Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Examing the causes of sciatica
- Nick A Francis (23 June 2007)
-
A Symptom, not a Disease
- William G Notcutt (25 June 2007)
-
Causes of sciatica: any common factors with herpes zoster?
- Hazel Thornton (27 June 2007)
-
Diagnosis and Treatment of Sciatica
- Jeremy CT Fairbank (29 June 2007)
-
The therapist's role
- Richard Bartley (2 July 2007)
-
Pain in sciatica
- Peter J Morgan (3 July 2007)
-
Re: Causes of sciatica: any common factors with herpes zoster?
- Rachel G Belden (10 July 2007)
-
Clinical review of sciatica?
- Emma M Clark, David R Blake (26 July 2007)
-
Re: Examing the causes of sciatica
- Mathias Rosenbaum (17 September 2007)
-
Treatment of Sciatica
- Charles S Galasko (8 October 2007)
-
Referring a patient with suspected cauda equina syndrome
- Jaykar R Panchmatia (9 December 2007)
-
Early Surgical Intervention in Sciatica
- Matthew E Smith, Rory O'Connor, Senior Lecturer and Honorary Consultant in Rehabilitation Medicine, Leeds PCT and Leeds Teaching Hospitals NHS Trust (30 June 2008)
|
|
|||
|
Nick A Francis, Academic general practitioner Department of Primary Care and Public Health, Cardiff University, Cardiff, CF14 4XN
Send response to journal:
|
Koes et al state that 90% of cases of sciatica are caused by herniated disc, and mention lumbar stenosis and tumours as other possible causes. However, they also reference a study by Modic et al (1) which showed that only 65% of patients with 'radiculopathy' had a herniated disc on MRI scan (a proportion that was similar to those who had back pain only). Recent personal experience with sciatica (with positive straight leg raising) for 4 months left me feeling that I must have a herniated disc. An impression that was confirmed by my general practitioner. However, both the osteopath and the physiotherapists I saw felt that a herniated disc was unlikely due (among other things) to the fact that sitting relieved my symptoms and I had no neurological findings (I had paraesthesia but no objective findings). I was not convinced, but after a course of exercises designed to improve my posture and my core stability, I am now virtually pain free. Where has the general belief in the medical profession, that sciatica equals disc herniation, come from? Is it evidence based? Perhaps there is much we could learn from other healthcare professionals about differentiating between different causes of sciatica? Almost certainly further research is needed to identify the causes of sciatica (other than disc herniation causing compression of a nerve root), and to determine whether clinical findings can accurately identify the underlying cause. As far as treatment is concerned, my case is anecdote and may have resolved spontaneously. However, I wonder whether physical therapies might show greater benefit in trials where patients with sciatica are selected who are not thought to have disc herniation? References 1. Modic MT, Obuchowski NA, Ross J, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology 2005;237:597-604 Competing interests: None declared |
|||
|
|
|||
|
William G Notcutt, Consutlant in Pain Management james Paget University Hospital, Great Yarmouth, NR31 7EB
Send response to journal:
|
One of the problems that besets the understanding, management and research of lumbar spinal problems is defining what words mean. "Sciatica" is a word used to describe the symptom of pain down the back of the leg, implying a problem affecting the sciatic nerve. It is not a disease. However, in their opening line and throughout most of their article Koes and colleagues describe it as a disease. Unfortunately many patients and doctors also think of sciatica in this way. MRI scans demonstrate that much posterior and poterolateral leg pain is not due to a prolapsed disc although disc pathology may be a significant part of cause of the symptoms that the patient has. As for symptomatic treatment with analgesics, NSAIDs, epidural steroids etc., these do work in clinical practice for a large number of patients as part of the management to help them improve. Unfortunately clinical trials in this area are very difficult to undertake partly because of the difficulties in defining exactly what it is we are trying to study. Our own current therapy for these patients involves a number of therapeutic elements (information, physical, psychological, pharmacological, social etc) all of which probably have their part to play. Finally, it has become clear to me over the years that ones perspective on the management of these patients depends greatly on which secondary care specialty is involved and how they work together for the patients' benefit (spinal surgeons, neurosurgeons, pain specialists, physiotherpists, osteopaths, rheumatologists etc.). Consequently the interpretation of any clinical trials in the management of "Sciatica" has to be done with great caution. Competing interests: None declared |
|||
|
|
|||
|
Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences, University of Leicester. "Saionara", 31 Regent Street, Rowhedge, Colchester, CO5 7EA
Send response to journal:
|
Having suffered in the last three months from sciatica, then herpes zoster (shingles) for the second time – fortunately overlapping and not entirely concurrent - it was helpful to read Clinical Reviews [1] [2] on both these conditions in recent issues of the BMJ. No specific label had been attached to my severe hip and leg pain, in spite of a collaborative effort by osteopath, GP, radiologist at local hospital, and patient. At the time, before I went down with shingles, I did tentatively suggest some kind of infection as a possible cause of my hip and leg pain. So I have been interested to read the clinical reviews and the rapid responses that have suggested that cause and diagnosis of `sciatica` is not a simple matter, that imaging may be indicated “if there are indications that the sciatica may be caused by underlying disease (infections, malignancies) rather than disc herniation”, and that more research is needed. A recent rapid response [3] http://www.bmj.com/cgi/eletters/334/7605/1211#169502 to the Clinical Review on herpes zoster suggested use of vitamin B12 for this condition. I idly wondered whether my recent craving for Marmite might be significant? It is also interesting to speculate, or even to seriously consider, if there might be any possible connection between the two episodes, implicating an infectious (viral) cause(s) for both. Could there be a common causal factor? References: [1] David W. Wareham, Judith Breuer. Herpes zoster. Clinical Review. BMJ 2007; 334:1211-1215 [2] B.W.Koes, M.W. van Tulder, W.C.Peul. Diagnosis and treatment of sciatica. BMJ 2007 334:1313-1317 [3] George Y. Caldwell. Liver extract and cyanocobalamin in treating herpes zoster. Bmj.com rapid response 26th June 2007 http://www.bmj.com/cgi/eletters/334/7605/1211#169502 Competing interests: None declared |
|||
|
|
|||
|
Jeremy CT Fairbank, Consultant Orthopaedic surgeon Nuffield Orthopaedic Centre, Oxford OX3 7LD
Send response to journal:
|
I was disappointed that this article, apparently based on current evidence, used the entirely non-evidence-based term "sciatica". From the Greek it literally means hip pain. In English, Oxford English Dictionary gives precedent to a quote from Timon of Athens*, where sciatica is a curse placed on the senators. None of this is a good basis for current usage which is supposed to be a term to describe nerve root or radicular pain, as the authors note but do not discuss. The problem is that patients with back pain may also have referred pain, a phenomenon first pointed out by Kellgren over 60 years ago1. Clinicians are not good at making this distinction, but they should at least try. This issue takes on greater importance when studying the evidence base where often this distinction is not made. Persisting use of the archaic word sciatica in the clinical setting is not in the best interests of sufferers of a miserable and disabling condition. It remains an effective curse, but English terms such as nerve root pain or radicular pain better describe the clinical problem. On a different but also fundamental point, we now have good evidence from Finland that disc prolapse is largely driven by genetics (it explains 60% variance)2. It is not, as is commonly thought, caused by various abuses of the lumbar spine. I believe that this finding should be fundamental to our thinking about this condition. Disc prolapse is common and often asymptomatic. Many attacks resolve, but predicting the longer term sufferer is not straightforward. It is here that surgery may play a part, recognising that at least 10% will get further attacks of radicular pain come what may. It is essential that this complex equation is discussed with patients. Sadly there is no evidence to support any non-operative care beyond time and analgesics. There are small but very important risks attached to disc surgery. None of the trials, including the SPORT studies are large enough to give rates for these complications. Patients have to be given this information in a clear fashion. The language of evidence-based medicine does not translate well to the clinic. Patients will take decisions on the basis of pain and disability severity, life impact, and on their attitude to risk. This needs a good and honest doctor to help make the correct decision. 1. Kellgren J. Sciatica. Lancet 1941;1:561-4. 2. Videman T, Battie M, Ripatti S, et al. Determinants of the Progression in Lumbar Degeneration: A 5-Year Follow-up Study of Adult Male Monozygotic Twins. Spine 2006;31:671-8. * Plagues, incident to men,
William Shakespeare: Timon of Athens, Act IV. Scene I Competing interests: None declared |
|||
|
|
|||
|
Richard Bartley, Physiotherapist Denbigh Infirmary
Send response to journal:
|
Quote from Fairbank: “Sadly there is no evidence to support any non- operative care beyond time and analgesics.” This includes the physical therapies. Unfortunately, some non- operative care can be worse than no care at all. The peristent need for therapists to place their hands on patients with nerve root pain, may not always serve these sufferers well. I believe physical therapists have a vital role in providing support for patients with this miserable and disabling condition. For patients equipped with listening skills, advice and reassurance from a good and honest therapist can help them better manage their symptoms and be better informed when it comes to important decisions regarding surgery. The pursuit of non-evidence-based treatments, however well-meaning, at the expense of patient education, is to me a lost opportunity to do something useful. Competing interests: None declared |
|||
|
|
|||
|
Peter J Morgan, General Practitioner Principal Kyle of Lochalsh. IV40 8DD
Send response to journal:
|
Koes et al state that sciatica is characterized by pain radiating in a dermatomal pattern. This is not correct. It is an important diagnostic point that while sensory loss and paraesthesiae do follow a dermatomal pattern, the sensation of pain is felt in a myotomal pattern. the two are not the same. Competing interests: None declared |
|||
|
|
|||
|
Rachel G Belden, public records researcher New Brunswick NJ 08903
Send response to journal:
|
Friday before last (June 29, 2007), I developed typical sciatica - pain starting near the base of the spine and spreading down my (right) leg - severe enough so that I wondered how I was going to take a train trip the following day to visit my cousin in South Jersey for the weekend. However, I went to bed that night with a heating pad applied to the lower spine area and kept it going most of the night. About 2 hours before arising, I turned the heating pad off and, when I did stand up, found that I had no pain. Took the weekend trip and forgot all about the incident. However, the pain reasserted itself on Monday morning - in spades! My stepson, who is a chiropractor, brought his table, confirmed that I had sciatica, and gave me an adjustment at my home. On Wednesday, he adjusted me again, informing me that I could expect the condition to last 2 weeks or longer, with many ups and downs along the way. Somehow (was it the pain?) I just could not remember what it was I had done to banish the symptoms when they first appeared the previous Friday. Finally, on Friday, July 6th, while in conversation with my cousin, I remembered what I had done a week earlier: the heating pad! I set it up again and slept with it most of the night. When I stood up the following morning, the pain was down to what it had formerly taken 4 Tylenol to accomplish. Encouraged, I used the heating pad again over much of Saturday and then again throughout most of Saturday night. Sunday morning (today), I stood up and walked with no pain. That situation has held all day. I do plan to continue using the heating pad over the next several nights to prevent any further flare-ups. Here's what I think is happening: Long ago, when already an adult, I contracted chickenpox. It "went away" but I'll bet the virus went and hid inside a spinal nerve, then surfaced as sciatica 30 years later. In other words, I think, in my case (and perhaps in many others?) sciatica is just a different manifestation of shingles. Applying heat to the virus for lengthy periods inactivated it, just as applying heat to a viral (or bacterial) respiratory infection clears it more quickly. Kind of like an artificial fever, perhaps. Sciatica is often treated by alternating hot and cold packs every 20 minutes or so - the hot packs to increase circulation and removal of toxins from the area, the cold packs to reduce swelling. However, I believe applying heat steadily for 3 hours or more is much more effective in deactivating the virus. It's important to recognize, though, that, as long as the heat is on, the swelling (and pain) will continue. But, after the heating pad is shut off and there is a cooling-down period of an hour or two, the swelling and pain will have decreased. Each time the viruses are heated and deactivated further, the cool-down period will be followed by improvement of symptoms, until the symptoms are gone. However, as mentioned above, I believe that, even when the symptoms are gone, it is important to continue with the heating pad for several days until the virus has really made a solid retreat. (I believe if I had continued with the heating pad initially, there would not have been the flare-up last week. I hope this will be useful. Rachel G Belden Competing interests: None declared |
|||
|
|
|||
|
Emma M Clark, SpR Rheumatology Royal National Hospital of Rheumatic Diseases, Bath. BA1 1RL, David R Blake
Send response to journal:
|
Sirs: We elected to discuss this article at our weekly Rheumatology Journal Club and it was suggested, by one of us, that as a clinical review it was about as useful as recent flood defences at Tewksbury! Moderate opinion considered this a little harsh, but we concluded that starkly stating that “analgesics, NSAIDs and muscle relaxants do not seem to be more effective than placebo in reducing symptoms” of sciatica, without stressing that absence of evidence, is not evidence of absence of effect, is exceptionally misleading. We wondered if the authors, who presumably have not experienced sciatica, were suggesting that we do not prescribe analgesics to our patients? Clinical experiential knowledge, acquired over years, clearly indicates that the pain of sciatica may be variably assisted by analgesics. Temporary comfort is afforded which aids mobility. The fact that three years later there may be no difference between those that had analgesics and those that didn’t is not the point. This pragmatic observation that analgesics may provide short lived comfort for those with sciatica is made many times every day and it is wrong to ignore this in a systematic review. The word systematic “indicates a methodical analysis”. There is nothing methodical in ignoring extensive clinical expertise: It is foolish and of course potentially dangerous when misused by a “health economist” who may be motivated by a distorted political agenda. Such things we believe happen. Otherwise we liked the review! Competing interests: None declared |
|||
|
|
|||
|
Mathias Rosenbaum, GP, chiropraktor, MDT practitioner Lübeck germany
Send response to journal:
|
As nobody, either by imaging or clinical examination, can "identify the underlying cause" but obviously some guys are able to give relief, why the hell do we continue wasting money to identify unidentifiable pathomorphology instead of studying what gives pain relief? Why also don't we study clinical predictors like symptom response to mechanical (what else is osteopathy or physiotherapy?) and repeated mechanical procedures leading to the clear formulation of subgroups of what seems to be a clue to sucessful management of back pain? The MDT/McKenzie group again and again produces evidence to do so which not a single back pain therapist, either doctor or physiotherapist, should afford to ignore without disadvantaging his patients. Testing for centralisation (and non- centralisiation) on repeated mechanical loading is a highly predictive measure for managing back pain- intentionally ignoring! the "precise underlying pathological- anatomical source" after exclusion of redflags. We had a look at bacteria in stomachs for something around sixty years in the last century and operated on millions of ulcerated stomachs without recognizing the meaning of an obvious - and reliable - finding, whose realization lead to a never expected success of peptic ulcer therapy. Ignoring reliability and validity of the assessements of symptom response and centralisation findings reminds me strongly of this pre-eradication period in internal medicine. But how long can we afford to go on wasting money for unnecessary imaging, non-specific treatments (what you see is what you get...) which never showed that they are more effective than waiting for "natural" improvement, or to operate on millions of backs instead of stomachs? Competing interests: None declared |
|||
|
|
|||
|
Charles S Galasko, Emeritus Professor Orthopaedic Surgery Retired
Send response to journal:
|
Re: Koes et al. Diagnosis and treatment of sciatica, 23 June 2007 . The advice given in this clinical review is dangerous. If cauda equina syndrome is suspected or the patient suffers acute severe paresis or progressive paresis the patient must be sent to hospital and preferably a spinal unit immediately. All the evidence suggests that decompression of an impending or developing cauda equina syndrome gives the patient the optimum chance of recovery of bladder function, bowel function, muscle weakness etc. whereas a delay, even of hours, can substantially effect the outcome resulting in permanent bladder dysfunction, bowel dysfunction, impotency in males, loss of vaginal sensation in females, other sensory disturbances and muscle weakness. Yours faithfully Professor Charles S B Galasko Competing interests: None declared |
|||
|
|
|||
|
Jaykar R Panchmatia, Orthopaedic surgery trainee University College London Hospital, NW1 2PG
Send response to journal:
|
I read Koes et al with great interest. I think that a greater emphasis needs to be placed on the importance of recognising cauda equina syndrome early and conveying clinical findings to a spinal unit succinctly and with clarity. Compression of the cauda equina is a surgical emergency. Prompt diagnosis, referral to a spinal unit and treatment are essential in ensuring a good outcome. Access to MRI scanners is often limited; consequently the clinical findings of the referring doctor are key. Here are a few tips on how to assess a patient with suspected cauda equina syndrome and effectively communicate your findings to the on- call spinal surgeon: History • Does the patient have back pain and/ or sciatica? Is the sciatica
unilateral or bilateral?
Examination • When conducting a locomotor and neurological examination complete a
detailed assessment of sensation around the anus, genitals and perineum.
If the patient has a catheter, tug it gently- can the patient feel this?
Finally • Empathise with the patient- the symptoms of cauda equina syndrome
can be both frightening and embarrassing
Competing interests: None declared |
|||
|
|
|||
|
Matthew E Smith, Specialist registrar in Rehabilitation Medicine Mid Yorkshire NHS Trust, Rory O'Connor, Senior Lecturer and Honorary Consultant in Rehabilitation Medicine, Leeds PCT and Leeds Teaching Hospitals NHS Trust
Send response to journal:
|
We note with interest the outcome of the study by van den Hout et al. and the accompanying economic analysis. The trial contained a number of unusual aspects that make it hard for us to agree with the conclusion that surgery is effective in reducing pain in the short term. Firstly, as is clearly stated, the research nurses collecting outcome data were not blinded as to which trial arm their patients were enrolled on. Furthermore, the same research nurses were heavily involved in the management of patients. Another curious feature of this trial was that all patients in the surgical arm were given physiotherapy and cared for in nine specialist centres, while the ‘control’ arm patients were cared for by presumably a large number of different GP’s and did not routinely access physiotherapy. It is not stated whether these patients were able to access their web based information resources(1). What is particularly striking about this trial is that not a single patient undergoing surgical treatment suffered a serious neurological adverse event. As the accompanying editorial points out, the risk of neurological damage related to surgery is around 1%(2). The lifetime costs of paraplegia(3) would greatly alter any cost benefit analysis whether economic or psychosocial. The small chance of cauda equina syndrome or paraplegia following surgery combined with the knowledge that long term outcomes would not improve, makes early surgery an unattractive option for patients, despite the authors’ conclusions. Sciatica due to lumbar disc herniation is highly refractory to medical interventions.(2,4) This study highlights only one aspect of lumbar root pain and does not consider the multifactorial input from psychosocial issues inherent in most pain diagnoses. We would welcome a Cochrane review of available evidence for managing this common and disabling condition and a randomised control trial of surgery against this best available evidence. 1. Wilco C. Peul, Hans C. van Houwelingen, Wilbert B. van den Hout, Ronald Brand, Just A.H. Eekhof, Joseph T.J. Tans, Ralph T.W.M. Thomeer, Bart W. Koes. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:2245-56 2. Jordon J, Konstantinou K, Morgan TS, Weinstein J. Herniated lumbar disc. Clin Evid 2007 http://clinicalevidence.bmj.com/ceweb/conditions/msd/1118/1118.jsp 3. Michael M. Priebe, MD, Anthony E. Chiodo, MD, William M. Scelza, MD, Steven C. Kirshblum, MD, Lisa-Ann Wuermser, MD, Chester H. Ho, MD. Spinal cord injury medicine. 6. Economic and societal issues in spinal cord injury. Arch Phys Med Rehabil 2007;88(3 Suppl 1):S84-8. 4. Luijsterburg PA, Verhagen AP, Ostelo RW, van Os TA, Peul WC, Koes BW: Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spine J. 2007 16:881–899 Competing interests: None declared |
|||