Epidural injection of steroid and pain medication versus placebo
Evidence-Based Spine Surgery, 09/10/09
Epidural steroid injections for treatment of sciatica did not confer significant additional benefit over placebo injection in patients who had had symptoms for less than one year. While steroid injections may afford short–term improvements in pain and movement, this beneficial effect was transient, and there was no statistical difference between active and placebo treatments after 4 weeks of follow–up. Treatment of sciatica with epidural steroids has exhibited no significant functional benefit, nor does it reduce the need for surgery. Outcomes varied minimally by injection site across studies, not based on direct comparisons.
by Jeffrey H. Tucker, DC, DACRB
Neuromobilization is a technique that details the assessment and analysis of radiculopathy. It involves specific maneuvers for upper and lower extremity sensory disturbances.1 Most musculoskeletal pain and dysfunction represents the result of a failure of adaptation.
It is easy to imagine that nerves can become stuck from disc pathology, lateral canal stenosis, fascial glue or any other structure that wraps, invests, supports, separates, connects, divides or may become sticky. The ground substance can become thick and sticky. It is likely that a nerve can become “held” or “stuck” in an area of ground substance that has become viscous or gel-like, or in areas of inflammation.
Neuromobilization is one of the least invasive therapeutic interventions that can start the healing and repair of radiculopathy. The femoral nerve, sciatic nerve, median nerve, radial nerve and ulnar nerve have lines of pull. Neuromobilization procedures are directed at multiple joints, and it is difficult to determine exactly where the nerve may be stuck.
The techniques are taught with two people simultaneously making the correction on the patient. Since it is not always possible for practitioners to have an assistant available to aid in the correction, I have found that a deep muscle stimulator (DMS) device is extremely useful. The hand-held device provides percussion and concussion vibration that allows specific point pressure to increase circulation and oxygenation to the tissues. The stimulator device will allow the muscle to achieve a new resting length. Fascia is stretched and will change length and hold the new form. The stimulator device also relieves joint irritation and inflammation to the surrounding area and nerve; a fixation or joint stiffness may cause a nerve to be hypomobile and irritated every time it is pulled.
Once the patient is comfortable doing at-home stabilization protocol exercises for the neck and back, it is time for them to progress to more advanced corrective exercises. For example, with the patient relaxed in the centrated side-lying posture, you can use a stimulator device in the sciatic-notch region for sciatic-nerve radiculopathy while the patient is talked through actively moving the top leg into abduction, hip flexion, and foot dorsiflexion/plantarflexion.
Advanced Exercises for the Femoral Nerve
Reverse lunge: Stand with feet hip-width apart in front of a mirror with a resistance band wrapped/tied around the knees. Ensure your lumbar spine is in neutral and your back is tall, with your shoulders back and head up. Slide backward with your right leg and bend your left knee only halfway down. Ensure that your front knee is in line with your toes and your back has remained upright, with your lumbar spine in neutral and your hips level. Allow a stretch in the right iliopsoas muscle region. Push back up with the right leg. Your back should remain totally still and your hips level as you performed the push-back. The idea is to slide your right foot back until your left leg bends at 90 degrees. Slide your right foot up to start position, pulling up with the glute of your left leg. Keeping your abs tight will help you keep balance. Finish all reps on one side and then switch sides. Perform 10-15 reps per side.
Prone hip flexor stretch: Lie prone on the floor with the involved-side knee flexed to 90 degrees. The opposite leg is straight on the floor with both ASIS pressed into the floor. Wrap a resistance band around the bent-knee ankle and grab the other end with both hands. Actively extend the hip and pull on the band so the thigh is raised off the floor. Make sure the ASIS stay in contact with the floor. Hold this for a 30-second count while performing diaphragm breathing. Perform three to five reps.
Resistance-band side walk: Place a resistance band around your ankles. Stand with your feet hip-width apart and get into a small knee-bend position. Step to the side with your left leg, then bring your right leg toward the left leg, but not all the way, so you keep some tension on the band. Continue across the room, stepping out with your left leg. Return to the other side of the room, facing the same way stepping out with your right foot. Make sure the foot doesn’t get out from under the knee. Move five steps to the right and five steps to the left. This can be repeated until felt in the gluteus medius.
- Based on a technique course taught by Dr. Kim Christensen.