FEATURE OPINION — Every day I have new patients come to me with symptoms of pain in their hips and legs. Commonly, these patients have been to orthopedic surgeons or other specialists thinking the pain is stemming from their hip or knee when the problem is really coming from the spine.
I’m commonly asked “why is it hurting in my hip or leg if the problem is in my spine?” This is a very confusing point for patients and rightfully so. There are two common conditions in the back that cause pain in the hip and leg: spinal stenosis and a herniated disc causing sciatica.
Spinal stenosis is very common. It is not a matter of if you are going to develop spinal stenosis but when. It is not uncommon for patients to have spinal stenosis by age 40, but it usually doesn’t develop until into the 60s or 70s. Stenosis is just a medical term for narrowing. In order for your spinal nerves to reach your legs, they must travel through the spinal canal via the spinal cord. Bulging disks, bone spurs and thickened ligaments around the spinal canal can cause the canal to narrow. This most commonly happens in the lower lumbar spine.
Symptoms of spinal stenosis include low back, hip and leg pain. This pain can be on the left or right only but is most often felt in both hips or legs. Pain usually worsens the longer a patient stands or walks and commonly subsides soon after sitting down. This is due to the fact that when one is standing or walking, the narrowed central canal narrows even more. Patients suffering from spinal stenosis commonly give a history of “the shopping cart sign:” Leaning over a shopping cart usually relieves their symptoms. That narrowing tends to open more widely when sitting down or leaning over.
The second most common symptom I hear about in my clinic is a herniated disc causing sciatic pain. This pain radiates down the back into the buttock, knee and occasionally the foot. Whereas spinal stenosis is typically felt in both legs, herniated discs are commonly felt in one leg.
Herniated disc sciatic pain typically worsens when sitting for extended periods of time. Sitting puts increased pressure on the disc and causes the disc protrusion to get bigger. The larger protrusion then further narrows the tiny nerve openings on the side of the spinal canal called neuroforamen and irritate the spinal nerve causing sciatic pain. Ultimately, both the pain from the spinal stenosis and herniated discs are treated similarly.
A primary care physician or interventional spine specialist help diagnose both conditions. A full history and physical exam should be performed. Sometimes further testing, such as x-rays, CT scans, MRIs and nerve conduction studies, is needed to confirm the diagnosis. Surgery is usually not required to treat these conditions unless a significant amount of numbness or weakness is noted on the physical exam. Successful conservative treatments include physical therapy, medications and x-ray guided epidural steroid injections.
Physical therapy can typically teach patients certain postural changes, pelvic tilting or other core strengthening exercises that help prevent and minimize the symptoms of spinal stenosis and herniated discs. Anti-inflammatories, corticosteroids, acetaminophen, opiates and non-opiate pain medications, as well as neuropathic (anti-convulsant) medications, can treat these symptoms. Periodic epidural steroid injections are very successful at alleviating this spinal stenosis and sciatic pain.
Ultimately, if conservative treatment fails, minor surgical treatment is sometimes necessary to relieve the pain. As a last resort, surgery is sometimes needed to relieve the pain. A laminectomy is commonly required for spinal stenosis, and a microdiscectomy is typically performed for disc herniation. These are typically considered low risk surgeries and are usually done as either an outpatient or a 24-hour hospital stay. The ultimate goal, however, is to get patients out of pain without surgery.
If you are having pain that radiates in your back, hip, leg or foot that worsens with extended standing, walking or sitting, you may have spinal stenosis or a herniated disc. With medications, physical therapy or epidural injections, you can often get pain relief without surgery.
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Written by Court Empey for St. George Health and Wellness magazine and St. George News.
Empey is fellowship trained in interventional pain medicine, completing this training at the world famous Mayo Clinic. A native to St. George, he graduated from both Dixie High School and Dixie College, then completing his bachelor’s degree at the University of Utah in biochemistry with honors.
He was also an honor graduate of the George Washington University where he obtained his medical doctorate degree. He then returned to the University of Utah to complete an internship in internal medicine and a medical residency in anesthesiolgy. Lastly, he completed his training in interventional pain medicine at the Mayo Clinic in both Scottsdale, Arizona, and Rochester, Minnesota.
With the highest level of training available for a pain specialist, he has had extensive training in medical management, physical medicine/physical therapy, cancer pain therapy, psychology and lifestyle modification. He believes in a multi-disciplinary approach to pain treatment.
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