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Sciatica

Advice cannot be provided on an individual basis. The Society cannot accept any responsibility for the use of the information provided, the user and their health care professionals must retain responsibility for their health care management.

Content

Dear Patient

The following information was put together to help in the decision-making process. The graphs show the answers of the members of EuroSpine, the Spine Society of Europe, considered to be the European experts in the field of treatment of spine pathology. This information should help you to learn and understand what most of the experts in the field would do in each specific situation. The information reflects a “common sense” approach to treatment of the members of EuroSpine, yet does not replace a careful evaluation of your individual situation. Therefore, if you find a significant difference between the answers below and you doctor’s opinion, ask your doctor what made him/her reach this decision.

Each specific situation has to be evaluated on an individual basis. EuroSpine and its members cannot be held responsible for any misunderstandings (or misdiagnosis) based on the information provided here, which in no way attempts to replace a targeted evaluation.

Sciatica is the term used to describe pain down the leg caused by irritation or inflammation of one of the nerve roots that make up the sciatic nerve. Most commonly it is due to a disc prolapse within the lumbar spine. Another common cause is spinal stenosis or a narrowing of the canal through which the nerve travels. Spinal stenosis occurs more frequently with increasing age. There can sometimes be a combination of disc prolapse and narrowing of the space available for the nerve.

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THE HEALTHY LUMBAR SPINE

General anatomy

The lumbar spine is between the chest and pelvis at the back of the abdomen. It is a very strong structure that carries the nerves to the legs, bowel and bladder. There are five bones – vertebrae – linked together by discs and ligaments that allow mobility of the trunk.

The spine is made up of many small bones called vertebrae. These are separated by discs that allow the spine to bend (see illustration below). This structure of vertebrae and discs is supported along its length by muscles and ligaments. The spinal cord threads through the centre of each vertebra, carrying nerves from the brain to the rest of the body.

The soft tissues of the lumbar spine simply refer to the parts that are not bone. At the back of the spine, powerful muscles as well as ligaments and tendons link the vertebrae. Discs are special, very strong joints at the front of the spine. There are smaller joints at the back of the spine called facet joints. All these joints allow a certain degree of movement.

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INTRODUCTION

Nerve root pain comes from a nerve in the back. As nerves carry messages about sensations and control of muscles, disorders can cause pain, numbness, increased sensitivity or weakness of muscles. The pain is often felt in the area of the body supplied by that nerve. It is common for the leg nerves and arm nerves to be affected.

Lumbar nerve pain (often called sciatica) generally occurs below the knee. Back pain is usually felt between the lower ribs and the buttocks. In many cases, there is a combination of back and leg pain. In sciatica, the leg pain is worse than the back pain. While sciatica is usually caused by a disc prolapse (a slipped disc), there are other causes. Sometimes, nerve pain can be caused by conditions such as diabetes or even infections such as shingles.

Brachial neuralgia (nerve pain in the arm) is very similar to sciatica, but comes from the neck nerves. Radicular pain is a term doctors use to describe pain when it is mainly from a single nerve root.

This information is intended for those who generally suffer from nerve pain rather than back pain. Very often, nerve pain and back pain are present at the same time. If the pain in the limb is worse than the back pain, it is more likely to come from the nerve.

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SOME COMMON PATTERNS OF NERVE ROOT PAIN IN THE LEG

Many patients seem to recognize the nerve pain they have from this diagram, but please remember it is only one part of the diagnosis of nerve pain.

Nerve pain can range from severe to quite mild pain. Sometimes it has a specific characteristic such as burning or pins and needles. Some patients find the pain is worse if they cough or sneeze. It may be worse in certain positions and better in others. Some activities such as walking or gentle cycling may ease the pain, while sitting or laying still can make it worse.

In addition to the pain, other nerve functions can also be affected. Numbness or altered sensation is common. Muscle weakness can also occur.

The S1 nerve weakness can affect the calf muscle or the muscles around the outer ankle, causing a limp.

The L5 nerve weakness will sometimes affect the ability to lift the big toe.

The L4 nerve weakness can affect the muscles that lift the foot; a severe weakness is called a foot drop.

Although quite frightening, many episodes of sciatica get better fairly quickly on their own.

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HEALING

When a disc prolapses (or slips), it loses its normal nutrition of fluid and therefore shrinks quite quickly.

A disc prolapse can be thought of as a piece of moist fish/meat left on a plate, shrivelling up and shrinking in size.

The part of the disc that is left behind will often repair itself.

As people get older their discs become stiffer and have less jelly, which is why disc prolapses are less common in older people.

The best way to deal with the problem is to exercise sensibly, stay active, avoid being overprotective and lead as normal a life as possible.

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DIAGNOSIS

In the initial stages, most patients only need to see their GP. The diagnosis is made largely from the symptoms and the initial examination.

Here are some of the common examination findings:

Spinal movements produce limb pain. For instance, in the case of lumbar nerve root pain (sciatica), bending down to touch one's toes causes the pain to spread to the leg.

Nerve stretching tests causes pain to spread down the limb.

Simple tests of the function of the nerve (e.g. power, reflex and sensory tests) help identify which nerve is likely to be the one causing the pain. Healthcare professionals perform these tests as part of the diagnosis.

The severity of nerve root pain is NOT related to how large the disc is and can vary a great deal. Distress and fear often worsens the pain. In order to understand how best to deal with sciatica, sound information is vital.

Sciatica generally gets better; the only situation, in which it is considered an emergency, is when there is numbness between the legs or difficulty with bladder or bowel control.

LOSS OF SENSATION BETWEEN THE LEGS AND AROUND THE BUTTOCKS
OR LOSS OF CONTROL OF THE BOWELS OR BLADDER
OR BOTH

THIS IS AN EMERGENCY – IT IS RARE, BUT IF IT OCCURS, IT MUST BE DEALT WITH PROMPTLY

IT'S CALLED CAUDA EQUINA SYNDROME


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THE MAIN POINTS OF NERVE ROOT PAIN

  • Pain spreads to the leg or arm, generally below the knee or elbow.
  • Pain is often associated with altered sensations, pins and needles, burning or numbness.
  • Pain in the leg or arm lasts for long periods.
  • Coughing and sneezing can make the limb pain worse.
  • The limb pain is the main pain.

What is a prolapsed disc?

The intervertebral discs have a jelly-like centre (the pulposus), which can ooze through a tear in the strong gristle of the disc (the annulus). The jelly then compresses the nearby nerve root and inflames it, causing pain in the area of the limb supplied by the nerve.

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PROGNOSIS

Fortunately, most episodes do not last long. Medication and therapeutic measures can help, but there is no usual quick fix. Natural recovery has to take place. Most patients improve within six weeks of the start of the symptoms in the limb.

By thirteen weeks, the majority of patients show considerable improvement and are virtually back to normal, but low-grade symptoms may sometimes persist for several months.

If the pain ‘centralizes’ or moves away from the limb towards the spine, this is a sign of improvement.

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THINGS THAT MAY HELP; MANY OF WHICH SHOULD BE DISCUSSED WITH THE DOCTOR

Specialist's opinion:
1) If non-operative treatment is indicated the measures to be taken are rated as follows: (useless: 0, extremely helpful: 100)
“Normal pain killers”

86 %
Non-steroidal anti-inflammatory drugs

100 %
Muscle relaxants

63 %
Corticosteroid medication

64 %
Nerve pain medication (gabapentin or similar)

62 %
Physiotherapy

83 %
Manual therapy

52 %
Traction

32 %
Epidural injections

76 %
Nerve root injections

81 %
Other

2 %
Total: 49 Specialists answered


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DRUG TREATMENTS

Medication is used to help with the pain and can improve your quality of life while healing takes place.

Effective drugs include non-steroidal anti-inflammatory drugs, pain-relieving drugs, nerve pain-relieving drugs and (if a spasm is present) muscle relaxation drugs. For additional advice, please see our booklet “Routine medications for musculoskeletal problems”.

Not all of these medications are always necessary. Exact decisions on what you need are made by your GP/hospital doctor. Very often, a combination of different medications taken regularly can provide an umbrella of pain relief. This is more helpful than just taking tablets when the pain is really bad. It is easier to keep pain away, rather than trying to get rid of it once it starts.

One type of medication from each of the three main groups can be combined with medication from the other groups
  • Anti-inflammatories: Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Simple analgesics: Paracetamol, co-codamol, co-dydramol
  • Nerve pain medication: Amitriptyline, gabapentin

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PHYSIOTHERAPY AND MANUAL THERAPIES

Assessment and good advice regarding correct posture and lifestyle are usually given early in the episode. In some cases, manual therapy may even cause symptoms to increase and not help much.

If most of the limb pain has subsided, then such treatment can be considered to ease any residual stiffness, and progressively reactivate and rehabilitate back to full function.

Certain exercises can sometimes be very helpful – McKenzie’s exercises seem to help reduce leg pain in some patients.

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INJECTION THERAPY

Injection therapy is usually only required if the problem does not settle satisfactorily after an appropriate period of time.

These treatments can be provided by a variety of specialists, including rheumatologists, pain management anaesthetists, radiologists and orthopaedic surgeons.

The two injection techniques most often employed are:

1. Epidural injections into the space around the nerves in the spine and the spinal canal. These can be lumbar or caudal.

2. Nerve root canal injections are more specific to the affected nerve and require x-ray control to locate where the irritated nerve exits the spine. These are sometimes called peri-radicular injections or foraminal epidurals.

Both injection techniques have the aim of relieving pain and inflammation in the nerve, while natural healing continues. They can be repeated if required. Both methods seem equally safe. Complications are uncommon, but can include infection or damage to nerves or blood vessels.

TREATMENTS THAT DO NOT WORK OR MAY BE HARMFUL

  • Traction
  • Manipulation of the spine under anaesthesia


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SURGERY

Specialist's opinion:
2) The best timing for surgery for nerve root pain that is not improving is:
Less than four weeks

4 votes
4-8 weeks

22 votes
8-12 weeks

16 votes
After 3 months

6 votes
Before one year

1 votes
Total: 49 Specialists answered
3) Surgery for radiologically confirmed nerve root compression should be advocated if the following concordant symptoms are present
Uncontrollable pain with sensory deficit

33 votes
Uncontrollable pain with motor deficit

44 votes
No pain but motor deficit

20 votes
Controllable pain with sensory deficit

3 votes
Controllable pain with motor deficit

25 votes
Cauda equina syndrome

41 votes
Total: 48 Specialists answered
The majority of patients get better without surgery. In most cases, the pain subsides with time.

Surgery can be very helpful if the pain doesn’t settle with simpler measures. An operation is the most reliable way to reduce the leg pain quickly, but surgery does have some associated risks.

Specialist's opinion:
4) The following statements apply to the comparison between surgical treatment and non-surgical treatment for sciatica (completely false: 0, completely true: 100)
Muscle weakness gets better quicker

74 %
Pain gets better quicker

100 %
Sensory deficit gets better quicker

59 %
Less risk of recurrence

47 %
Improved long-term outcome

38 %
The benefit always outweighs the risks

49 %
The results are better with early surgery

53 %
Total: 46 Specialists answered
The results of surgery depend on the specific clinical picture, and some patients may not be suitable.

Surgery is for the pain in the leg. It does not seem to alter the chance of future attacks of sciatica. It is better for pain than numbness or weakness. Numbness does not usually cause many problems.

After surgery, 75% of sciatica patients show considerable improvement, 20% show improvement but have some minor persisting symptoms, about 5% are not helped at all, and about 1% may even be worse off.

Complications can occur and include general complications associated with any operation and specific complications related to the spine.

The death rate within 30 days of surgery in a large study was 0.5 per 1,000, or a risk of 0.05%.

A dural tear is when the lining of the spinal canal is disrupted and can result in a leak of spinal fluid. This happens in about 3% of operations. This does not usually lead to any long-term complications.

Infection can occur, but is rare. Serious infection occurs in less than 1% of cases. Damage to nerves and blood clots in the spine or lungs can also occur.

Serious complications such as death or paralysis can also occur, but are fortunately rare. A catastrophic complication of this type might occur with a risk of 1 per 400 or 500 cases. Each individual should discuss the risks and benefits of operative and non-operative treatment with the surgeon.

Specialist's opinion:
5) The risk of a serious complication (death or paralysis) following disc surgery is estimated at
1:1000

30 votes
1:500

8 votes
1:100

3 votes
1:10

0 votes
Other

5 votes
Total: 46 Specialists answered
6) The risk of a complication such as infection following disc surgery is estimated at
1:1000

7 votes
1:500

14 votes
1:100

20 votes
1:10

1 votes
Other

4 votes
Total: 46 Specialists answered
7) The risk of a complication such as a leak of spinal fluid during or after disc surgery is estimated at
1:500

8 votes
1:100

19 votes
1:33

15 votes
1:20

4 votes
Other

0 votes
Total: 46 Specialists answered

Disc surgery

During the operation, the part of the disc irritating the nerve root is removed.

Specialist's opinion:
8) My most frequently used technique for disc surgery is (only one answer)
Traditional open decompression with or without microscope

33 votes
Disc prosthesis

2 votes
Minimal open decompression (using tubes, etc.)

10 votes
Percutaneous automated nucleotomy

0 votes
Percutaneous laser

1 votes
IDET

0 votes
Chymopapain

0 votes
Other

0 votes
Total: 46 Specialists answered
9) Simultaneous fusion with disc surgery is likely to be indicated (indicate all that apply)
Always

0 votes
In the presence of advanced facet arthrosis

6 votes
In the presence of radiological instability

33 votes
In long-standing history of back pain

18 votes
In surgery for recurrence

24 votes
Never

3 votes
Other

4 votes
Total: 46 Specialists answered
Usually the operation involves an overnight stay in hospital. The length of the stay for this type of surgery has decreased significantly over the last ten years in almost all countries.

A recent study in Sweden of 25,000 surgical cases found the risk of requiring a further operation for sciatica within ten years of the first at only 7%; the same risk as without surgery. Re-admission to hospital and re-operation were more frequent in the early years after operation. In more specific terms, the risk of re-operation at one year and at ten years was 5% and 10% respectively.

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AFTER THE OPERATION

Nowadays, common advice would be to mobilise and return to normal quickly. It seems that advice given in the past to return slowly to normal over twelve weeks was unnecessarily cautious.

Individual surgeons may have their own exercise programme that they wish patients to follow.

A common schedule might involve early walking, little and often; then to start cycling and swimming by two weeks. This would be followed by a return to clerical type work at three weeks, and light manual work at four to six weeks, lifting nothing heavier than 10 kg.

You should be back to full unrestricted activity at twelve weeks, including heavy manual work and contact sports.

Generally, you should be safe to drive when you are able to walk briskly for about 400 yards (usually about three weeks post op). It is advisable to reduce driving to below 500 miles a week for the first three months.

GENERAL ADVICE
Listed below are some dos and don’ts to help you understand and manage your back pain.

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DO

  • Take a regular umbrella of pain relief to control the pain. Anti-inflammatory medication can be very helpful and should be used if possible.
  • Stay as active as possible; rest does not speed recovery.
  • Stay at work or return back to work as soon as possible. It will hurt whether or not you are working, and normal activities will not delay recovery.
  • Distract yourself from the pain; leisure activities, work or things you enjoy help to take your mind off the pain and fewer painkillers may then be required.

DON’T

  • Don’t be frightened of the pain. (Hurt does not mean harm).
  • Don’t give in; doing less leads to weakness and stiffness.
  • Don’t panic if the pain increases; small setbacks during the healing period/process are quite common.
  • Don’t suffer the pain; take painkillers at an early stage so that you can get moving earlier. Simple painkillers do not mask the pain, they do not allow you to harm or damage yourself.

KEY POINTS

  • Nerve root pain usually settles over time.
  • Medications and adjustments in lifestyle can help to improve your quality of life while healing takes place.
  • Only a small number of patients who don’t settle/recover within the usual period of time need to go to hospital for tests and other interventions.
  • Most disc problems heal over time and recurrence is rare.

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USEFUL INFORMATION SOURCES FOR PATIENTS

Low back

  • The Back Book, The Stationary Office, Tel +44/0870 600 5522, ISBN 011 322312 9 (£1.25)
  • Your Back Operation, The Stationary Office, Tel +44/08706005522, ISBN 011 7035459

Neck pain

  • The Whiplash Book, The Stationary Office, Tel +44/0870 600 5522, ISBN 011 702862 2 (£2.50)
  • The Neck Book, The Stationary Office, Tel 0870 600 5522, ISBN 011 7033219

Websites

An excellent site that gives occupational and primary care information for both doctors and patients.

These are the BMJ-approved information sources for patients. Useful, modern and practical advice for self-management.

Good information covering the spectrum of available treatments. The emphasis is on patients helping patients and self-care and awareness. They have a broad range of useful publications.

Information and resources for patients with nerve pain, particularly when it radiates to a limb.

A good site for British patients with patients’ views and a chatroom. Links to more technical sites.
© The above text, figures and data are property of EUROSPINE®, the Spine Society of Europe and may not be reproduced or used in any other way.

EUROSPINE, April 2007

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