Sciatica

What is Sciatica?

Sciatic pain (http://www.wikidoc.org/index.php/Sciatica_overview) is often called sciatica and is a result of compression, irritation or inflammation of the sciatic nerve. It can also give rise to to back pain. Three things can happen when a nerve is compressed. Compression can give rise to pain, numbness, weakness or some combination of the above. Remember that the term sciatica only refers to symptoms, not the cause of the symptoms or diagnosis. This is an important distinction because the specific treatment will depend on the diagnosis.

 

ICD-10 CODE ICD-10 CODE DESCRIPTION
M54.30 Sciatica, unspecified side
M54.31 Sciatica, right side
M54.32 Sciatica, left side
M54.40 Lumbago with sciatica, unspecified side
M54.41 Lumbago with sciatica, right side
M54.42 Lumbago with sciatica, left side

https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx?KeyWord=sciatica&bc=AAAAAAAAAAACAA%3d%3d&

 

The sciatic nerve includes branches from many nerves from Lumbar 4 to Sacral 3, and supplies sensation to nearly the whole leg. The sciatic nerve also innervates the muscles of the back of the thigh, and those of the leg and foot. (http://www.wikidoc.org/index.php/Sciatic_nerve)

 

Any compression or irritation of a spinal nerve root L4-S3 will give rise to symptoms in the nerve’s distribution. A good example of this is a spinal disc herniation. (https://www.youtube.com/watch?v=tXlpZwA42Ck)  In this situation, a portion of the soft disc interior migrates peripherally through a tear in the annulus and results in a protrusion or herniation.

The herniation can be a problem because it is “space occupying” in a confined space (spinal canal) where the nerve must travel as well. If there is not enough room for the nerve and disc herniation, then symptoms can arise acutely.

ICD-10

M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region

https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx?KeyWord=disc%20&bc=AAAAAAAAAAACAA%3d%3d&

 

Another common cause of sciatica is spinal stenosis. In this condition the sciatic nerve is compressed by overgrowth of bone and soft tissue inside of the spinal canal. Spinal stenosis is usually the result of long-term degenerative problems.

Treatment of sciatica can be divided into medical or conservative treatment and surgical treatment. Medical or conservative treatment is pursued first because a herniated disc will resorb and become asymptomatic about 90% of the time. Only 10% of herniated discs go on to need surgical intervention.

Medical treatment of a herniated lumbar disc causing sciatica can be started with exercise and physical therapy, such as McKienze exercises (http://www.spine-health.com/wellness/exercise/pain-relief-mckenzie-treatment). Other options are chiropractic and acupuncture. Other medical treatment can include medications such as an anti-inflammatory medication (http://www.wikidoc.org/index.php/Non-steroidal_anti-inflammatory_drug) or oral steroids (http://www.wikidoc.org/index.php/Steroid). Muscle relaxants and anti-depressant medications can also be used.

 

Epidural steroid injections are the mainstay of pain management treatment of painful sciatica. (http://www.wikidoc.org/index.php/Epidural#Epidural_steroid_injection)

They are often given in a series of 3 injections and can be very helpful or not do much good. When they don’t do much good, it suggests that the problem might require surgery if enough time has passed. The reasons why epidurals work is a topic of hot debate these days.

Code Description Medical Payment***
Non Facility* Facility**
62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

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https://ocm.ama-assn.org/OCM/CPTRelativeValueSearchResults.do?locality=1&keyword=epidural

 

When conservative measures don’t work, and the symptoms are significant and persistent then surgical treatment is an option. There are a wide variety of surgical techniques to treat sciatic that depend on the cause of the sciatica.

In times past, a large incision in the back was made to open the spinal canal and pull the spinal cord aside and remove the disc herniation.

 

There was a time that chymopapain was injected into a herniated disc to “dissolve” it.

62292 Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar

 

 

Currently there are many versions of “minimally invasive” procedures that can be performed with fluoroscopic x-ray only

62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar

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https://ocm.ama-assn.org/OCM/CPTRelativeValueSearchResults.do?locality=1&keyword=intervertebral+disc

 

The disc can now be removed under direct vision with a small incision and a microscope too.

63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

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Endoscopic spine surgery is available as well as laser surgery that can be performed with or without direct vision of the disc to be removed. There are numerous techniques to perform this on an outpatient basis.

 

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