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Sciatica

Sciatica is a pain in the leg due to irritation of the sciatic nerve. The pain generally goes from the front of the thigh to the back of the calf, and may also extend upward to the hip and down to the foot. more...

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In addition to pain, there may be numbness and difficulty moving or controlling the leg.

Although sciatica is a relatively common form of low back pain and leg pain, the true meaning of the term is often misunderstood. Sciatica is a set of symptoms rather than a diagnosis for what is irritating the nerve root and causing the pain.

Causes of sciatica

Sciatica is generally caused by compression of the sciatic nerve. It is sometimes divided into two main categories. "True" sciatica is caused by compression at the nerve root from a "slipped disc" (a herniated disc in the spine), roughening and enlarging and/or misalignment of the vertebrae. "Pseudo-sciatica" is caused by compression of more peripheral sections of the nerve, usually from soft tissue tension in the piriformis or other related muscles. Unhealthy postural habits such as excessive sitting in chairs and sleeping in the fetal position, along with insufficient stretching and exercise of the relevant myofascial areas, can lead to both the vertebral and soft tissue problems associated with sciatica.

Other causes of sciatica include infections and tumors.

Sciatica may also be experienced in late pregnancy either as the result of the uterus pressing on the sciatic nerve, or secondarily from muscular tension or vertebral compression associated with the extra weight and postural changes inherent in pregnancy.

Pelvic entrapment of the sciatic nerve can also generate symptoms resembling spinal compression of the nerves. The most predominant form of this condition is known as piriformis syndrome. With this condition the piriformis muscle, which is located beneath the gluteal muscles, contracts in spasm and strangles the sciatic nerve, which is located beneath the muscle.

Yet another source of sciatica symptoms is caused by active trigger points in the lower back or gluteal muscles. In this case, the referred pain is not, in fact, coming from compression of the sciatic nerve, though the pain distribution down the buttocks and leg can be quite similar. Trigger points occur when muscles become ischemic (low blood flow) due to injury or chronic muscular contraction. The muscles most commonly associated with trigger points causing sciatica symptoms are the quadratus lumborum, the gluteus medius and minimus, and the deep hip rotators.

Treatment

Because of the many conditions that can compress nerve roots and cause sciatica, treatment options often differ from patient to patient. A combination of treatment options is often the most effective course.

Most cases of sciatica can be effectively treated by physical therapy or massage therapy (specifically neuromuscular therapy), and appropriate changes in behavior and environment (for example cushioning, chair and desk height, exercise, stretching, self treatment of trigger points). Other conservative treatment options include Somatic Movement Education, anti-inflammatory medications (i.e. NSAIDs or oral steroids), pain medications, and epidural steroid injections. Chiropractic manipulation often helps. In approximately 10-20% of cases, surgery is required to correct the problem.

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Predictive value of the duration of sciatica for lumbar discectomy/Author's reply
From Journal of Bone and Joint Surgery, 6/1/05 by Brown, M F

Sir,

I read with interest the article by Ng and Sell1 in the May 2004 issue entitled "Predictive value of the duration of sciatica for lumbar discectomy". It is a rigorous assessment of this much debated question, but to call it a prospective, cohort study, despite the fact that the duration of symptoms varies at recruitment, may lead readers to draw a possibly erroneous conclusion.

It is the nature of sciatica from disc prolapse that patients may improve at any time, with a gradual decrease in the incidence of patients experiencing sufficient improvement to obviate the need for surgery. The necessary corollary of this is that the longer a patient has had sciatica, the nearer is he or she to the worse end of the spectrum of disease. This may be the entire explanation of the worse outcome - by waiting longer, one is not predicting a worse result from surgery, but merely selecting a worse group of patients.

What is needed is a cohort study with recruitment based on an intention to treat (by any means - conservative or operative), not on an intention to operate. My feeling is that waiting over a year may indeed be associated with a worse outcome, but unless the dropout rate of patients improving spontaneously during the waiting time is known, it cannot be proven.

doi:10.1302/0301-620X.87B6.16677

M. F. BROWN, PhD, FRCSEd(Orth)

University Hospital of North Staffordshire

Stoke-on-Trent, UK.

1. Ng LCL, Sell P. Predictive value of the duration of sciatica for lumbar discectomy. J Bone Joint Surg [Br] 2004;86-B:546-9.

Author's reply:

Sir,

We thank Mr Brown for his interest in our paper. In answer to his comment, we would consider it unlikely that readers of the Journal would draw an erroneous conclusion on the data presented. The title of the paper makes it clear that the cohort in question is an operative one. Our article contributes to the literature regarding the optimum timing for operation in radicular pain.

The perfect answer to a question often needs to be balanced against the practical realities of clinical practice. The dropout rate to follow-up of a prospective cohort of non-operatively treated patients would be so high that the suggested comparison based on intention to treat could not be achieved in our clinics. A better level of evidence would be a randomised, controlled trial.

Readers of our paper will have noted that patients still improve in terms of pain after a year of symptoms, but that decline in disability as indicated by the outcome measures used showed less change with time, perhaps suggestive of the development of biopsycho-social factors with chronic symptom duration. It is the authors' feeling, that this is the major factor, but it remains to be proven.

doi:10.1302/0301-620X.87B6.16678

P. SELL, BM, MSc, FRCS

L. NG, BM, MRCS

Leicester General Hospital, Leicester, UK.

Copyright British Editorial Society of Bone & Joint Surgery Jun 2005
Provided by ProQuest Information and Learning Company. All rights Reserved

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