Sciatica -Lumbar radiculopathy

Sciatica is a set of symptoms rather than a specific diagnosis and is caused by a herniated lumbar disc in the vast majority of cases.Often applied to any presentation of low back and leg pain Lumbosacral radiculopathy is a more specific term – impingement of lumbosacral nerve roots as they emerge from the spinal canal
 4th and 5th Lumbar nerve roots ( L4-L5 )
First two Sacral (S1 and S2 ).Sciatic nerve- largest nerve in body Disturbance anywhere along the course of the sciatic nerve 
can cause –> Sciatica
○ most common are disc ruptures and osteoarthritis at
L4 – L5
L5 – S1
L3 – L4 – less frequently
 Radiating pain , tingling and numbness – dermatomal distribution
may be accompanying motor weakness in a corresponding myotomal distribution
 Symptoms typically extend 
○ below the knee from buttocks
○ across the back of thigh
○ outer calf
○ often to foot and toes.Acute sciatica
 generally has a 
 good prognosis with pain and disability usually improving within 
2-4 weeks- with or
 without treatment

Back pain accounts 
for 7 % of GP consultations
 and more than 30 % of people still have clinically 
significant symptoms 
after a year after onset of sciatica .Causes- Herniated intervertebral disc ( slipped disc ) with nerve root compression 90 % of cases Lumbar stenoses Spondylolisthesis – a proximal vertebra moves forward relative to a distal vertebra Infection ( rare ) Cancer ( rare ) – often due to metastatic disease Genetic factors ( could have a role in disc degeneration and herniation ).Asymptomatic disc
 herniation on CT/MRI are 
common and there is no
 clear relationship between
 the extent of disc protrusion 
and the degree of clinical 
symptoms

Mainly diagnosed by history and clinical examination Usually unilateral
B/L pain may happen with 
♦ central disc herniation
♦ lumbar stenosis
♦ spondylolisthesis Drawings may be used to evaluate the distribution Increased back and sciatic pain with coughing , sneezing , straining or other forms of Valsalva maneuver may suggest disc rupture
 S1 compression –> reduction or loss of ankle reflex
L3-L4 compression –> variable reduction in knee reflex
L5 compression –> inconsistent changes in reflexes
 Straight leg raise test – Lasègue’s test
Positive test –> reproduction or marked worsening of the patients initial pain and firm resistance to further elevation of leg Sensitivity 90 % but specificity low. Cross straight- leg-raising -test 
( Fajersztajn’s test ) involves raising the unaffected leg

Red flags- Cauda equina syndrome
 Spinal fracture
 Cancer
 Infections
as discitis , vertebral osteomyelits or 
spinal epidural abscess

Differential diagnosis- Osteoarthritis- referred pain from hip Spondyloarthopathies – eg sacroillitis in ankylosing spondylitis Intervertebral facet joint pain Trochanteric bursitis Piriformis syndrome Peroneal palsy or other neuropathies Spina claudication Aseptic necrosis of femoral head Myelopathy or a higher cord lesion Non specific causes as
○ prostatitis
○ PID
○ Pelvic mass
○ Aortic aneurysm
○ Pancreatitis
○ Acute cholecytitis

Unilateral leg pain greater than low back pain Pain radiating to foot or toes Numbness and paraesthesia in the same distribution SLR induces more leg pain Localised neurology – that is limited to one nerve root.Do not routinely offer imaging in a non-specialist setting for people with LBP with or without sciatica ( NICE )
 X ray not routinely recommended – discs cannot be seen on XR

During 1 yr f/u irrespective of a surgical or conservative management- MRI findings seem not helpful in determining which patients might fair better with early surgery compared with a strategy of prolonged conservative management 
( J Neurosurg Spine Jun 2016 )

Referral for further care- Red flag symptoms and signs- admit / refer urgently as appropriate Consider referral to Physiotherapy for
○ manual therapy – spinal manipulation , mobilisation or massage as part of a treatment package including exercise Progressive persistent or severe neurological deficit ( Neurosurgery or T/ O ) Consider referral to specialist LBP & sciatica service for assessment of an epidural corticosteroid / local anaesthetic injection Consider referral for spinal decompression when non surgical treatment has not improved pain or function NICE also recommends referral to rediofrequency denervation if conservative treatment nor worked – main source of pain from structures supplied by medial branch nerve and pain is rated 5 or more on a visual analogie scale

management- NSAIDs- carry out risk assessment + gastroprotection for short term relief Weak opioids ( with or without paracetamol) only if NSAID is contraindicated , not tolerated or has been ineffective Do not offer weak opioids for managing chronic lower back pain Do not offer paracetamol alone Anti-epileptics
Pregabalin – poor evidence ( NEJM 2017 ) does not decrease pain
Gabapentin – has shown greater efficacy in pain reduction compared to placebo

LINKS AND RESOURCES

INFORMATION FOR PATIENTS

NHS on sciatica https://www.nhs.uk/conditions/sciatica/

Printable 2 page leaflet- auto-download from Mid Essex Hospital Services https://www.meht.nhs.uk/EasysiteWeb/getresource.axd?AssetID=22207&type=Full&servicetype=Attachment

36 page booklet from Arthritis Research on back pain https://www.versusarthritis.org/media/1248/back-pain-information-booklet.pdf

2 page printable leaflet from Pain relief foundation Org https://painrelieffoundation.org.uk/wp-content/uploads/2015/04/DEALING-WITH-PAIN-sciatica1.pdf

Exercises for sciatica from NHS https://www.nhs.uk/live-well/exercise/exercises-for-sciatica/

Keele University leaflet for back pain endorsed by NICE https://startback.hfac.keele.ac.uk/wp-content/uploads/2019/03/Start-Patient-Leaflet-1-black-and-white.pdf

Simple back pain exercises leaflet from CSP Org ( Arthritis research ) https://www.csp.org.uk/system/files/7_back_pain.pdf

Information from Health share Oxfordshire org with a helpful video https://healthshareoxfordshire.org.uk/what-is-back-pain/scatia

Neuropathic pain 8 page printable leaflet from Painconcern org -an excellent resource http://painconcern.org.uk/wp-content/uploads/2019/12/Neuropathic-pain-v.1.pdf

Fit for work advice on sciatica https://support.fitforwork.org/app/answers/detail/a_id/592/~/sciatica

INFORMATION FOR CLINICIANS

Low back pain and sciatica in over 16s : assessment and management NG 59 https://www.nice.org.uk/guidance/ng59

Chartered Society of Physiotherapy Clinical update: low back pain and sciatica Neil O’Connell examines the clinical guideline on low back pain and sciatica, which was recently updated by NICE https://www.csp.org.uk/frontline/article/clinical-update-low-back-pain-and-sciatica

Keele STarT Back Screening Tool http://www.rotherhamccg.nhs.uk/Downloads/Top%20Tips%20and%20Therapeutic%20Guidelines/Therapeutic%20guidelines/Start%20Back%20Tool%20screening%20and%20Scoring.pdf

Startback website https://startback.hfac.keele.ac.uk/

SIGN management of chronic pain https://www.sign.ac.uk/assets/sign136_2019.pdf

Europe PMC Diagnosis and treatment of sciatica http://europepmc.org/article/PMC/1895638

A good read Clinical practice guidelines for the management of non-specific low back pain in primary care : an updated overview Oliveira, C.B., Maher, C.G., Pinto, R.Z. et al. Eur Spine J (2018) 27: 2791. https://doi.org/10.1007/s00586-018-5673 https://link.springer.com/article/10.1007/s00586-018-5673-2 

References

1. Diagnosis and treatment of sciatica BMJ 2007 ; 334 :1313
2. Sciatica N Engl J Med 2015 ; 372-1240-1248 ( March 26 , 2015 )
3. A Summary of the Guideline for the Evidence-Informed Primary Care Management of Low Back Pain http://www.ipts.org.il/_Uploads/dbsAttachedFiles/LBPGUIDELINESNov25.pdf
4. Low back pain and sciatica in over 16s : assessment and management NICE guideline NG59 November 2016 https://www.nice.org.uk/guidance/ng59/chapter/Recommendations
5. Jordan, Joanne L et al. “Herniated lumbar disc: injection interventions for sciatica.” BMJ Clinical Evidence vol. 2016 1118. 9 Feb. 2016 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4747321/
6. CKS Sciatica ( Lumbar radiculopathy ) via https://cks.nice.org.uk/sciatica-lumbar-radiculopathy
7. Chou R, Qaseem A, Snow V, et al, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel*. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–491. doi: https://doi.org/10.7326/0003-4819-147-7-200710020-00006
8. Sciatica from disk herniation : Medical treatment or surgery Erick Legrand et al Joint Bone Spine , 2007-12-01 , volume 74 , Issue 6 , Pages 530-535 https://www.sciencedirect.com/science/article/pii/S1297319X07002862?via%3Dihub
9. Pregabalin and gabapentin for the treatment of sciatica Kellvin Robertson et al Journal of Clinical Neuroscience , 2016-04-01 , Volume 26 , Pages 1-7 https://www.jocn-journal.com/article/S0967-5868(15)00525-1/fulltext#secst115
10. Low Back Pain and Sciatica Anthony H Wheeler et al Medscape February 2016 https://emedicine.medscape.com/article/1144130-overview
11. Treating sciatica in the face of poor evidence BMJ 2012 ;344:e487
12. Low back pain and sciatica : summary of NICE guidance BMJ 2017 ;356 :i6748
13. Drugs for relief of pain in patients with sciatica : systemic review and meta-analysis BMJ 2012 ; 344 :e497
14. Trial of Pregabalin for Acute and Chronic Sciatica N Engl J Med . 2017 Mar 23 ; 376 (12) : 1111-1120 ( Abstract )
15. BodyinMind.Org ; Pregabalin for sciatica increasing prescription but is it effective ? https://bodyinmind.org/pregabalin-sciatica/
16. Sciatica :what the rheumatologist needs to know Maurits van Tulder et al. Nat Rev Rheumatol. 2010 Mar;6(3):139-45. doi: 10.1038/nrrheum.2010.3. Epub 2010 Feb 9.
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18. Jensen Rikke K, Kongsted Alice, Kjaer Per, Koes Bart. Diagnosis and treatment of sciatica BMJ 2019; 367 :l6273 https://www.bmj.com/content/367/bmj.l6273?gclid=CjwKCAjwxqX4BRBhEiwAYtJX7es45paKpADWTGgWDhl7jmfTKmWYENJaVWltUOorRP8WL0uhBDxtVRoCf8IQAvD_BwE
19. Valat JP, Genevay S, Marty M, Rozenberg S, Koes B. Sciatica. Best Practice & research. Clinical Rheumatology. 2010 Apr;24(2):241-252. DOI: 10.1016/j.berh.2009.11.005. ( Abstract )
20. Lewis R, Williams N, Matar HE, et al. The Clinical Effectiveness and Cost-Effectiveness of Management Strategies for Sciatica: Systematic Review and Economic Model. Southampton (UK): NIHR Journals Library; 2011 Nov. (Health Technology Assessment, No. 15.39.) 3, Background. Available from: https://www.ncbi.nlm.nih.gov/books/NBK99305/