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 |
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 |
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 Nov 99.Volume 9, Issue 11, November 1999 Jan 00.Volume 10, Issue 1, January 2000 Dec 00.Volume 10, Issue 12, December 2000 Sep 04.Volume 14, Issue 9, September 2004 Jul 08.Volume 18, Issue 7, July 2008 Nov 08.Volume 18, Issue 11, November 2008 Oct 09.Volume 19, Issue 10, October 2009 Feb 10.Volume 20, Issue 2, February 2010 May 10.Volume 20, Issue 5, May 2010 | ||
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 Nov 99.Volume 9, Issue 11, November 1999 Mar 02.Volume 12, Issue 3, March 2002 Oct 10.Volume 20, Issue 10, October 2010 Jul 12.Volume 22, Issue 7, July 2012 Oct 12.Volume 22, Issue 10, October 2012 |
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 Mar 96.Volume 6, Issue 3, March 1996 Nov 99.Volume 9, Issue 11, November 1999 Jan 01.Volume 11, Issue 1, January 2001 Feb 01.Volume 11, Issue 2, February 2001 Sep 02.Volume 12, Issue 9, September 2002 Oct 04.Volume 14, Issue 10, October 2004 Oct 08.Volume 18, Issue 10, October 2008 Oct 09.Volume 19, Issue 10, October 2009 Nov 10.Volume 20, Issue 11, November 2010 Mar 11.Volume 21, Issue 3, March 2011 Jul 11.Volume 21, Issue 7, July 2011 Jul 12.Volume 22, Issue 7, July 2012 Dec 12.Volume 22, Issue 12, December 2012 |
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.