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Sciatica: what the rheumatologist needs to know

Nature Reviews Rheumatology volume 6, pages 139–145 (2010)Cite this article

Subjects

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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References

  1. Koes, B. W., van Tulder, M. W. & Peul, W. C. Diagnosis and treatment of sciatica. BMJ 334, 1313–1317 (2007).

    Article  CAS  Google Scholar 

  2. Fairbank, J. C. Sciatica: an archaic term. BMJ 335, 112 (2007).

    Article  Google Scholar 

  3. Bombardier, C, Esmail, R. & Nachemson, A. L. The Cochrane Collaboration Back Review Group for spinal disorders. Spine (Phila. Pa 1976) 22, 837–840 (1997).

    Article  CAS  Google Scholar 

  4. Bouter, L. M., Pennick, V. & Bombardier, C. Cochrane Back Review Group. Spine (Phila. Pa 1976) 28, 1215–1218 (2003).

    Google Scholar 

  5. Hagen, K. B., Hilde, G., Jamtvedt, G. & Winnem, M. Bed rest for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD001254. doi: 10.1002/14651858.CD001254.pub2 (2004).

  6. Clarke, J. A. et al. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD003010. doi: 10.1002/14651858.CD003010.pub4 (2007).

  7. Gibson, J. N. & Waddell, G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD001350. doi:10.1002/14651858.CD001350.pub4 (2007).

  8. Ostelo, R. W., Costa, L. O., Maher, C. G., de Vet, H. C. & van Tulder, M. W. Rehabilitation after lumbar disc surgery: an update Cochrane review. Spine (Phila. Pa 1976) 34, 1839–1848 (2009).

    Article  Google Scholar 

  9. Konstantinou, K. & Dunn, K. M. Sciatica: review of epidemiological studies and prevalence estimates. Spine (Phila. Pa 1976) 33, 2464–2472 (2008).

    Article  Google Scholar 

  10. Raj, P. P. Intervertebral disc: anatomy-physiology-pathophysiology-treatment. Pain Pract. 8, 18–44 (2008).

    Article  Google Scholar 

  11. Jensen, M. C. et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N. Engl. J. Med. 331, 69–73 (1994).

    Article  CAS  Google Scholar 

  12. Modic, M. T. et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology 237, 597–604 (2005).

    Article  Google Scholar 

  13. Weber. H., Holme, I. & Amlie, E. The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam. Spine 18, 1433–1438 (1993).

    Article  CAS  Google Scholar 

  14. Vroomen, P. C. A. J., de Krom, M. C., Slofstra, P. D. & Knottnerus, J. A. Conservative treatment of sciatica: a systematic review. J. Spinal Disord. 13, 463–469 (2000).

    Article  CAS  Google Scholar 

  15. Legrand, E., Bouvard, B., Audran, M., Fournier, D. & Valat, J. P. Sciatica from disk herniation: medical treatment or surgery? Joint Bone Spine 74, 530–535 (2007).

    Article  Google Scholar 

  16. Miranda, H., Viikari-Juntera, E., Martikainen, R., Takala, E. P. & Riihimaki, H. Individual factors, occupational loading, and physical exercise as predictors of sciatic pain. Spine (Phila. Pa 1976) 27, 1102–1109 (2002).

    Article  Google Scholar 

  17. Younes, M. et al. Prevalence and risk factors of disk-related sciatica in an urban population in Tunisia. Joint Bone Spine 73, 538–542 (2006).

    Article  Google Scholar 

  18. Kaila-Kangas, L. et al. History of physical work exposures and clinically diagnosed sciatica among working and nonworking Finns aged 30 to 64. Spine (Phila. Pa 1976) 34, 964–969 (2009).

    Article  Google Scholar 

  19. Vroomen, P. C., de Krom, M. C. & Knottnerus, J. A. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J. Neurol. 246, 899–906 (1999).

    Article  CAS  Google Scholar 

  20. Devillé, W. L., van der Windt, D. A., Dzaferagic, A., Bezemer, P. D. & Bouter, L. M. The test of Lasègue: systematic review of the accuracy in diagnosing herniated discs. Spine (Phila. Pa 1976) 25, 1140–1147 (2000).

    Article  Google Scholar 

  21. Jarvik, J. G. & Deyo, R. A. Diagnostic evaluation of low back pain with emphasis on imaging. Ann. Intern. Med. 137, 586–597 (2002).

    Article  Google Scholar 

  22. Govind, J. Lumbar radicular pain. Aust. Fam. Physician 33, 409–412 (2004).

    PubMed  Google Scholar 

  23. Awad, J. N. & Moskovich, R. Lumbar disc herniations: surgical versus nonsurgical treatment. Clin. Orthop. Relat. Res. 443, 183–197 (2006).

    Article  Google Scholar 

  24. Hagen, K. B., Jamtvedt, G., Hilde, G. & Winnem, M. F. The updated Cochrane review of bedrest for low back pain and sciatica. Spine (Phila. Pa 1976) 30, 542–546 (2005).

    Article  Google Scholar 

  25. Luijsterburg, P. A. J. et al. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur. Spine J. 16, 881–899 (2007).

    Article  Google Scholar 

  26. Luijsterburg, P. A. et al. Physical therapy plus general practitioners' care versus general practitioners' care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Eur. Spine J. 17, 509–517 (2008).

    Article  Google Scholar 

  27. Goupille, P., Mulleman, D., Paintaud, G., Watier, H. & Valat, J. P. Can sciatica induced by disc heriation be treated with tumor necrosis factor α blockade? Arthritis Rheum. 56, 3887–3895 (2007).

    Article  CAS  Google Scholar 

  28. Korhonen, T. et al. The treatment of disc herniation-induced sciatica with infliximab: results of a randomised, controlled, 3-month follow-up study. Spine (Phila. Pa 1976) 30, 2724–2728 (2005).

    Article  Google Scholar 

  29. Arts, M. P. et al. Tubular diskectomy vs conventional microdiskectomy for sciatica: a randomized controlled trial. JAMA 302, 149–158 (2009).

    Article  CAS  Google Scholar 

  30. Ryang, Y., Oertel, M. F., Mayfrank, L., Gilsbach, J. M. & Rohde, V. Standard open microdiscectomy versus minimal access trocar microdiscectomy: results of a prospective randomized study. Neurosurgery 62, 174–181 (2008).

    Article  Google Scholar 

  31. Weber, H. Lumbar disc herniation. A prospective study of prognostic factors including a controlled trial. Part I. J. Oslo City Hosp. 28, 33–61 (1978).

    CAS  PubMed  Google Scholar 

  32. Weber, H. Lumbar disc herniation. A controlled prospective study with ten years of observation. Spine (Phila. Pa 1976) 8, 131–140 (1983).

    Article  CAS  Google Scholar 

  33. Buttermann, G. R. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J. Bone Joint Surg. Am. 86, 670–679 (2004).

    Article  Google Scholar 

  34. Osterman, H., Seitsalo, S., Karppinen, J. & Malmivaara, A. Effectiveness of microdiscectomy for lumbar disc herniation. Spine (Phila. Pa 1976) 31, 2409–2414 (2006).

    Article  Google Scholar 

  35. Weinstein, J. N. et al. Surgical vs nonoperative treatment for lumbar disk herniation: the spine patient outcomes research trial (SPORT): a randomized trial. JAMA 296, 2441–2450 (2006).

    Article  CAS  Google Scholar 

  36. Weinstein, J. N. et al. Surgical vs nonoperative treatment for lumbar disk herniation: the spine patient outcomes research trial (SPORT) observational cohort. JAMA 296, 2451–2459 (2006).

    Article  CAS  Google Scholar 

  37. Peul, W. C. et al. Surgery versus prolonged conservative treatment for sciatica. N. Engl. J. Med. 356, 2245–2256 (2007).

    Article  CAS  Google Scholar 

  38. Tullberg, T., Isacson, J. & Weidenhielm, L. Does microscopic removal of lumbar disc herniation lead to better results than the standard procedure? Results of a one-year randomized study. Spine (Phila. Pa 1976) 18, 24–27 (1993).

    Article  CAS  Google Scholar 

  39. Lagarrigue, J. & Chaynes, P. Comparative study of disk surgery with or without microscopy. A prospective study of 80 cases [French]. Neurochirurgie 40, 116–120 (1994).

    CAS  PubMed  Google Scholar 

  40. Henriksen, L., Schmidt, V., Eskesen, V. & Jantzen, E. A controlled study of microsurgical versus standard lumbar discectomy. Br. J. Neurosurg. 10, 289–293 (1996).

    Article  CAS  Google Scholar 

  41. Katayama, Y. et al. Comparison of surgical outcomes between macro discectomy and micro discectomy for lumbar disc herniation: a prospective randomized study with surgery performed by the same spine surgeon. J. Spinal Disord. Tech. 19, 344–347 (2006).

    Article  Google Scholar 

  42. Huang, T. J., Hsu, R. W., Li, Y. Y. & Cheng, C. C. Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J. Orthop. Res. 23, 406–411 (2005).

    Article  CAS  Google Scholar 

  43. Zhang, C. et al. Microendoscopic discectomy, a less traumatic procedure for lumbar disk herniation. Chin. J. Traumatol. 10, 311–314 (2007).

    Google Scholar 

  44. Shin, D. A., Kim, K. N., Shin, H. C. & Yoon, D. H. The efficacy of microendoscopic discectomy in reducing iatrogenic muscle injury. J. Neurosurg. Spine 8, 39–43 (2008).

    Article  Google Scholar 

  45. Righesso, O., Falavigna, A. & Avanzi, O. Comparison of open discectomy with microendoscopic discectomy in lumbar disc herniations: results of a randomized controlled trial. Neurosurgery 61, 545–549 (2007).

    Article  Google Scholar 

  46. Hermantin, F. U., Peters, T., Quartararo, L. & Kambin, P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J. Bone Joint Surg. Am. 81, 958–965 (1999).

    Article  CAS  Google Scholar 

  47. Dutch Society for Neurology. Clinical guideline: lumbosacral radicular syndrome [Dutch]. (Dutch Society for Neurology, Urecht, 2008).

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Author information

Author notes

  1. M. van Tulder maurits.van.tulder@falw.vu.nl

Authors and Affiliations

  1. Department of Health Sciences & EMGO Institute for Health and Care Research, VU University, De Boelelaan 1085, 1081, HV Amsterdam, The Netherlands

    Maurits van Tulder

  2. Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands

    Wilco Peul

  3. Department of General Practice, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands

    Bart Koes

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  3. Bart Koes
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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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