Evidence-Based Prognostication in a Case of Sciatica
Sciatica is a condition characterized by leg pain that radiates along a specific pattern in the leg, often accompanied by sensory symptoms. In most cases (about 90%), it is caused by a herniated disc that compresses the nerve root.
The prognosis for sciatica is generally considered favorable. However, there is a lack of systematic reviews on the topic, and the evidence regarding specific prognostic factors, especially for non-surgical treatments, is conflicting.
Despite this, chiropractors routinely communicate prognoses to patients as part of the informed consent process. This case report aims to use research literature to estimate the clinical prognosis of a patient with a lumbar disc herniation and sciatica in an evidence-based manner.
In a reported study, a man of 43 years visited with ongoing pain in his right buttock and leg, which began following a workout at the gym. The pain persisted and was accompanied by numbness in the right thigh, leg, and foot.
The intensity of the pain was rated at seven out of 10. An MRI revealed a lumbosacral disc herniation causing compression on the right S1 nerve root. Despite attempting heat therapy and over-the-counter anti-inflammatory medications, the pain did not improve.
Consequently, the patient was advised to use ice and a stronger anti-inflammatory drug. Chiropractic treatment was also suggested as part of the management plan.
During the examination, the patient showed normal lumbar spine range of motion, but experienced mild low back pain during seated extension. Palpation revealed reduced joint mobility and pain in the lumbosacral and sacroiliac joints, as well as gluteal muscle spasm on the right side.
The right quadratus lumborum muscle was hypertonic. The Straight Leg Raise and Yeoman’s tests induced pain and paraesthesia in the right leg. Other tests were negative, except for a decreased Achilles tendon reflex and mild decreased sensation in the outer right foot (S1 dermatome).
Based on the patient’s age, history, physical examination, and MRI results, a preliminary diagnosis of right-sided lumbosacral disc herniation with sciatica was made.
Two prospective cohort studies reported by litarature included a sample of 154 consecutive patients with MRI-confirmed lumbar disc herniation and sciatica. The studies had a follow-up period of two years, with acceptable follow-up rates for motor weakness, sensory deficit, and pain/disability levels. Validated outcome measures were used, and the studies identified some prognostic factors for sciatic recovery. Overall, the studies were considered valid.
The results of the studies suggest that non-surgical treatment leads to positive outcomes for sciatic pain and motor recovery. Clinicians can use the 95% confidence intervals to estimate the probability and accuracy of these outcomes over time.
Specifically, around 81% of patients experienced relief from leg pain within an average of six months through non-surgical treatment. Among those initially experiencing motor deficits, only 25% continued to have muscle weakness, while 47% of individuals with sensory deficits still had sensory loss.
Additionally, 25% of patients who received non-surgical treatment had a recurrence of leg pain within one year after achieving initial relief.
The current patient had similar characteristics to the study sample reported by literature, including age, clinical features, symptom duration, and leg pain severity. The conservative treatments received by the study sample were also available to the patient. Therefore, the results of the cohort studies were deemed applicable.
The patient had a good prognosis for leg pain recovery with conservative care, with a 72-90% chance of improvement within six months. However, there was a 15-35% chance of pain recurrence within a year. Sensory recovery was less favorable, with a 32-62% probability of ongoing sensory loss after two years, regardless of treatment approach.
The case reported by literature focused on observation, the patient was not informed of the prognostic estimates. However, the decision regarding conservative treatment or surgery would have been discussed.
Typically, conservative treatment is advised for the first 6-8 weeks, unless there is progressive neurological decline. Early surgery may provide quicker relief, but long-term outcomes do not show significant disparities.
No particular conservative therapy has proven superiority for sciatica. In making decisions, clinical experience, patient preference, and evidence-based medicine all play crucial roles.
Valid and precise prognostic information is useful for counseling patients and making treatment decisions. However, systematic reviews on the prognosis of sciatica are limited, and further studies are needed to validate prognostic factors for non-surgical treatment.
In this case, estimates of pain and sensory recovery were based on evidence from two cohort studies.