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<div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox">
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'''Original Editors'''<span style="line-height: 1.5em;">&nbsp;</span>[[User:Daan Vandebriel|Daan Vandebriel]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;
== Introduction ==
</div>
Sciatica refers to radiating pain along the course of the [[Sciatic Nerve|sciatic nerve]]  from the lower back or buttock to one or both legs or an associated [[Sacral Plexus|lumbosacral nerve root]].
== Search Strategy  ==


Databases:  
A common mistake is referring to any [[Low Back Pain|low back pain]] or [[Radiculopathy|radicular]] leg pain as sciatica<ref name=":6" />.


*PubMed
Sciatica is a clinical diagnosis based on the presence of radiating pain in one leg, with or without the associated neurological deficits of parasthesia and muscle weakness<ref name=":3">Jensen RK, Kongsted A, Kjaer P, Koes B. Diagnosis and treatment of sciatica. BMJ. 2019 Nov 19;367:l6273. </ref>, which are the direct result of sciatic nerve or sciatic nerve root pathology.
*PEDro
*Google Scholar
*Web of Knowledge


<br>  
Sciatica pain often is worsened with flexion of the [[Lumbar Anatomy|lumbar spine]], twisting, bending, or coughing<ref name=":6" />.
[[File:Sciatic_nerve.png|alt=|right|frameless|372x372px]]


Keywords:
== Anatomy ==
The sciatic nerve is made up of the L4 through S2 nerve roots which coalesce at the [[pelvis]] to form the sciatic nerve. At up to 2 cm in diameter, the sciatic nerve is easily the largest nerve in the body. 


Sciatica, low back pain, sciatica AND diagnosis, sciatica AND differential diagnosis, low back pain AND differential diagnosis, straight leg raise, piriformis syndrome AND sciatica, sciatica AND neurological test, sciatica AND test, sciatica AND treatment, sciatica AND pain, sciatica AND physical therapy.<br>
The sciatic nerve provides direct motor function to the [[hamstrings]], lower extremity [[Hip Anatomy|adductors]], and indirect motor function to the [[Gastrocnemius|calf muscles]], [[Tibialis Anterior|anterior lower leg muscles]], and some intrinsic [[Foot Anatomy|foot]] muscles.


== Definition/Description  ==
Indirectly through its terminal branches, the sciatic nerve provides sensation to the posterior and lateral lower leg as well as the plantar foot.
== Etiology ==


<span style="line-height: 1.5em;">Sciatica is the result of a neurological problem in the back or an entrapped nerve in the pelvis or buttock<ref name="Ardman et al.">Ardman C. et al., Sciatica Solutions: Diagnosis, treatment and cure of spinal and piriformis problems, 1st edition, W.W. Norton &amp;amp;amp;amp;amp;amp;amp;amp; Company, 2007</ref>.
Any condition that may structurally impact or compress the sciatic nerve may cause sciatica symptoms.  
There are a set of neurological symptoms such as: </span>


*<span style="line-height: 1.5em;">Pain (intense pain in the buttock)</span>
[[Sciatic Nerve Injury|Sciatic nerve injury]] can also result in sciatica symptoms (such as pain, muscle weakness and paresthesia) and is usually caused by a traumatic injury (pressure, stretching or cutting), rather than compression or irritation of the nerve. Please read our [[Sciatic Nerve Injury|sciatic nerve injury]] page for more information.
*<span style="line-height: 1.5em;">Lumbosacral radicular leg pain</span>
*<span style="line-height: 1.5em;">Numbness</span>
*<span style="line-height: 1.5em;">Muscular weakness</span>
*<span style="line-height: 1.5em;">Gait dysfunction</span>
*<span style="line-height: 1.5em;">Sensory impairment</span>
*<span style="line-height: 1.5em;">Sensory disturbance</span>
*<span style="line-height: 1.5em;">Hot and cold or tinglings or burning sensations in the legs</span>
*<span style="line-height: 1.5em;">Reflex impairment</span>
*<span style="line-height: 1.5em;">Paresthesias or dysesthesias and oedema in the lower extremity that can be caused by the irritation of the sciatic nerves (the lumbar nerve L4 and L5 and the sacral nerves S1,S2 and S3).<ref name="Ardman et al." /><ref name="Jacobs et al.">Jacobs W. et al., Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review (of RCT’s) (1A)</ref><ref name="Ailianou et al.">Ailianou A. et al., Review of the principal extra spinal pathologies causing sciatica and new MRI approaches., The Britisch Journal of Radiology, 2012, 85(1014): 672-681 (2C)</ref>
</span>


The causes of sciatica can be categorised into spinal or non-spinal causes  or iatrogenic<ref name=":10" />:


'''Spinal causes:'''
* [[Spinal Stenosis|Spinal stenosis]] (due to degenerative bone disorders, trauma, inflammatory disease)
* [[Spondylolisthesis]]
* [[Lumbar Discogenic Pain|Herniated or bulging lumbar intervertebral disc]]
* Spinal or paraspinal mass ([[Oncology|malignancy]], [[Overview of Traumatic Brain Injury|epidural hematoma]] or abscess)<ref name=":0">Davis DH, Wilkinson JT, Teaford AK, Smigiel MR. Sciatica produced by a sacral perineurial cyst. Tex Med. 1987 Mar;83(3):55-6.</ref>


<br>
'''Non Spinal causes:'''
*[[Piriformis Syndrome|Piriformis syndrome]]
*[[Pregnancy Related Pelvic Pain|Pregnancy]]
*[[Lumbar Radiculopathy]]
* Pelvic tumours
* Trauma to leg


== Clinically Relevant Anatomy  ==
'''Iatrogenic causes:'''
*Direct surgical trauma
*Faulty positioning during anaesthesia
*Injection of neurotoxic substances
*Tourniquets
*Dressings, casts or faulty fitting orthotics
*Radiation


<span style="line-height: 1.5em;">The nerves that are involved with sciatica form the terminal of the [[Lumbosacral Biomechanics|lumbosacral plexus]]: L4-L5-S1-S2-S3<ref name="Ailianou et al." />&nbsp;</span><br>
== Epidemiology ==


== Epidemiology /Etiology<br> ==
* Annual incidence of 1% to 5%<ref name=":6">Davis D, Maini K, Vasudevan A. Sciatica. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2020. PMID: 29939685.</ref>
* Lifetime incidence reported between 10% to 40%<ref name=":6" />
* No gender predominance<ref name=":6" />
* Peak incidence occurs in patients in their fourth decade<ref name=":6" />
* Rarely occurs before age 20 (unless traumatic)<ref name=":6" />
* No association with body height has been established except in the age 50 to 60 group<ref name=":6" />
* Increased incidence in those with poor general health (including presence of co-morbidities and smoking) and the presence of psychological factors such as depression<ref name=":4">Parreira P, Maher CG, Steffens D, Hancock MJ, Ferreira ML. Risk factors for low back pain and sciatica: an umbrella review. Spine J. 2018 Sep;18(9):1715-1721.</ref>
* [[Physical Activity|Physical activity]] increases incidence in those with prior sciatic symptoms and decreased in those with no prior symptoms<ref name=":6" />.
* Occupational predisposition has been shown in machine operators, truck drivers, and jobs where workers are subject to physically awkward positions<ref name=":0" /> or physical stress on the spine such as vibration<ref name=":4" />
== Clinical Presentation ==
[[File:Lower-dermatomes.jpg|right|frameless]]
Patients with sciatica can present with neurological symptoms such as:
*Radicular pain in the distribution of the lumbosacral nerve root
*Sensory impairment/disturbance, such as hot and cold or tingling/ burning sensations in the legs or numbness
*Muscular weakness
*[[Reflexes|Reflex]] impairment
*[[Gait and Lower Limb Observation of Paediatrics - (GALLOP)|Gait]] dysfunction


Sciatica can begin suddenly and symptoms may be intermittent or constant. Symptoms may worsen with increased intra-abdominal pressure (for example coughing). <ref name="Ailianou et al." /><ref name="4">Jacobs W. et al., Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review (of RCT’s) (1A)</ref>  
Sciatica symptoms of  paresthesias or dysesthesias and oedema in the lower extremity can differ, depending on which nerve is affected<ref name="Koes" /><ref name="Kika" />
 
*'''L4:''' When the L4 nerve is compressed or irritated, the patient feels pain, tingling and numbness in the thigh. The patient also feels weak when straightening the leg and may have a diminished knee jerk reflex.
<br> The most common cause of Sciatica is compression of the sciatic nerve (nerve root, L4, L5, S1, S2, S3) by a herniated disc. <ref name="Ardman et al." /><ref name="Ailianou et al." />
*'''L5:''' When the L5 nerve is compressed or irritated, the pain, tingling and numbness may extend to the foot and big toes.
 
*'''S1:''' When the S1 nerve is compressed or irritated, the patient feels pain, tingling and numbness on the outer part of the foot. The patient also experiences weakness when elevating the heel off the ground and standing on tiptoes. The ankle jerk reflex may be diminished.
<span style="line-height: 1.5em;">Other causes of sciatica can include:</span>
== Differential Diagnosis  ==
 
A thorough differential list is important in considering a diagnosis of sciatica and should include:
*Spinal stenosis <ref name="Ardman et al." /><ref name="Lewis et al.">Lewis R. et all., The clinical effectiveness and cost-effectiveness of management strategies for sciatica: a systematic review and economic model, Health Technology Assessment 2011, Vol. 15: no.39 (1A)</ref>
* Herniated lumbosacral [[Disc Herniation|disc]]
*Spondylosis: a degenerative spinal osteoarthritis&nbsp;<ref name="Ardman et al." />
* [[Cauda Equina Syndrome|Cauda Equina]] syndrome
*Nerve entrapment: a muscle in the buttock may compress the sciatic nerve and cause pain. For example the piriformis syndrome.<ref name="Ardman et al." />
* [[Muscle Injuries|Muscle]] spasm
*Inflammation and swelling from arthritis, sprains, joint slippage or infection. Infections can be caused by iliopsoas, pelvic and gluteal abscesses. <ref name="Ardman et al." /><ref name="Ailianou et al." />
* Nerve root impingement
*Vascular problems: due to increased blood volume in the spine during the late stages of pregnancy, the fixed space inside the spinal cord may narrow and cause compression on the nerves.<ref name="Ardman et al." />
* Epidural abscess
*Central mechanisms: stroke, cerebral hemorrhage or sclerosis can cause pain in the sciatic area.<ref name="Ardman et al." />&nbsp;
* Epidural hematoma
*Traumatic pathologies: <ref name="Ailianou et al." /><ref name="Lewis et al." />
* [[Renal Cancer|Tumor]]
 
* [[Pott's Disease|Potts Disease]], also known as spinal tuberculosis
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; o Proximal hamstring injuries/avulsions<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; o Compression of the adjacent sciatic nerve caused by edema, inflammation and haematoma formed around the affected tendon.
* [[Piriformis Syndrome|Piriformis syndrome]]
 
*Gynecological pathologies:&nbsp;<ref name="Ailianou et al." />
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; o Ectopic endometriosis, ovarian cysts and pregnancy may result in sciatica. The right side is more commonly affected.<br>
 
Rare causes of Sciatica:&nbsp;<ref name="Ailianou et al." /><br>


*Osteochondroma can affect the lumbar spine and the femoral neck, which can result in sciatic nerve compression
== Evaluation  ==


<br>
Sciatica is most commonly diagnosed by:


== Characteristics/Clinical Presentation  ==
'''History:'''


The hallmark symptom of sciatica is pain. The type of pain can vary: it may be sharp, feel like electric shocks, discomfort or <br>numbness… <ref name="Ardman et al." /><br>Pain is a result of irritation of the sciatic nerve<ref name="Ailianou et al." />. As stated above, it can be constant or intermittend<ref name="Ardman et al." />. The pain may be worsened by certain movements like coughing or sneezing (these movements increase the intra abdominal pressure)<ref name="Lewis et al." />. Sitting, bending, prolonged standing or rising from a sitting position can aggravate or increase the pain. In regards to relief the pain, the supine position decreases the pressure on the herniated disc and will subsequently decrease pain<ref name="Ailianou et al." />. Pain is located along the distribution of the nerve and can be felt in the back, buttocks, knee and leg. It only radiates to one side of the leg and can result in reduced power, reflexes and sensation in the nerve root<ref name="Lewis et al." />. Also gait dysfunction (toe walking, foot drop and knee buckling)<ref name="Ardman et al." />, paresthesias or dysesthesias are frequent neurological symptoms<ref name="Ailianou et al." />.  
Complaints of radiating pain in the leg, which follows a [[Dermatomes|dermatomal pattern]]<ref name="Koes">Koes BW, van Tulder MW, Peul WC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1895638/pdf/bmj-334-7607-cr-01313.pdf Diagnosis and treatment of sciatica]. BMJ. 2007 Jun 23;334(7607):1313-7. </ref>
* Pain generally radiates below the knee, into the foot<ref name="Kika">Konstantinou K, Lewis M, Dunn KM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481089/pdf/586_2012_Article_2398.pdf Agreement of self-reported items and clinically assessed nerve root involvement (or sciatica) in a primary care setting.] Eur Spine J. 2012 Nov;21(11):2306-15.</ref>
* Patients complain about low back pain, which is usually less severe than the leg pain<ref name="Koes" />
* Patients may also report sensory symptoms.
'''Special tests:'''


<span style="line-height: 1.5em;">Sciatica can be caused by the compression or irritation of nerve L4, L5, S1, S2 and S3. The sciatica symptoms depend on which nerve is compressed or irritated.</span>
Clinicians should always look for and inquire about [[The Flag System|red flags]] when evaluating sciatica or in patients who present with any low back pain. Patients with signs of urinary retention or decreased anal sphincter tone should be urgently referred for investigation as this suggests [[Cauda Equina Syndrome|cauda equina syndrome]].


*L4:When the L4 nerve is compressed or irritated the patient feels pain, tingling and numbnessiIn the thigh. The patient also feels weak when straightening the leg and may have a diminished knee jerk reflex.<br>
*'''Lasègue’s test'''
*L5:When the L5 nerve is compressed or irritated the pain, tingling and numbness may extend to the foot and big toes.<br>
*S1:When the S1 nerve is compressed or irritated the patient feels pain, tingling and numbness on the outer part of the foot. The patient also experiences weakness when elevating the heel off the ground and standing on tiptoes. The ankle jerk reflex may be diminished.


[[Image:Lower-dermatomes.jpg]]  
Also called as [[Straight Leg Raise Test|straight leg raising test]] (SLR) is the most commonly performed physical test for diagnosis of sciatica and lumbar disc hernia . The SLR is considered positive when it evokes radiating pain along the course of the sciatic nerve and below the knee between '''30''' and '''70''' degrees of '''hip flexion'''. Studies of its capacity to diagnose lumbar disc hernia show high sensitivity but low specificity.<ref name=":7">Kamath SU, Kamath SS. Lasègue’s sign. J Clin Diagn Res [Internet]. 2017 [cited 2023 Mar 27];11(5):RG01–2. Available from: <nowiki>http://dx.doi.org/10.7860/JCDR/2017/24899.9794</nowiki></ref>
{{#ev:youtube|JmvGHszR_X4}}
<ref>Clinical Examination Videos. Straight leg raise test - Lasegue’s sign [Internet]. Youtube; 2017 [cited 2023 Mar 27]. Available from: https://www.youtube.com/watch?v=JmvGHszR_X4
</ref>


== Differential Diagnosis  ==
* '''Bragard test'''


*Non-specific low back pain (box 2)&nbsp;<ref name="Ardman et al." />
[[Bragard's Sign|Bragard test]] is a modification of the SLR, where ankle dorsiflexion is applied at the end of the SLR. Dorsiflexion reduces the SLR angle at which the test is positive and can be used to differentiate neural symptoms from musculoskeletal symptoms.<ref name=":7" />
*[[Piriformis Syndrome|Piriformis syndrome]]<ref name="Lewis et al." />&nbsp;
[[File:Bragard test.jpg|center|thumb|Distal structural differentiation for proximal symptoms with ankle dorsiflexion (also known as Bragard test)]]
*Muscular problems (sprain, spasm, …)<ref name="Ardman et al." />  
*Vascular problems (claudication, [[Compartment Syndrome|compartment syndrome]]&nbsp;<ref name="Ardman et al." />)
*[[Lymphatic Obstruction (Lymphedema)|Chronic edema]]<ref name="Ardman et al." />


<br>
* '''[[Bowstring Sign|Bowstring test]]'''


== Diagnostic Procedures  ==
Also known as the popliteal compression test or posterior tibial nerve stretch sign. The patient can be examined in sitting or in a supine position. The examiner flexes the knee and applies pressure on the popliteal fossa, evoking sciatica. Some examiners do it after SLRT by flexing the knee to relieve the buttock pain. The pain would be reproduced by a quick snap on the posterior tibial nerve in the popliteal fossa.<ref>Das JM, Nadi M. Lasegue Sign. StatPearls Publishing; 2022.</ref>


Sciatica is most commonly diagnosed by:<br>  
{{#ev:youtube|v=orb-VI51QF0&t=11s|300}}<ref>CRTechnologies. Bowstring Test (CR). Available from: http://www.youtube.com/watch?v=orb-VI51QF0&t=11s [last accessed 03.04.2023]</ref>


History taking: <br>&nbsp; &nbsp; &nbsp;o Complaints of radiating pain in the leg, which follows a dermatomal pattern<ref name="Koes">B.W Koes, M.W Van Tulder, W.C Peul. Diagnosis and treatment of sciatica. BMJ, 23 JUNE 2007, VOLUME 334, p.1313-1314 (1A)</ref>.<br>&nbsp; &nbsp; &nbsp;o Pain generally radiates below the knee, into the foot<ref name="Kika">Kika Konstantinou, Martyn Lewis, Kate M. Dunn. Agreement of self-reported items and clinically assessed nerve root involvement (or sciatica) in a primary care setting. Eur Spine J (2012) 21:2306–2315. (1B)</ref>.<br>&nbsp; &nbsp; &nbsp;o Dermatome maps used to locate the distribution of the pain<ref name="Koes" />.<br>&nbsp; &nbsp; &nbsp;o Patients complain about low back pain, which is usually less severe than the leg pain<ref name="Koes" />.<br>&nbsp; &nbsp; &nbsp;o Patients may also report sensory symptoms).
'''Imaging:'''


The diagnostic value of patient history and physical examination has not been sufficiently studied<ref name="Koes" /><ref name="8">Kenneth Jeffrey Miller DC, DABCO. Physical assessment of lower extremity radiculopathy and sciatica. Journal of Chiropractic Medicine (2007) 6, 75–82 (2C)</ref>. Overall, if a patient reports radiating pain in one leg and has a positive result on one or more neurological tests, indicating nerve root tension or neurological deficit, the diagnosis of sciatica seems justified<ref name="Koes" />.<br>The use of imaging to confirm the diagnosis of sciatica is not very useful<ref name="Koes" /><ref name="9">Abdelilah el Barzouhi, M.D., Carmen L.A.M. Vleggeert-Lankamp, M.D., Ph.D., Geert J. Lycklama, Nijeholt, M.D., Ph.D., Bas F. Van der Kallen, M.D.,Wilbert B. van den Hout, Ph.D., Wilco C.H. Jacobs, Ph.D.,Bart W. Koes, Ph.D., and Wilco C. Peul, M.D., Ph.D. Magnetic Resonance Imaging in Follow-up Assessment of Sciatica. New England Journal of Medicine, 368;11 nejm.org march 14, 2013, P.1000 (1B)</ref>. It may be indicated if there are red flags in the acute phase. Imaging may be indicated in patients with severe symptoms who fail to respond to conservative treatment for 6-8 weeks<ref name="Koes" /> or to find the underlying cause of the sciatica<ref name="9" />.<br><br>  
It may be used if pain persists for more than 12 weeks or the patient develops progressive neurological deficits<ref name=":3" />
* [[X-Rays|Plain films]] of the lumbosacral spine may evaluate for fracture or spondylolisthesis
* Noncontrast [[CT Scans|CT scan]] may be performed to evaluate fracture if plain films are negative
* In cases where the neurologic deficit is the present or mass effect is suspected, immediate [[MRI Scans|MRI]] is the standard of care in establishing the cause of the pain and ruling out pressing surgical pathology<ref name=":0" />


== Outcome Measures  ==
== Outcome Measures  ==
Many to choose from, below are but a few, all dependant on cause and assessment.
* [[36-Item Short Form Survey (SF-36)|Short Form-36]] bodily pain (SF-36 BP)
* [https://www.physio-pedia.com/index.php5?title=Oswestry_Disability_Index Oswestry disability index]
* [https://www.physio-pedia.com/index.php5?title=Roland%E2%80%90Morris_Disability_Questionnaire Roland-Morris disability index]
* [[Visual Analogue Scale|VAS-score]]: one of leg pain and one of back pain<ref name=":1">Brouwer PA, Peul WC, Brand R, Arts MP, Koes BW, van den Berg AA, van Buchem MA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697136/pdf/1471-2474-10-49.pdf Effectiveness of percutaneous laser disc decompression versus conventional open discectomy in the treatment of lumbar disc herniation; design of a prospective randomized controlled trial.] BMC Musculoskelet Disord. 2009 May 13;10:49.  </ref>
* [[McGill Pain Questionnaire|McGill pain Questionnaire]]<ref name=":1" />: this questionnaire looks at the location, intensity, quality and pattern of the pain as well as alleviating and aggravating factors<ref>Ngamkham S, Vincent C, Finnegan L, Holden JE, Wang ZJ, Wilkie DJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3285427/pdf/nihms-260699.pdf The McGill Pain Questionnaire as a multidimensional measure in people with cancer: an integrative review.] Pain Manag Nurs. 2012 Mar;13(1):27-51.</ref>
* [[Timed Up and Go Test (TUG)|TUG]]
* Tampa Scale for Kinesiophobia<ref name=":2">Monticone M, Ferrante S, Teli M, Rocca B, Foti C, Lovi A, Brayda Bruno M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897823/pdf/586_2013_Article_2889.pdf Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis.] A randomised controlled trial. Eur Spine J. 2014 Jan;23(1):87-95. </ref>
* [[Pain Catastrophizing Scale|Pain Catastrophising Scale]]<ref name=":2" />


*[[Oswestry Disability Index|The Oswestry Disability Index (ODI)<ref name="10">Dionne CE. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. 2008</ref>.<br>]]
== Medical Management    ==
 
[[File:Massage image.jpg|right|frameless]]
*[https://www.duo.uio.no/bitstream/handle/10852/28055/dravhandling-haugen.pdf?sequence=3 Sciatica Bothersomeness Index (SBI)<ref name="Patrick">Patrick DL. Assessing health-related quality of life in patients with sciatica. 1995 (2B)</ref>,<ref name="Grovle">Grøvle L. Reliability, validity, and responsiveness of the Norwegian versions of the Maine-Seattle Back Questionnaire and the Sciatica Bothersomeness and Frequency Indices. 2008.  (2B)</ref><br>]
Most patients improve over time with conservative treatment including exercise, manual therapy, and pain management<ref name=":3" />
 
* '''Pharmacology:''' a short course of oral [[NSAIDs in the Management of Rheumatoid Arthritis|NSAIDs]]; [[Pain Medications|Opioid and non-opioid analgesics]]; muscle relaxants; anticonvulsants for neurogenic pain; localized corticosteroid injections.
<br>
* '''Surgical evaluation:''' to address structural abnormalities such as: disc herniation, epidural hematoma, epidural abscess or tumour may be considered if no improvement following 6-8 weeks of conservative treatment<ref name=":3" />. One study found that although it may speed up recovery, the effect is similar to conservative care at one year<ref name=":3" />
 
* '''Physical therapy management'''
== Examination  ==
 
*Neurological testing<ref name="Koes" />
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; o Myotomes<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; o Reflexes (L4-S3)<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; o Sensations (Dermatomes)
 
*Neural tension tests (preferably in a seated position<ref name="8" />)<br>&nbsp; &nbsp; &nbsp; o [[Straight Leg Raise Test|Straight leg raise test]]<ref name="Koes" /><ref name="Kika" /><ref name="8" /><ref name="13">Lawrence M. Urban, BA, DPT. The Straight-Leg-Raising Test: A Review. JOSPT Vol. 2. No. 3, p.117-129</ref><br>&nbsp; &nbsp; &nbsp; o Crossed straight leg raise test<ref name="Koes" />,<ref name="Ailianou et al." /><br>&nbsp; &nbsp; &nbsp; o [[Slump Test|Slump test<ref name="8" />]]<br>&nbsp; &nbsp; &nbsp; o [[Femoral Nerve Tension Test|Femoral nerve tension test]]<ref name="Kika" /><br>
 
*Lumbar mobility assesment<ref name="Koes" />
 
== Medical Management <br>  ==
 
Ice or heat is often used in the treatment of sciatica. Heat or ice is usually placed on the affected area for 20 minutes every 2 hours <ref name="Mary">Marybetts Sinclair .Modern Hydrotherapy for the Massage Therapist. Wolters Kluwer.2008. P273-274.</ref> . <br>Medications are commonly prescribed for the treatment of Sciatica but evidence from clinical trials, suggesting the use of analgesics to relieve pain is limited <ref name="15">Sciatica (lumbar radiculopathy) - Management". http://www.cks.nhs.uk/sciatica_lumbar_radiculopathy/management/scenario_sciatica_lumbar_radiculopathy/treatment/basis_for_recommendation.</ref> .Research failed to show a significant difference between placebos, NSAIDs, analgesics, and muscle relaxants. There is limited evidence for the use of opioids and compound drugs <ref name="16">Vroomen, PC; De Krom, MC; Slofstra, PD; Knottnerus, JA (2000). "Conservative treatment of sciatica: a systematic review". Journal of Spinal Disorders 13 (6): 463–469. doi:10.1097/00002517-200012000-00001. PMID 11132976. (1A)</ref> , <ref name="17">Roelofs, Pepijn DDM; Deyo, Rick A; Koes, Bart W; Scholten, Rob JPM; Van Tulder, Maurits W (2008). "Non-steroidal anti-inflammatory drugs for low back pain". In Roelofs, Pepijn DDM. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD000396.pub3. PMID 18253976. (1A)</ref> .
 
For severe cases of sciatica an epidural steroid injection is often used. This treatment consists of an injection of a steroid in the affected area to reduce the inflammation and pain. The effects are temporary and can last from one week to a year. Epidural injections are not succesful for every patient <ref name="18">Larry P. Credit,Sharon G. Hartunian,Margaret J. Nowak .Relieving sciatica. Old Broadway.2000.p 16</ref> , <ref name="19">John Barrett,Douglas Noel Golding. The practical treatment of backache and sciatica. Redwood Burn Limited. 1984.p43-49.</ref> .<br>
 
For extreme cases of Sciatica elective surgery may also be an option. This surgery attempts to eliminate the underlying. When the underlying cause is lumbar spinal stenosis, a lumbar laminectomy surgery is recommended. With this surgery, the small portion of the bone and/or disc material that is pinching the nerve root is removed. In cases of where a disc is herniated, a microdescectomy is recommended. With this surgery a small opening is created and with the use of magnification the portion of the herniated disc that is pinching the nerve is removed. <ref name="20">Ludwig Ombregt,Pierre Bisschop,Herman J. ter Veer.A system of orthopaedic medicine, Volume 1 .Second edition.Churchil livingstone. 2003. P 929-934.</ref> , <ref name="21">John Barrett,Douglas Noel Golding. The practical treatment of backache and sciatica. Redwood Burn Limited. 1984.p97-103.</ref>
 
== Physical Therapy Management <br>  ==
 
In most cases of sciatica, conservative treatment is favored. However, there is still some controversy surrounding it. The evidence does not show that one treatment is superior to the other<ref name="22">Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Pim A. J. Luijsterburg, Arianne P. Verhagen, Raymond W. J. G. Ostelo, Ton A. G. van Os, Wilco C. Peul, Bart W. Koes. European Spine Journal July 2007, Volume 16, Issue 7, pp 881-899 (1A)</ref>. Therefore we will discuss the several treatment options.<br>
 
A very important part of the therapy can be informing the patient about sciatica and giving him advice<ref name="23">Physical therapy plus general practitioners’ care versus general practitioners’ care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Pim A. J. Luijsterburg, Arianne P. Verhagen, Raymond W. J. G. Ostelo, Hans J. M. M. van den Hoogen, Wilco C. Peul, Cees J. J. Avezaat and Bart W. Koes. Eur Spine J. 2008 April; 17(4): 509–517. Published online 2008 January 3. (1B)</ref>,<ref name="40">Lewis R, Williams NH, Sutton AJ, Burton K, Din N, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I, Wilkinson C. Comparative Clinical Effectiveness of Management Strategies for Sciatica: Systematic Review and Network Meta-Analyses. The Spine Journal  (2013), doi: 10.1016/j.spinee.2013.08.049. (1A)</ref>. But the education of sciatica is not yet investigated in randomized controlled trials<ref name="Koes" />,<ref name="40" />. During therapy it is very important to give patients necessary information, advice them about staying active and give them information about treatment modalities. It is very important that the patient is physically an active participant in therapy and can take responsibility in the treatment process. The physical therapist also needs to be a coach for the patient<ref name="24">The efficacy of systematic active conservative treatment for patients with severe sciatica: a single-blind, randomized, clinical, controlled trial. Albert HB, Manniche C. Spine (Phila Pa 1976). 2012 Apr 1;37(7):531-42. (1B)</ref>.<br>
 
Corticosteroid injections and traction are two treatment options that have limited evidence and are therefore not recommended for the treatment of sciatica<ref name="23" />,<ref name="24" />,<ref name="25">Traction for low-back pain with or without sciatica. Judy A Clarke2, Maurits W van Tulder1,*, Stefan EI Blomberg3, Henrica CW de Vet4, Geert J van der Heijden5, Gert Brønfort6, Lex M Bouter7 (1A)</ref>.&nbsp;If we compare bed rest as a treatment for sciatica with doing nothing at all, there seems to be no difference. On a short term there is no difference regarding overall improvement and pain and disability<ref name="22" />,<ref name="26">Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica. Hofstee DJ, Gijtenbeek JM, Hoogland PH, van Houwelingen HC, Kloet A, Lötters F, Tans JT. J Neurosurg. 2002 Jan;96(1 Suppl):45-9 (1B)</ref>,<ref name="40" />.<br>
 
In a few articles acupuncture has been proven to reduce pain in the back. The practice is centered on the philosophy of achieving or maintaining well being through the open flow of energy via specific pathways in the body. Hair-thin needles are inserted into the skin near the area of pain<ref name="27">Larry P. Credit,Sharon G. Hartunian,Margaret J. Nowak .Relieving sciatica. Old Broadway.2000.p 30-34.</ref><ref name="28">John Barrett,Douglas Noel Golding. The practical treatment of backache and sciatica. Redwood Burn Limited. 1984.p75-82.</ref><ref name="40" />. Other articles have found no reduction of pain with acupuncture<ref name="22" />.<br>
 
Massage therapy has proven to be useful with the treatment of back pain. It promotes blood circulation, muscle relaxation and the release of endorphins<ref name="29">Daniel C. Cherkin, Karen J. Sherman, Janet Kahn, Robert Wellman, Andrea J. Cook, Eric Johnson, Janet Erro, Kristin Delaney, Richard A. Deyo. A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain: A Randomized, Controlled Trial. Annals of Internal Medicine, 2011; 155 (1): 1-9 (1B)</ref>,<ref name="30">Larry P. Credit,Sharon G. Hartunian,Margaret J. Nowak .Relieving sciatica. Old Broadway.2000.p 65-71.</ref>,<ref name="31">Massage therapy helps to increase range of motion, decrease pain and assist in healing a client with low back pain and sciatica symptoms.Jada Bell. Journal of Bodywork and Movement Therapies Volume 12, Issue 3 , Pages 281-289, July 2008. (3B)</ref>. <br>
 
<u>Herniated Disc Sciatica Management</u>:
 
*Extension exercises or press ups are often prescribed; for example, Upper Back Extension<ref name="32">Stuart McGill.Low back disorders: evidence-based prevention and rehabilitation. Second edition. Human Kinetics. 2007.P222.</ref>.
 
<u></u>
 
<u>Spinal Stenosis Sciatica Management</u>:
 
*Flexion exercises of the lower back are suggested. Flexing the lower spine opens the spinal canal and allows the irritation or impingement to resolve. Stretching exercises for the back are forward flexion. For strengthening the abdominal muscles [[Hook-lying March|Hook-lying March]] and [[Curl-ups|Curl-Ups]] excercises are fequently used<ref name="33">http://www.spine-health.com/wellness/exercise/exercise-sciatica-spinal-stenosis (5)</ref>.
 
There is no evidence found for this management. Physical therapists use these exercises since it has been shown to have efficacy for some patients.<br>
 
<u></u>
 
<u>Degenerative Disc Disease Sciatica Management</u>:
 
*A dynamic lumbar stabilization program is recommended. Through this program the patient finds the most comfortable position for the lumbar spine and pelvis and attempts to maintain this position during activities. When performed correctly, this exercise can improve the proprioception of the lumbar spine and reduce the excess motion at the spinal segments. This reduces the amount of irritation at these segments, relieving pain and protecting the area from further damage. Examples of these exercises are; [[Hook-lying March|Hook-lying March]], [[Hook-lying march combination|Hook-lying March Combination]] and [[Bridging|Bridging]]<ref name="33" />.
 
<br>
 
<u>Spondylolisthesis Sciatica Management</u>:
 
*Flexion based exercises and stabilization excercises are included in this program. The objective of this program is to improve the stability of the lumbar spine in flexed positions. A few examples of exercices are: [[Hooked-lying march|Hooked-lying]]&nbsp;March; [[Curl-ups|Curl-Ups]] and [[Pelvic Tilt|Pelvic Tilt]]<ref name="33" />,<ref name="34">Donald W. Scheumann. The balanced body: a guide to deep tissue and neuromuscular therapy. Third edition. Lippincott Williams &amp;amp;amp;amp;amp;amp; Wilkins.p176.</ref>.
 
<br>
 
<u>Piriformis Syndrome Sciatica Management</u>:
 
*Stretching the piriformis muscle, hamstring muscles and hip extensor muscles may decrease and improve range of motion<ref name="33" />.
 
There is no evidence found for this management. Physical therapists use these exercises since it has been shown to have some efficacy for some patients.<br>
 
<br>
 
<u>Sacroiliac Joint Dysfunction Sciatica Management</u>:
 
*This management strategy consists of range of motion exercises for the SI joint; this can help restore normal movement and alleviate irritation of the sciatic nerve. The three most important exercises are: [[Single Knee to chest Stretch|Single Knee to Chest Stretch]]<ref name="35">Marcia K. Anderson. Fundamentals of sports injury management. Second edition. Lippincott Williams &amp;amp;amp;amp;amp;amp; Wilkins .1997.p100.</ref>; Press-Up and [[Lumbar Rotation|Lumbar Rotation]]<ref name="36">American Academy of Orthopaedic Surgeons .Athletic training and sports medicine.Jones and Bartlett Publishers.2006.P552-553.</ref>(non-weight bearing).
 
<br>
 
Chiropractic treatment is based on the hypothesis that vertebral decompression can be prevented by a flexion-distraction procedure. During this procedure, there is greater intervertebral space and less compression on the vertebral elements: for example, the patient lies on his/her stomach with a little flexion in the spine and due to downward flexion a distraction occurs. It has been proven that this treatment decreases the interdiscal pressure<ref name="37">Larry P. Credit,Sharon G. Hartunian,Margaret J. Nowak .Relieving sciatica. Old Broadway.2000.p 42-46.</ref>,<ref name="38">A randomized clinical trial and subgroup analysis to compare flexion–distraction with active exercise for chronic low back pain.Maruti Ram Gudavalli, Jerrilyn A. Cambron, [...], and Avinash G. Patwardhan. (1B)</ref><br>
 
<br>
 
A study by Albert et al examined the efficacy of systematic active conservative treatment. Two treatments contained identical information and advice, but differed in the type of exercise program.
 
*Treatment 1 contained symptom-guided exercises. These consisted of back-related exercises<ref name="39">Albert et al, The efficacy of systematic active conservative treatment for patients with severe Sciatica, a single-blind randomized clinical controlled trial, 2012, Lippincott Williams &amp;amp;amp;amp;amp;amp; Wilkins, SPINE vol 37, no.7, pp 531-542 (1B)</ref>.
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - The patient’s directional preference guided the directional end-range exercise<ref name="39" />,<ref name="41">Anne Thackeray, Julie M. Fritz, Gerard P. Brennan, Faisel M. Zaman and Stuart E. Willick. A Pilot Study Examining the Effectiveness of Physical Therapy as an Adjunct to Selective Nerve Root Block in the Treatment of Lumbar Radicular Pain From Disk Herniation: A Randomized Controlled Trial. PHYS THER. 2010; 90:1717-1729. (1B)</ref> and &nbsp; &nbsp;<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; postural instructions (based on the McKenzie method of assessing pain-related-physical impairment)<ref name="39" />. <br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Stabilizing exercises<ref name="39" />,<ref name="41" /> for the transverse abdominis and multifidus muscles<ref name="39" />.<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Dynamic exercises for the outer layers of the abdominal wall and back extensors. <br><br>You can see the full treatment strategies and exercises in the link below: treatmentprogram sciatica (→ Link plaatsen)<br>There is no evidence found for these exercises but physical therapists use these exercises since it has been shown to have some efficacy for some patients.
 
<br>
 
*Treatment 2 contained Sham exercises. The exercises were not back related and were low-dose exercises to stimulate an increase in systemic blood circulation. Examples of exercises:


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Exercise 1: Squeeze buttocks<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; The patient lies supine and squeezes the buttocks. Contraction is held for 5 seconds. The exercises are repeated 10 times. <br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; The patient only contracts the gluteal muscles.<br>  
== Physical Therapy Management    ==
In most cases of sciatica, conservative treatment is favoured. The evidence does not show that one treatment is superior to the other<ref name="p2">Luijsterburg PA, Verhagen AP, Ostelo RW, van Os TA, Peul WC, Koes BW. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219647/pdf/586_2007_Article_367.pdf Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review.] Eur Spine J. 2007 Jul;16(7):881-99.</ref>


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Exercise 2: Swing<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; The patient is standing with the legs sligthly apart. The shoulders are relaxed and the patient swings the arms loosely <br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; alongside the body. This exercise is repeated 20 times.<br>  
'''Patient Education''': to include information on the nature of low back back, advice on self-management techniques and encouragement to continue normal activities<ref name=":5">National Institute for Health and Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management: NICE Guideline [NG59] 2016. Available from <nowiki>https://www.nice.org.uk/guidance/ng59</nowiki> [Accessed 13 Nov 2021]</ref>


You can see the full document of Sham exercises below: Sham exercises (→ Link plaatsen)<br>There is no evidence found for these exercises but physical therapists use these exercises since it has been shown to have some efficacy for some patients.<br>The patients had more faith in the Sham exercises but the outcomes of the symptom-guided exercise treatment were better. This cannot be used as an standard procedure because every patient is different and reacts differently to treatment<ref name="39" />. <br>
'''Promote self management techniques such as''':  


== Key Research<br>  ==
# use of [[Thermotherapy|hot]] or [[Cryotherapy|cold packs]] for comfort and to decreased inflammation
# avoidance of inciting activities or prolonged sitting/standing
# Regularly changing position i.e. from sitting to standing
# practicing good erect [[posture]]
# use of proper [[Lifting|lifting techniques]]


*Genevay S, Finckh A, Zufferey P, Viatte S, Balagué F, Gabay C. Adalimumab. In acute sciatica reduces the long-term need for surgery: a 3-year follow-up of a randomised double-blind placebo-controlled trial. 2011 Oct 13.(C)
'''Exercise:'''
*Ashworth J, Konstantinou K, Dunn KM. Prognostic Factors in Non-Surgically Treated Sciatica: A Systematic Review. 2011 Sep 25.(A1)<br>
*Wassenaar M, van Rijn RM, van Tulder MW, Verhagen AP, van der Windt DA, Koes BW, de Boer MR, Ginai AZ, Ostelo RW. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. 2011 Sep 16.(A1)<br>
*Van Rijn RM, Wassenaar M, Verhagen AP, Ostelo RW, Ginai AZ, de Boer MR, van Tulder MW, Koes BW. Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. 2011 Sep 14.(A1)
*Righesso O, Falavigna A, Avanzi O. Correlation between persistent neurological impairment and clinical outcome following microdiscectomy for treatment of lumbar disc herniation. 2011 Aug 10.(C)
*Erginousakis D, Filippiadis DK, Malagari A, Kostakos A, Brountzos E, Kelekis NL, Kelekis A. Comparative prospective randomized study comparing conservative treatment and percutaneous disc decompression for treatment of intervertebral disc herniation. 2011 Aug.(B)


== Resources <br>  ==
exercises to increase [[Core Strengthening|core strength]], gentle [[stretching]] of the lumbar spine and hamstrings, regular light exercise such as walking, swimming, or [[aquatherapy]]


*Loren Fishman, Carol Ardman. Sciatica Solutions: Diagnosis, Treatment, and Cure of Spinal and Piriformis Problems. W W Norton &amp; Co Inc. 2007. (D)
'''Manual therapy:''' spinal manipulation, mobilisation or soft tissue techniques such as massage - used alongside exercise and patient education<ref name=":5" />
*John Barrett, Douglas Noel Golding. The practical treatment of backache and sciatica.1984. (D)
*Larry P. Credit,Sharon G. Hartunian,Margaret J. Nowak .Relieving sciatica. Old Broadway.2000.p 30-34. (D)


== Clinical Bottom Line  ==
'''Comprehensive treatment:'''
# [[Disc Herniation]]
# [[Lumbar Discogenic Pain]]
# <u></u>[[Lumbar Spinal Stenosis|Spinal Stenosis]]
# <u></u>[[Degenerative Disc Disease]]
# [[Spondylolisthesis]]
# [[Piriformis Syndrome]]
# [[Sacroiliac Joint Syndrome|Sacroiliac Joint Dysfunction]]
# [[Sciatic Nerve Injury]]
# [[Therapeutic Corticosteroid Injection|Corticosteroid injections]]
# [[Acupuncture]]
# [[Massage|Massage therapy]]


add text here <br>


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
{{#ev:youtube|v=4t8L4zHQ2nQ&t=7s|300}}<ref>Physio Fitness | Physio REHAB | Tim Keeley. Treatment for lumbar spine disc bulge and sciatica - wk 1 | Feat. Tim Keeley | No.58 | Physio REHAB . Available from: http://www.youtube.com/watch?v=4t8L4zHQ2nQ&t=7s [last accessed 03.04.2023]</ref>


<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1FYSEY2m9I7_sB43mJKBFys-qNH8mnMtAosYLehw9mGq-9GkEi|charset=UTF-8|short|max=10</rss>


*http://www.spinecentre.com.hk/thumbnail-list-layout-en/case-study-2-sciatica-and-disc-protrusion#2 - Sciatica and Disc Protrusion<ref name="Hong Kong Spine Centre">Hong Kong Spine Centre. Clinical Case Studies:case study #2: Sciatica and Disc Protrusion.http://www.spinecentre.com.hk/thumbnail-list-layout-en/case-study-2-sciatica-and-disc-protrusion. (accessed 17 August 2013)</ref>
== Concluding Remarks ==
[[File:Exercise group.jpg|right|frameless|450x450px]]There are many causes of sciatica and the disorder is best managed with a team of healthcare professionals that includes an orthopedic surgeon, physical therapist, neurologist, rehabilitation nurse, and a pain specialist.


== <span style="font-size: 20px; line-height: 1.5em;">References</span> ==
* The key to sciatica is patient education.
* The majority of cases of sciatica are best managed conservatively.
* Patients should be encouraged by the clinician and nurse to lose weight, stop smoking and enroll in a physical therapy program.
* Bed rest should be limited.
* The pharmacist should caution the patient against the use of prescription-strength medications to avoid dependence and other adverse effects.
* Surgery should only be undertaken when conservative methods have failed.
* Regular exercise is essential<ref name=":0" />  


<references />
== Summary ==
<div class="editorbox">
''The following video gives a summary of sciatica:''{{#ev:youtube|https://www.youtube.com/watch?v=VYj-JfX0wT0|width}}<ref name=":10">Osmosis. Sciatica. Available from: https://www.youtube.com/watch?v=VYj-JfX0wT0 (last accessed 15.3.2019)</ref>
<br>  
== References  ==
<br></div>  
<references /><br>
[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]] [[Category:Condition]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Neurology]] [[Category:Neurodynamics]] [[Category:Lumbar]] [[Category:Lumbar_Conditions]]
[[Category:Lumbar Spine - Conditions]]
[[Category:Lumbar Spine]]
[[Category:Neurology]]  
[[Category:Neurodynamics]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Older People/Geriatrics]]
[[Category:Older People/Geriatrics - Conditions]]
[[Category:Conditions]]

Latest revision as of 11:40, 26 April 2023

Original Editor - Daan Vandebriel Top Contributors - Karina Leahy, Daan Vandebriel, Jolien Wauters, Rosie Swift, Lucinda hampton, Kim Jackson, Lauren Lopez, Aya Alhindi, Shauni Van Overstraeten, WikiSysop, Admin, Simisola Ajeyalemi, 127.0.0.1, Naomi O'Reilly, Yvonne Yap, Kirenga Bamurange Liliane, Ewa Jaraczewska, Evan Thomas, George Prudden and Yannick Goubert

Introduction[edit | edit source]

Sciatica refers to radiating pain along the course of the sciatic nerve from the lower back or buttock to one or both legs or an associated lumbosacral nerve root.

A common mistake is referring to any low back pain or radicular leg pain as sciatica[1].

Sciatica is a clinical diagnosis based on the presence of radiating pain in one leg, with or without the associated neurological deficits of parasthesia and muscle weakness[2], which are the direct result of sciatic nerve or sciatic nerve root pathology.

Sciatica pain often is worsened with flexion of the lumbar spine, twisting, bending, or coughing[1].

Anatomy[edit | edit source]

The sciatic nerve is made up of the L4 through S2 nerve roots which coalesce at the pelvis to form the sciatic nerve. At up to 2 cm in diameter, the sciatic nerve is easily the largest nerve in the body. 

The sciatic nerve provides direct motor function to the hamstrings, lower extremity adductors, and indirect motor function to the calf muscles, anterior lower leg muscles, and some intrinsic foot muscles.

Indirectly through its terminal branches, the sciatic nerve provides sensation to the posterior and lateral lower leg as well as the plantar foot.

Etiology[edit | edit source]

Any condition that may structurally impact or compress the sciatic nerve may cause sciatica symptoms.

Sciatic nerve injury can also result in sciatica symptoms (such as pain, muscle weakness and paresthesia) and is usually caused by a traumatic injury (pressure, stretching or cutting), rather than compression or irritation of the nerve. Please read our sciatic nerve injury page for more information.

The causes of sciatica can be categorised into spinal or non-spinal causes or iatrogenic[3]:

Spinal causes:

Non Spinal causes:

Iatrogenic causes:

  • Direct surgical trauma
  • Faulty positioning during anaesthesia
  • Injection of neurotoxic substances
  • Tourniquets
  • Dressings, casts or faulty fitting orthotics
  • Radiation

Epidemiology[edit | edit source]

  • Annual incidence of 1% to 5%[1]
  • Lifetime incidence reported between 10% to 40%[1]
  • No gender predominance[1]
  • Peak incidence occurs in patients in their fourth decade[1]
  • Rarely occurs before age 20 (unless traumatic)[1]
  • No association with body height has been established except in the age 50 to 60 group[1]
  • Increased incidence in those with poor general health (including presence of co-morbidities and smoking) and the presence of psychological factors such as depression[5]
  • Physical activity increases incidence in those with prior sciatic symptoms and decreased in those with no prior symptoms[1].
  • Occupational predisposition has been shown in machine operators, truck drivers, and jobs where workers are subject to physically awkward positions[4] or physical stress on the spine such as vibration[5]

Clinical Presentation[edit | edit source]

Lower-dermatomes.jpg

Patients with sciatica can present with neurological symptoms such as:

  • Radicular pain in the distribution of the lumbosacral nerve root
  • Sensory impairment/disturbance, such as hot and cold or tingling/ burning sensations in the legs or numbness
  • Muscular weakness
  • Reflex impairment
  • Gait dysfunction

Sciatica symptoms of paresthesias or dysesthesias and oedema in the lower extremity can differ, depending on which nerve is affected[6][7]

  • L4: When the L4 nerve is compressed or irritated, the patient feels pain, tingling and numbness in the thigh. The patient also feels weak when straightening the leg and may have a diminished knee jerk reflex.
  • L5: When the L5 nerve is compressed or irritated, the pain, tingling and numbness may extend to the foot and big toes.
  • S1: When the S1 nerve is compressed or irritated, the patient feels pain, tingling and numbness on the outer part of the foot. The patient also experiences weakness when elevating the heel off the ground and standing on tiptoes. The ankle jerk reflex may be diminished.

Differential Diagnosis[edit | edit source]

A thorough differential list is important in considering a diagnosis of sciatica and should include:

Evaluation[edit | edit source]

Sciatica is most commonly diagnosed by:

History:

Complaints of radiating pain in the leg, which follows a dermatomal pattern[6]

  • Pain generally radiates below the knee, into the foot[7]
  • Patients complain about low back pain, which is usually less severe than the leg pain[6]
  • Patients may also report sensory symptoms.

Special tests:

Clinicians should always look for and inquire about red flags when evaluating sciatica or in patients who present with any low back pain. Patients with signs of urinary retention or decreased anal sphincter tone should be urgently referred for investigation as this suggests cauda equina syndrome.

  • Lasègue’s test

Also called as straight leg raising test (SLR) is the most commonly performed physical test for diagnosis of sciatica and lumbar disc hernia . The SLR is considered positive when it evokes radiating pain along the course of the sciatic nerve and below the knee between 30 and 70 degrees of hip flexion. Studies of its capacity to diagnose lumbar disc hernia show high sensitivity but low specificity.[8]

[9]

  • Bragard test

Bragard test is a modification of the SLR, where ankle dorsiflexion is applied at the end of the SLR. Dorsiflexion reduces the SLR angle at which the test is positive and can be used to differentiate neural symptoms from musculoskeletal symptoms.[8]

Distal structural differentiation for proximal symptoms with ankle dorsiflexion (also known as Bragard test)

Also known as the popliteal compression test or posterior tibial nerve stretch sign. The patient can be examined in sitting or in a supine position. The examiner flexes the knee and applies pressure on the popliteal fossa, evoking sciatica. Some examiners do it after SLRT by flexing the knee to relieve the buttock pain. The pain would be reproduced by a quick snap on the posterior tibial nerve in the popliteal fossa.[10]

[11]

Imaging:

It may be used if pain persists for more than 12 weeks or the patient develops progressive neurological deficits[2]

  • Plain films of the lumbosacral spine may evaluate for fracture or spondylolisthesis
  • Noncontrast CT scan may be performed to evaluate fracture if plain films are negative
  • In cases where the neurologic deficit is the present or mass effect is suspected, immediate MRI is the standard of care in establishing the cause of the pain and ruling out pressing surgical pathology[4]

Outcome Measures[edit | edit source]

Many to choose from, below are but a few, all dependant on cause and assessment.

Medical Management[edit | edit source]

Massage image.jpg

Most patients improve over time with conservative treatment including exercise, manual therapy, and pain management[2]

  • Pharmacology: a short course of oral NSAIDs; Opioid and non-opioid analgesics; muscle relaxants; anticonvulsants for neurogenic pain; localized corticosteroid injections.
  • Surgical evaluation: to address structural abnormalities such as: disc herniation, epidural hematoma, epidural abscess or tumour may be considered if no improvement following 6-8 weeks of conservative treatment[2]. One study found that although it may speed up recovery, the effect is similar to conservative care at one year[2]
  • Physical therapy management

Physical Therapy Management[edit | edit source]

In most cases of sciatica, conservative treatment is favoured. The evidence does not show that one treatment is superior to the other[15]

Patient Education: to include information on the nature of low back back, advice on self-management techniques and encouragement to continue normal activities[16]

Promote self management techniques such as:

  1. use of hot or cold packs for comfort and to decreased inflammation
  2. avoidance of inciting activities or prolonged sitting/standing
  3. Regularly changing position i.e. from sitting to standing
  4. practicing good erect posture
  5. use of proper lifting techniques

Exercise:

exercises to increase core strength, gentle stretching of the lumbar spine and hamstrings, regular light exercise such as walking, swimming, or aquatherapy

Manual therapy: spinal manipulation, mobilisation or soft tissue techniques such as massage - used alongside exercise and patient education[16]

Comprehensive treatment:

  1. Disc Herniation
  2. Lumbar Discogenic Pain
  3. Spinal Stenosis
  4. Degenerative Disc Disease
  5. Spondylolisthesis
  6. Piriformis Syndrome
  7. Sacroiliac Joint Dysfunction
  8. Sciatic Nerve Injury
  9. Corticosteroid injections
  10. Acupuncture
  11. Massage therapy


[17]


Concluding Remarks[edit | edit source]

Exercise group.jpg

There are many causes of sciatica and the disorder is best managed with a team of healthcare professionals that includes an orthopedic surgeon, physical therapist, neurologist, rehabilitation nurse, and a pain specialist.

  • The key to sciatica is patient education.
  • The majority of cases of sciatica are best managed conservatively.
  • Patients should be encouraged by the clinician and nurse to lose weight, stop smoking and enroll in a physical therapy program.
  • Bed rest should be limited.
  • The pharmacist should caution the patient against the use of prescription-strength medications to avoid dependence and other adverse effects.
  • Surgery should only be undertaken when conservative methods have failed.
  • Regular exercise is essential[4]

Summary[edit | edit source]

The following video gives a summary of sciatica:

[3]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Davis D, Maini K, Vasudevan A. Sciatica. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2020. PMID: 29939685.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Jensen RK, Kongsted A, Kjaer P, Koes B. Diagnosis and treatment of sciatica. BMJ. 2019 Nov 19;367:l6273.
  3. ↑ 3.0 3.1 Osmosis. Sciatica. Available from: https://www.youtube.com/watch?v=VYj-JfX0wT0 (last accessed 15.3.2019)
  4. ↑ 4.0 4.1 4.2 4.3 Davis DH, Wilkinson JT, Teaford AK, Smigiel MR. Sciatica produced by a sacral perineurial cyst. Tex Med. 1987 Mar;83(3):55-6.
  5. ↑ 5.0 5.1 Parreira P, Maher CG, Steffens D, Hancock MJ, Ferreira ML. Risk factors for low back pain and sciatica: an umbrella review. Spine J. 2018 Sep;18(9):1715-1721.
  6. ↑ 6.0 6.1 6.2 Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of sciatica. BMJ. 2007 Jun 23;334(7607):1313-7.
  7. ↑ 7.0 7.1 Konstantinou K, Lewis M, Dunn KM. Agreement of self-reported items and clinically assessed nerve root involvement (or sciatica) in a primary care setting. Eur Spine J. 2012 Nov;21(11):2306-15.
  8. ↑ 8.0 8.1 Kamath SU, Kamath SS. Lasègue’s sign. J Clin Diagn Res [Internet]. 2017 [cited 2023 Mar 27];11(5):RG01–2. Available from: http://dx.doi.org/10.7860/JCDR/2017/24899.9794
  9. ↑ Clinical Examination Videos. Straight leg raise test - Lasegue’s sign [Internet]. Youtube; 2017 [cited 2023 Mar 27]. Available from: https://www.youtube.com/watch?v=JmvGHszR_X4
  10. ↑ Das JM, Nadi M. Lasegue Sign. StatPearls Publishing; 2022.
  11. ↑ CRTechnologies. Bowstring Test (CR). Available from: http://www.youtube.com/watch?v=orb-VI51QF0&t=11s [last accessed 03.04.2023]
  12. ↑ 12.0 12.1 Brouwer PA, Peul WC, Brand R, Arts MP, Koes BW, van den Berg AA, van Buchem MA. Effectiveness of percutaneous laser disc decompression versus conventional open discectomy in the treatment of lumbar disc herniation; design of a prospective randomized controlled trial. BMC Musculoskelet Disord. 2009 May 13;10:49.
  13. ↑ Ngamkham S, Vincent C, Finnegan L, Holden JE, Wang ZJ, Wilkie DJ. The McGill Pain Questionnaire as a multidimensional measure in people with cancer: an integrative review. Pain Manag Nurs. 2012 Mar;13(1):27-51.
  14. ↑ 14.0 14.1 Monticone M, Ferrante S, Teli M, Rocca B, Foti C, Lovi A, Brayda Bruno M. Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial. Eur Spine J. 2014 Jan;23(1):87-95.
  15. ↑ 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 Jul;16(7):881-99.
  16. ↑ 16.0 16.1 National Institute for Health and Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management: NICE Guideline [NG59] 2016. Available from https://www.nice.org.uk/guidance/ng59 [Accessed 13 Nov 2021]
  17. ↑ Physio Fitness | Physio REHAB | Tim Keeley. Treatment for lumbar spine disc bulge and sciatica - wk 1 | Feat. Tim Keeley | No.58 | Physio REHAB . Available from: http://www.youtube.com/watch?v=4t8L4zHQ2nQ&t=7s [last accessed 03.04.2023]


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