Sciatic Pain

by David Wells, D.C., L.Ac.

How often do you get a patient with severe burning pain down one leg, barely able to walk, unable to live with the pain but terrified of surgery? Do you feel confident in your abilities or scared that you will fail to relieve their pain? Personally, I love getting these patients. Maybe that’s why I get so many of them.

The first thing to know is what is causing their pain. No, it is not Liver qi stagnation. Changing their diet and helping them express their emotions will not help. We have to think of this problem from a mechanical perspective. That means thinking about anatomy and thinking about what can cause such severe pain. The patient’s history will tell you most of what you need to know if you understand how to interpret their story in light of anatomy. So let’s review the anatomy of the lower back.

The sciatic nerve and all spinal nerve roots are behind the discs. Separating the discs from the spinal nerves is the tough outer ring of the disc, called the annulus fibrosis and behind that is the posterior longitudinal ligament. Most of the material inside the disc is malleable. Think of toothpaste in a tube. You can squeeze one end of the tube, and the material bulges towards the other end. The tube itself is like the annulus fibrosis. It contains the material inside. So as we bend forward and back or side to side, the material inside the disc squeezes from one side to another. What a great thing--a flexible, shock absorbing disc that allows movement between each vertebra. I should mention that there is a hard ball of connective tissue inside each disc called the nucleus pulposus. This serves as a pivot point in the center of each disc.

So let’s ask the patient when and how this pain began. He says, “I was bent over in the garage, picking up a toolbox. It was an awkward position. I kinda twisted and I know I should have used my knees but I had some junk in the way so I just bent over using my back. It happened yesterday afternoon. I felt it in my back at the time but I thought it would get better. Then as the evening wore on, the pain got worse and worse in my back and down my right leg. I hardly slept all night. My wife had to drive me in. I can barely sit. I feel a little better walking around or lying down but this is killing me. Am I going to have surgery for this? I have a buddy who had this last year and he had surgery. He still can’t do the things he used to do.” (Patient’s don’t always tell us their fears so explicitly but we must always be aware that they have those fears).

So what does the mechanism of onset tell us if we remember the anatomy of the sciatic nerve and the discs? Remember, the nerve passes through a small hole (neuroforamen) behind the disc. The patient bent forward, squeezing the disc towards the nerve. In order for the disc to touch the nerve, the annulus fibrosis and the ligament must have torn at least partially. Did it tear completely, allowing the nucleus pulposus to push into the neuroforamen? No, that would have resulted in immediate pain down the course of the sciatic nerve and that pain would not be better or worse depending on body position. We do need to check the severity of the disc lesion by asking if it resulted in the inability to control bowel or bladder function. “No,” the patient replies, “but is makes my leg hurt to bear down on the toilet.” That response is consistent with a disc bulge and in fact is your first orthopedic finding. You can write in your chart, “Valsalva’s Maneuver positive for right sciatic pain”.

To answer the patient’s question about the need for surgery, ask the patient to walk on tip-toes and on his heels. You may have to steady him because of his pain, but if he is able to perform Heel Walking and Toe Walking (your next orthopedic tests), he is not a surgical candidate. You can explain this to your patient. Surgery is not performed to relieve pain. It is performed to restore function. His function is okay as demonstrated by his ability to walk on his heels and his toes.

The treatment I would perform in this circumstance is to needle Yao Tong Xue (Back Pain Point) and ask the patient to walk or dance around the room. Generally, I ask them to do the Samba or something like it. They look at me like I am nuts but within a few seconds their pain is usually gone or greatly diminished. See why I love getting these patients? I love the look of amazement on their faces. This is a very teachable moment. I tell the patient that acupuncture is able to reduce their pain and inflammation but that the important task is to use this opportunity to reshape the disc so it can heal in the correct position and not cause this problem over and over again. I then teach them the prone McKenzie position to reshape the disc and instruct them to do this a few minutes out of every hour. I generally hand the patient a bottle of Chinese herbs to reduce the pain and promote healing and schedule the patient for follow-up care in the next day or two. This whole encounter takes about a half hour of my time but from the patient’s point of view, a miracle has occurred. They will tell their friends this story over and over again.

About the Author:

David Wells, D.C., L.Ac.

Dr. Wells has been a tireless advocate of acupuncture and Oriental medicine, serving as President of the California Association of Acupuncture and Oriental Medicine, President of the Council of Acupuncture and Oriental Medicine Associations, Founder and President of the Center for Oriental Medical Research and Education and Bylaws Chair of the American Association of Acupuncture and Oriental Medicine.

In his continuing efforts to include acupuncturists in the healthcare system, he founded and was President of AcuNET, the first company to include acupuncturists in managed care. Later, as Medical Director of Landmark Healthcare, he brought inclusion of acupuncture as a covered benefit through insurance companies in 17 states.

His private practice is focused primarily on musculoskeletal pain and dysfunction. He currently treats around 120 patients per week using a combination of acupuncture, non-force chiropractic techniques, herbs, nutrition, and therapeutic exercises. He has taught acupuncture orthopedics all over the United States and in Korea.

To learn more about diagnosing and treating a range of musculoskeletal problems quickly and efficiently from Dr. Wells, he is speaking on the following topic for Lotus Institute. All classes are approved for 8 CEUs/PDAs by the California Acupuncture Board, Illinois Acupuncture Board, and NCCAOM.

Class by the Author:

Acupuncture Orthopedics

• 12/6/09 Los Angeles, CA