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Sciatica: what the rheumatologist needs to know

Abstract

Sciatica is a set of symptoms rather than a specific diagnosis, and is caused by a herniated lumbar disc in the vast majority of cases. The most important symptom is lower limb pain radiating below the knee and into the foot and toes. The clinical course of acute sciatica is generally favorable, with most pain and related disability improving within 2–4 weeks with or without treatment. Diagnosis mainly involves history taking and physical examination. Imaging is warranted if there is evidence of an underlying pathology other than disc herniation, such as infection or malignancy, and in patients with severe symptoms that do not improve after 6–8 weeks of conservative treatment. MRI is the preferred imaging modality, as it can visualize soft tissues better than CT and does not expose the patient to ionizing radiation. Conservative treatment is generally the first-line option in patients with sciatica; however, the currently available evidence does not show any intervention—including a broad range of conservative and surgical approaches—to have clearly superior outcomes. Thus, patient preference seems to be an important factor in the clinical management of sciatica.

Key Points

  • Most patients who present with acute sciatica have a good prognosis, with pain and disability usually improving within 2–4 weeks with or without treatment

  • MRI is the preferred option if imaging is considered necessary, for example in patients who do not improve after 6–8 weeks of conservative therapy

  • Conservative treatment is the first-line option and should include an active approach, with patients being reassured and advised to continue their daily activities as much as possible

  • Early surgery after 6–12 weeks of sciatic pain gives faster recovery than prolonged conservative treatment with delayed surgery, but the 1-year prognosis is similar for both management strategies

  • None of the newer minimally invasive surgical techniques has clinically relevant benefits over standard open microdiscectomy in patients with sciatica

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Figure 1: Illustration of disc herniation.

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van Tulder, M., Peul, W. & Koes, B. Sciatica: what the rheumatologist needs to know. Nat Rev Rheumatol 6, 139–145 (2010). https://doi.org/10.1038/nrrheum.2010.3

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