentially lying on their stomach with local anesthesia. We numb that area and then we, through a needle, are able to deliver steroids to that particular area. And the reason why it works is because when you have a herniated disc that's compressing a nerve, for example, that causes an inflammatory response. That's almost as if I stuck my hand out of a door and closed the door on it. So, that creates inflammation. Giving steroid in that particular area can decrease the inflammation and, as a result, decrease the pain.

Now, to be clear, the injection does not treat the underlying cause. That disc is still there. However, because it has anti-inflammatory properties in that area, it can help with the symptoms. And then, really, that's when we reinforce things like physical therapy to help you long term.

Melanie Cole, MS: And when does it really require surgery?

Dr Daniel Pak: So, there are a few things that we look for in terms of when we decide a patient is an appropriate candidate for surgery. Now, among other things, they should have failed conservative therapies, everything that we talked about before, like physical therapy, medications, and injections. Other things that we look for are specific warning signs. So if someone has profound weakness of the leg, bowel or bladder incontinence, numbness in kind of the pelvis and the genital regions are signs of severe nerve root compression that needs to be addressed with a surgical consultation. So, those are kind of main things that we look for.

Melanie Cole, MS: This is so informative. Dr. Pak, you're a great educator. I'd like you to speak about collaboration. You and I were talking about this a little bit off the air and how important that is now that we all come together. And you've mentioned physical therapy and exercise. But obviously, if someone needs surgeons, there's surgeons involved. You're in pain management, there's physical therapy, there's all these things involved. Now, how do you collaborate together?

Dr Daniel Pak: I work as a part of a comprehensive spine center here, and I'm very fortunate that we take a team-based multidisciplinary approach with every patient that walks through the door. As you mentioned, I am an interventional spine specialist, a pain management specialist, but I work with a lot of other healthcare providers such as rehab doctors, neurologists, orthopedic and neurosurgical spine surgeons, as well as physical therapists. And we all have our own roles in kind of the patient care model. So while certainly I can provide a part of the care, oftentimes I'll consult with a lot of these other people to make sure that I communicate exactly what I think is going on and also what may potentially help them and vice versa, I also receive that feedback. Generally, I find that when we all kind of work together, that really works in favor of the patient's outcomes.

Melanie Cole, MS: It really is a comprehensive approach. And as you are a pain management specialist, as you said, an interventional, this is such an exciting time and really in your field, such a burgeoning field that you're in, I'd love for you to offer your best advice to people that are currently struggling with sciatica or may have been diagnosed with herniated disc or get that pain from a weak low back, weak core. What things would you like to tell them about helping themselves in the long term?

Dr Daniel Pak: Prevention is key. So, exercising regularly, maintaining good core strength, good lift mechanics, really, really important to prevent this from happening. Now, back pain, unfortunately, is extraordinarily common, and 80% of people will experience back pain at some point in their lives, as you suggested you also had experienced an episode of this.

And so for people who do have symptoms, don't fret, most of these symptoms will resolve naturally on their own without any need for intervention or surgery. So while very common, it can be alarming, but it's very treatable and manageable. So when you develop these symptoms, certainly go see either your primary care physician or get a referral to a pain management specialist and certainly we'd be happy to help you.

Melanie Cole, MS: Great advice. Dr. Pak, thank you so much for joining us today. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, iHeart, Pandora, so many places.

And for more health tips, go to weillcornell.org and you can search podcasts and find all of them there. And parents, don't forget to check out Kids Health Cast. That's a great one for parents. So much great information there as well. I'm Melanie Cole. Thanks so much for joining us today.

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