Sciatica

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Original Editors Daan Vandebriel

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Search Strategy

Databases:

• PubMed
• PEDro
• Google Scholar
• Web of Knowledge

Keywords:

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.

Definition/Description

Sciatica is the result of a neurological problem in the back or an entrapped nerve in the pelvis or buttock. There are a set of neurological symptoms such as:

• Pain (intense pain in the buttock)
• Lumbosacral radicular leg pain
• Numbness
• Muscular weakness
• Gait dysfunction
• Sensory impairment
• Sensory disturbance
• Hot and cold or tinglings or burning sensations in the legs
• Reflex impairment
• 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).

Clinically Relevant Anatomy

The nerves that are involved with sciatica form the terminal of the lumbosacral plexus: L4-L5-S1-S2-S3 

Epidemiology /Etiology

Sciatica can begin suddenly and symptoms may be intermittent or constant. Symptoms may worsen with increased intra-abdominal pressure (for example coughing).

The most common cause of Sciatica is compression of the sciatic nerve (nerve root, L4, L5, S1, S2, S3) by a herniated disc.

Other causes of sciatica can include:

• Spinal stenosis
• Spondylosis: a degenerative spinal osteoarthritis 
• Nerve entrapment: a muscle in the buttock may compress the sciatic nerve and cause pain. For example the piriformis syndrome.
• Inflammation and swelling from arthritis, sprains, joint slippage or infection. Infections can be caused by iliopsoas, pelvic and gluteal abscesses.
• 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.
• Central mechanisms: stroke, cerebral hemorrhage or sclerosis can cause pain in the sciatic area. 
• Traumatic pathologies:

            o Proximal hamstring injuries/avulsions
            o Compression of the adjacent sciatic nerve caused by edema, inflammation and haematoma formed around the affected tendon.

• Gynecological pathologies: 

            o Ectopic endometriosis, ovarian cysts and pregnancy may result in sciatica. The right side is more commonly affected.

Rare causes of Sciatica: 

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

Characteristics/Clinical Presentation

The hallmark symptom of sciatica is pain. The type of pain can vary: it may be sharp, feel like electric shocks, discomfort or
numbness…
Pain is a result of irritation of the sciatic nerve. As stated above, it can be constant or intermittend. The pain may be worsened by certain movements like coughing or sneezing (these movements increase the intra abdominal pressure). 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. 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. Also gait dysfunction (toe walking, foot drop and knee buckling), paresthesias or dysesthesias are frequent neurological symptoms.

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.

• 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.
  
• 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

• Non-specific low back pain (box 2) 
• Piriformis syndrome 
• Muscular problems (sprain, spasm, …)
• Vascular problems (claudication, compartment syndrome )
• Chronic edema

Diagnostic Procedures

Sciatica is most commonly diagnosed by:

History taking:
     o Complaints of radiating pain in the leg, which follows a dermatomal pattern.
     o Pain generally radiates below the knee, into the foot.
     o Dermatome maps used to locate the distribution of the pain.
     o Patients complain about low back pain, which is usually less severe than the leg pain.
     o Patients may also report sensory symptoms).

The diagnostic value of patient history and physical examination has not been sufficiently studied. 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.
The use of imaging to confirm the diagnosis of sciatica is not very useful. 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 or to find the underlying cause of the sciatica.

Outcome Measures

• The Oswestry Disability Index (ODI)[10].
  

• Sciatica Bothersomeness Index (SBI)[11],
  

Examination

• Neurological testing

          o Myotomes
          o Reflexes (L4-S3)
          o Sensations (Dermatomes)

• Neural tension tests (preferably in a seated position)
        o Straight leg raise test
        o Crossed straight leg raise test,
        o Slump test[8]
        o Femoral nerve tension test
  

• Lumbar mobility assesment

Medical Management

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 .
Medications are commonly prescribed for the treatment of Sciatica but evidence from clinical trials, suggesting the use of analgesics to relieve pain is limited .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 , .

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 , .

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. ,

Physical Therapy Management

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. Therefore we will discuss the several treatment options.

A very important part of the therapy can be informing the patient about sciatica and giving him advice,. But the education of sciatica is not yet investigated in randomized controlled trials,. 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.

Corticosteroid injections and traction are two treatment options that have limited evidence and are therefore not recommended for the treatment of sciatica,,. 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,,.

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. Other articles have found no reduction of pain with acupuncture.

Massage therapy has proven to be useful with the treatment of back pain. It promotes blood circulation, muscle relaxation and the release of endorphins,,.

Herniated Disc Sciatica Management:

• Extension exercises or press ups are often prescribed; for example, Upper Back Extension.

Spinal Stenosis Sciatica Management:

• 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 and Curl-Ups excercises are fequently used.

There is no evidence found for this management. Physical therapists use these exercises since it has been shown to have efficacy for some patients.

Degenerative Disc Disease Sciatica Management:

• 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 Combination and Bridging.

Spondylolisthesis Sciatica Management:

• 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; Curl-Ups and Pelvic Tilt,.

Piriformis Syndrome Sciatica Management:

• Stretching the piriformis muscle, hamstring muscles and hip extensor muscles may decrease and improve range of motion.

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.

Sacroiliac Joint Dysfunction Sciatica Management:

• 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; Press-Up and Lumbar Rotation(non-weight bearing).

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,

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.

          - The patient’s directional preference guided the directional end-range exercise, and    
            postural instructions (based on the McKenzie method of assessing pain-related-physical impairment).
          - Stabilizing exercises, for the transverse abdominis and multifidus muscles.
          - Dynamic exercises for the outer layers of the abdominal wall and back extensors.

You can see the full treatment strategies and exercises in the link below: treatmentprogram sciatica (→ Link plaatsen)
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.

• 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:

          - Exercise 1: Squeeze buttocks
            The patient lies supine and squeezes the buttocks. Contraction is held for 5 seconds. The exercises are repeated 10 times.
            The patient only contracts the gluteal muscles.

          - Exercise 2: Swing
            The patient is standing with the legs sligthly apart. The shoulders are relaxed and the patient swings the arms loosely
            alongside the body. This exercise is repeated 20 times.

You can see the full document of Sham exercises below: Sham exercises (→ Link plaatsen)
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.
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.

Key Research

• 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)
  
• 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)
  
• 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

• Loren Fishman, Carol Ardman. Sciatica Solutions: Diagnosis, Treatment, and Cure of Spinal and Piriformis Problems. W W Norton & 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

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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