Wisdom Wednesday: Neuropathy

Neuropathy or nerve pathology is a term used to describe damage to a nerve as opposed to pain and inflammation. The signs of neuropathy are numbness, tingling and/or loss of strength but often these symptoms are overshadowed by pain.

Think of neuropathy as a loss of nerve function. If the damage is to the afferent nerve (signals going to the brain) supply, then the loss is sensory. If the efferent nerves (signals coming from the brain) are damaged, then a loss of motor control ensues.

Let’s look at sciatica, where the pain runs from the spine down the back of the leg. True sciatica effects approximately 5% of the population but many physicians continue to call all leg pain “sciatica”. When the nerve is just inflamed, treatment is fairly straight forward – correction of all injury reflexes, reduction of inflammation with supplementation and spinal/pelvic manipulation will resolve most cases is a couple of weeks.

However, if the sciatic neuralgia (nerve pain) is complicated by neuropathy, the prognosis is less favorable. In addition to the treatment described above, the nerve must also heal. Unfortunately, peripheral nerves are the slowest healing tissue in the human body.

The most common cause of neuropathy is diabetes. Over 50% of all Americans are either diabetic or pre-diabetic. About half of that number are developing neuropathy but currently are asymptomatic. The other half are well aware of their neuropathy symptoms.

It is said that all diabetics develop sciatica and are never cured. While that statement is certainly not true there is some truth in that statement.

I rely on two herbs and a former B vitamin to support healing from neuropathy. If a sciatic patient has no objective findings of neuropathy, I prefer to concentrate on reducing inflammation. However, once the inflammation is under control, if the patient is not responding well, it’s time to consider treating for neuropathy even if all the findings are symptomatic.

Wisdom Wednesday: A Simple Case of Sciatica?

A forty-nine year old male presented at my office with complaints of chronic low back pain with radiation down the right leg into the foot. He states that the back pain began almost a year ago. He was treated 2-3 times a week by a chiropractor but noted no benefit after a month and discontinued care.

Seven weeks ago, after sneezing, the pain shot down the right leg. The leg pain has been constant ever since, but varies in intensity. His orthopedic surgeon diagnosed a herniated disc and prescribed muscle relaxants and anti-inflammatory medication that failed to provide any relief.

An MRI performed two days prior to his initial visit in my office shows desiccation of the L4/L5 and L5/S1 discs with apparent prolapse at L5/S1 impinging the thecal sac.

Based on the history and MRI, I had several questions (please review my blog “The Patient History” posted September 16, 2015):

• Why didn’t he respond to a month of fairly intensive chiropractic care?
•  His pain radiates along the course of the femoral nerve, not the sciatic nerve. Why was he diagnosed with sciatica?
• If sneezing caused the prolapse at L5/S1, why isn’t the sciatic nerve affected and why are both discs desiccated? That takes at least a year, maybe as much as five years to show on imaging studies.
• The femoral nerve does exit from L4/L5 but that disc looks much healthier than the L5/S1 disc that supplies the sciatic nerve. Is this really a disc problem?

On examination, he had great difficulty arising from a chair (Minor’s Sign – imagine an old coal miner arising from a rocking chair) and exhibited marked antalgic posture (he leaned forward and to the left about 45 degrees) favoring the right leg to walk. Both these findings are secondary to protective muscle spasm.

Steroids No Better for Sciatica Pain Than Placebo

Sciatica affects about 1 in 10 people in their lifetime, researchers say. For this new study, 269 people with sciatica were randomly assigned to take an oral steroid (prednisone) or a placebo for 15 days. The participants were followed for up to a year.

“When we compared the prednisone to placebo, there was a modest improvement in function,” said study researcher Dr. Harley Goldberg, director of spine care services at Kaiser Permanente San Jose Medical Center in California. People reported they could go about their daily activities somewhat better than before.

However, “when we compared the pain [between the two groups], there was actually no difference,” he said.

Usual treatments for herniated disk-related sciatica range from self-care, steroid pills and anti-inflammatory medications, physical therapy, or epidural steroid injections, Goldberg said. When all else fails, surgery is an option, he explained.

This new study found that after a year, the likelihood of spine surgery was no less for those who took prednisone than for those who took a placebo, the researchers reported in the May 19 issue of the Journal of the American Medical Association.

The study, which ran from 2008 to 2013, included adults who had had the radiating leg and buttock pain for up to three months and said it affected their daily lives. All had a herniated disk, which triggers the pain, confirmed by an MRI.

Side effects, such as insomnia, increased appetite and nervousness, were twice as common at three weeks in the steroid group. Nearly half reported at least one side effect, compared to about one-quarter of the placebo group.

For anyone suffering from sciatica, Dr. Nick Shamie, chief of orthopedic spine surgery at UCLA Medical Center, Santa Monica, said a specialist’s evaluation and guidance is crucial. “Have them guide you,” he said.

He cautioned against rushing to surgery, pointing to a 2006 study, also published in JAMA, that found sciatica patients were no better two years after surgery in terms of functioning and pain than those who did not have surgery.

Wisdom Wednesday: Inositol

Inositol is a “vitamin like” substance that is found is nature and can be manufactured in laboratories. It was at one time considered a B vitamin. However, because the human body can make inositol from glucose, that vitamin status was revoked. Mice cannot make inositol and a deficiency in the diet causes mouse alopecia.

By comparison, vitamin D is also made in the human body just by exposure to sunlight. It is converted from cholesterol rather than glucose. It really is a hormone, not a vitamin. However, the nutrition board still considers vitamin D a vitamin. Even the world of vitamins is political.

Inositol is used to treat neuropathy, depression (especially bipolar disorder), polycystic ovarian syndrome (PCOS) and multiple sclerosis (MS). MS patients are unable to synthesize inositol and the addition of inositol to the diet dramatically reduces MS symptoms.

The dosage of inositol can be quite high. For PCOS, 1200mg per day is a typical dose while 18 grams per day is often used in treating MS.

Inositol opens the blood brain barrier, allowing more nutrients to enter the nervous system. This often facilitates repair of neuropathy. Cocaine dealers often cut their coke with inositol. It enhances the effects and speed of the drug on the brain, while dramatically improving profits. Be aware if you purchase a large container of inositol at the health food store, the clerk is going to assume you are a drug dealer.

Wisdom Wednesday: Chronic Low Back Pain

This new patient has been suffering from left sided sciatica for three months. About six weeks ago, he was hospitalized and treated for sciatica. During the hospital stay, he developed a perforated large intestine and had surgery, removing about a foot of large intestine and installing a colostomy bag. Subsequent surgery to remove the colostomy bag was successful. However, he developed C. difficile as a result of antibiotic therapy. After a few weeks, they were able to control the diarrhea well enough to send him home. He still has radiating pain down his left leg, his bowels are still inflamed with frequent diarrhea, and he now notes body wide aches.

Compare this history with the case of acute low back pain from last week’s Wisdom Wednesday. Obviously, this case is much more complex. On reviewing his history, he describes the pain as running down the anterior aspect of the left leg to the knee with occasional radiation into the groin. This is not the course of the sciatic nerve and, in fact, he was suffering from femoral neuralgia rather than sciatica. I have no clear information on the cause of the perforated intestine. However, I do comment on the relationship between these illnesses in my conclusions.

C. difficile kills about 1600 people in the US each year as the result of electrolyte imbalances associated with the diarrhea. It is an opportunistic infection that overgrows following the use of antibiotics. Please see my blog “Serious Diarrheal Infection in Kids Linked to Antibiotics” posted on March 14, 2014. Adults commonly develop C. difficile during hospital stays.

QA evaluation revealed impairment of Autogenic Facilitation (AF). Therapy Localization (TL) was to the surgical site of the perforated colon. This was corrected by Injury Recall Technique (IRT) restoring AF. Testing for inflammation was negative for prostaglandins, leukotrienes, cytokines, and histamine. However, nitric oxide was positive with a good response to L-glutamine, a particular probiotic (Saccharomyces boularidii), and folic acid. Challenge of the ilio-lumbar ligament was positive on the left, and after IRT correction, it returned again in weight bearing. TL was positive to the L4 vertebra, but no manipulation was performed.