02/11/2018
🔵 Sciatica is a symptom rather than a specific diagnosis.
This is a painful sensation is referred pain from the lower back ralated to nerve root compression
📌 Mechanical hypothesis:
* Presence of disc herniation in asymptomatic subjects
* Pressure on normal nerve roots does not cause pain
* Pressure on adjacent level nerve roots does not cause pain
* Severe symptoms without evidence of nerve root compression
* Symptom severity does not correlate with the size of the disc herniation B Outcome might be favourable with conservative treatment
* Outcome might be favourable despite persistence of the disc herniation
* Discectomy has only moderate long-term success
📌 Clinical features:
Sciatica is a symptom rather than a specific diagnosis.
The most important symptom is leg pain radiating below the knee and into the foot and toes.
Clinical findings of neurological deficit, such as muscle weakness and reflex changes, may also be present.
In 90% of cases, sciatica is caused by a herniated disc with nerve-root compression, but lumbar canal or foraminal stenosis and (less often) tumours or cysts are other possible causes.
📌 Diagnosis:
No history items or physical examination tests have both high sensitivity and high specificity.
The straight-leg-raising test (or Lasegue’s sign) is the most commonly used physical test. The sensitivity of the straight-leg-raising test is estimated to be 91%, specificity 26%.
The crossed straight-leg-raising test has a pooled specificity of 88%, but a sensitivity of only 29%.
Signs and symptoms that help to distinguish between sciatica and non-specific low-back pain are unilateral leg pain greater than low- back pain, pain radiating to foot or toes, numbness and paraesthesia in the same distribution, straight- leg-raising test induces more leg pain and localised neurology, which is limited to one nerve root.
📌Course and prognosis:
Most pain and related disabilities resolve within 2️⃣ weeks.
At present, there is no clear insight into factors associated with a poor or favourable outcome.
📌 Treatment options:
*️⃣Non-surgical treatments:
There is consensus that treatment of sciatica in the first 6–8 weeks should be conservative.
In the presence of ‘red flags’, specific causes (e.g., infection, tumour, osteoporotic fractures) may be present and further investigations, such as imaging and laboratory diagnostics, are indicated.
Opioid-resistant pain, motor deficit or cauda equina syndrome are conditions that justify referral to a specialist to discuss emergency surgery.
*️⃣Non-pharmacological modalities:
Rest and bed rest cannot be recommended, and such advice has been found to have a harmful effect in acute low-back pain.
The use of physical therapy (exercise therapy plus giving information and advice about sciatica), is supported especially for patients reporting severe disability at baseline.
No evidence supports the use of acupuncture, spinal manipulation and corsets in cases of sciatica and these modalities of management cannot be recommended.
Traction is also not currently recommended.
*️⃣Pharmacological modalities 💊
There is no evidence to support the efficacy of analgesics in sciatica.
When NSAIDs are prescribed, long-term use should be avoided as much as possible.
Epidural corticosteroid injections 💉 could be recommended as a means of reducing pain in the short term although no long-term effects can be expected.
*️⃣Surgery:
Absolute indications for surgery include altered bladder function, progressive muscle weakness and opioid-resistant pain intensity.
The short-term benefit of early surgery continued to narrow. For leg pain, an early effect appears to favour surgery from 2 to 26 weeks, but the effect is nearly equal between surgical and non-surgical treatment at 1 year.
🔖Practice points:
* Provide the patient with adequate information about sciatica (causes, no need to perform diagnostic imaging, expected prognosis and possibility of recovery without surgery, etc.).
* Provide advice to stay active and continue daily activities.
* Surgery provides faster relief than conservative treatment for patients with greater than 6–8
weeks of sciatica.
* Results between surgery and conservative care are similar at 1 year and beyond
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