Sciatica: Difference between revisions

No edit summary
m (Text replacement - "</big>" to "")
 
(38 intermediate revisions by 6 users not shown)
Line 1: Line 1:
<div class="editorbox"> '''Original Editor '''- [[User:User Name|Daan Vandebriel]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
<div class="editorbox"> '''Original Editor '''- [[User:User Name|Daan Vandebriel]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


== Description  ==
== Introduction ==
[[File:Sciatic nerve.png|right|frameless]]
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]].  
Sciatica is a debilitating condition in which the patient experiences pain and/or paresthesias in the distribution of the [[Sciatic Nerve|sciatic nerve]] or an associated lumbosacral nerve root.
* A common mistake is referring to any low back pain or radicular leg pain as sciatica.
* Sciatica is specific to the pain that is a direct result of sciatic nerve or sciatic nerve root pathology. 
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 pain often is worsened with flexion of the [[Lumbar Anatomy|lumbar spine]], twisting, bending, or coughing.
* The sciatic nerve provides direct motor function to the [[hamstrings]], lower extremity [[Hip Anatomy|adductors]], and indirect motor function to the [[Gastrocnemius|calf muscles]], anterior lower leg muscles, and some intrinsic [[Foot Anatomy|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.
Most cases of sciatica result from an [[Inflammatory Myopathies|inflammatory condition]] leading to an irritation of the sciatic nerve. <ref name=":0">Davis DH, Wilkinson JT, Teaford AK, Smigiel MR. Sciatica produced by a sacral perineurial cyst. Texas Medicine. 1987 Mar 1;83(3):55-6.Available from:https://www.statpearls.com/kb/viewarticle/28772/ (last accessed 12.9.2020)</ref>


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


Any condition that may structurally impact or compress the sciatic nerve may cause sciatica symptoms.
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.
* The most common cause of sciatica is a [[Lumbar Discogenic Pain|herniated or bulging lumbar intervertebral disc.]]
* In the [[Older People Introduction|older persons]], [[Lumbar Spinal Stenosis|lumbar spinal stenosis]] may cause these symptoms as well.
* [[Spondylolisthesis]] or a relative misalignment of one vertebra relative to another may also result in sciatic symptoms.
* [[Lumbar Anatomy|Lumba]]<nowiki/>r or [[Pelvic Floor Anatomy|pelvic]] muscular spasm and/or inflammation may impinge a lumbar or sacral nerve root causing sciatic symptoms.
* A spinal or paraspinal mass including [[Oncology|malignancy]], [[Overview of Traumatic Brain Injury|epidural hematoma]], or epidural abscess may also cause a mass-like effect and sciatica symptoms<ref name=":0" />


== Epidemiology  ==
Sciatica pain often is worsened with flexion of the [[Lumbar Anatomy|lumbar spine]], twisting, bending, or coughing<ref name=":6" />.  
* No gender predominance
[[File:Sciatic_nerve.png|alt=|right|frameless|372x372px]]
* Peak incidence occurs in patients in their fourth decade
* Lifetime incidence reported between 10% to 40%
* Annual incidence of 1% to 5%
* No association with body height has been established except in the age 50 to 60 group.
* Rarely occurs before age 20 (unless traumatic)
* [[Physical Activity|Physical activity]] increases incidence in those with prior sciatic symptoms and decreased in those with no prior symptoms.
* Occupational predisposition has been shown in machine operators, truck drivers, and jobs where workers are subject to physically awkward positions<ref name=":0" />.


== Clinical Presentation  ==
== Anatomy ==
[[File:Lower-dermatomes.jpg|right|frameless]]
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. 
<span style="line-height: 1.5em;">Patient with sciatica can present with neurological symptoms such as: </span>
*<span style="line-height: 1.5em;">Pain (intense pain in the buttock)</span>
*<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.">Ardman C. et al., Sciatica Solutions: Diagnosis, treatment and cure of spinal and piriformis problems, 1st edition, W.W. Norton &amp; Company, 2007</ref><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 style="line-height: 1.5em;">Sciatica symptoms can also differ, depending on which nerve is affected.</span>
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.
*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>
*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.
== Differential Diagnosis  ==
A thorough differential list is important in considering a diagnosis of sciatica and should include.
* Herniated lumbosacral disc
* Muscle spasm
* Nerve root impingement
* Epidural abscess
* Epidural hematoma
* Tumor
* [[Pott's Disease|Potts Disease]], also known as spinal tuberculosis
* [[Piriformis Syndrome|Piriformis syndrome]]<ref name=":0" />


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


Sciatica is most commonly diagnosed by:<br>1. History
Any condition that may structurally impact or compress the sciatic nerve may cause sciatica symptoms.  
* 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>.
* 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>.
* Dermatome maps used to locate the distribution of the pain<ref name="Koes" />.
* Patients complain about low back pain, which is usually less severe than the leg pain<ref name="Koes" />.
* Patients may also report sensory symptoms).
2. Imaging (if warranted)
* 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. Pain that has been persistent for 6 to 8 weeks and not responding to conservative management should be imaged.
* 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<ref name=":0" />


== Outcome Measures ==
[[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.  


*[[Oswestry Disability Index|The Oswestry Disability Index (ODI)<ref name="p0">Dionne CE. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. 2008</ref>]][[Sciatica|<span class="mw-reflink-text">[11]</span>]][[Sciatica|<span class="mw-reflink-text">[10]</span>]][[Sciatica|<span class="mw-reflink-text">[10]</span>]][[Sciatica|<span class="mw-reflink-text">[10]</span>]][[Sciatica|<span class="mw-reflink-text">[10]</span>]][[Sciatica|<span class="mw-reflink-text">[10]</span>]]<span class="mw-reflink-text">[10]</span>.
The causes of sciatica can be categorised into spinal or non-spinal causes  or iatrogenic<ref name=":10" />:
*[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>][[Sciatica|<span class="mw-reflink-text">[12]</span>]][[Sciatica|<span class="mw-reflink-text">[11]</span>]][[Sciatica|<span class="mw-reflink-text">[11]</span>]][[Sciatica|<span class="mw-reflink-text">[11]</span>]][[Sciatica|<span class="mw-reflink-text">[11]</span>]][[Sciatica|<span class="mw-reflink-text">[11]</span>]]<span class="mw-reflink-text">[11]</span>,<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>
== Examination  ==


*See [[Lumbar Assessment]]
'''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>


== Medical Management    ==
'''Non Spinal causes:'''
*[[Piriformis Syndrome|Piriformis syndrome]]
*[[Pregnancy Related Pelvic Pain|Pregnancy]]
*[[Lumbar Radiculopathy]]
* Pelvic tumours
* Trauma to leg


'''Patient Education'''  
'''Iatrogenic causes:'''
* Use of hot or cold packs for comfort and to decreased inflammation
*Direct surgical trauma
* Avoidance of inciting activities or prolonged sitting/standing
*Faulty positioning during anaesthesia
* Practicing good, erect posture
*Injection of neurotoxic substances
* Engaging in exercises to increase core strength
*Tourniquets
* Gentle stretching of the lumbar spine and hamstrings
*Dressings, casts or faulty fitting orthotics
* Regular light exercises such as walking, swimming, or aquatherapy
*Radiation
* Use of proper lifting techniques
'''Medical Therapies'''
* A short course of oral NSAIDs
* Opioid and nonopioid analgesics
* Muscle relaxants
* Anticonvulsants for neurogenic pain
* In the event oral NSAIDs are insufficient, a course of oral corticosteroids may be beneficial
* Localized corticosteroid injections
* Deep tissue massage may be helpful
* Physical therapy consultation
* Surgical evaluation and correction of any structural abnormalities such as disc herniation, epidural hematoma, epidural abscess or tumor


== Physical Therapy Management    ==
== Epidemiology ==


{{#ev:youtube|4t8L4zHQ2nQ|412}}
* 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


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="p2">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> (LOE 1A). Therefore we will discuss the several treatment options.<br>
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.
*'''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  ==
A thorough differential list is important in considering a diagnosis of sciatica and should include:
* Herniated lumbosacral [[Disc Herniation|disc]]
* [[Cauda Equina Syndrome|Cauda Equina]] syndrome
* [[Muscle Injuries|Muscle]] spasm
* Nerve root impingement
* Epidural abscess
* Epidural hematoma
* [[Renal Cancer|Tumor]]
* [[Pott's Disease|Potts Disease]], also known as spinal tuberculosis
* [[Piriformis Syndrome|Piriformis syndrome]]


A very important part of the therapy can be informing the patient about sciatica and giving him advice<ref name="p3">Lawrence M. Urban, BA, DPT. The Straight-Leg-Raising Test: A Review. JOSPT Vol. 2. No. 3, p.117-129</ref> (LOE 2A),<ref name="p0" /> (LOE 5). But the education of sciatica is not yet investigated in randomized controlled trials<ref name="Koes" /> (LOE 1A),<ref name="p0" />. 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="p4">Jacobs W. et al., Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review (of RCT’s) (1A)</ref> (LOE 1A).<br>
== Evaluation  ==


Corticosteroid injections and traction are two treatment options that have limited evidence and are therefore not recommended for the treatment of sciatica<ref name="p3" /> (LOE 2A),<ref name="p4" /> (LOE 1A),<ref name="p5">Sciatica (lumbar radiculopathy) - Management". http://www.cks.nhs.uk/sciatica_lumbar_radiculopathy/management/scenario_sciatica_lumbar_radiculopathy/treatment/basis_for_recommendation.</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="p2" /> (LOE 1A),<ref name="p6">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> (LOE 1A),<ref name="p0" /> (LOE 5).<br>
Sciatica is most commonly diagnosed by:


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="p7">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>(LOE 1A) <ref name="p8">Kenneth Jeffrey Miller DC, DABCO. Physical assessment of lower extremity radiculopathy and sciatica. Journal of Chiropractic Medicine (2007) 6, 75–82 (2C)</ref>(LOE 2C) <ref name="p0" />(LOE 5). Other articles have found no reduction of pain with acupuncture<ref name="p2" />.<br>
'''History:'''


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="p9">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>(LOE 1B),<ref name="p0" />(LOE 5),<ref name="p1">John Barrett,Douglas Noel Golding. The practical treatment of backache and sciatica. Redwood Burn Limited. 1984.p97-103.</ref>. <br>  
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:'''


<u>Herniated Disc Sciatica Management</u>:
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]].


*Extension exercises or press ups are often prescribed; for example, Upper Back Extension<ref name="p2" />(LOE 1A).
*'''Lasègue’s test'''


<u></u>  
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>


<u>Spinal Stenosis Sciatica Management</u>:
* '''Bragard test'''


*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]] exercises are frequently used<ref name="p3" />(LOE 2A).
[[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" />
[[File:Bragard test.jpg|center|thumb|Distal structural differentiation for proximal symptoms with ankle dorsiflexion (also known as Bragard test)]]


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


<u></u>  
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>


<u>Degenerative Disc Disease Sciatica Management</u>:
{{#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>


*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="p3" />(LOE 2A).
'''Imaging:'''


<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" />


<u>Spondylolisthesis Sciatica Management</u>:  
== 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" />


*Flexion based exercises and stabilization exercises 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 exercises are: [[Hooked-lying march|Hooked-lying]]&nbsp;March; [[Curl-ups|Curl-Ups]] and [[Pelvic Tilt|Pelvic Tilt]]<ref name="p3" />(LOE 2A),<ref name="p4" />(LOE 1A).
== Medical Management    ==
[[File:Massage image.jpg|right|frameless]]
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.
* '''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'''


<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>
<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="p3" />(LOE 2A).
 
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="p5" />; Press-Up and [[Lumbar Rotation|Lumbar Rotation]]<ref name="p6" />(LOE 1A) (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="p7" />(LOE 1A),<ref name="p8" />(LOE 2C)
 
<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="p9" />(LOE 1B).


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - The patient’s directional preference guided the directional end-range exercise<ref name="p9" />,<ref name="p1" /> 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="p9" />. <br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Stabilizing exercises<ref name="p9" />,<ref name="p1" /> for the transverse abdominis and multifidus muscles<ref name="p9" />.<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: treatment program 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.
'''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>


<br>
'''Promote self management techniques such as''':


*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:
# 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]]


&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>
'''Exercise:'''


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Exercise 2: Swing<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; The patient is standing with the legs slightly 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>
exercises to increase [[Core Strengthening|core strength]], gentle [[stretching]] of the lumbar spine and hamstrings, regular light exercise such as walking, swimming, or [[aquatherapy]]


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="p9" />(LOE 1B). <br>  
'''Manual therapy:''' spinal manipulation, mobilisation or soft tissue techniques such as massage - used alongside exercise and patient education<ref name=":5" />


== Key Research  ==
'''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]]


*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)
*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  ==
{{#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>


*Loren Fishman, Carol Ardman. Sciatica Solutions: Diagnosis, Treatment, and Cure of Spinal and Piriformis Problems. W W Norton &amp; Co Inc. 2007. (D)
*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)
*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>


== Clinical Bottom Line  ==
== 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.


add text here
* 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 ==
''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>
== References ==
<references /><br>
<references /><br>
[[Category:Lumbar Spine - Conditions]]  
[[Category:Lumbar Spine - 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, Naomi O'Reilly, Simisola Ajeyalemi, 127.0.0.1, George Prudden, Yannick Goubert, Yvonne Yap, Kirenga Bamurange Liliane, Ewa Jaraczewska and Evan Thomas

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]


Retrieved from "https://www.physio-pedia.com/index.php?title=Sciatica&oldid=332172"