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PubMed1996

Altered lower limb vascular perfusion in patients with sciatica secondary to disc herniation.

STUDY DESIGN: The present study attempts to document deep vascular abnormalities of the lower extremity in cases of sciatica secondary to discal herniation using Tc-99m methylene diphosphonate angiography. OBJECTIVES: Vascular abnormalities are studied compared with the contralateral extremity and normal control subjects. An attempt is made to determine the clinical usefulness of the current technique. SUMMARY OF BACKGROUND DATA. Thermography has occasionally evidenced a decreased cutaneous temperature in patients with sciatica. There have been no studies to date looking at the total vascular flow in this condition, mainly constituted by the muscular perfusion. METHODS: Thirty patients with sciatica secondary to discal herniation, 16 patients with chronic low back pain referred to the thigh, and 31 control subjects were examined by isotopic angiography of the posterior aspect of the thigh after intravenous injection of Tc-99m methylene diphosphonate. The affected side was compared with the nonpainful side, and the difference was expressed as a percentage. Control subjects were used as reference values. RESULTS: Abnormality in vascularization of the lower extremity was found in 24 (80%) of patients with sciatica and in 11 (68.7%) of the patients with low back pain. The median blood flow difference was, respectively, -12.5% and +4% in these two groups versus +2.9% in the control group. The differences between the sciatica group and the other groups were statistically significant. No correlation was found with the clinical parameters studied. CONCLUSION: Vascular perfusion abnormalities observed in patients with sciatica secondary to disc herniation may be more important than previously considered and possibly result from alteration in sympathetic vascular autoregulation.

Aged↗

PubMed2002

Magnetic resonance imaging findings in relation to the COL9A2 tryptophan allele among patients with sciatica.

STUDY DESIGN: The phenotype of patients with sciatica who have the Trp2 allele is characterized cross-sectionally. OBJECTIVE: To determine whether it is possible to differentiate patients with the Trp2 allele clinically or by magnetic resonance imaging. SUMMARY OF BACKGROUND DATA: Several studies have indicated a positive family history for intervertebral disc disease. Previously, a dominantly inherited defect was identified in the COL9A2 gene that changed a codon for glutamine to that for tryptophan in the alpha2 chain of collagen IX (Trp2 allele). This change may render intervertebral discs more fragile. METHODS: Clinical findings, clinical symptoms, and magnetic resonance imaging (1.5-T) findings from 159 patients with sciatica were evaluated according to the presence of the Trp2 allele. Additionally, the magnetic resonance imaging scans of 22 family members from three families were evaluated. These scans were analyzed intervertebral disc and endplate degeneration, Schmorl's nodes, transverse tears (hyperintensity in the region of Sharpey's fibers), high-intensity zone lesions (bright spots in the dorsal anulus), and radial tears (hyperintense linear area from the nucleus to the outer part of the anulus on T2 sequences). RESULTS: Six patients with sciatica and 11 family members had the Trp2 allele. No homozygotes were found. Clinical symptoms of patients with and those without the Trp2 allele were similar. Patients with sciatica who had the Trp2 allele were significantly more flexible (P < 0.05), according to the modified Schober measure. The disc and endplate degeneration in 6 patients with the Trp2 allele and their 18 controls (matched for age, occupation, gender) without the allele did not differ significantly, whereas family members with the Trp2 allele had a greater degree of disc and endplate degeneration at L5-S1. The overall prevalence of endplate degeneration was high in this study. The prevalences of dorsal transverse tears, high-intensity zone lesions, and Schmorl's nodes did not differ among patients with sciatica or family members according to the presence of the Trp2 allele. There was, however, a trend for increased prevalence of radial tears in nonherniated discs among the Trp2 allele-positive subjects (3 of 6 patients with sciatica and 3 of 11 family members), as compared with the Trp2-negatives subjects (none of 18 "matched" patients or 11 family members). CONCLUSION: The patients with the Trp2 allele were more flexible, and more often tended to have a radial tear in a nonherniated disc than their control counterparts.

Adult↗

PubMed2004

Efficacy of etanercept in the treatment of acute, severe sciatica: a pilot study.

OBJECTIVES: To explore the efficacy of a tumour necrosis factor alpha (TNFalpha) inhibitor (etanercept, Enbrel) in patients with severe sciatica. METHODS: A pilot study of etanercept was conducted in patients admitted to hospital for acute severe sciatica. Ten consecutive patients received three subcutaneous injections of etanercept (25 mg every 3 days) in addition to standard analgesia. Response was evaluated at day 10 (T1) and week 6 (T2) using a visual analogue scale for leg pain (VASL) and for low back pain (VASB), and two validated functional scores: the Oswestry disability index (ODI) and the Roland Morris disability questionnaire (RMDQ). The control group consisted of 10 patients with severe sciatica, who took part in an observational study on i.v. methylprednisolone. RESULTS: In the etanercept group all variables improved: VASB from 36 to 7; VASL from 74 to 12; RMDQ from 17.8 to 5.8, and ODI from 75.4 to 17.3; all p<0.001. Pain (VASL and VASB: p<0.001) and ODI (p<0.05) were significantly better in the etanercept group than in the methylprednisolone group. CONCLUSION: In this open, historical group controlled study, patients with severe sciatica had sustained improvement after a short treatment with etanercept that was better than standard care plus a short course of methylprednisolone. These results suggest that inhibition of TNFalpha is beneficial in the treatment of sciatica and support a pathological role for TNFalpha in the pathogenesis of sciatica. These results need to be confirmed by a randomised controlled trial.

Acute Disease↗

PubMed2006

Therapeutic effect and outcome predictors of sciatica treated using transforaminal epidural steroid injection.

OBJECTIVE: The objectives of this retrospective study were to assess the therapeutic effect of transforaminal epidural steroid for sciatica and to identify outcome predictors. MATERIALS AND METHODS: Transforaminal epidural steroid injections were performed in 248 patients from June 2003 to May 2004. Fifty-six patients (33 women, 23 men; mean age, 53.3 years; age range, 30-83 years) were included. Therapeutic effects were evaluated 2 weeks after injection. The possible outcome predictors were as follows: intraepineural or extraepineural injection, saddle-type distribution pattern (contrast material distributed rostrally to the epidural portion of the preganglionic nerve root) or not saddle type, cause of sciatica (spinal stenosis vs herniated disk), patient age, patient sex, and duration of sciatica (acute or subacute [< 6 months] vs chronic [> 6 months]). The relationships between possible outcome predictors and therapeutic effects were analyzed. Statistical analysis was performed using Fisher's exact test, the chi-square test, and multiple logistic regression analysis. RESULTS: Forty-three (76.8%) of the 56 patients achieved a satisfactory result 2 weeks after transforaminal epidural steroid injection. Nineteen (65.5%) of the 29 patients treated by intraepineural injection and 24 (88.9%) of the 27 patients treated by extraepineural injection achieved a satisfactory result, and this difference was significantly different (p < 0.05). Other possible predictors of a better outcome were identified--that is, saddle-type pattern of contrast distribution, a herniated disk, and sciatica of less than 6 months' duration. Multiple regression analysis showed that the only factor significantly associated with outcome was the type of injection (p = 0.04, odds ratio: 5.01). CONCLUSION: Transforaminal epidural steroid is an effective tool for managing sciatica, and an extraepineural injection may be a predictor of a better outcome for sciatica treated using transforaminal epidural steroid.

Adult↗

PubMed2005

Cost-effectiveness and safety of epidural steroids in the management of sciatica.

OBJECTIVES: To investigate the clinical effectiveness of epidural steroid injections (ESIs) in the treatment of sciatica with an adequately powered study and to identify potential predictors of response to ESIs. Also, to investigate the safety and cost-effectiveness of lumbar ESIs in patients with sciatica. DESIGN: A pragmatic, prospective, multicentre, double-blind, randomised, placebo-controlled trial with 12-month follow-up was performed. Patients were stratified according to acute (<4 months since onset) versus chronic (4-18 months) presentation. All analyses were performed on an intention-to-treat basis with last observation carried forward used to impute missing data. SETTING: Rheumatology, orthopaedic and pain clinics in four participating centres: three district hospitals and one teaching hospital in the south of England. PARTICIPANTS: Total of 228 patients listed for ESI with clinically diagnosed unilateral sciatica, aged between 18 and 70 years, who had a duration of symptoms between 4 weeks and 18 months. INTERVENTIONS: Patients received up to three injections of epidural steroid and local anaesthetic (active), or an injection of normal saline into the interspinous ligament (placebo). MAIN OUTCOME MEASURES: The primary outcome measure was the Oswestry Disability Questionnaire (ODQ); measures of pain relief and psychological and physical function were collected. Health economic data on return to work, analgesia use and other interventions were also measured. Quality-adjusted life-years (QALYs) were calculated using the SF-6D, calculated from the Short Form (SF-36). Costs per patient were derived from figures supplied by the centres' finance departments and a costings exercise performed as part of the study. A cost-utility analysis was performed using the SF-36 to calculate costs per QALY. RESULTS: ESI led to a transient benefit in ODQ and pain relief, compared with placebo at 3 weeks (p = 0.017, number needed to treat = 11.4). There was no benefit over placebo between weeks 6 and 52. Using incremental QALYs, this equates to and additional 2.2 days of full health. Acute sciatica seemed to respond no differently to chronic sciatica. There were no significant differences in any other indices, including objective tests of function, return to work or need for surgery at any time-points. There were no clinical predictors of response, although the trial lacked sufficient power to be confident of this. Adverse events were uncommon, with no difference between groups. Costs per QALY to providers under the trial protocol were 44,701 pounds sterling. Costs to the purchaser per QALY were 354,171 pounds sterling. If only one ESI was provided then costs per QALY fell to 25,745 pounds sterling to the provider and 167,145 pounds sterling to the purchaser. ESIs thus failed the QALY threshold recommended by the National Institute for Health and Clinical Excellence (NICE). CONCLUSIONS: Although ESIs appear relatively safe, it was found that they confer only transient benefit in symptoms and self-reported function in a small group of patients with sciatica at substantial costs. ESIs do not provide good value for money if NICE recommendations are followed. Additional research is suggested into the epidemiology of radicular pain, producing a register of all ESIs, possible subgroups who may benefit from ESIs, the use of radiological imaging, optimal early interventions, analgesic agents and nerve root injections, the use of cognitive behavioural therapy in rehabilitation, improved methods of assessment, a comparative cost-utility analysis between various treatment strategies, and methods to reduce the effect of scarring and inflammation.

Acute Disease↗

PubMed2026

No Efficacy of Dexamethasone Injections for Acute Sciatica: A Double-Blind Randomized Study Versus Saline.

BACKGROUND: The efficacy of caudal injections for patients with acute sciatica remains controversial. The DEXHIA study was designed to evaluate whether ultrasound-guided caudal injection of dexamethasone provides superior clinical outcomes compared with saline placebo. METHODS: This prospective, randomized, placebo-controlled, double-blind trial included adult patients with sciatica secondary to lumbar disc herniation of less than 3 months' duration. Participants were randomly assigned in a 1:1 ratio to receive either 16 mg of dexamethasone (4 mL) diluted with 16 mL of saline (DEXA group) or 20 mL of saline alone (PLACEBO group), administered by ultrasound-guided caudal epidural injection. The primary outcome was the change in the Oswestry Disability Index (ODI) at 3 weeks. Secondary outcomes included leg pain and low back pain assessed by visual analogue scale (VAS), health-related quality of life (SF-36), need for repeat epidural injection, and need for lumbar surgery. Clinical assessments were performed at 3 weeks, 3 months, and 6 months. RESULTS: A total of 106 patients were randomized, with 53 participants assigned to each treatment group. The primary endpoint was not met, as the improvement in ODI at 3 weeks did not differ significantly between groups (mean change: -9.5 ± 4.4 in the DEXA group versus -13.8 ± 4.4 in the PLACEBO group; p = 0.18). No significant differences were observed for any relevant secondary outcome at any follow-up time point. During the 6-month follow-up, 34 patients in the DEXA group and 30 patients in the PLACEBO group underwent a second, non-blinded injection of dexamethasone (ns). Lumbar surgery was performed in 10 patients in the DEXA group and nine patients in the PLACEBO group (ns). Injection-related adverse events were mild and transient but occurred more frequently in the DEXA group. CONCLUSIONS: Caudal injection of soluble dexamethasone conferred no clinical benefit over saline placebo in patients with acute sciatica. SIGNIFICANCE STATEMENT: Epidural injections are widely used worldwide for the treatment of resistant sciatica and have been extensively studied in multiple meta-analyses. However, their clinical value remains debated due to the limited methodological quality of most available studies. We conducted a methodologically rigorous randomized, placebo-controlled trial, which yielded negative results. These findings question the efficacy of caudal epidural injection of a non-particulate corticosteroid administered via a remote (sacrococcygeal) approach for disc-related sciatica. TRIAL REGISTRATION: The trial was registered under European Clinical Trials No. 2021-001571-17 and ClinicalTrials.gov identifier NCT05000658.

Adult↗

PubMed2002

Advice to stay active as a single treatment for low back pain and sciatica.

BACKGROUND: Low back pain is one of the most common conditions managed in primary care. Restricted activity, rest, and symptomatic analgesics are the most commonly prescribed treatment for low back pain and sciatica. OBJECTIVES: To assess the effects of advice to stay active as single treatment for patients with low back pain. SEARCH STRATEGY: Computerised searches in MEDLINE, EMBASE, Sport, The Cochrane Controlled Trials Register, Musculoskeletal Group's Trials Register and Scisearch, and scanning of reference lists from relevant articles were undertaken. Relevant studies were also traced by contacting authors. Date of the most recent searches: December 1998. SELECTION CRITERIA: We included all randomised trials or quasi-randomised trials where the study population consisted of adult patients with low back pain or sciatica, in which one comparison group was advised to stay active. The main outcomes of interest were pain, functional status, recovery and return to work. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed the validity of included trials and extracted data. Investigators were contacted to collect missing data or for clarification when needed. MAIN RESULTS: Four trials, with a total of 491 patients, were included. Advice to stay active was compared to advice to rest in bed in all trials. Two trials were assessed to have low risk of bias and two to have moderate to high risk of bias. The results were heterogeneous. Results from one high quality trial of patients with acute simple LBP found small differences in functional status [Weighted Mean Difference (on a 0-100 scale) 6.0 (95% CI: 1.5, 10.5)] and length of sick leave [WMD 3.4 days (95% CI: 1.6, 5.2)] in favour of staying active compared to advice to stay in bed for two days. The other high quality trial compared advice to stay active with advice to rest in bed for 14 days for patients with sciatic syndrome, and found no differences between the groups. One of the high quality trials also compared advice to stay active with exercises for patients with acute simple LBP, and found improvement in functional status and reduction in sick leave in favour of advice to stay active. REVIEWER'S CONCLUSIONS: The best available evidence suggests that advice to stay active alone has small beneficial effects for patients with acute simple low back pain, and little or no effect for patients with sciatica. There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica. If there is no major difference between advice to stay active and advice to rest in bed, and there is potential harmful effects of prolonged bed rest, then it is reasonable to advise people with acute low back pain and sciatica to stay active. These conclusions are based on single trials.

Bed Rest↗

PubMed1997

[Differential sciatica pain diagnosis from the neurologic viewpoint].

Low back pain and sciatica with or without neurological deficits represent frequent disorders in clinical practice. Both, history and neurological examination are essential for localizing underlying lesions and initiating appropriate investigations. Pain location, sensory symptoms, motor signs and reflexes are extremely reliable in indicating which motor root(s) or peripheral nerve(s) are affected. Sometimes, pain and/or paraesthesia are the only presenting symptoms. Therefore differential diagnosis of low back pain and sciatica is various. This article summarizes the differential diagnosis of low back pain and sciatica according to the site of the lesion as follows: 1. lesions of the spinal cord, 2. lesions of the nerve roots (L4, L5, S1-S3), 3. lesions of the lumbosacral plexus, 4. peripheral nerve lesions (sciatic nerve, peroneal nerve), 5. low back pain and sciatica due to neuropathies, and 6. low back pain and sciatica as a symptom of other neurological disorders. Additionally, the status of neuroradiological procedures in establishing diagnosis is discussed.

Diagnosis, Differential↗

PubMed2005

The potential value of blood biomarkers of intervertebral disk metabolism in the follow-up of patients with sciatica.

STUDY DESIGN: This is a prospective study with a follow-up period of 4 years. OBJECTIVES: The study aimed to evaluate the possible clinical utility of three biomarkers [i.e., keratan sulfate (KS), hyaluronan, and cartilage oligomeric matrix protein] measured in peripheral blood in severe acute sciatica at intake and follow-up. SUMMARY OF BACKGROUND: Our previous study and others have pointed out the interest of different laboratory tests in the acute phase of sciatica. Several blood biomarkers have been reported useful in the long-term follow-up of patients with osteoarthritis. We have found no information about the potential interest of these tests in spinal disorders. METHODS: Patients were admitted to the hospital for intensive conservative management of acute sciatica (n=82). A subgroup of patients (n=33) was selected based on the duration of symptoms at visit 1, and included those with the shortest (n=24) as well as those with the longest (n=9) duration of sciatica. Blood samples were drawn, centrifuged, and the plasma frozen. Antigenic KS, hyaluronan, and cartilage oligomeric matrix protein were measured by ELISA. Patients were re-evaluated at an average of 4.3 years (range: 2.1-6.8 years). RESULTS: Thirty-three subjects with an average age of 49.2+/-10.2 years participated. At intake, levels of the three biomarkers evaluated were within the range of normal values. No significant differences were found between the results of patients with a short history of sciatica (< or =3 weeks) and those with a long duration of symptoms (>20 weeks). At follow-up, a significant increase (P<0.05) in all three biomarkers was found. CONCLUSIONS: A single measurement of these three biomarker molecules does not seem to have any diagnostic or therapeutic relevance in patients with acute radicular compression. The significance of the increase in all three biomarkers after a mean follow-up of 4.3 years is unclear; it might reflect metabolic processes involved in degenerative spinal disorders. Even though we found no correlation with clinical outcome, we believe that more research is needed.

Adult↗

PubMed2001

Fibrous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica.

STUDY DESIGN: Report of seven patients with fibrous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica, whose radiographic findings were negative and who experienced relief from sciatica immediately after the entrapment was released. OBJECTIVES: To describe a new clinical entity of fibrous adhesive entrapment of lumbosacral nerve roots with negative radiographic findings. SETTING: Orthopaedic department, Japan. METHODS: Clinical evaluation and post-operative outcome in seven patients with entrapment of lumbosacral nerve roots because of fibrous adhesion confirmed intraoperatively. RESULTS: Radiographic examinations by magnetic resonance imaging (MRI), myelography, and computed tomographic (CT) myelography demonstrated neither disc herniations nor spinal stenosis in all seven patients, and differential nerve root block was effective for relieving sciatica and low back pain. We confirmed, intraoperatively, entrapment of the nerve root by fibrous adhesion, and all seven patients were relieved from sciatica and low back pain postoperatively. CONCLUSION: This study presented seven patients with sciatica caused by fibrous adhesive entrapment of lumbosacral nerve roots who underwent decompression and release of fibrous adhesion. Radiographic examinations, such as MRI, myelography and CT myelography, showed no compressive shadows and also differential nerve root block was effective for its diagnosis. This study seems to be the first report of patients with entrapment of lumbosacral nerve roots caused by fibrous adhesion, whose radiographic findings were negative.

Adult↗

PubMed2001

Rapid progression of acute sciatica to cauda equina syndrome.

OBJECTIVE: To demonstrate the importance of clinical examination and continued vigilance for neurologic deterioration in patients with sciatica. Cauda equina syndrome, a rare sequela of sciatica, is considered a medical emergency requiring surgical decompression. CLINICAL FEATURES: A 32-year-old woman had sciatica that rapidly progressed to cauda equina syndrome. Magnetic resonance imaging revealed the presence of a large nonsequestered disk fragment in the lower lumbar spine. INTERVENTION AND OUTCOME: The disk fragment was surgically excised. The patient experienced immediate pain relief after surgery but retained neurologic deficits. After 6 months of rehabilitation, neurologic integrity was restored, aside from patchy sensory loss of the left foot and buttocks. At the 6-month follow-up, the patient's sciatica had not returned. CONCLUSIONS: Most cases of sciatica, regardless of cause, will self-resolve; as a result, there might be a tendency to maintain a low index of suspicion for serious, progressive disorders such as cauda equina syndrome. Patients need to be educated as to signs of this emergency condition and informed as to the possible consequences of delaying treatment. By maintaining a high index of suspicion for any case that fails to respond as expected to a course of conservative therapy or that demonstrates signs of cauda equina syndrome, chiropractors can assume a pivotal role by investigating and referring appropriately and by aiding in active rehabilitation postoperatively.

Acute Disease↗

PubMed1997

A prospective analysis of magnetic resonance imaging findings in patients with sciatica and lumbar disc herniation. Correlation of outcomes with disc fragment and canal morphology.

STUDY DESIGN: A two-part observational study. In Part 1, consecutive lumbar magnetic resonance imaging scans in patients with sciatica meeting enrollment criteria were prospectively and blindly analyzed by a set protocol. In Part 2, further clinical findings at the time of the magnetic resonance imaging were obtained by retrospective chart review and outcome assessment done at follow-up of more than 2 years. OBJECTIVES: To determine the quantitative magnetic resonance findings of disc and canal measures in patients with sciatica and to analyze the predictive values of these magnetic resonance imaging and clinical variables on outcomes. METHODS: Part 1: Consecutive patients with a primary diagnosis of sciatica who came to lumbar magnetic resonance imaging were enrolled, and magnetic resonance imaging dimensions of discs and canal at the herniated level were collected. Part 2: Of 186 patients in Part 1, 135 were followed for more than 2 years; 87 were treated conservatively, and 48 were treated surgically. Outcomes were judged on satisfaction, activity level, medication intake, and reported pain at follow-up (mean, 2.6 years). RESULTS: Part 1: Wide ranges of disc and canal measurements were seen in all parameters. Significant differences in all magnetic resonance parameters were noted between male and female patients. Men had proportionately greater canal compromise by the affected disc than women. Positive sciatic tension signs and short duration of symptoms correlated with large disc herniation. Right-sided symptomatic herniations were usually larger than left. Part 2: At follow-up, predictors of outcome were determined independently for the surgery and the nonoperative groups. In the nonoperative group, a shorter duration of sciatica was the most significant predictor of a good outcome (P = 0.0018). Moreover, a duration of symptoms less than 6 months, no involvement with litigation, and younger age were also correlated with a favorable outcome. The only magnetic resonance parameter associated with good outcome was a small ratio of disc hemiarea to remaining canal hemiarea (P = 0.045). For the surgical group, a larger anteroposterior disc length was the most significant independent predictor of a positive outcome (P < 0.0001). Larger ratios of disc area to canal area are also significantly associated with good outcomes (P < 0.0001), as are large disc areas and small remaining canal areas. Large right-left canal widths and small disc widths are also identified as predictors of a favorable outcome. Of the clinical parameters, concurrent medical illness, workers' compensation involvement, and female gender appear to be the most significantly correlated with poor outcome. All fair or poor surgical outcomes were in patients with smaller (< 6 mm) disc herniations. CONCLUSIONS: Quantitative measurements by magnetic resonance imaging of disc and canal morphology of 188 patients with sciatica indicate a wide range of herniation and canal sizes, with significant differences between men and women. In a cohort of 135 patients followed for more than 2 years, demographic and clinical features appeared to predict outcomes of nonoperative treatment, whereas morphometric features of disc herniation and the spinal canal seen on magnetic resonance imaging were much more powerful predictors of surgical outcomes.

Adult↗

PubMed2001

Primary pelvic hydatid cyst: an unusual cause of sciatica and foot drop.

STUDY DESIGN: A case report of primary pelvic hydatid cyst causing sciatica and foot drop. OBJECTIVE: To document the occurrence of primary pelvic hydatid cyst as one of the hidden causes of lower limb weakness and foot drop, and to recommend inclusion of the pelvic cavity when assessing sciatica and foot drop. SUMMARY OF BACKGROUND DATA: It is common to see foot drop caused by peripheral lesions around the knee or disc herniation in the lumbar spine, but if these sites were excluded, the pelvic cavity must be examined for hidden disease that may explain the cause of foot drop and sciatica. METHODS: The authors involved in the care and management of this patient were interviewed and all medical records, radiologic investigations, and related literature were reviewed. RESULTS: After exclusion of spinal and peripheral causes of foot drop, computed tomography of the pelvis showed a well-localized cystic swelling in the right side of the pelvis over the lumbosacral plexus roots. Surgical excision of the cyst resulted in partial recovery of the foot drop at 3 years of follow-up. CONCLUSION: Primary pelvic hydatid cyst rarely causes pressure on the lumbosacral plexus. This was a case of hydatid cyst in the pelvis causing sciatica and foot drop, and it indicates the pelvis as a hidden source of sciatica and foot drop. After surgical excision followed by 4 months' mebendazole therapy, there was no evidence of recurrence on long-term follow-up.

Adult↗

PubMed2004

Efficacy of infliximab for disc herniation-induced sciatica: one-year follow-up.

STUDY DESIGN: An open-label trial. OBJECTIVES: To test the long-term efficacy of infliximab, a monoclonal antibody against tumor necrosis factor-alpha (TNF-alpha), in disc herniation-induced sciatica. SUMMARY OF BACKGROUND DATA: Our recent trial indicated that a single infusion of 3 mg/weight-kg of infliximab produced a rapid curative effect in disc herniation-induced sciatica. Here, we describe the 1-year effect of a 3 mg/kg of infliximab in these 10 patients and our experience with a lower dose of 1 mg/kg of infliximab for the same indication in 2 additional patients. METHODS: Patients with severe sciatica were treated with a single infusion of infliximab, 3 mg/weight-kg in 10 patients and 1 mg/kg in 2 patients, intravenously over 2 hours. The outcomes (leg and back pain on a 100-mm visual scale, Oswestry disability, clinical signs) were assessed at 1 week, 2 weeks, 1 month, 3 months, 6 months, and 1 year after the infusion. The outcomes with 3 mg/kg of infliximab were compared to 62 patients who received periradicular saline for sciatica in a previous trial. The resorption rate of disc herniations from baseline to 1 year was compared between infliximab and control groups. RESULTS: The response to 1 mg/kg of infliximab for leg pain was good only in 1 of the 2 patients treated, whereas the response to 3 mg/kg of infliximab for leg pain was sustained in most patients over the 1-year follow-up. The 1-year response significantly favored 3 mg/kg of infliximab over periradicular saline in leg pain (P = 0.005) and disability (P = 0.003). Neurologic abnormalities normalized more comprehensively in the infliximab group (P = 0.001). Reduction in disc herniation volume did not differ between the infliximab-treated patients and controls. CONCLUSIONS: The results showed that the beneficial effect of a single infusion of 3 mg/kg of infliximab for herniation-induced sciatica is sustained in most patients over a 1-year follow-up period. Furthermore, infliximab does not seem to interfere with the spontaneous resorption of disc herniations.

Antibodies, Monoclonal↗

PubMed2006

Traction for low back pain with or without sciatica: an updated systematic review within the framework of the Cochrane collaboration.

STUDY DESIGN: Systematic review. OBJECTIVE: To determine if traction is more effective than reference treatments, placebo/sham traction, or no treatment for low back pain (LBP). SUMMARY OF BACKGROUND DATA: Various types of traction are used in the treatment of LBP, often in conjunction with other treatments. METHODS: We searched MEDLINE, EMBASE, and CINAHL to November 2004, and screened the latest issue of the Cochrane Library (2004, issue 4) and references in relevant reviews and our personal files. We selected randomized controlled trials (RCTs) involving any type of traction for the treatment of acute (less than 4 weeks duration), subacute (4-12 weeks), or chronic (more than 12 weeks) nonspecific LBP with or without sciatica. Sets of 2 reviewers independently performed study selection, methodological quality assessment, and data extraction. Because available studies did not provide sufficient data for statistical pooling, we performed a qualitative "levels of evidence" analysis, systematically estimating the strength of the cumulative evidence on the difference/lack of difference observed in trial outcomes. RESULTS: A total of 24 RCTs (2177 patients) were included. There were 5 trials considered high quality. For mixed groups of patients with LBP with and without sciatica, we found: (1) strong evidence that there is no statistically significant difference in short or long-term outcomes between traction as a single treatment, (continuous or intermittent) and placebo, sham, or no treatment; (2) moderate evidence that traction as a single treatment is no more effective than other treatments; and (3) limited evidence that adding traction to a standard physiotherapy program does not result in significantly different outcomes. For LBP with sciatica, we found conflicting evidence in several of the comparisons: autotraction compared to placebo, sham, or no treatment; other forms of traction compared to other treatments; and different forms of traction. In the remaining comparisons, there were no statistically significant differences; level of evidence is moderate regarding continuous or intermittent traction compared to placebo, sham, or no treatment, and is limited regarding different forms of traction. CONCLUSION: Based on the current evidence, intermittent or continuous traction as a single treatment for LBP cannot be recommended for mixed groups of patients with LBP with and without sciatica. Neither can traction be recommended for patients with sciatica because of inconsistent results and methodological problems in most of the studies involved. However, because high-quality studies within the field are scarce, because many are underpowered, and because traction often is supplied in combination with other treatment modalities, the literature allows no firm negative conclusion that traction, in a generalized sense, is not an effective treatment for patients with LBP.

Humans↗

PubMed2003

Tumor necrosis factor-alpha monoclonal antibody, infliximab, used to manage severe sciatica.

STUDY DESIGN: An open-label study was conducted. OBJECTIVE: To evaluate the efficacy and safety of infliximab, a monoclonal chimeric antibody, against tumor necrosis factor-alpha (TNFalpha) for the treatment of severe sciatica. SUMMARY OF BACKGROUND DATA: Evidence from animal studies indicates that TNFalpha plays a role in the pathophysiology of sciatica. Anti-TNFalpha therapy has not been previously evaluated in sciatic patients. METHODS: In this study, 10 patients with disc herniation-induced severe sciatica received infliximab (Remicade 3 mg/kg) intravenously over 2 hours. The outcome was assessed at 1 hour, 1 week, 2 weeks, 1 month, and 3 months after the infusion and compared to historical control subjects consisting of 62 patients who received saline in a trial of periradicular infiltration for sciatica. Leg pain was the primary outcome, with more than a 75% decrease from the baseline score constituting a painless state. Fisher's exact test and repeated measures analysis of variance were used for statistical analysis. RESULTS: At 1 hour after the infusion, leg pain had decreased by 50%. At 2 weeks, 60% of the patients in the infliximab group were painless, as compared with 16% of the control patients (P = 0.006). The difference was sustained at 3 months (90% vs 46%; P = 0.014). Infliximab was superior over the whole follow-up period in terms of leg pain (P = 0.003) and back-related disability (P = 0.004). At 1 month, every patient in the infliximab group had returned to work, whereas 38% of the control subjects still were on sick leave (P = 0.02). None of the patients treated with infliximab underwent surgery during the follow-up period. No immediate or delayed adverse drug reactions and no adverse effects related to medication were observed. CONCLUSIONS: Anti-TNFalpha therapy is a promising treatment option for sciatica. There is an urgent need for a randomized controlled trial to evaluate whether thesepromising early results can be confirmed.

Adult↗

PubMed2004

Bed rest for acute low-back pain and sciatica.

BACKGROUND: Low-back pain (LBP) is a common reason for consulting a general practitioner, and advice on daily activities is an important part of the primary care management of low-back pain. OBJECTIVES: To assess the effects of advice to rest in bed for patients with acute LBP or sciatica. SEARCH STRATEGY: We searched the Cochrane Back Group Specialized Registry, CENTRAL, MEDLINE, EMBASE, Sport, and SCISEARCH to March 2003, reference lists of relevant articles, and contacted authors of relevant articles. SELECTION CRITERIA: Randomised or controlled clinical trials with quasi-randomisation (alternate allocation, case record numbers, dates of birth, etc.), in any language, where the effectiveness of advice to rest in bed was evaluated. The main outcomes of interest were pain, functional status, recovery and return to work. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed the internal validity of included trials and extracted data. Investigators were contacted to obtain missing information. MAIN RESULTS: Eleven trials (1963 patients) were included in this updated version. There is high quality evidence that people with acute LBP who are advised to rest in bed have a little more pain [Standardised Mean Difference (SMD) 0.22 (95% Confidence Interval (CI): 0.02, 0.41)] and a little less functional recovery [SMD 0.29 (95% CI: 0.05, 0.45)] than those advised to stay active. For patients with sciatica, there is moderate quality evidence of little or no difference in pain [SMD -0.03 (95% CI: -0.24, 0.18)] or functional status [SMD 0.19 (95% CI: -0.02, 0.41)] between bed rest and staying active. For patients with acute LBP, there is moderate quality evidence of little or no difference in pain intensity or functional status between bed rest and exercises. For patients with sciatica, there is moderate quality evidence of little or no difference in pain intensity between bed rest and physiotherapy, but small improvements in functional status [Weighted Mean Difference 6.9 (on a 0-100 scale) (95% CI: 1.09, 12.74)] with physiotherapy. There is moderate quality evidence of little or no difference in pain intensity or functional status between two to three days and seven days of bed rest. REVIEWERS' CONCLUSIONS: For people with acute LBP, advice to rest in bed is less effective than advice to stay active. For patients with sciatica, there is little or no difference between advice to rest in bed and advice to stay active. There is little or no difference in the effect of bed rest compared to exercises or physiotherapy, or seven days of bed rest compared with two to three.

Acute Disease↗

PubMed2002

Prognostic value of MRI findings in sciatica.

The natural course of sciatica due to disc herniation is generally favourable but individually unpredictable. Some patients recover only after prolonged conservative therapy or surgery. This study aims to ascertain whether magnetic resonance (MR) imaging features can be used to predict outcome of sciatica and help to identify patients unlikely to respond to conservative management. For a transversal diagnostic study 274 primary care patients underwent early MR imaging for leg pain. One hundred and thirty-three patients with sciatica were followed for 3 months, both patients and physicians being unaware of MR imaging findings. At 12 weeks a favourable prognosis was indicated by the following features: annular rupture (P= 0.02) and nerve root compression on MR imaging (P = 0.03). Poor prognosis was indicated by disc herniation in the foramen (P = 0.004). Our findings show that early MR imaging features are related to prognosis. However, the associations are not strong enough to justify routine use of early MR imaging to predict the prognosis of sciatica.

Adolescent↗