Diagnosis and Treatment of Sciatica

Sciatica is a condition where one experiences radiating pain in the legs. This pain is usually caused by inflammation or compression of the nerve roots in the lower back, specifically in the L4-S1 region, which form the sciatic nerve.

It can be quite uncomfortable and limit a person’s ability to carry out their daily tasks effectively.

The significance of conservative treatment options for sciatica is emphasized in recent clinical guidelines from Denmark, the US, and the UK.

As a result of these guidelines, a clinical update has been developed with the goal of offering a comprehensive overview of diagnosing sciatica and essential management principles. The update specifically caters to non-specialists, providing them with valuable insights.

The term “sciatica” is often used inconsistently due to its lack of a clear and universally accepted definition among clinicians and patients. As alternatives, medical professionals have suggested terms like radicular pain and lumbosacral radicular syndrome.

In this article, we consider sciatica and radicular pain to have the same meaning. The term radiculopathy is employed to describe the condition where a nerve root is affected, potentially leading to neurological symptoms like weakness or numbness.

Sciatica is characterized by a combination of aching and sharp leg pain that extends below the knee into the foot and toes. The pain can have a sudden or gradual onset and its intensity can vary.

It is frequently accompanied by concurrent low back pain. Disc herniations affecting specific nerve roots result in pain in different regions of the leg. Other symptoms include tingling, numbness, and muscle weakness in the affected leg.

What Is The Prevalence Of Sciatica?

The occurrence of sciatica varies among studies. In a UK primary care study, around 60% of patients experiencing back and leg pain were diagnosed with sciatica.

In a Danish primary care study, neurological examinations confirmed sciatica in 2% of patients attending chiropractic clinics and 11% of patients in general practices who were suffering from low back pain.

What Factors Contribute to the Development of Sciatica?

Compression of the nerve root and inflammation are the primary factors responsible for sciatica. The leading cause of sciatica is typically disc herniation caused by degenerative changes associated with aging, although trauma is infrequently involved.

Inflammation triggers the absorption of herniated disc material, often leading to improvement without surgical intervention. Additionally, sciatica can be caused by foraminal stenosis, soft tissue stenosis, or uncommon extraspinal conditions.

Smoking, obesity, and involvement in manual labor are modifiable factors that increase the risk of developing sciatica.

What Are the Methods Used to Diagnose Sciatica?

The primary method for diagnosing sciatica is a clinical evaluation that relies on the individual’s symptoms and findings from a physical examination.

Important factors to consider include leg pain that surpasses back pain, pain experienced below the knee, and accompanying symptoms like tingling, numbness, or muscle weakness. Although there isn’t a specific test for sciatica, positive findings during the examination can support the diagnosis.

It is crucial to exclude serious conditions such as cancer, trauma, or infection. Symptoms such as urinary retention or decreased anal sphincter tone are red flags that necessitate immediate referral for further evaluation.

How Does Imaging Contribute To The Diagnosis Of Sciatica?

Imaging is generally not recommended as a routine practice for non-specific low back pain, which includes sciatica, according to clinical guidelines. However, it may be appropriate to consider imaging if symptoms worsen or persist beyond 12 weeks, or if there are progressive neurological deficits.

Magnetic resonance imaging (MRI) is the preferred choice for imaging due to its higher safety profile compared to computed tomography (CT). On the other hand, radiography is usually not considered beneficial, and the interpretation of MRI findings may not have a significant impact on the course of treatment.

What Is The Outlook For Patients With Sciatica?

The outlook for most people with sciatica is typically positive, as they often experience symptom improvement through conservative treatment or surgical interventions. However, a minority may not fully recover, and some may continue to experience ongoing symptoms.

The presence of leg pain alongside low back pain is associated with heightened levels of pain, disability, and reduced quality of life. Factors such as the severity, duration of symptoms, and radiological findings do not consistently predict the success of conservative management in achieving recovery.

In a recent study, approximately 55% of patients reported improvement after one year of treatment, while longer durations of pain and patient beliefs about the condition’s long-term nature were associated with a less favorable prognosis.

What Are The Approaches To Managing Sciatica?

Managing sciatica involves addressing the distressing symptoms that can significantly impact daily life and productivity.

It is important to acknowledge the individual’s concerns and fears, while providing information about the typical course of sciatica and reassuring them that symptoms usually improve over time.

Treatment options should be discussed, taking into consideration the person’s preferences and priorities, in order to develop a personalized management plan that best suits their needs.

Non-Invasive Treatment Methods

The initial approach to treatment aims to address pain and preserve functional abilities as the compression and inflammation associated with sciatica subside.

Patients are encouraged to remain physically active and avoid prolonged bed rest to minimize the impact of the condition on their daily lives. It is important to educate individuals about monitoring and promptly reporting any changes in symptoms, such as an escalation of leg pain or the emergence of neurological deficits.

By actively managing symptoms and promoting a proactive approach, patients can optimize their recovery and minimize the impact of sciatica on their well-being.

Physical Activity and Manual Therapy

Engaging in exercise, which encompasses a variety of recommended exercises, can contribute to the reduction of leg pain intensity in the short term. It is possible to complement exercise with manual therapy, such as spinal mobilization.

However, acupuncture is not recommended for individuals with sciatica. Guidelines suggest avoiding traction and electrotherapies for individuals experiencing back pain, regardless of whether it is accompanied by sciatica or not.

Medication

The effectiveness of pain medications for sciatica is not well-established, and they can potentially cause negative effects. Non-steroidal anti-inflammatory drugs (NSAIDs) do not show significant improvement in pain and disability compared to placebo, while corticosteroids may offer temporary relief of symptoms.

However, both NSAIDs and corticosteroids carry an elevated risk of adverse events. There is limited or insufficient evidence to support the use of other medications such as paracetamol, benzodiazepines, opioids, antidepressants, anticonvulsants, and biological agents for sciatica, and their use is not recommended.

Spinal Injections

Guidelines on spinal injections differ in their recommendations. NICE guidelines recommend offering epidural injection of local anaesthetic and steroid in the lumbar nerve root area in people with acute, severe sciatica where they would otherwise be considered for surgery.

The Danish national clinical guidelines do not recommend their use as the beneficial effect was estimated to be very low and only short term based on limited evidence.

Surgery

Individuals who experience persistent chronic pain for a duration of more than 12 weeks, despite undergoing conservative treatment methods, may be considered for surgical intervention.

It is essential to confirm the presence of lumbar disc herniation at the specific nerve root level through the utilization of imaging techniques and clinical examination.

Open micro discectomy is the prevailing surgical procedure, although less invasive approaches like endoscopic surgery are also utilized. Discectomy rates have demonstrated variation, but on the whole, they have exhibited an upward trend across European countries.

According to literature, a systematic review of five randomized controlled trials found low-quality evidence indicating that early surgery within 6-12 weeks of radicular pain may provide faster relief compared to prolonged conservative care.

However, no significant differences in clinical outcomes were observed between surgery and conservative care at one- and two-year follow-ups.

In instances of significant or progressive neurological deficits, such as motor weakness or bladder dysfunction, surgery is advised.