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 Hi Sherman-- This could get a little long, so I'll apologize in 
advance. Far and away, most back pain and sciatica has a mechanical 
origin. This means that "joint dysfunction" or jammed joints are usually 
the culprit. Even in the presence of disc bulges and herniations .I know 
that sounds bizarre, so let me explain. About 60-70% of Americans have 
bulges or herniations in their spine, and don't even know it. This is 
because certain other parameters must exist for them to express 
symptoms. So, when a patient has back or leg pain and is also found to 
have a disc lesion, it's very tempting to blame the pain on the disc. 
This is often a mistake in logic, and a trap that can send you down the 
wrong road of treatment. Over the last 25 years, 70% of my patient load 
has been dealing with low back pain and/or sciatica. Probably 90-95% of 
these cases can be treated successfully with skilled (and I emphasize 
that word as not nearly all manipulators are skilled) manipulation. The 
remaining 5-10% will respond to spinal decompression therapy, which is a 
relatively new, but very effective, tool for even the most painful and 
degenerated spines. I have been using one since the beginning of 2007, 
and wish I had had it over the entire course of my career. We have a 
Veteran's Hospital here, and they refer many patients to me, several of 
whom are on disability retirement for their backs, and they are actually 
recovering with decompression, when nothing else has worked. Some of 
them have recovered, and still receive a disability check!  Go figure. A 
few percent of patients will respond to epidural injections (which are 
relatively safe and work about 50% of the time), and very rare cases of 
instability and intractable pain then become candidates for surgery. 
Surgery is, and should be, a very rare option for treating back pain or 
sciatica these days .The medical profession is in some pretty hot water 
over the abuse of spinal fusion surgeries, as they are expensive and 
have a high failure rate.  To keep this on  track, there is a  
situation  that calls for immediate  emergency surgery, and that is when 
a disc blows out in the lumbar spine and causes spinal cord pressure, 
resulting in numbness in the "saddle area" of the thighs and pelvis, 
weakness, and loss of bladder or bowel function. This is called a "cauda 
equina" syndrome (named after the "horse's tail" appearance of the 
lumbar nerves) and the results will be permanent if surgery to 
decompress the area is not performed within a few hours. I have never 
seen a case in 25 years, so it is very rare.
    There are some general rules of thumb about treatable back pain. If 
it is below the belt line and off to one side, worse in the morning and 
improves with activity, hurts to rise and sit from a chair, doesn't 
radiate below the knee, and doesn't really hurt when you cough or 
sneeze, the news is good--it's very treatable. If it hurts  a lot on 
cough/sneeze, is better in the morning and worse with activity, radiates 
below the knee, with numbness/weakness/loss of reflexes/loss of muscle 
mass and is accompanied by significant imaging studies (MRI confirming a 
disc herniation, for example), you're in for a longer ride. Either way, 
a really good chiro (and I am more aware than anyone how hard they are 
to find) is still a good place to start. Manipulation isn't used at the 
level of the disc damage, but rather above and below it, and sometimes 
the disc will heal. If not, then decompression, epidurals, and surgery, 
in that oversimplified order.  Good luck,   Dr Q

 



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