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PubMed1999

The efficacy of a risk factor-based cognitive behavioral intervention and electromyographic biofeedback in patients with acute sciatic pain. An attempt to prevent chronicity.

STUDY DESIGN: An investigation of the efficacy of an individually scheduled, risk factor-based cognitive behavioral therapy and a standardized electromyographic biofeedback intervention in the prevention of chronicity in patients with acute sciatica and psychosocial risk factors for chronicity. OBJECTIVES: To investigate the possibility of enhancing pain relief and preventing chronicity in patients with acute sciatica, based on a screening for psychosocial high-risk factors of chronification. SUMMARY OF BACKGROUND DATA: Psychological interventions were evaluated mainly in patients with chronic low back pain. Numerous randomized trials have demonstrated their efficacy, whereas the amount of pain relief was found to be marginal. METHODS: Subjective and behavioral outcome parameters were compared with the respective parameters in age-, gender-, and diagnosis-matched high- and low-risk patients. No additional behavioral treatment for in-patient medical therapy was offered to the patients. Outcome of these patients also was compared with that of a group of refusers of behavioral therapy. Psychological, functional, and behavioral variables were measured before and after treatment and at 3-, 6-, 12- and 18-month follow-up visits. Changes over time, group differences, and possible group x time interactions were analyzed by analysis of variance and nonparameteric comparisons. RESULTS: Data analysis showed a statistically and clinically significant, beneficial effect of both behavioral interventions. However, risk factor-based cognitive behavioral therapy was superior to electromyographic biofeedback intervention with respect to pain relief and application for early retirement. The cognitive behavioral therapy showed a similar good outcome (e.g., 90% showed a clinical significant pain reduction) as the low-risk patients (83% pain reduction). High risk patients and refusers of therapy showed a poor outcome in pain (33% and 20% pain reduction, respectively), disability, and work performance. CONCLUSIONS: Individually scheduled, risk factor-based cognitive behavior therapy could be a beneficial treatment modality, which can be offered, in addition to a medical treatment, to patients with acute sciatica and psychosocial high risk factors for chronicity. It may be an effective way to prevent chronification in these patients.

Acute Disease↗

PubMed2000

Symptoms, signs, and functional disability in adult spondylolisthesis.

STUDY DESIGN: A cross-sectional clinical study. OBJECTIVES: To determine whether there are specific symptoms, signs, and functional disability associated with adult spondylolisthesis. SUMMARY OF BACKGROUND DATA: In spite of the common occurrence of adult spondylolisthesis, the symptoms, signs, and disability associated with it have not been analyzed in a large, well-defined group of patients. METHODS: The symptoms, signs, and disability of 111 consecutive patients with adult spondylolisthesis, before randomized treatment with fusion or physiotherapy, were compared with those of 39 patients with nonspecific low back pain before lumbar fusion. The patients completed a questionnaire covering clinical history and symptoms and submitted a pain drawing. The signs were documented. Functional disability and pain were quantified by 12-function and 2-pain visual analog scales, respectively. RESULTS: Sixty-two percent of the patients reported low back pain as well as sciatica, 7% sciatica only, and 31% low back pain only. Specific signs were infrequent. A positive straight leg raising test result in 12% and an L5 sensory disturbance in 13% were the most common. The symptoms were similar in patients with spondylolisthesis and chronic low back pain, but the chronic low back pain group reported more functional disability. Patients with a nonorganic pain drawing (widespread, nonspecific pain) were more often blue collar workers; were more often and longer on sick leave; and reported reduced mental condition, sexual function, functional ability, and more pain than patients with an organic pain drawing (localized, specific pain). CONCLUSIONS: The clinical pattern and functional disability in adult spondylolisthesis and in low back pain of nonspecific origin are similar. Sciatica in adult spondylolisthesis is typically not associated with a positive straight leg raising test result.

Activities of Daily Living↗

PubMed2000

Inflammatory cells, motor weakness, and straight leg raising in transligamentous disc herniations.

STUDY DESIGN: Possible statistically significant relationships between inflammatory cells and either motor weakness or straight leg raising were determined. OBJECTIVES: To look for any clinically relevant links between inflammatory cells in disc herniations and signs of radiculopathy. SUMMARY OF BACKGROUND DATA: Many studies have during recent years shown a presence of various types of inflammatory cells in disc herniations, but their clinical relevance has been questioned. To be clinically relevant, a presence of inflammatory cells should show a clear relationship to clinical evidence of nerve root involvement. Macrophages repeatedly demonstrated in a high proportion of disc herniations studied are of particular interest. Their major role may be in disc herniations tissue resorption and not in sciatica. METHODS: A total of 96 disc herniations, all transligamentous, were analyzed by immunohistochemistry for presence of macrophages, T or B lymphocytes, and activated T lymphocytes separately. From recorded patient data, motor weakness and straight leg raising data were compared with a presence or absence of abundant (+ = at least 20 cells in a group) inflammatory cells. When not abundant, inflammatory cells were classified as "only few cells" (+) and grouped together with "no cells" (-). Patients with or without motor weakness were compared. Straight leg raising was compared for a positive (at <70 degrees ) or a negative test, and separately using the median as cut-off value. Groups were compared by chi-square analysis with the level of statistical significance set at P<0.05. RESULTS: None of the four inflammatory cell types showed any significant association with motor weakness. Nor was any association observed when comparing positive and negative straight leg raising. With the median (straight leg raising = 47.5 degrees ) as cut-off, only activated T cells showed a weak (chi2 = 4.40, P<0.05) relationship with tighter straight leg raising, but none of the other cell types did. Even when straight leg raising was < 47.5 degrees, three times more disc herniations lacked (n = 34) inflammatory cells than showed (n = 13) inflammation. In a subgroup of only sequestrated discs, the findings were similar. However, in the patients with a bilaterally positive straight leg raising (n = 25), the prevalence of at least one inflammatory cell type was much higher in sequestrated discs (80%) than in extrusions (33%). This may suggest more subtle interrelationships between type of disc herniation, straight leg raising, and inflammatory cells. CONCLUSIONS: The results of this study do not support a clinically relevant role for disc herniation inflammatory cells in sciatica. For the cells to be clinically relevant, a strong relationship between a presence of inflammatory cells and either or both of motor weakness and a tight straight leg raising should have been observed. The authors conclude that macrophages, which have been demonstrated in a high proportion of disc herniations in previous studies, are probably more important for disc tissue resorption processes than for producing sciatica. Other types of inflammatory cells are more rarely observed and may have no clinical meaning at all. However, more subtle interrelationships, considering the various types of disc herniations, should be further explored.

Adolescent↗

PubMed2003

Changes in nerve root motion and intraradicular blood flow during an intraoperative straight-leg-raising test.

STUDY DESIGN: An intraoperative straight-leg-raising (SLR) test was conducted to investigate patients with lumbar disc herniation to observe the changes in intraradicular blood flow, which then were compared with the clinical features. OBJECTIVE: The legs of each patient were hung down from the operating table as a reverse SLR test during surgery, and intraradicular blood flow was measured. SUMMARY OF BACKGROUND DATA: It is not known whether intraradicular blood flow changes during the SLR test in patients with lumbar disc herniation. METHODS: The subjects were 12 patients with lumbar disc herniation who underwent microdiscectomy. The patients were asked to adopt the prone position immediately before surgery, so that their legs hung down from the operating table. A reverse SLR test was performed to confirm the angle at which sciatica developed. During the operation, the nerve roots affected by the hernia were observed under a microscope. Then the needle sensor of a laser Doppler flow meter was inserted into each nerve root immediately above the hernia. The patient's legs were allowed to hang down to the angle at which sciatica had occurred, and the change in intraradicular blood flow was measured. After removal of the hernia, a similar procedure was repeated, and intraradicular blood flow was measured again. RESULTS: Intraoperative microscopy showed that the hernia was adherent to the dura mater of the nerve roots in all patients. The intraoperative reverse SLR test showed that the hernia compressed the nerve roots, and that there was marked disturbance of gliding, which was reduced to only a few millimeters. During the test, intraradicular blood flow showed a sharp decrease at the angle that produced sciatica, which lasted for 1 minute. Intraradicular flow decreased by 40% to 98% (average, 70.6% +/- 20.5%) in the L5 nerve root, and by 41% to 96% (average, 72.0% +/- 22.9%) in the S1 nerve roots relative to the blood flow before the test. At 1 minute after completion of the test, intraradicular blood flow returned to the value obtained at baseline. After removal of the hernia, all thepatients showed smooth gliding of the nerve roots during the second intraoperative test, and there was no marked decrease in intraradicular blood flow. CONCLUSIONS: This study demonstrated that the blood flow in the nerve root is reduced when the nerve root is compressed in vivo.

Adult↗

PubMed1988

The value of accurate clinical assessment in the surgical management of the lumbar disc protrusion.

One hundred patients with lumbar disc protrusions were studied. Thirty six "control" patients were admitted in the same time period with low back pain and sciatica but with subsequently "normal" myelograms and no surgery. The aim of this paper was to relate history and clinical signs to the myelograms and surgical findings. Ninety nine per cent of our patients presented with sciatica (controls 94%). The most frequently found sign in patients with a disc protrusion was reduction of ipsilateral straight leg raising (98%). However, 55% of controls also showed this sign. There were three signs that, when present, particularly indicated a disc protrusion; "crossed straight leg raising" (pain on contralateral straight leg raising), measured calf wasting and impaired ankle reflex: the latter being especially indicative of an L5-S1 disc protrusion. There were two further important signs, weakness of dorsiflexion of the foot and scoliosis of the lumbar spine. However, such signs occurred in about half the patients and so clinical diagnosis in the remaining half depended on obtaining a good history of sciatica, and paying due regard to severity of the pain, the mobility of the patient, the ability and desire to work and the overall personality. Satisfactory results of surgery simply depend on finding and removing a definite disc protrusion. Using these methods of selection, 98% have returned to their original employment, 86% within 3 months of the operation. For a patient with no abnormal signs and a normal myelogram, surgical treatment should not be advised.

Adult↗

PubMed1989

Pseudoaneurysm of the inferior gluteal artery presenting as sciatic nerve compression.

A pseudoaneurysm of the inferior gluteal artery presenting as sciatic nerve compression is reported in a 40-year-old woman. Following a transvaginal needle biopsy for endometriosis, the patient developed left sciatic pain and a nonpulsatile mass palpable in the left buttock thought to represent a pyriformis hematoma. Sequential computed tomographic scans were consistent with this diagnosis. Persistent pain and progression of neurological deficits led to surgical exploration. Posterior exposure of the pyriformis muscle and proximal sciatic nerve revealed a large pseudoaneurysm of the inferior gluteal artery compressing the nerve. A laparotomy was performed and the internal iliac artery was ligated, followed by evacuation of the aneurysm contents and repair of the aneurysm neck via a posterior approach. The patient has remained pain-free with progressive improvement in neurological function after 1 year follow-up. Aneurysms of the gluteal artery are unusual, predominantly occur after significant pelvic trauma, and rarely present as sciatica. Pertinent aspects of the patient history and clinical findings are atypical for discogenic sciatica. Because of the rarity of this entity, preoperative diagnosis is usually not achieved. Angiography or magnetic resonance imaging should be performed in patients with atypical sciatica and a mass in the region of the proximal sciatic nerve, particularly after trauma.

Adult↗

PubMed1979

Midline prolapse of a lumbar intervertebral disc with compression of the cauda equina.

Midline prolapse of a disc causing compression of the cauda equina is rare but needs urgent diagnosis and surgical treatment. The onset of bladder and rectal paralysis with saddle anaesthesia should be viewed with a high index of suspicion in a patient with backache and sciatica. Eight cases were seen over a period of five years, and they fell into three clinical groups. Group I patients presented with a sudden onset without any previous symptoms related to the back. Group II patients had a history of recurrent episodes of backache and sciatica, the latest episode resulting in involvement of the cauda equina. The group III patient was indistinguishable from one with a tumour as he presented with backache and sciatica slowly progressing to paralysis of the cauda equina. The prolapse was at the disc between L5 and S1 vertebrae in 50 per cent of the patients, most of whom did not have any limitation of straight leg raising. Urgent myelography and equally urgent removal of the disc within two weeks of the onset of the symptoms resulted in almost complete motor and bladder recovery within five months after the operation in most cases. However, recovery of sensation and sexual function was incomplete even four years after the operation.

Adult↗

PubMed2004

Low-back pain following surgery for lumbar disc herniation. A prospective study.

BACKGROUND: Lumbar disc herniation often causes sciatica. Although surgery may provide relief of sciatic pain, it is uncertain how surgery affects the relief of low-back pain. The purpose of the present prospective study was to assess the efficacy of discectomy in the treatment of low-back pain associated with lumbar disc herniation. METHODS: Between 1998 and 2001, forty consecutive patients with single-level, unilateral lumbar disc herniation were treated surgically. The first twenty patients (Group 1) underwent standard discectomy, and the second twenty (Group 2) underwent microendoscopic discectomy. Curettage of the disc space was not performed. All forty patients were prospectively followed, and clinical outcomes were evaluated with use of a questionnaire. The mean duration of follow-up was forty months. RESULTS: All forty patients were satisfied with the outcome. Leg pain decreased rapidly (within one month) in all patients and continued to decrease at the time of the latest follow-up. There was no significant difference between the two groups in terms of leg pain, with the numbers available (p = 0.39). A significant decrease in the mean low-back pain score was noted at the time of the latest follow-up (p = 0.0007). CONCLUSIONS: Excision of a herniated disc for relief of sciatica provided rapid relief of sciatica and low-back pain. The findings of the present small study suggest that lumbar disc herniation might be a possible cause of low-back pain.

Adolescent↗

PubMed1978

A rational approach to the use of epidural medication in the treatment of sciatic pain.

The results of a series of 120 epidural injections given as treatment for backache and sciatica using Methylprednisolone and local anaesthetic, performed in the Gloucestershire area, are presented and compared with other published results. Wide variations in the results of this treatment are found and these may in part be explained on the basis of the variable severity of the histological changes known to occur in and around nerve roots in cases of sciatica. The pathogenesis of sciatica in lumbar disc disease is discussed in relation to its treatment by epidural injections of a long-acting steroid. It is shown that the treatment is more successful in acute onset cases and cases that have epidurals within 6 months of the onset of symptoms and it is suggested that earlier epidurals are given in cases that do not respond to the usual conservative measures. Manipulation of the spine and sciatic stretch should not be carried out at the same time as the epidural, as these procedures may adversely affect the results in some cases and certainly tend to make them more difficult to assess.

Acute Disease↗

PubMed1978

Complications following intraspinal injections of steroids. Report of two cases.

Intrapinal steroids have been recommended for the treatment of sciatica and various other conditions. The procedure is controversial; moreover, evidence suggests that the steroid hormones can be delivered to the site of inflammation more easily by systemic administration. Serious complications that have arisen from the procedure are reviewed. The courses of two women who received intraspinal steroids for the treatment of sciatica and who developed severe meningitis as a consequence are reported. It is suggested that the value of intraspinal steroids in the treatment of disc-related sciatica is unproven and if they are used, one must be alert to the complications.

Adult↗

PubMed1986

Thermography: a call for scientific studies to establish its diagnostic efficacy.

Thermography is reported to provide objective evidence of physiologic dysfunction in patients with low back pain and sciatica. This diagnostic test is appealing because it is painless, non-invasive, has no known adverse biologic effects, presents comprehensible graphic information, requires only a moderate investment in equipment, and should be an inexpensive procedure to perform. Unfortunately, the complete scientific information necessary to assess its diagnostic reliability is not available. This article discusses other experiments which have been performed to assess the diagnostic accuracy of tests for low back pain and sciatica and outline some features of an experimental protocol which would be essential to establish the reliability of thermography in the diagnosis of low back pain and sciatica due to herniated nucleus pulposus.

Back Pain↗

PubMed1999

The incidence of sacroiliac joint disease in patients with low-back pain.

PURPOSE: The clinical presentation of intervertebral disc, facet joint, nerve root, and sacroiliac (SI) joint diseases are often indistinguishable. SI joint arthritis likely accounts for a significant proportion of what is called "low-back pain" or "sciatica." Our goal was to determine the incidence of SI joint arthritis in patients with this presentation. METHODS: Computed tomographic (CT) scans of the lumbosacral spine (LSS) of patients referred with low-back pain, sciatica, spinal stenosis or disc pathology were gathered over a 3-month period. Scans were retrospectively reviewed by 2 independent readers for SI joint arthritis. When there was disagreement, the 2 readers reviewed the case and reached a concensus opinion. SI joint arthritis was considered to be present if subchondral sclerosis, osteophytosis, or cartilage loss was noted on the CT scan. RESULTS: The SI joint(s) were visualized by both readers on 64 LSS CT scans performed in 29 women and 35 men, mean age 52 years. By the aforementioned criteria, 16 SI joints (25%) were considered normal by both readers. In 48 cases (75%), there was evidence of osteoarthritis. The diagnosis of osteoarthritis was made by concensus opinion in 8 of these 48 cases (16%). CONCLUSION: There is a relatively high incidence of SI joint arthritis in patients undergoing evaluation for "low-back pain" or "sciatica." Hence, SI joint arthritis should be considered a possible diagnosis in these patients.

Arthritis↗

PubMed2000

[Local and general anti-inflammatory treatment of common low back pain].

Non-steroidal anti-inflammatory drugs are often prescribed with analgesics. They are proposed at the acute phase of low back pain or sciatica, or during flares of chronic back pain. Efficacy of NSAIDs have been demonstrated in acute back pain with randomised clinical trials. Efficacy is less clearly demonstrated in chronic back pain and sciatica. Local injections of steroids are required after failure of analgesics and NSAIDs, in patients with sciatica and chronic back pain. Different routes of injection are possible, depending of the symptoms and the mechanism of compression.

Acute Disease↗

PubMed2001

[Inducible nitric oxide synthase expression and nitric oxide production by monocytes in systemic sclerosis].

We investigated nitric oxide (NO) production and inducible NO synthase (iNOS) expression by cultured peripheral blood mononuclear cells (PBMC) in systemic sclerosis (SSc). Eighteen patients with SSc were compared to two control groups: 16 rheumatoid arthritis patients (RA) and 23 mechanical sciatica patients. The sum of nitrites and nitrates was determined by fluorimetry in sera and spectrophotometry in supernatants. Inducible iNOS was detected in cultured PBMC by immunofluorescence, immunoblot and flow cytometry with or without IL-1 beta + TNF alpha, IL-4 or IFN gamma from day 1 to day 5. NO metabolite concentrations in the plasma were lower in SSc (34.3 mumol/l +/- 2.63 SEM) than in RA (48.3 mumol/l +/- 2.2; p < 0.02) and sciatica (43.3 mumol/l +/- 5.24; p < 0.03) patients. iNOS was detected in cultured monocytes in the 3 groups but induction occurred on day 1 in RA, day 2 in sciatica and only on day 3 in SSc, whatever the stimulus. The concentrations of NO metabolites are decreased in SSc patients and the induction of iNOS in PBMC is delayed. Low levels of NO, a vasodilator, may be involved in vasospasm, which is critical in SSc. This may suggest therapeutic implications.

Arthritis, Rheumatoid↗

PubMed2001

Diagnosis and treatment of piriformis syndrome.

Piriformis syndrome remains a controversial diagnosis, despite its having first been described over 60 years ago. The controversy stems from several factors: variable and sometimes unclear cause, similarity to other more easily recognizable causes of sciatica, lack of consistent objective diagnostic findings, and relative rarity. Nevertheless, it is reasonable to infer that sciatic pain may be caused by compression anywhere along its length, from the spinal root level to the popliteal fossa, as is peripheral nerve entrapment elsewhere in the body. Pathologic changes at the greater sciatic notch may well be the source of sciatic pain and should be considered by the clinician. The diagnosis of piriformis syndrome remains one of exclusion, however, and in patients who present with sciatica, more common causes such as lumbar disease should be investigated and ruled out first. After excluding the most common causes of sciatica, physicians can use the criteria described here to investigate the possibility of piriformis syndrome. If properly diagnosed, it can often be treated effectively with either surgical or nonsurgical means.

Combined Modality Therapy↗

PubMed1959

Stretching of the sciatic nerve; a means of relieving postoperative pain following removal of ruptured lumbar intervertebral discs.

Stretching the sciatic nerve for the relief of "sciatica" was frequently employed before 1900 and was subsequently abandoned, probably because it was done without sufficient scrutiny of the indications. The procedure has recently been employed in cases in which "sciatica" remains following the operative removal of ruptured intervertebral discs, and it has been instrumental in relieving postoperative "sciatica" when the cause was the formation of adhesions about the lumbar nerve roots. If the nerve root is compressed by recurrent disc protrusion or by adjacent bone, the manipulation usually increases the pain, a phenomenon that has been helpful from a diagnostic standpoint.

Exercise Therapy↗

PubMed1991

[Analysis of the results of surgery and nucleolysis using papain in 1085 cases of lumbar disk hernias].

1,085 patients have been treated for intervertebral disc herniation with lombo-sciatica: in 751 cases surgical discectomy without laminectomy has been performed with or without microscope; 334 underwent papain nucleolysis. The two clinical groups were separated on clinical and radiographic backgrounds: nucleolysis was performed in patients with no motor disturbance, no stenosis of the lumbar canal, no displaced fragment; the other patients received surgical treatment. The results were evaluated according to MacNab's criteria with a follow-up of 12 to 84 months (mean 17.2 months). The results after surgical treatment were excellent in 53.8% and good in 36.8% of the cases. For papain treatment they were excellent in 32.7% and good in 38.8% of the cases. Papain nucleolysis therefore appears to be an efficient method for the treatment of intervertebral disc herniations associated with lombo-sciatica but, overall, gives poorer results than surgery in spite of a strict selection procedure. In this study, complications due to papain nucleolysis were restricted to chemical spondylodiscitis (5 cases) and to 2 benign allergic syndromes. Statistical analysis of all the cases and multifactorial correlation research pointed out the importance of "workmen's compensation" as prognostic factor. Since this study, 90% of the patients presenting with disc herniation associated with lombo-sciatica recalcitrant to medical treatment undergo surgical discectomy; papain nucleolysis is reserved for sub-ligamentary and non-displaced forms without stenosis of the lumbar canal and represent 10% of our current population.

Adolescent↗

PubMed1989

Percutaneous automated lumbar nucleotomy.

The results of percutaneous automated lumbar nucleotomy in the treatment of lumbar disc herniation were assessed in a series of 39 patients. The technique consists of mechanical decompression of the herniated intervertebral disc without total excision. Only one-space discs were treated by this method. Sciatica was the predominant clinical symptom in 30 cases, and lumbar pain in 9 cases. Good to very good results were obtained in 70% of patients with sciatica and in 55% of patients with lumbar pain. After 4 cases of nucleotomy performed after failure of nucleolysis were excluded, the proportion of very good results rose to 77% in sciatica. Conversely, it seems that a number of failed nucleotomies can be treated by nucleolysis. Nucleotomy is very well tolerated and deserves to be used as first-line treatment of single and radiologically well documented lumbar disc herniations.

Adult↗