Diagnosis and treatment of sciatica

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

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

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

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