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PubMed2004

Factors predicting outcomes of mechanical sciatica: a review of 1092 cases.

UNLABELLED: As an extremely common symptom and major source of lost productivity, mechanical sciatica places a heavy burden on public health. METHODS: We retrospectively reviewed 1092 medical records to determine the epidemiological, clinical, imaging study, and therapeutic characteristics of mechanical sciatica. We also looked for factors associated with adverse outcomes. RESULTS: Mean patient age was 45.0 +/- 13.3 years, and 61.8% of patients were women. A history of low back pain was noted in 35.2% of cases. A single nerve root was involved in 68% of cases, and L5 was the most commonly affected root. Disk herniation was the cause in 58.4% of patients. First-line conservative treatment provided relief in 75% of cases, and the overall 6-month outcome was favorable in 76.5% of cases. CONCLUSION: The multivariate analysis conducted in the overall patient population showed that factors associated with adverse 6-month outcomes were heavy labor (odds ratio (OR) = 1.69; 95% confidence interval (95% CI) = 1.01-2.86; P = 0.049) and obesity (OR = 1.5; 95% CI = 1.01-2.47; P = 0.05).

Adolescent↗

PubMed2005

Pathophysiology of disk-related sciatica. I.--Evidence supporting a chemical component.

Sciatica in patients with disk disease was long ascribed to pressure put on the sciatic nerve root by a herniated disk. However, a role for chemical factors acting in conjunction with this mechanical insult is suggested by a number of clinical observations: disk surgery does not consistently provide pain relief, large disk herniations are not always symptomatic, severe pain may be present in patients without imaging evidence of nerve root compression, the severity of symptoms and neurological signs is not well correlated with the size of the disk herniation, and conservative therapy is often effective. Experimental studies have provided further evidence for a chemical component: disk herniations can undergo spontaneous resorption, the intervertebral disk is immunogenic, and mediators for inflammation have been identified within intervertebral disk tissue. The current pathophysiological theory incriminates proinflammatory substances secreted by the nucleus pulposus (NP). When preexisting or concomitant mechanical injury to a nerve root occurs, these substances can cause nerve root pain. Animal experiments have established that the NP can induce functional and structural nerve root abnormalities in the absence of mechanical compression and that this effect is mediated by substances located at the surface of NP cells. Methylprednisolone, diclofenac, indomethacin, doxycycline, and cyclosporine induce variable inhibition of this effect. Available information points to tumor necrosis factor-alpha (TNF-alpha) as the main candidate among substances potentially responsible for nerve root pain. Therefore, trials of TNF-alpha antagonists in patients with disk-related sciatica are warranted.

Animals↗

PubMed2004

Spinal manipulation, epidural injections, and self-care for sciatica: a pilot study for a randomized clinical trial.

OBJECTIVE: To assess the feasibility of recruiting sciatica patients and to evaluate their compliance in preparation for a full-scale randomized clinical trial. We also aimed to determine the responsiveness of key outcome measures. METHODS: Thirty-two subjects were randomly assigned to spinal manipulation (n=11), epidural steroid injections (n=11), or self-care education (n=10). No between-group comparisons were planned because of the small sample size. RESULTS: At week 12 (the end of the treatment phase), the outcome measures indicating the most improvement/change were the Oswestry disability score (mean, 22.9; SD, 19.9; effect size [ES], 1.8), leg pain severity (mean, 2.9; SD, 1.7; ES, 1.7), and if the symptoms were bothersome (mean, 25.2; SD, 16.0; ES, 1.6). Twenty-four patients were either "very satisfied" or "completely satisfied," and 22 of 32 patients reported 75% or 100% improvement. After 52 weeks, the outcome measure showing the most improvement/change was leg pain severity (mean, 2.3; SD, 2.6; ES, 1.35), followed by the Oswestry disability score (mean, 15.6; SD, 20; ES, 1.2) and if symptoms were bothersome (mean, 18.1; SD, 22.6; ES, 1.1). Eighteen patients were either "very satisfied" or "completely satisfied," and 15 of 32 patients reported 75% or 100% improvement. CONCLUSIONS: The results of this pilot study suggest that it is feasible to recruit subacute and chronic sciatica patients and to obtain their compliance for a full-scale randomized clinical.

Adult↗

PubMed2003

Corticospinal excitability in patients with unilateral sciatica.

Patients suffering from sciatica may develop altered patterns of corticospinal drive to muscles of the leg. Electromyographic recordings were made bilaterally from tibialis anterior and lateral gastrocnemius muscles during transcranial magnetic stimulation of the motor cortex from nine patients with unilateral sciatica and seven healthy controls. The mean thresholds for eliciting motor evoked potentials (MEPs) and the silent period were higher in the patients than in the control subjects. In addition, there was a positive correlation between the patients' self rated score of disability (the Oswestry Disability Index) and their threshold for MEPs and the silent period. This study suggests that the chronic pain experienced by the patients leads to a reduction in corticospinal drive to the legs. These changes might help to relax muscles close to the perceived site of pain and so alleviate symptoms. Investigation of these patients following remedial treatment will allow us to establish if the changes are transient in nature.

Disability Evaluation↗

PubMed2005

Genetic variations in IL6 associate with intervertebral disc disease characterized by sciatica.

Intervertebral disc disease (IDD) characterized by sciatica is a common disorder affecting about 5% of individuals. Environmental factors can predispose to this disease, but IDD has a strong genetic background. Recent evidence suggests that inflammation is one of the key factors in the etiology of IDD. Here, a possible role of the inflammatory mediator genes was studied in 155 patients with IDD-related sciatica and 179 controls. Forty-eight patients were analyzed for mutations in the IL1A, IL1B, IL6 and TNFA genes, and 16 polymorphisms in 10 candidate cytokine genes (IL1A, IL1B, IL1RN, TNFA, IL2, IL4, IL4R, IL6, IL10, IFNG) were genotyped from all subjects. No disease-causing mutations were identified in IL1A, IL1B, IL6 or TNFA. Allele frequencies were, however, significantly different between the two groups for IL6 SNP, T15A in exon 5 (P=0.007). Furthermore, the genotypes AA and AT of the exon 5 SNP were more common in the patients (P=0.011; OR=4.4, 95% CI=1.2-15.7; AR=7.5%, 1.6-13.1%). Haplotypes were then generated for four IL6 SNPs, G-597A, G-572C, G-174C, and T15A in exon 5. Haplotype GGGA was more common in the patients (P=0.011; OR=4.8, 95% CI=1.6-14.5). To evaluate attributable risk, haplotype pairs were assigned for the individuals. The presence of GGGA/GGGA or GGGA/other genotypes had an OR of 5.4 (95% CI=1.5-19.2). Association of GGGA with disease was highly significant (P=0.0033), and the associated AR was 6.8% (1.9-11.5%). These findings support the role of IL-6 genetic variations in discogenic pain.

Adult↗

PubMed1992

The natural history of sciatica: a prospective radiological study.

This prospective study was set up to record the changes in the intervertebral disc accompanying resolution of sciatica following conservative treatment. Patients presenting with sciatica (n = 165) were examined by computed tomography (CT) of the lumbar spine. Disc lesions were classified into the following groups: herniation, sequestration, generalized bulge and focal bulge. Follow-up CT of the pathological disc was performed in 106 of the 165 patients after 1 year and identical anatomical sections were compared. All patients were initially treated conservatively by the injection of steroid and local anaesthetic at the intervertebral disc/nerve root interface. Of 84 cases of disc herniation and sequestration 64 (76%) showed either complete or partial resolution on follow-up CT examination. Of 22 cases with either a generalized or focal bulge of the disc 18 (82%) were unchanged on follow up. The classical disc herniation in a young patient is the type of disc lesion most likely to show greatest improvement at follow-up CT.

Adolescent↗

PubMed1994

Supralevator anorectal abscess presenting as acute low back pain and sciatica.

Anorectal abscess is a suppurative process that begins in the anal glands. Clinical presentation is variable and depends on the direction and tissue plane along which the infection tracks. All cases require urgent incision and drainage. We report an unusual case of a supralevator abscess in a man who presented to the emergency department on two occasions with acute low back pain and sciatica. The case demonstrates the importance and difficulty of identifying the exceptional case among the numerous routine cases of mechanical low back pain. Attentiveness to atypical features should direct the clinician to a more extensive evaluation for serious illness. The case also illustrates that sciatica is not a diagnostic end-point but rather a label for a pain syndrome that encompasses a long differential diagnosis.

Abscess↗

PubMed2001

Sciatica caused by epidural gas. Four case reports.

We report four cases of sciatica caused by gas in the epidural space with no other abnormality. Only 21 similar cases have been reported. Clinical features are identical to those of common sciatica, and plain radiographs are often uninformative. Computed tomography shows a low-density epidural collection displacing the nerve root.

Adult↗

PubMedDate not supplied

Predicting outcomes of transforaminal epidural injections for sciatica.

BACKGROUND CONTEXT: Previous studies on epidural injections have focused on efficacy and have not evaluated factors predicting outcomes of epidural injections. PURPOSE: To determine which patient factors are associated with transforaminal epidural injection outcomes for sciatica. STUDY DESIGN: Cross-sectional study design at a university spine center. PATIENT SAMPLE: Consecutive patients with sciatica who have had an electromyography study and a transforaminal epidural injection between January 1999 and July 2001. OUTCOME VARIABLE: The outcome variable was a composite score of the patients' pain severity and medication use compared with their initial visit. Independent variables included demographics, previous back surgery, pain severity at initial presentation, pain medication use at initial presentation, litigation, having Social Security Disability Insurance (SSDI) or workers' compensation, electromyography results. METHODS: Medical information was gathered on the variables listed above. RESULTS: Seventy-six patients, mean age 50.4 years and 49% female, participated. At a mean follow-up of 122 days (SD 146.3), 35 (47%) were improved, 21 (28% were unchanged) and 12 (16%) were worse. Initial correlation analysis showed some relationship between outcomes and having SSDI or workers' compensation (R=.43, p<.001), lifting requirements at work (R=.44, p=.002), working status (R=-.31, p=.02), and electromyogram evidence of radiculopathy (R=-.25, p=.04). Regression analysis showed that having SSDI or workers' compensation was the primary factor associated with worse outcomes. CONCLUSIONS: When controlled for SSDI/workers' compensation, lifting requirements at work, but not working status and radiculopathy, also were associated with outcomes but the association was not as strong. This paper brings into question the utility of offering epidural injections to patients who are on SSDI/workers' compensation and require heavy lifting at work.

Adult↗

PubMed2006

Brucellar spondylo-discitis with rapidly progressive spinal epidural abscess presenting with sciatica.

STUDY DESIGN: Case report. OBJECTIVE: To present a patient with spinal brucellosis, which was initially presented with sciatica and misdiagnosed as a lumbar disc herniation owing to nonspecific neurological and radiological findings. The delay in diagnosis led to rapid progression of the disease and complications. SETTING: Department of Neurosurgery at a tertiary university teaching hospital (Sutcu Imam University Medical Center in Turkey). CASE REPORT: A 57-year-old woman with a history of low-back pain for 6 months, fatigue, and severe left-sided sciatica for the last 3 months presented to our hospital. Three months earlier, at another hospital, she had had a negative Rose-Bengal test for brucellosis and a lumbar computed tomography performed at that time showed only minimal L4-5 annular bulging. For 2 months, she was treated with analgesics for 'lumbar disc herniation' without relief of pain. On presentation to our department, her magnetic resonance imaging (MRI) examination showed edema and minimal annular bulging at L3-4 and L4-5. When her Rose-Bengal test returned positive, she was started on triple antibiotics for presumed Brucella infection. When symptoms and neurologic signs worsened while taking antibiotics, repeat MRI scan showed a spinal epidural abscess at the L4-5 level. Emergent surgery and 8 weeks of antibiotics resulted in cure. CONCLUSION: In areas endemic for brucellosis, subtle historical and exam features should be sought to exclude an infection such as brucellar sponylo-discitis. Appropriate serological tests should be readily available to confirm or exclude this diagnosis in selected patients, to avoid delays in antibiotic treatment.

Brucellosis↗

PubMed1999

The anatomical basis of sciatica secondary to herniated lumbar disc: a review.

The purpose of this manuscript is to illustrate the key anatomical and biomechanical elements involved in the etiopathogenesis of sciatica, and to demonstrate how periradicular fibrosis contributes to the pathophysiology of recurrent post-operative sciatica. History, etiology, anatomy and diagnosis of herniated inter-vertebral disc are reviewed. The straight leg raising exam is a well accepted test in the diagnosis of lumbar disc herniation. In the post-operative patients, the results of the straight leg raising test are affected by the presence of scar and fibrosis around the lumbar root(s) involved. The mechanisms by which perineural fibrosis and adhesions change and compromise the neural dynamics and causes symptoms to recur in the post-operative patient are discussed. Due to its dramatic clinical relevance, prevention of periradicular fibrosis has high priority in the surgical management of herniated lumbar disc. Such a goal should be obtained by using a combination of appropriate indication to surgery, impeccable operative technique and the use of an effective anti-fibrotic agent.

Fibrosis↗

PubMed1999

A retrospective study to assess the results of CT-directed peri-neural root infiltration in a cohort of 56 patients with low back pain and sciatica.

Fifty-six patients with low back pain and sciatica following radiological investigation were found to have abnormalities at multiple levels, more than one of which could be responsible for the clinical picture or at a single level, which correlated poorly with the clinical findings. Thirty-four patients had a diagnostic peri-neural root infiltration to clarify whether surgery would be appropriate. Evaluation of the technique was by reduction in analgesia. Eighteen patients have had surgery, 14 with a successful, two a moderate and two a poor outcome. Four patients have been denied and two are awaiting an operation. Ten patients referred for a diagnostic procedure deferred surgery in favour of a therapeutic course. Of 22 patients referred directly for a therapeutic course, 15 had a successful, three a moderate and four a poor result. CT-directed peri-radicular root infiltration is a useful adjunct in the management of low back pain and sciatica.

Anesthesia, Local↗

PubMed1987

Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections.

Four treatment regimens for patients with specified combinations of low back pain and sciatica were evaluated. The largest group studied had low back pain with limited straight-leg raising (SLR) and in them the beneficial effect of manipulation in hastening pain relief was highly significant. In similar patients without limitation of SLR, the effect was of borderline significance. In all the other groups, treated patients also recovered more quickly than their controls. Traction, for patients with low back pain and sciatica, and epidural injections when a root palsy was present also produced some significant pain relief. The effect of sclerosants for back pain was less clear.

Adolescent↗

PubMed1988

Outpatient lumbar epidural corticosteroid injection in the management of sciatica.

The value of epidural injections of corticosteroid as an outpatient treatment of sciatica has been hitherto uncertain. An epidural injection of 80 mg methylprednisolone in 10 ml physiological saline was compared with an interspinous injection of 2 ml physiological saline in a double blind fashion amongst 39 outpatients. Significant differences of pain relief were seen between the two groups within 2 weeks. This benefit disappeared for six (35%) patients within 6 months of treatment although 11 (65%) successfully treated subjects had sustained improvement up to this time. Outpatient epidural injections of corticosteroid are thus a useful short-term means of relieving pain in sciatica but probably have little effect on the long-term natural history of symptoms. Factors associated with a failure to respond to epidural steroid injections are discussed.

Adrenal Cortex Hormones↗

PubMed2002

Glucocorticoid epidural for sciatica: metabolic and endocrine sequelae.

OBJECTIVE: The study was designed to investigate the effect of epidural administration of glucocorticoid on insulin sensitivity. METHODS: Ten healthy individuals with sciatica underwent a short insulin tolerance test before and twice following (at 24 h and 1 week) a caudal epidural containing 80 mg triamcinolone. Fasting glucose, insulin and cortisol concentrations were also measured. RESULTS: The rate of glucose disappearance after insulin administration (k(ITT)) fell from 3.6%/min before the epidural to 1.9%/min 24 h afterwards (P=0.001) and returned to pretreatment values by 1 week. Significantly raised fasting insulin and glucose levels also reflected impaired insulin sensitivity immediately after the epidural. Morning cortisol levels were suppressed after the epidural (49 nmol/l at 24 h and 95 nmol/l at 1 week vs 352 nmol/l at baseline; P<0.01). CONCLUSIONS: Epidural administration of glucocorticoid results in potent suppression of insulin action and this should be taken into account when patients with diabetes require treatment for sciatica.

Adult↗

PubMedDate not supplied

Epidemiologic and clinical studies of long-term prognosis of low-back pain and sciatica.

In order to justify the selection of therapeutic measures for low-back pain and sciatica, epidemiologic and clinical studies were performed of the natural histories or the long-term prognosis of those symptoms. The main conclusions drawn in relation to decision making are as follows: low-back pain is more frequent than sciatica or intermittent claudication, but the latter is more disabling; acute attacks are generally more disabling than chronic pain, and the frequency may be more closely related to poor prognosis than the duration; radiologic findings are of little value in differentiating the incidence and degree of the symptoms during life; myelographic or peridurographic abnormalities do not always suggest poor prognosis.

Acute Disease↗

PubMedDate not supplied

Low-back pain and sciatica following total hip replacement: a report of two cases.

Two cases of low-back pain and sciatica following total hip replacement are reported. Both patients were operated upon and after lumbar decompression were free of pain. A theory is presented to suggest that the lengthening of the limb after total hip replacement puts excess tension on the spinal nerves and, in conjunction with preexisting degenerative disc disease, will precipitate low-back pain and sciatica.

Aged↗

PubMedDate not supplied

Neurologic patterns in unilateral sciatica. A prospective study of 100 new cases.

A prospective study of 100 patients with neurologic deficits due to their first attacks of sciatica was performed. (Major published studies are nearly all retrospective and contain some patients who have had multiple attacks of sciatica). Characteristic motor patterns for L3-4, L5, and S1 root lesions were found. L3-4 lesions (17%) were significantly more common in 60+ age group. Lesions of L5 were significantly more common than S1 (approximately 2 to 1), a result which differs from all other major series. Reasons for this are discussed. Sensory disturbance (62%) was nerve present within motor loss and had poor localizing value.

Adult↗