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sciatica; lumbosacral radiculopathy; sciatic neuropathy

Etiology: 1) entrapment neuropathy - herniated disc (L5 or S1 most comon) 85% [15] 2) inflammation compromising the L5 or S1 root 3) spinal cord tumor or abscess, spinal stenosis 4) myofascial pain syndromes 5) trochanteric bursitis 6) vascular malformations 7) diabetic neuropathy 8) shingles 9) entrapment of sciatic nerve by piriformis muscle 10) endometriosis [6] Clinical manifestations: 1) pain in the lower back & hip radiating down posterior aspect of thigh, posterior & anterior aspect of leg & into foot along the distribution of the sciatic nerve - leg pain as severe or more severe than low back pain [16] 2) paresthesias, numbness 3) hyporeflexia on affected extremity (L2, L3, L4) -> L5, S1 lesions: reflexes seldom affected 4) pain aggravated by: a) spinal movement, i.e. bending b) sneezing c) coughing d) straining 5) pain on straight leg raising a) pain below the knee at < 70 degrees b) indicates nerve root compression at L5-S1 c) crossed straight leg raising - pain elicited on affected side with contralateral straight leg raising - specific for lumbar radiculopathy [31] - not as sensitive as ipsilateral straight leg raising 6) loss of sensation in a dermatomal distribution 7) decreased to absent deep tendon reflexes, especially ankle jerk 8) dermatomal signs & reflex changes may be absent when only a single nerve root is affected 9) local muscle weakness & atrophy may be present a) differential circumference of > 2 cm at the right versus left calf &/or thigh suggests atrophy b) weakness of ankle & great toe dorsiflexion [4] 10) dorsiflexion at the ankle aggravates pain, plantar flexion relieves the pain 11) sensory loss in foot Laboratory: 1) electromyography 2) sensory evoked potential Radiology: 1) plain radiographs of lumbosacral spine - standing flexion-extension radiographs of lumbar spine if suspected lumbar spondylolisthesis 2) magnetic resonance imaging to delineate anatomy of nerve root compression & herniated disc - adding a coronal short T1 inversion recovery (STIR) MRI sequence might help in difficult diagnostic cases (short acquisition time & low cost) [14] - repeat MRI at 1 year does not distinguish reliably patients who have improved from those who have not [12] Differential diagnosis: - lumbar spondylolisthesis Management: 1) physical therapy - early referral to physical therapy improves outcomes at 6 months [27] 2) lumbar spinal manipulation may be of benefit 3) acupuncture of benefit for chronic sciatica from herniated disk [33] 4) oral agents - non-steroidal anti-inflammatory agents (NSAIDs) - amitriptyline 10 mg PO QHS - glucocorticoid - methylprednisolone - prednisone for 15 days [17] - start 60 mg/day, taper to 20 mg/day - modest improvements in function - no improvement in pain - gabapentin [16] - non-inferior to epidural steroid injection - no randomized trials - pregabalin (Lyrica) does not improve pain of sciatica [24] 5) parenteral agents - epidural steroids - of no value [5,9]; of value [NEJM Knowledge+] - consider if associated with herniated disc [8] - small short-term benefit not clinically significant [11,18] - no long-term benefit [18]; no benefit > 6 months [29] - uncertainty about which patients might benefit [30] - risks likely exceed benefits [11] - may be treatment of choice if renal insufficiency, physical therapy of no benefit & surgery not an option [NEJM Knowledge+] - nerve root injections under fluoroscopic guidance - betamethasone plus bupivicaine [5] - trigger point injection with bupivicaine - etanercept no better than epidural steroids or saline [10] - pulsed radiofrequency, delivered into the back with a thin needle (anesthesia not required) - relief of back pain & sciatica pain >= 1 year [25] 6) surgery for disk herniation & nerve root impingement/compression a) diskectomy may have initial benefits that decline with time [32] - at 1 year, surgery comparable to conservative management for sciatica due to disc herniation [7] b) consider microdiskectomy if documented nerve-root compression with persistent sciatic pain for 4-12 months [26] c) consider spinal cord stimulation if persistent pain after surgery [8] - a closed-loop spinal cord stimulator that measures & adjusts to neural response is associated with greater pain reduction compared with a fixed-output, open-loop system at 3 & 12 months [28] 7) prognosis: - 50-70% of patients spontaneously improve within 4 weeks [19]

Related

low back pain (LBP) sciatic nerve straight leg raising (SLR)

Specific

lumbosacral radiculoplexus neuropathy

General

radiculopathy sciatic neuropathy

References

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  22. Peul WC, van Houwelingen HC, van den Hout WB et al Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007 May 31;356(22):2245-56. PMID: 17538084 Free Article
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  25. Susman E Radiofrequency Pulses End Back Pain - Probes guided to herniated disk appears to enhance pain relief and healing. MedPage Today. Nov 30, 2018 https://www.medpagetoday.com/meetingcoverage/rsna/76612 - Napoli A, et al T Guided Pulsed Radiofrequency in Patients with Acute Low Back Pain and Sciatica: 1 Year Follow-Up versus Image-Guided Injection Only as Control Group, Radiological Society of North America (RSNA) 2018.
  26. Bailey CS, Rasoulinejad P, Taylor D et al. Surgery versus conservative care for persistent sciatica lasting 4 to 12 months. N Engl J Med 2020 Mar 19; 382:1093 PMID: 32187469 https://www.nejm.org/doi/10.1056/NEJMoa1912658
  27. Fritz JM et al Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica. A Randomized Controlled Trial. Ann Intern Med. 2020 Oct 6. PMID: 33017565 https://www.acpjournals.org/doi/10.7326/M20-4187 - Foster NE, Reddington M Early Referral to Physical Therapy: A Reasonable Choice for Primary Care Patients With Sciatica Ann Intern Med. 2020 Oct 6.Schilling LS, Markman JD. Rheum Dis Clin North Am. 2016 Feb;42(1):137-55 PMID: 33017567 https://www.acpjournals.org/doi/10.7326/M20-6545
  28. Mekhail N, Levy RM, Deer TR et al Durability of Clinical and Quality-of-Life Outcomes of Closed-Loop Spinal Cord Stimulation for Chronic Back and Leg PainA Secondary Analysis of the Evoke Randomized Clinical Trial. JAMA Neurol. Published online January 8, 2022 PMID: 34998276 https://jamanetwork.com/journals/jamaneurology/fullarticle/2788004
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  31. NEJM Knowledge+ Neurology
  32. Liu C et al. Surgical versus non-surgical treatment for sciatica: Systematic review and meta-analysis of randomised controlled trials. BMJ 2023 Apr 19; 381:e070730. PMID: 37076169 Free article https://www.bmj.com/content/381/bmj-2022-070730
  33. Gever J Acupuncture for Sciatica: Will This Trial Finally Silence the Skeptics? Findings from new study raise the bar MedPage Today October 14, 2024 https://www.medpagetoday.com/rheumatology/backpain/112381 - Tu JF, Shi GX, Yan SY et al Acupuncture vs Sham Acupuncture for Chronic Sciatica From Herniated Disk: A Randomized Clinical Trial. JAMA Intern Med. 2024 Oct 14. PMID: 39401008 - Kneifati-Hayek JZ, Katz MH. Moving the Needle on Acupuncture Trials. JAMA Intern Med. 2024 Oct 14. PMID: 39401014