Diagnosis and treatment of sciatica
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39223.428495.BE (Published 21 June 2007) Cite this as: BMJ 2007;334:1313
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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?
• Ask specifically about bowel and bladder dysfunction. If the patient is
unable to pass urine assess whether this is due to a hypotonic bladder and
reduced sensation or due to severe pain resulting in a fear of passing
urine
• Ask about any sexual dysfunction
• Document the duration of all symptoms
• Ask about risk factors including a history of disc disease, neoplasia,
infection and trauma.
• Ask the patient about their previous level of fitness and ask if they
are taking any anticoagulants including aspirin.
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?
• Are Achilles tendon reflexes present bilaterally?
• Does the patient have a palpable bladder?
• Was anal sphincter tone present on digital rectal examination?
Finally
• Empathise with the patient- the symptoms of cauda equina syndrome
can be both frightening and embarrassing
• Empathise with the spinal surgeon- he/ she is making a decision based on
your findings and is often working with limited resources such as
available beds
• If you are unsure seek the advice of a colleague
• Re- assess the patient frequently
• Document your findings clearly- cauda equina syndrome is a common source
of litigation
Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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,
Your potent and infectious fevers heap
On Athens, ripe for stroke! Thou cold sciatica,
Cripple our senators, that their limbs may halt
As lamely as their manners.
William Shakespeare: Timon of Athens, Act IV. Scene I
Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
Early Surgical Intervention in Sciatica
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
Competing interests: No competing interests