1. The different types of patients with Sciatica from a lumbar disc Manoj Krishna. Spinal Surgeon www.spinalsurgeon.com

2. Type 1: Sciatica without disc protrusion Predominant leg pain Increased on sitting Eased on walking MRI shows disc degeneration but no neural compression Rx- Interbody Fusion Mechanism: ? Sinuvertebral Nerve Irritation. – ? Leakage of chemicals into disc space

3. Type 2: Small central disc protrusion Causes more back pain than sciatica These symptoms more likely to become chronic Contained disc – still within PLL 38% do poorly from discectomy Rx- Do well with a Interbody Fusion

4. Type 2 Contained Central Disc Protrusions Spasms, Locking Left thigh and leg pain Sitting < 5 minutes

5. Type 3: Large Central Disc protrusion- Cauda Equina Syndrome History of back pain One day the back pain disappears and patient gets sciatica with buttock numbness and dribbling, or bilateral leg pain Surgical emergency Urgent discectomy needed

6. Type 3 Cauda Equina Syndrome.

7. Type 4: Sequestered postero-lateral disc protrusion Present with unilateral sciatica Severe pain initially Highest chance of settling spontaneously Manage with an epidural injection or just pain relief till the pain settles

8. Type 4 Pain settled on its own at 6 weeks from onset May develop back pain later

9. Type 5: Contained postero-lateral disc protrusion Not extruded into the disc space Often Broad based 38% persistent sciatica with discectomy( Carragee) Less likely to settle spontaneously with conservative measures Or- may settle and develop an instability pattern, with recurring episodes of leg pain Needs an interbody fusion

10. WWW.KSPINE.NET Type 5 Intermittent LBP several years. Then Rt sciatica – LBP settled. Scoliotic tilt and stooped forwards 40 degrees. Rt SLR=40 L5 decreased sensation

11. Type 6: Far lateral disc protrusion Often at L34 Not easy to see on an MRI scan Causes thigh pain- and quads wasting Rx: Nerve Root Block- usually all that is needed Discectomy: Needs a far-lateral approach Or, consider doing an interbody fusion 7% of disc herniations

12. Type 6 RD Fraser et al- Adelaide. JBJS 1997 30 cases Foraminal Nerve Root Blocks Only 3 needed surgery

13. Type 7: Small disc protrusion in a tight spinal canal causing Stenosis Patients have a narrow spinal canal with no symptoms Even a small disc protrusion tips the balance causing a combination of leg pain, heavy legs, loss of co-ordination Neuro deficit is out of proportion to the size of the disc protrusion Needs urgent decompression- risk of cauda equina syndrome

14. Type 8 Features of both left sciatica and spinal stenosis Need to worry that this could progress to a cauda equina syndrome Struggling to walk Acute onset, rapid progression

15. Type 9: Recurrent Herniation at same level 10% at 2 years( McGirt et al, Spine, 2009) Higher if larger annular defect Higher if limited discectomy done But...more back pain associated with larger disc removals

16. Type 8 Discectomy Oct 2000 – Recurrence of LBP and Lt leg pain. Pain very severe. ‘ My Life is Hell’ VAS - 9/10 Small Recurrent disc protrusion

17. 10 year outcomes of discectomy Yorimitsu et al. Spine. 131 cases 12.5% had a recurrent disc herniation 75% had back pain 13% had severe pain Back pain associated with a degenerate disc at time of surgery, age less than 35 and reduced disc height ‘the remaining disrupted discs must continuously bear the weight and support the trunk for the rest of the patient’s life’

18. Epidural Steroids vs Discectomy Buttermann. JBJS, 2004 RCT At 6 weeks randomised into 2 groups( N=169) 92% discectomy group very happy. 56% of epidural group happy Subsequent discectomy had a similar outcome. Half of patients in epidural group avoided surgery at 3 years

19. How long is it reasonable for a patient to suffer and wait for the pain to settle? ( knowing that they can wake up from surgery with the leg pain gone and if they accept the small risks of surgery?) Should the doctor decide? Or the patient who is experiencing the pain?

20. Complications of Discectomy British Association of Spine Surgeons( 2005) 3.5% dural leaks in primary discectomy 13% in revision cases Infections rates 3%( Rohde,Spine)