Treating sciatica in the face of poor evidence
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e487 (Published 13 February 2012) Cite this as: BMJ 2012;344:e487All rapid responses
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Dr Chou fails to grasp the difference by definition between dermatome and dynatome when describing the distribution of sensation versus the distribution of pain.
He seems not to have read his own editorial, in which he states that compression of nerves is most common as the nerves exit the spinal canal.
Competing interests: No competing interests
Dr. Bernhard and Dr. Grayson both suggest that an editorial1 on drugs for sciatica/radiculopathy should have addressed surgery and epidural steroid injections. However, both the editorial—and the systematic review2 which it commented on—focused on the benefits and harms of systemic drugs. Other types of treatment for sciatica, including surgery or epidural steroids, have been reviewed elsewhere.3, 4 Indeed, most trials of epidural steroids for radiculopathy show some short-term benefit compared with a sham procedure, but no long-term benefits.3 For surgery, some trials also found that short-term benefits compared with non-surgical therapy were no longer present with more prolonged follow-up.4
As Dr. Bernhard points out, L4/L5 and L5/S1 refers to disc levels. The nerve roots that are affected by disc herniations at these levels can vary depending on the location of the herniation, though the corresponding nerve roots usually affected are L5 and S1. Pain and motor deficits associated with L5 and S1 radiculopathy are usually in typical dermatomal and myotomal distributions, though overlap and variation can occur.5 I did not state that radiculopathy is primarily caused by far lateral extraforaminal protrusions. In fact, compression can occur anywhere along the nerve root after it emerges from the spinal cord. Regardless, the specific location of nerve root compression and the dermatomal distribution of symptoms has no bearing on drug effectiveness or drug choices for this condition.
References:
1. Chou R. Treating sciatica in the face of poor evidence. BMJ 2012;344:e487
2. Pinto RZ, Maher CG, Ferreira ML, Ferreira PH, Hancock M, Oliveira VC, McLachlan AJ, Koes B. Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ 2012;344:e497
3. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine 2009;34:1078-93.
4. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine 2009;34:1094-109
5. Vroomen PC, de Krom MC, Wilmink JT. Pathoanatomy of clinical findings in patients with sciatica: a magnetic resonance imaging study. J Neurosurg: Spine 2000;92:135-41
Competing interests: Research funding from the American Pain Society to develop guidelines on low back pain evaluation and treatment; consultant for Wellpoint, Blue Cross Blue Shield Association, and Palladian Health (all of which deliver or manage healthcare and do not manufacture drugs)
L4/5 and L5s1 are disc levels.
The roots are L5 and S1. Cochrane reviews and at least two randomised prospective trials demonstrate efficacy of surgery. Pain occurs in a dynatomal distribution which is less specific than a dermatomal one.
The commonest anatomical locations for nerve compression by disc protrusion are within the spinal canal, typically the posterolateral protrusion and the central one. The far lateral extraforaminal protrusion is rather rare. I cannot understand why this review was published when it is full of fundamental errors. The author clearly does not understand the condition he is writing about. I hope he does not have to treat it.
Competing interests: No competing interests
This article is a disgrace. Dr Chou, who is probably not a rheumatologist or musculoskeletal physician, does not seem to have heard of epidural injections with steroid. There is plenty of evidence of the efficacy of this treatment in sciatica, and it is wrong for an editorial article to appear to state that there is no treatment with evidence. Non-specialist doctors resding this article will get a completely wrong impression. Oral drug treatment is not enough. If Dr Chou had sciatica he would want to be properly treated and should have one or more epidural injections. I will not quote a lot of articles here but just one, one of the best: K. Bush and S. Hillier, 1991, Spine, 16, 572-5, entitled A Controlled Trial of Caudal Epidural Injections of Triamcinolone plus Procaine in the Management of Intractable Sciatica.
Competing interests: No competing interests
Whilst it is clear that there is very little evidence in supporting any guide in drug choices in patients with lumbosacral radiculopathy, acute care physicians both in primary and secondary care often fail patients on another level.
This condition is often a chronic and debilitating one not only because of its physical manifestation but also its psychological consequences that are almost always underestimated. It has direct effects on simple daily activities like emptying the dishwater and there is extensive evidence to suggest it is infrequently accompanied by a certain element of depression.
I remember walking out of the MR scan suite with tears in my eyes thinking this would be the end of a healthy life style I always managed to match with a busy clinical one. I however stumble across a fantastic osteopath (not a clinician!) who had a very frank and amicable chat with me.
This condition is about understanding it, accepting it and most important implementing changes in your everyday life.
It is not the end of physical exercise or indeed the end of the world! The rush of endorphins I used to get at those spinning classes or weight-lifting sessions were replaced by those I gained at swimming or pilates classes.
Anxiety, stress (and depression?) increase the amount of pain which results in muscle spasms, a vicious circle.
The advice was clear and sound: change your life style and fight depression.
Four months after my injury, I was back at the gym and cope fine (ignore?) with my limb numbness.
More importantly, my professional vision changed completely and I found myself giving advice to patients about body posture, exercise, support rather than prescribing medications that notoriously make little difference.
A holistic approach is what is often most needed here, not a prescription pad!
Competing interests: The author suffers from lumbosacral radiculopathy himself
Re: Treating sciatica in the face of poor evidence
I want to second the writer who recommended swimming and pilates. I have tried various drug regimes - currently amitryptillin and gabapentin -and they do seem to dull the pain but I have experienced the most long-lasting relief and improved mental wellbeing from swimming and pilates. I signed up for swimming lessons to learn front crawl - since breaststroke can exacerbate back problems - and I still attend weekly. I take pilates classes twice a week and do 15 minutes of pilates/physio exercises every morning. Perhaps it is the experience of being able to do something for myself rather than being a passive drugtaker that helps. GPs should recommend both of these activities to patients - and why not some RCTs too?
Competing interests: No competing interests