Sciatica: Difference between revisions
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===Alternative medicine=== |
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Moderate quality evidence suggests that [[spinal manipulation]] is effective for the treatment of acute sciatica.<ref name=Leininger2011/> For chronic sciatica the evidence is poor.<ref name=Leininger2011>{{cite journal |pages=105–125 |doi=10.1016/j.pmr.2010.11.002 |title=Spinal Manipulation or Mobilization for Radiculopathy: A Systematic Review |year=2011 |last1=Leininger |first1=Brent |last2=Bronfort |first2=Gert |last3=Evans |first3=Roni |last4=Reiter |first4=Todd |journal=Physical Medicine and Rehabilitation Clinics of North America |volume=22 |pmid=21292148 |issue=1}}</ref> Spinal manipulation has been found to be generally safe for the treatment of disc-related pain however case reports have found an association with [[cauda equina syndrome]].<ref>{{cite journal|last=Tamburrelli|first=FC|coauthors=Genitiempo, M; Logroscino, CA|title=Cauda equina syndrome and spine manipulation: case report and review of the literature.|journal=European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society|date=2011 May|volume=20 Suppl 1|pages=S128-31|pmid=21404036}}</ref> Spinal manipulation is [[contraindication|contraindicated]] for disc herniations when there are progressive neurological deficits.<ref name=WHO-chiro-guidelines>[http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf WHO guidelines on basic training and safety in chiropractic. "2.1 Absolute contraindications to spinal manipulative therapy", p. 21.] [[WHO]]</ref> In those with sciatica believed to be due to piriformis syndrome botulism toxin injections may improved pain, and or function |
Moderate quality evidence suggests that [[spinal manipulation]] is effective for the treatment of acute sciatica.<ref name=Leininger2011/> For chronic sciatica the evidence is poor.<ref name=Leininger2011>{{cite journal |pages=105–125 |doi=10.1016/j.pmr.2010.11.002 |title=Spinal Manipulation or Mobilization for Radiculopathy: A Systematic Review |year=2011 |last1=Leininger |first1=Brent |last2=Bronfort |first2=Gert |last3=Evans |first3=Roni |last4=Reiter |first4=Todd |journal=Physical Medicine and Rehabilitation Clinics of North America |volume=22 |pmid=21292148 |issue=1}}</ref> Spinal manipulation has been found to be generally safe for the treatment of disc-related pain however case reports have found an association with [[cauda equina syndrome]].<ref>{{cite journal|last=Tamburrelli|first=FC|coauthors=Genitiempo, M; Logroscino, CA|title=Cauda equina syndrome and spine manipulation: case report and review of the literature.|journal=European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society|date=2011 May|volume=20 Suppl 1|pages=S128-31|pmid=21404036}}</ref> Spinal manipulation is [[contraindication|contraindicated]] for disc herniations when there are progressive neurological deficits.<ref name=WHO-chiro-guidelines>[http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf WHO guidelines on basic training and safety in chiropractic. "2.1 Absolute contraindications to spinal manipulative therapy", p. 21.] [[WHO]]</ref> In those with sciatica believed to be due to piriformis syndrome botulism toxin injections may improved pain, and or function.<ref>{{cite journal|last=Waseem|first=Z|coauthors=Boulias, C; Gordon, A; Ismail, F; Sheean, G; Furlan, AD|title=Botulinum toxin injections for low-back pain and sciatica.|journal=Cochrane database of systematic reviews (Online)|date=2011 Jan 19|issue=1|pages=CD008257|pmid=21249702}}</ref> |
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== References == |
== References == |
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Revision as of 20:28, 2 March 2013
| Sciatica | |
|---|---|
| Specialty | Orthopedic surgery, neurology  |
Sciatica (/[invalid input: 'icon']saɪˈætɪkə/; sciatic neuritis or lumbar radiculopathy)[1] is a set of symptoms including pain that may be caused by general compression or irritation of one of five spinal nerve roots that give rise to each sciatic nerve, or by compression or irritation of the left or right or both sciatic nerves. The pain is felt in the lower back, buttock, or various parts of the leg and foot. In addition to pain, which is sometimes severe, there may be numbness, muscular weakness, pins and needles or tingling and difficulty in moving or controlling the leg. Typically, the symptoms are only felt on one side of the body. Pain can be severe in prolonged exposure to cold weather.
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 root of the nerve, causing the pain. This point is important, because treatment for sciatica or sciatic symptoms often differs, depending upon the underlying cause of the symptoms and pain levels. Sciatica is also referred to as Lumbar Radiculopathy,[2] which involves compression of the sciatic nerve roots caused by a herniated (torn) or protruding disc in the lower back.
The first known use of the word sciatica dates to 1451.[3]
Cause
Spinal disc herniation
Spinal disc herniation pressing on one of the sciatic nerve roots is a relatively common cause.
Sciatica caused by pressure from a disc herniation and swelling of surrounding tissue can spontaneously subside if the tear in the disc heals and the pulposus extrusion and inflammation cease.
Sciatica can also be caused by tumours impinging on the spinal cord or the nerve roots. Severe back pain extending to the hips and feet, loss of bladder or bowel control, or muscle weakness, may result from spinal tumours or cauda equina syndrome. Trauma to the spine, such as from a car accident, may also lead to sciatica.
Spinal stenosis
Other compressive spinal causes include lumbar spinal stenosis, a condition in which the spinal canal (the spaces through which the spinal cord runs) narrows and compresses the spinal cord, cauda equina, or sciatic nerve roots. This narrowing can be caused by bone spurs, spondylolisthesis, inflammation, or herniated disc, which decreases available space for the spinal cord, thus pinching and irritating nerves from the spinal cord that travel to the sciatic nerves.
Piriformis syndrome
In 15% of the population, the sciatic nerve runs through, or under the piriformis muscle rather than beneath it. When the muscle shortens or spasms due to trauma or overuse, it can compress or strangle the sciatic nerve beneath the muscle. Conditions of this type are generally referred to as entrapment neuropathies; in the particular case of sciatica and the piriformis muscle, this condition is known as piriformis syndrome. It has colloquially been referred to as "wallet sciatica" since a wallet carried in a rear hip pocket will compress the muscles of the buttocks and sciatic nerve when the bearer sits down. Piriformis syndrome may be a cause of sciatica when the nerve root is normal.[4][5]
Pregnancy
Sciatica may also occur during pregnancy as a result of the weight of the fetus pressing on the sciatic nerve during sitting or during leg spasms. While most cases do not directly harm the fetus or the mother, indirect harm may come from the numbing effect on the legs which can cause loss of balance and falling. There is no standard treatment for pregnancy induced sciatica.[6]
Pathophysiology
Sciatica is generally caused by the compression of lumbar nerves L3, L4 or L5 or sacral nerves S1, S2, or S3, or by compression of the sciatic nerve itself. When sciatica is caused by compression of a dorsal nerve root (radix) it is considered a lumbar radiculopathy (or radiculitis when accompanied with an inflammatory response). This can occur as a result of a spinal disk bulge or spinal disc herniation (a herniated intervertebral disc), or from roughening, enlarging, or misalignment (spondylolisthesis) of the vertebrae, or as a result of degenerated discs that can reduce the diameter of the lateral foramen (natural hole) through which nerve roots exit the spine. The intervertebral discs consist of an annulus fibrosus, which forms a ring surrounding the inner nucleus pulposus. When there is a tear in the annulus fibrosus, the nucleus pulposus (pulp) may extrude through the tear and press against spinal nerves within the spinal cord, cauda equina, or exiting nerve roots, causing inflammation, numbness or excruciating pain. Inflammation in the spinal canal can also spread to adjacent facet joints and cause lower back pain and/or referred pain in the posterior thigh(s). Pseudosciatic pain can also be caused by compression of peripheral sections of the nerve, usually from soft tissue tension in the piriformis or related muscles.
The spinal discs are composed of a tough spongiform ring of cartilage ("annulus fibrosus") with a more malleable center ("nucleus pulposus"). The discs separate the vertebrae, thereby allowing room for the nerve roots to properly exit through the spaces between the vertebrae. The discs cushion the spine from compressive forces, but are weak to pressure applied during rotational movements. That is why a person who bends to one side, at a bad angle to pick something up, may more likely herniate a spinal disc than a person jumping from a ladder and landing on his or her feet.
Herniation of a disc occurs when the liquid center of the disc bulges outwards, tearing the external ring of fibers, extrudes into the spinal canal, and compresses a nerve root against the lamina or pedicle of a vertebra, thus causing sciatica. This extruded liquid from the "nucleus pulposus" may cause inflammation and swelling of surrounding tissue, which may cause further compression of the nerve root in the confined space in the spinal canal.
Diagnosis
Sciatica is typically diagnosed by physical examination, and the history of the symptoms.[7] Generally if a person reports the typical radiating pain in one leg as well as one or more neurological indications of nerve root tension or neurological deficit, sciatica can be diagnosed.[8]
The most applied diagnostic test is the straight leg rising test, or Lasègue's sign, which is considered positive if pain in the sciatic nerve is reproduced with between 30 and 70 degrees passive flexion of the straight leg.[9]
Diagnosis of sciatica through imaging can be achieved either with computerised tomography or with magnetic resonance imaging.[10] MR neurography has been shown to diagnose 95% of severe sciatica patients, while as few as 15% of sciatica sufferers in the general population are diagnosed with disc-related problems.[11] MR neurography may help diagnose piriformis syndrome—another cause of sciatica that does not involve disc herniation.[citation needed]
Management
When the cause of sciatica is due to a lumbar disc herniation, most cases resolve spontaneously over weeks to months.[12] Initially treatment in the first 6-8 weeks should be conservative.[7] There does not appear to be a significant difference in outcomes between advice to stay active and recommendations of bed rest.[13] Similarly, physical therapy (exercises) has not been found better than bed rest.[14]
Medication
Although medications are commonly prescribed for the treatment of sciatica, evidence for analgesics is poor.[15] Specifically NSAIDs do not appear to improve immediate pain and all NSAIDs appear about equivalent.[15] Evidence is also lacking in use of opioids and muscle relaxants.
Surgery
Elective surgery for unilateral sciatica involves the removal of part of the disc. While it results in short term benefits, long term benefits are unclear.[16] Treatment of the underlying cause of the compression is needed in cases of epidural abscess, epidural tumors, and cauda equina syndrome.
Alternative medicine
Moderate quality evidence suggests that spinal manipulation is effective for the treatment of acute sciatica.[17] For chronic sciatica the evidence is poor.[17] Spinal manipulation has been found to be generally safe for the treatment of disc-related pain however case reports have found an association with cauda equina syndrome.[18] Spinal manipulation is contraindicated for disc herniations when there are progressive neurological deficits.[19] In those with sciatica believed to be due to piriformis syndrome botulism toxin injections may improved pain, and or function.[20]
References
- ^ "sciatica" at Dorland's Medical Dictionary
- ^ Conditions of the Spine - Lumbar Radiculopathy. (2010). Retrieved December 3, 2012 from http://www.njpcc.com/conditions-of-the-spine/lumbar-radiculopathy-sciatica.html
- ^ Oxford English Dictionary, 2nd Ed. "a1450a Mankind (Brandl)."
- ^ Kirschner, Jonathan S.; Foye, Patrick M.; Cole, Jeffrey L. (2009). "Piriformis syndrome, diagnosis and treatment". Muscle & Nerve. 40 (1): 10–18. doi:10.1002/mus.21318. PMID 19466717.
- ^ Lewis, A. M.; Layzer, R.; Engstrom, J. W.; Barbaro, N. M.; Chin, C. T. (2006). "Magnetic Resonance Neurography in Extraspinal Sciatica". Archives of Neurology. 63 (10): 1469–1472. doi:10.1001/archneur.63.10.1469. PMID 17030664.
- ^ Sciatic nerve compression during pregnancy
- ^ a b Valat, JP (2010 Apr). "Sciatica". Best practice & research. Clinical rheumatology. 24 (2): 241–52. PMID 20227645.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Koes, B W; Van Tulder, M W; Peul, W C (2007). "Diagnosis and treatment of sciatica". BMJ. 334 (7607): 1313–1317. doi:10.1136/bmj.39223.428495.BE. PMC 1895638. PMID 17585160.
- ^ Speed, C. (2004). "Low back pain". BMJ. 328 (7448): 1119–1121. doi:10.1136/bmj.328.7448.1119. PMC 406328. PMID 15130982.
- ^ Gregory, DS; Seto, CK; Wortley, GC; Shugart, CM (2008). "Acute lumbar disk pain: navigating evaluation and treatment choices". American family physician. 78 (7): 835–42. PMID 18841731.
- ^ Filler, Aaron G.; Haynes, Jodean; Jordan, Sheldon E.; Prager, Joshua; Villablanca, J. Pablo; Farahani, Keyvan; McBride, Duncan Q.; Tsuruda, Jay S.; Morisoli, Brannon (2005). "Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment". Journal of Neurosurgery: Spine. 2 (2): 99–115. doi:10.3171/spi.2005.2.2.0099. PMID 15739520.
- ^ Casey, E (2011 Feb). "Natural history of radiculopathy". Physical medicine and rehabilitation clinics of North America. 22 (1): 1–5. PMID 21292142.
{{cite journal}}: Check date values in:|date=(help) - ^ Hagen, KB (2004 Oct 18). "Bed rest for acute low-back pain and sciatica". Cochrane database of systematic reviews (Online) (4): CD001254. PMID 15495012.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Luijsterburg, Pim A. J.; Verhagen, Arianne P.; Ostelo, Raymond W. J. G.; Os, Ton A. G.; Peul, Wilco C.; Koes, Bart W. (2007). "Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review". European Spine Journal. 16 (7): 881–899. doi:10.1007/s00586-007-0367-1. PMC 2219647. PMID 17415595.
- ^ a b Pinto, RZ (2012 Feb 13). "Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis". BMJ (Clinical research ed.). 344: e497. PMID 22331277.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Bruggeman, AJ (2011 Feb). "Surgical treatment and outcomes of lumbar radiculopathy". Physical medicine and rehabilitation clinics of North America. 22 (1): 161–77. PMID 21292152.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ a b Leininger, Brent; Bronfort, Gert; Evans, Roni; Reiter, Todd (2011). "Spinal Manipulation or Mobilization for Radiculopathy: A Systematic Review". Physical Medicine and Rehabilitation Clinics of North America. 22 (1): 105–125. doi:10.1016/j.pmr.2010.11.002. PMID 21292148.
- ^ Tamburrelli, FC (2011 May). "Cauda equina syndrome and spine manipulation: case report and review of the literature". European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 20 Suppl 1: S128-31. PMID 21404036.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ WHO guidelines on basic training and safety in chiropractic. "2.1 Absolute contraindications to spinal manipulative therapy", p. 21. WHO
- ^ Waseem, Z (2011 Jan 19). "Botulinum toxin injections for low-back pain and sciatica". Cochrane database of systematic reviews (Online) (1): CD008257. PMID 21249702.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help)