Sciatica: which intervention?

doi:10.1136/bmj.319.7205.302

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Ash Samanta, consultant,
Jo Beardsley, research assistant

Department of Rheumatology, Leicester Royal Infirmary NHS Trust, Leicester LE1 5WW

Correspondence to: A Samanta

Accepted 9 February 1999

Low back pain with sciatica is one of the most common complaints for which patients seek medical advice, and the condition has considerable economic consequences in terms of healthcare resources and lost productivity. Most patients return to their normal activities within six months. For many patients, such as the one described below, a lengthy spell off work can have serious repercussions, and a rapid return to work is imperative.

Summary points

Conservative management of sciatica may fail to bring relief, and a more invasive treatment is required

Evidence shows that an epidural injection of corticosteroids produces short term relief; adverse effects are few and not usually serious

Chemonucleolysis or discectomy have higher success rates but a greater risk of more serious adverse events

Long term results after surgery are only slightly better than non-surgical intervention

Patients require an individualised approach using best evidence and the application of clinical art and expertise

Case report

A man of 27 presented with low back pain of acute onset that was complicated by pain radiating down his right leg. The problem had coincided with a recent spell of gardening and had worsened progressively over the next few days, ultimately developing into numbness and tingling of the right foot. Although analgesics had controlled the pain, his foot had become noticeably weaker. At this stage he had consulted his general practitioner.

He was found to be fit and healthy; he had no history of similar complaints Physical examination showed that he had reduced forward flexion of the lumbar spine; straight leg raising was limited to 45° on the right hand side. A sciatic stretch test on his right leg had positive results, and responses to light touch and pin prick were reduced on the lateral side and over the dorsum of the right foot. …