Sunday, September 28, 2008

Chiropractor NYC

Dr. Steven Shoshany-NYC ChiropractorInnovative Chronic Back pain treatments include the DRX 9000, Cold laser therapy, Kinesio taping, SpineForce 3 Dimensional Rehab.Physical therapy,Graston technique.

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Saturday, September 27, 2008

What does Kinesio Taping do?

Dr. Steven Shoshany NYC Chiropractor and Spinal Decompression Specialist

What Does Kinesio Taping Do?

Kinesio Taping gives support and stability to your joints and muscles without affecting circulation and range of motion. It is also used for Preventive Maintenance, Edema, and Pain Management

Kinesio Taping was invented by a Doctor of Chiropractic, and is utilized- especially by SPORTS Chiropractors throughout the world. Kinesio Taping helps the body heal naturally, can be used preventatively, as treatment, in rehab, during competition, or as a ‘take home’ treatment applied by the Chiropractor (medical doctors give drugs, chiropractic doctors give tape) .

Kinesio Taping is a technique based on the body's own natural healing process. This Kinesio Taping exhibits its efficacy through the activation of neurological and circulatory systems. This method basically stems from the science of Kinesiology, hence the name "Kinesio". Muscles are not only attributed to the movements of the body but also control the circulation of venous and lymph flows, body temperature, etc. Therefore, the failure of the muscles to function properly induces various kinds of symptoms.

Consequently, so much attention was given to the importance of muscle function that the idea of treating the muscles in order to activate the body's own healing process came about. Using an elastic tape, it was discovered that muscles and other tissues could be helped by outside assistance. Employment of Kinesio Taping creates a totally new approach to treating nerves, muscles, and organs. The first application of Kinesio Taping was for a patient with articular disorders.

For the first 10 years, chiropractors, acupuncturists and other medical practitioners were the main users of Kinesio Taping. Soon thereafter, Kinesio Taping was used by the Japanese Olympic volleyball players and word quickly spread to other athletes. Today, Kinesio Taping is accepted by medical practitioners and athletes in Japan, United States, Europe, South America and other Asian countries.

The Kinesio Taping Method is applied over muscles to reduce pain and inflammation, relax overused tired muscles, and to support muscles in movement on a 24hr/day basis. It is non-restrictive type of taping which allows for full range of motion.

In contrast, traditional sports' taping is wrapped around a joint strictly for stabilization and support during a sporting event obstructing the flow of bodily fluids... an UNDESIRABLE side-effect.

Kinesio Tape is used for anything from headaches to foot problems and everything in between. Examples include: muscular facilitation or inhibition in pediatric patients, carpal tunnel syndrome, lower back strain/pain (subluxations, herniated disc), knee conditions, shoulder conditions, hamstring, groin injury, rotator cuff injury, whiplash, tennis elbow, plantar fasciitis, patella tracking, pre and post surgical edema, ankle sprains, athletic preventative injury method, and as a support method.
Contact Dr. Steven Shoshany in Manhattan for Kinesio taping
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Friday, September 26, 2008

Spinal decompression Manhattan NYC-Herniated disc Center

Last night I had an interesting new patient come into the office.
She came into the office in a severely antalgic lean (this means she was hunched forward and bent to side).
She came in with her hospital discharge papers and was in serious pain. The type of back pain that required her to take (Vicodin, Percoset, Darvoset and one or two muscle relaxers).
She was not even standing upright and was writhing in pain and basically collapsed at the front desk.
Now as a Spinal Decompression specialist and a Chiropractor practicing in NYC for over 10 years I have had my fair share of patients coming in with back pain and herniated disc issues.
The thing is she was told that she needed a surgery but she refused and left the hospital and came into our office.
She was unable to lay down on her stomach, on her side or any other position without screaming in pain (Not the type of patient that you want when new patients are in the waiting room).
I reviewed her MRI and she had Multiple disc herniations from the second Lumbar down to the fifth Lumbar.
She was interested in Non-surgical options. Tomorrow is her first visit on the DRX 9000 spinal decompression table, I look forward to helping her and seeing her walk out of the office feeling better.
This is not going to be a particularly easy case.
The nice thing about the DRX 9000 is that it starts in a vertical position and slowly brings the patient to a horizontal position and when the treatment is done it returns the patient slowly back up.
Another great tool that I will use is the Cox flexion distraction decompression table.
Cox Technic is performed on a specially designed chiropractic instrument (The Cox Table for flexion-distraction) which has a movable headpiece and a movable caudal piece (that part on which a patient's legs lie). Each section flexes, extends, laterally bends and circumducts (combination of flexion and lateral flexion), and long-y-axis plane distracts.
Once the patient is better and in less pain I use the SpineForce to Rehab the muscles and supporting structures.

Wednesday, September 24, 2008

Funny article about how health insurance is killing you!!!

Man Succumbs To 7-Year Battle With Health Insurance
September 22, 2008 | Issue 44•39
View it on the Onion click to view

—After years of battling crippling premiums and agonizing deductibles, local resident Michael Haige finally succumbed this week to the health insurance policy that had ravaged his adult life.

Enlarge Image
A healthy Michael Haige and his wife, six months before his courageous struggle with health insurance began.
Haige, who had suffered from limited medical coverage for nearly a decade, passed away early Monday morning. According to sources, the 46-year-old was laid to rest at Fairplains cemetery, surrounded by friends, family members, and more than $300,000 of mounting debt.

"I miss Michael every single day, but at least he can finally rest now," said Sheila Haige, who watched as insurance rates ate away at her husband over time. "What Michael went through, the humiliating forms, the invasive background checks, the complete loss of dignity and hope—I wouldn't wish that kind of torture on anyone."

Once a healthy and happy father of two, Haige saw his life forever change seven years ago when health insurance professionals diagnosed him with a preexisting condition. As months passed and his line of credit continued to deteriorate, the former high school football coach would experience excruciating headaches and bouts of nausea every time another hospital bill arrived.

"My dad always seemed invincible, like there was nothing in the world that could hurt him," son Ryan Haige said. "But then, one night, I found him bent over a stack of UB-92 and HCFA forms, and he was crying. I'd never seen my father look so scared in all my life."

Added Ryan, "Making those payments each month—it was killing him."

While family members refused to look at Haige's insurance plan as a death sentence, it soon became clear that their loved one was facing the biggest fight of his life. Countless visits to doctors, claims adjusters, and loan officers proved futile, with Haige being told at every turn that his case was hopeless.

"They said there was nothing they could do for him, that modern medicine was powerless against this monster," Sheila Haige said. "Still, Michael never gave up. He kept saying that he was going to beat the odds, that he was going to find some way to get coverage."

According to an independent study released last month by the Mayo Clinic, health insurance is the nation's No. 2 cause of death, claiming the lives of some 400,000 Americans each year. A silent killer, health insurance often strikes without warning, its harmful and profit-based policies avoiding detection until it is far too late. Although the cruel bureaucratic disorder does not discriminate, statistics have shown that senior citizens, young dependents, and those woefully underemployed are most at risk.

"I can't tell you the number of patients I've had to deliver the bad news to over the years," said Haige's longtime family physician, Dr. Howard Silverman. "It's never easy to look someone in the eye and tell them it's going to have to be out-of-pocket. For most of these poor people, prayer is the only hope."

Toward the end of Haige's seven-year ordeal, family members said, the once loving husband and father had become an empty husk of his former self.

"I remember the last thing he ever said to me," said eldest son Mark Haige, holding a small picture of his father during happier times, before the endless battery of co-pays began. "He took my hand in his, and he said, 'Son, promise me you'll never sign up for a high-deductible, network-model HMO.'"

While still angry and in shock over Michael's premature passing, Sheila and her two children say the whole experience has taught them the importance of family.

"If Dad were still with us, I know he would want us to be here, at home, supporting Mom," Mark Haige said. "She really hasn't been doing so well ever since Bankers Life and Casualty denied her life insurance claim."

I thought this was funny, and wanted to post it to my blog, everday patients complain about how their health insurance drives them crazy.
visit my website if you are interested in Chiropractic care in Manhattan.

Saturday, September 20, 2008


Kinesio tape becomes trendy fitness item


Phil Dalhausser has a tale of the tape that ends with him winning an Olympic gold medal.

The beach volleyball player strained an abdominal muscle in the crucial run-up to the Beijing Games when he couldn't afford a bad match, let alone to sit one out. He might have missed three weeks, but with the help of sports chiropractor Ernie Ferrel and Kinesio Tex Tape -- a product few outside the world of physical therapy knew about -- he helped the United States win in men's beach volleyball.

"I love the stuff, to be honest with you," Dalhausser said.

The Olympics were Kinesio Tex Tape's coming out party. Now it is the latest trainer's tool to become an American fitness fad, a Breathe Right strip for the new century.

The tape actually has been widely available for years. But hidden away under clothing for nearly three decades, it had never gotten quite the exposure it received until American beach volleyball player Kerri Walsh -- also part of gold-winning duo -- used it on her shoulder in China.

The life of Kinesio Taping director John Jarvis has been a hectic run of meetings, interviews and consultations ever since.

"With her wearing almost nothing, it definitely drew attention to the black (tape)," Jarvis said. "They were calling it everything from the spider web to the tarantula, you name it."

The company's Web site averaged 1,000 to 2,000 hits a day before the Olympics. It peaked at 400,000 hits, 4,000 e-mails and 1,200 phone calls a day after NBC commentators named the product on air.

"We received reports back from Google we were the second-most Googled term the first three days of the Olympics right behind Michael Phelps," Jarvis said. "So it's not bad company to be with, that's for sure."

As with many trendy fitness items, the tape soon will be making an appearance on a knee joint near you. But Ferrel cautions it's not a cure-all. He's been working with it for years and admits he's still learning how it helps.

"I think I'm scratching the surface," Ferrel said. "I think it's a good product for certain applications. For all applications? No. Sometimes you have to support that joint, you have to compress it."

What makes Kinesio tape different from your grandpa's tighty-whitey athletic tape is its wide range of uses, while still allowing the wearer to move and flex. Traditional athletic tape supports a joint with a stiffness that's more cast-like and has no real uses on injured muscles.

When Dalhausser called on his abdominals to help block three straight shots in the final set of the Olympic gold-medal match, the tape -- used in conjunction with massage therapy -- helped stop his muscle shy of the point of pain as he stretched out, then pulled forward with the muscle as he attacked.

No pain, all gain.

"The ab's gotten better, but I still put it on," Dalhausser said. "It's more of a mental thing. It's like when you roll your ankle, even though your ankle's better, you still throw on a brace or whatever. It's kind of the same kind of thing."

Among the first to use the tape post-Beijing was Patty Schnyder. The world's No. 11 tennis player had a tight abductor muscle going into her U.S. Open quarterfinals match against Elena Dementieva.

"So for a change I decided to try out this tape," she wrote in an e-mail to The Associated Press. "The normal wrap/support can be a little restrictive with the other muscles and this tape is able to focus on the specific muscle. It took away the pain instantly."

Ferrel, a member of the AVP Tour's medical board from Santa Barbara, Calif., treated Dalhausser with the tape in two ways. When applied while the athlete is at rest, the tape's wavy structure "pooches" or bunches the skin, pulling it away from the muscle and creating space that allows for extra circulation.

During competition, the tape can be used to support or limit a specific muscle or muscle group. It stretches up to twice its length, so a trainer can apply different amounts of tension as needed.

Ferrel, a self-described early doubter of the tape's therapeutic value, said it works in a variety ways.

"It gives you let's say that confidence that you've got a little more going for you than without it," Ferrel said. "To what degree? Is it 1 percent, 2-3-4-5-10? Well, I contend that if it's 1 percent at the Olympic level, that's a lot."

The ultimate test of the tape for Seattle Mariners head trainer Rick Griffin is baseball's 162-game schedule. He encountered the product more than a decade ago while speaking at a seminar in Japan and has used it since.

His biggest success came in 2001 when he used it daily on Bret Boone's ailing knee. The All-Star second baseman hit .331 with 37 home runs and 141 RBIs. He finished third in the MVP voting and used the tape for the next several years.

"A lot of guys don't like to put a big bulky wraps on," Griffin said. "We've found that putting the Kinesio tape on hamstring injuries or groin injuries or calf strains takes enough of the pressure away the guys are able to play every day."

Kinesio Taping sells about 200,000 rolls a year in the U.S. to medical professionals, who most commonly use it to treat lower back pain. Entry into the retail market was in the works before the Olympics. Now, every major pharmacy and sporting goods chain is clamoring for the tape.
Kinesio tape is sold at Living Well Medical in Manhattan call (212)645-8151

Wednesday, September 17, 2008

Plantar Fascitis treatment in NYC

Plantar fasciitis is a painful inflammatory condition of the foot caused by excessive wear to the plantar fascia that supports the arch or by biomechanical faults that cause abnormal pronation. The pain usually is felt on the underside of the heel, and is often most intense with the first steps of the day. It is commonly associated with long periods of weight bearing or sudden changes in weight bearing or activity. Obesity, weight gain, jobs that require a lot of walking on hard surfaces, shoes with little or no arch support, and inactivity are also associated with the condition.

Plantar fasciitis was formerly called "a dog's heel" in the United Kingdom. It is sometimes known as "flip-flop disease" among US podiatrists. The condition often results in a heel spur on the calcaneus, in which case it is the underlying condition, and not the spur itself, which produces the pain.

1 Treatment
1.1 Surgery
2 References

Many different treatments have been effective, and although it typically takes six to eighteen months to find a favorable resolution,[2] plantar fasciitis has a generally good long-term prognosis. The mainstays of treatment are stretching the Achilles tendon and plantar fascia, resting, keeping off the foot as much as possible, discontinuing aggravating activity, cold compression therapy, contrast bath therapy, weight loss, arch support and heel lifts, and taping. Care should be taken to wear supportive and stable shoes. Patients should avoid open-back shoes, sandals, "flip-flops", and any shoes without a raised heel. Molded foam clogs such as CrocsRx have been approved by the American Podiatric Medical Association and United States Ergonomics[3][4] as a healthy alternative to flip-flops. To relieve pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are often used but are of limited benefit.[5]. Patients should be encouraged to lessen activities which place more pressure on the balls of their feet because it increases tension in the plantar fascia. This is counter-intuitive because the pain is in the heel, and the heel is often sensitive to pressure which causes some patients to walk on the balls of their feet.

Local injection of corticosteroids often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic and injected slowly with a small-diameter needle.[6] Recurrence rates may be lower if injection is performed under ultrasound guidance.[7] Repeated steroid injections may result in rupture of the plantar fascia. This may actually improve pain initially, but has deleterious long-term consequences.

In cases of chronic plantar fasciitis of at least 10 months duration, one recent study has shown high success rates with a stretch of the plantar fascia.[8]

Pain with first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon before getting out of bed. Night splints can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease morning pain. These have many different designs, some of which may be hard and may press on the origin of the plantar fascia. Softer, custom devices, of plastizote, poron, or leather, may be more helpful. Orthoses should always be broken in slowly.

Therapeutic ultrasound has been shown in a controlled study to be ineffective as a treatment for plantar fasciitis. More recently, however, extracorporeal shockwave therapy (ESWT) has been used with some success in patients with symptoms lasting more than 6 months.[10] The treatment is a nonsurgical procedure, but is painful, and should be done either under sedation, or with local anaesthesia either with or without intravenous sedation (twilight sedation). Local anaesthesia by injection of drugs into the area can also be painful, and may incur the risks of neuritis, bleeding, and infection. ESWT re-inflames the area and in doing so increases blood flow to the area as a means to heal the area. It can take as long as six months following the procedure to see results. Results are variable, and one 2002 study reported ESWT for plantar fasciitis had no benefit.

Most patients should improve within one year of beginning non-surgical treatment, without any long-term problems. A few patients, however, will require surgery. Over 95% will then be relieved of their heel pain.

Prolotherapy has been shown to be effective in treating Plantar fasciitis.

Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure of the pain to improve. [14] Surgical procedures, such as plantar fascia release, are a last resort, and often lead to further complications such as a lowering of the arch and pain in the supero-lateral side of the foot due to compression of the cuboid bone.[15] An ultrasound guided needle fasciotomy can be used as a minimally invasive surgical intervention for Plantar Fasciitis. A needle is inserted into the Plantar Fascia and moved back and forwards to disrupt the fibrous tissue.

My Plantar Fascitis treatment involves
Graston Technique
As published in
August 2007

Plantar Fasciitis Treatment
by Mike Ploski, PT, ATC, OCS
© 2007 BioMechanics

Plantar fasciitis is an inflammatory condition of the plantar fascia characterized by pain at the heel and the medial arch of the foot. Clinical findings often reveal limited range of motion with ankle dorsiflexion and first metatarsophalangeal joint extension, an abnormal gait pattern, decreased foot strength, or abnormal posturing of the subtalar joint.

Conservative treatment approaches are often successful in managing this condition and revolve around reducing pain, promoting healing, restoring ROM and strength, and limiting those biomechanical deviations caused by structural abnormalities.
Soft tissue mobilization techniques can restore functional mobility to the plantar flexors and plantar fascia. They can be performed manually or with instruments. These procedures also can be used to promote tissue healing in chronic stages of soft tissue dysfunction.

The Graston Technique is a form of manual therapy that uses patented stainless steel instruments to restore soft tissue motion. The tools help the clinician to detect and then break up fascial restrictions (scar tissue). This procedure has been shown to be highly effective in the management of both acute and chronic cases of plantar fasciitis.

Along the gastrocnemius muscle: The rough, granular feel of fascial restrictions will be palpable as the Graston tool is drawn across dysfunctional tissue.

At the 1st MTP joint: Once lesions are found, the clinician can use smaller instruments to manipulate the soft tissue and break them up.

At the medial calcaneal tuberosity: When friction-type motion is applied at the origin of the plantar fascia on the medial calcaneal tuberosity, blood flow to the area is stimulated. This can result in new collagen production that in turn can accelerate the healing process.
Go to this link to see full article
in conjunction with
Cold laser therapy
Recent Harvard study Cold laser more beneficial than Ultrasound-Click to view

Kinesio taping
Muscles constantly extend and contract within a normal range, however, when muscles over-extend or over contract, such as when lifting an excessive amount of weight, muscles can not recover and become inflamed. When a muscle is inflamed, swollen or stiff due to fatigue, the space between the skin and muscle is compressed, resulting in constriction to the flow of lymphatic fluid. This compression also applies pressure to the pain receptors beneath the skin, which in turn communicates "discomfort signals" to the brain and emdash, thus the person experiences pain. This type of pain is known as myalgia, or muscular pain.Kinesio Taping® alleviates pain and facilitates lymphatic drainage by microscopically lifting the skin. The taped portion forms convolutions in the skin, thus increasing interstitial space. The result is that pressure and irritation are taken off the neural and sensory receptors, alleviating pain. Pressure is gradually taken off the lymphatic system, allowing it to channel more freely.

Friday, September 12, 2008

Living Well Medical- A full service spinal decompression clinic

Herniated disc treatment protocol. This protocol is designed to not only relive pain but increase disc height and reduce pressure on spinal nerves.
Treatment consists of
Physical therapy- 3 dimensional Rehab on the SpineForce designed to strengthen core musculature
Medical Massage
Chiropractic care
Spinal decompression on the DRX 9000
Cold laser therapy
Oxygen Therapy to enhance blood oxygen levels
Nutritional support using exclusive formulas designed to support tissue healing.
Power Plate vibrational training
Kinesio taping for herniated discs.
NYC Spinal Decompression NYC
visit my site

Thursday, September 04, 2008

Sciatica treatment in NYC

Sciatica treatment in NYC
Contact Dr. Steven Shoshany at (212) 645-8151
or visit or

I wanted to give a exhaustive description and defintion of Sciatica so i did some research and found a site and posted information below. enjoy!


Pain along the course of the sciatic nerve, originating from irritation of or trauma to its fibers above the knee.It is a symptom-with-a-range-of-causes:
In the literature of 15th Century Florence, the term sciatica described pain at the ischial tuberosity. Tuberculosis and arthritis were cited as suspected causes. Historically, a broad and varying definition suggested unclear pathogenesis. Distal pedal pain due to intermittent claudication and nerve entrapment at the fibular head are now termed “pseudo-sciatica” and “peroneal palsy,” respectively, but they have often been mistaken for sciatica. More recently, similar symptoms deriving from thalamic cerebrovascular accident, multiple sclerosis, thoracic spinal fracture, and “phantom limb” phenomena have been called sciatica because they share a similar distribution of pain. Symptoms from these causes differ from our core concept in that they involve only the neurons in the central nervous system. While a patient may accurately describe the pain as “sciatic,” the word would describe only the symptom and not the common pathophysiology. We suggest that a CVA in the conus medullaris might be a limiting example of true sciatica if it involved the lower motor and sensory neurons, but question whether anything more rostral could be true sciatica. Another borderline case would be a (rare) mononeuropathy multiplex involving the proximal sciatic nerve.
A study of 700 surgical cases performed under local anesthesia confirmed the utility of this definition, finding symptoms were reproduced only when the sciatic nerve or its involved roots were stimulated, stretched or compressed. Regardless of other tissue involvement or injury, the closer the stimulus to the site of nerve compression or tension, the greater the pain suffered by the patient. This pain could always be eliminated by injection of Xylocaine beneath the nerve sleeve proximal to the site of compression. 1
Due to variance in definition, studies putting the lifetime prevalence of ‘generic sciatica’ at 35% must be interpreted cautiously.2,3,4 Two independent studies with more precise definitions similar to ours yield lifetime prevalence of true nerve-related sciatica at 5% in men and 4% in women. 5,6 It is thought that back pain affects approximately 14% of adults annually; about 1-2% also have sciatica. 7 This amounts to 13% of 40,000,000 back pain cases per year: more than 5,000,000 cases annually.
Three pathogenic groups contain the common causes of sciatica. There are also a number of infrequent causes as well as a short list of habitual impostors.

One level:Laterally HNP/bulging disc
SpondylolisthesisMultiple levels:Arthritis


One level:Medially HNP/bulging disc
SpondylosisthesisMultiple levels:Boney/Ligamentum flavum


Piriformis syndrome:Overuse/sitting
Anatomical Ischial tunnel:Overuse

Uncommon causes-

Infectious: e.g., Tuberculosis
Autoimmune: e.g., Lupus Erythematosis,
Lumbosacral plexus
Neuropathy: e.g., Mononeuropathy Monoplex


Sacroiliac joint derangement
Intermittent claudication
Thalamic CVA
Peroneal palsy
Morton’s neuroma

Differential diagnosis begins with the location of the pain and the accompanying symptoms and signs.

Diagnosis from muscle weakness:
Flexing the thigh (with knee bent) – Dx: Radiculopathy at L 1 – 2
Extending the knee – Dx: Radiculopathy at L 3 – 4
Walking on the heels – Dx: Radiculopathy L 4 – 5
Walking on the toes – Dx: Radiculopathy L 5 – S1
Difficulty controlling the bowel or bladder – Dx: S 1 – 2 – 3

Note: Physical therapists often treat each of these conditions with McKenzie exercises appropriate for the level and severity of injury.
Diagnosis from numbness and/or paraesthesias:
Inguinal region, including side of testicle, labia majoris: L1
Upper front and side of thigh: L2
Main region of front of thigh down to or including knee: L3
Inside of calf, top of foot: L4 – 5
First web space, very outside of foot, outside of calf: S1
Middle back of thigh: S2
Middle portion of testicles, penis, labia majora, anus: S3
Glans penis, clitoris: S4
*Adapted from Fishman LM, Ardman CA. Sciatica Solutions: Diagnosis, treatment and cure of spinal and piriformis problems. W.W. Norton. New York. 2006.
Prediagnostic treatment for sciatica: Given the painful nature of sciatica, analgesia often precedes diagnostic workup. Many patients have already started a pain control regimen with ibuprofen or another over-the-counter non-steroidal anti-inflammatory by the time they reach the doctor. Nonsteroidal analgesia can be used in ascending order of potency: Tramadol (g of ultram), acetaminophen (g), meloxicam (g of mobic), celecoxib (g of celebrex), ketorolac (g toradol), diclofenac (g of voltaren), indomethacin (g). If ineffective, propoxyphene HCl (g of darvon), acetaminophen/hydrocodone (g of vicodin), meperidine (g of Demerol), codeine, acetaminophen/codeine (g of Tylenol #3), acetaminophen/oxycodone (g of Percocet), hydromorphone (g of Dilaudid), and oxymorphone (g of Opana) can be utilized. It should be noted that some common synthetic and semi-synthetic opiates include enough acetaminophen to approach hepatotoxicity at prolonged higher dosages.
Practical diagnosis: The diverse etiology of sciatica makes it necessary to be comprehensive and precise when evaluating a patient. Many clinicians rely on imaging early on in a patient’s treatment. Plain radiographs are rarely useful in the initial evaluation of non-geriatric acute back pain. They do not reveal herniated intervertebral discs nor spinal stenosis, and the findings on plain films are often unrelated to symptoms. E.g., spondylolisthesis can be seen in up to 5 percent of normal subjects. 8 Immediate X-ray of the lumbar spine should be reserved for patients with alarm symptoms suggestive of infection, cancer, violent wounds or fracture; however, a normal plain film itself does not rule out these conditions. In general, MRI or CT and EMG are required for definitive diagnosis of many spinal conditions. Nonetheless, these studies are not acutely necessary in patients with sciatica unless major neurological deficits or severe pain are present. Imaging studies may sometimes be deferred until 4-6 weeks of conservative therapy have failed.
Once obtained, there can still be an issue of misdiagnosis. One well-known study found that more than 30% of a group of pain-free subjects had serious spinal abnormalities on their MRIs. 9 If spinal pathology can be painless, it can also coexist with sciatica that has a different cause. This prompts the clinician to use EMG as an extension of the history and physical exam to confirm the diagnosis.
Treatment for Radiculopathy and Spinal Stenosis by cause:
Herniated Nucleus Pulposus: Whether central or lateral, usual treatment begins with analgesia and McKenzie and manual medical techniques, extension exercises, paraspinal myofascial work, modalities, Alexander work, and/or Yoga. Tapering oral steroids (starting dose often dexamethasone 8 – 16mg) over a 6-day to 3 week period may dramatically lower a patient’s pain, enabling him or her to tolerate an effective therapy program. Translaminar or transforaminal epidural injections are sometimes beneficial, though studies demonstrating the efficacy of these common practices are lacking.
True disc-related sciatica has a very high morbidity. This makes surgery an appealing alternative to conservative treatment for some patients. Many studies support surgery as the most efficient treatment. One analysis of medication use, ability to return to work, leisure activity and pain score found that after the first year of treatment, 30% of conservatively treated patients were satisfied with their outcome, while 60% of surgically treated patients reported satisfaction. 10 Surgery continued to lead until differences became insignificant at 10 years and beyond. Another study found 99.99% identical outcomes in surgical and non-surgical patients after 10 years. 11 It should be noted that in most studies the more severely involved patients tended to enter the surgical group.
One study followed patients hospitalized for disc-related sciatica for five years, comparing the 1/3 that refused surgery with the 2/3 that did not. At 5 years, 82% of the non-surgically treated patients still had pain in a sciatic distribution, versus 68% of the surgically treated patients. More than 13% of the surgical group required an additional operation for recurrent disc herniation. Outcome studies of this small group of patients found 84% in the WHO 'Severe handicap’ group. 12
Surgery may be an appealing option for many patients given the generally more favorable outcome. However, a recent study found little risk of serious or permanent injury when surgery for simple sciatica was delayed more than 7 months. 13 Given this information, a rational approach to treating sciatica clearly caused by a herniated disc is to attempt conservative treatment for 4-6 weeks. If intractable pain persists, a microdiscectomy or similar procedure can reasonably proceed.
Anterior spondylolisthesis, the most common form of spondylolisthesis, in which the upper vertebra is moved forward relative to the one below, may cause radiculopathy if it truncates neuroforamina, and/or spinal stenosis if the intramedullary space is narrowed. It is graded I through IV by the quartiles of vertebral body displacement. It is often successfully treated with an abdominal binder or lumbosacral corset, abdominal strengthening and postural training (the latter by a physical therapist or Alexander therapist). Yoga and Feldenkreis are also helpful. Beyond grade II, be it antero- retro- or lateral listhesis, surgical procedures that reestablish the proper alignment often utilize hardware such as titanium cages, and usually meet with considerable, but sub-total improvement that may not last more than 4-5 years. Studies of conservative medical, chiropractic or surgical treatment of spondylolisthesis are few.
Arthritis may narrow neuroforamina to cause radiculopathy unilaterally or bilaterally at one or more levels. Often, periodic episodes of increasing severity, frequency and duration occur after age 65-70. Pain as well as motor and sensory complaints will be gradual in onset, and at least early on, are often positional. Conservative strategy reduces the attendant inflammation, lowers peripheral and central sensitization, and increases range of motion at neighboring joints to reduce compromise at the affected level(s). 14 Non-steroidal and/or steroidal anti-inflammatories, yoga, and physical therapy often accomplish these three goals, respectively. 15, 16, 17 Although quite effective, steroids must be used with caution in osteoporotic patients. More advanced or complicated cases of arthritis may require surgery to remove deteriorated bone and disc material, osteophytes, or other matter impinging on the nerves. In these refractory patients, an EMG is helpful in identifying and characterizing the levels warranting treatment, and the severity of impingement.
Boney growth and/or swelling of the ligamentum flavum may narrow the lumbar intramedullary canal, causing single or multiple level spinal stenosis and resultant sciatica. The former may have genetic or arthritic pathogenesis, the latter inflammatory or traumatic. Conservative treatment aims to reduce the girth of the canal’s contents: tapered oral or epidural steroids, traction, and postural work by physical therapists, Alexander therapists and osteopathic physicians have had success.
While ligamentous swelling may subside naturally, boney narrowing will not. Surgical intervention, sometimes requiring stabilization procedures as well, should be considered when a progressive boney thickening is documented, but before emergent intervention is required. Cauda equina syndrome, a rare complication of spinal stenosis in which ascending numbness or weakness and bladder or bowel incontinence results from extreme pressure on descending rootlets within the intramedullary space, is one such surgical emergency.
In a recent study of nonemergent spinal stenosis surgery, outcome comparison of control and intervention groups at 1 and 4 years favored surgical treatment. After 8-10 years, a similar percentage of each group reported low back pain was improved but sciatica relief continued to favor the surgical group. 18 Because it is generally progressive, surgery for spinal stenosis may wisely occur before it is utterly mandatory, since its necessity may arise after the patient is too frail for it. 19
Piriformis syndrome is an under-recognized cause of sciatica. This was validated when 239 patients who failed conservative or surgical treatment for the above causes underwent MR neurography. Piriformis involvement was found in more than 2/3 of them. 20 Symptoms arise from compression of the sciatic nerve as it exits the buttock in relation to the piriformis muscle, due to spasm or tightness in the muscle. The chief environmental causes are overuse at health clubs, from running, outdoor activities, excessive sitting, trauma from auto accidents and falls. Anomalous relationships between the sciatic nerve and the inferior gluteal artery or vein at the greater sciatic foramen are uncommon but demonstrated anatomic bases for pain.
Diagnosis is made by EMG through delay of H-reflexes in flexion, adduction and internal rotation (the FAIR-test). Comparing affected with unaffected limbs helps rule out radiculopathy or spinal stenosis, and may be used in the 90% of cases that are unilateral. 21 Neural scan imaging (NMR) will show asymmetrical development of the affected piriformis muscle, and evidence of inflammation or focal narrowing of the sciatic nerve. EMG and NMR will only be positive if piriformis syndrome is present, and not in simple SI derangement alone. However, these conditions occur together with some frequency. Since the piriformis muscle arises in part from the sacroiliac joint, it is possible that SI joint derangement causes piriformis muscle spasm in these cases.
Conservative treatment begins with EMG- or fluoroscopically-guided steroid and Lidocaine/Marcaine injection of the piriformis muscle near its lateral musculotendinous junction, as well as stretching and relaxing the muscle, using ultrasound, myofascial release and spray/stretch techniques. Appropriate home yoga therapy is often successful over time. 22 Botulinum neurotoxin A or B, 300 or 12,500 units, respectively, in four locations throughout the muscle, are reported to significantly relieve 60% to 90% of resistant cases. 23 Neurovascular anomalies and ventral piriformis muscle scars require surgery which appears to benefit 60-80% of cases. 24
Confusion resolved:
While the rare vascular and neurological abnormalites have been shown to cause piriformis syndrome, the common variations in anatomy do not. Piriformis syndrome is often attributed to one or both branches of the sciatic nerve passing through the piriformis muscle, an anatomic “anomaly.” Cadaveric studies show that approximately 15% of the population has at least one branch of the sciatic nerve that travels such a course. Interestingly, in these people, the anatomy is bilateral more than 90% of the time. The “anomaly” theory comes into question in that complaints consistent with piriformis syndrome are bilateral in less than 10% of patients. Further, at surgery only 15% of patients had anatomy consistent with the “anomaly” theory, the same percentage that is seen in the general population. 25
Ischial tunnel syndrome:
The FAIR test is occasionally positive when entrapment is at a site other than the piriformis muscle. Four percent of sciatic nerve entrapment in the buttock is due to entrapment as the nerve passes close to the ischium. 26 The pudendal nerve may be separately involved. Neural scan is the definitive diagnostic tool for ischial tunnel syndrome. In these cases, treatment begins with myofascial release, modalities, and postural re-training. Surgery is reported but outcome studies lack sufficient numbers to be persuasive.
There are many other causes of sciatica, ranging from tumor and fracture to gunshot wound. In all the pathogenetic mechanism and the diagnosis can be understood on the anatomical bases that we have attempted to provide. Multiple conditions can coexist in which the analytical “either – or” approach is not recommended:
Proper initial treatment for a herniated disc is extension exercises, which is contraindicated in spondylolisthesis and non-disc forms of spinal stenosis. For these spinal stenoses and spondylolistheses, flexion is standard, a treatment which is contraindicated for most herniated discs. In the occurrence of both conditions, lateral strengthening and spinal work such as the yoga pose vasisthasana have proven useful in alleviating pain, with Fonar evidence of anatomical improvement. 27 To distinguish whether spinal stenosis or neuroforaminal pathology is the major causative factor in a given patient’s pain, other provocative tests, and functionally sensitive nerve-conduction are often helpful, though currently at the experimental stage.
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27 Fishman LM and Saltonstall E. Yoga for Osteoarthritis W.W. Norton, New York. Scheduled for
I would have to disagree with some of their conclusions, especially recommendations for surgery after 7 weeks of conservative treatment.
I have found that spinal decompression combined with an effective physical therapy protocol can correct most cases of sciatica within one month.