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sciatica

An Approach to the Differential Diagnosis of Sciatica in the Primary Care Setting

Teaser: 

Taryn Walker B.Kin, MM, 1 Vahagn Karapetyan MD PhD FRCSC,2 Greg McIntosh MSc,3 Christopher S Bailey MD FRCSC,4

1Department of Surgery, Schulich School of Medicine, Western University
2Department of Surgery, Schulich School of Medicine, Western University
3Director of Research Operations, Canadian Spine Outcomes and Research Network
4Department of Surgery, Schulich School of Medicine, Western University

CLINICAL TOOLS

Abstract: Sciatica is a well-recognized complaint, with the hallmark presenting symptom of lancinating pain running down the back of the leg, along the path of the sciatic nerve. While it is typically caused by a herniated lumbar disc within the spinal canal, an understanding of the course of the sciatic nerve and associated regional anatomy is useful in forming a broader differential diagnosis. In rare cases, sciatica, usually bilateral, is associated with a loss of bowel or bladder function, indicating cauda equina syndrome, a medical emergency. Other degenerative conditions of the lumbar spine such as spondylolisthesis and spinal stenosis can occasionally produce sciatica while deep gluteal pain is often used to describe the muscular causes. Malignancy, trauma, vascular causes and ectopic endometrial tissue can cause compression of the lumbosacral plexus within the pelvis and produce similar symptoms. In this review, we highlight the common clinical presentations, physical examination and relevant diagnostic investigations for a broad differential diagnosis of sciatica.
Key Words: Sciatica, leg dominant pain, nerve compression, straight leg raise.

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1. Herniated intervertebral disc accounts for up to 90% of sciatica cases 
2. An understanding of the course of the sciatic nerve and associated regional anatomy can be useful in forming a differential diagnosis; one should consider gluteal region sciatic compression disorders, pelvic pathology involving the lumbosacral plexus, malignancy, infection, trauma and conditions that mimic sciatica.
3. Patients usually have low back pain associated with their leg complaints, but genuine sciatica from a herniated lumbar disc produces leg pain that is the dominant symptom. Back dominant pain, with any direct nerve involvement, can extend into the leg, occasionally all the way to the foot, but unless the leg pain is more intense than the back pain, it is not sciatica. 
4. The physical examination should include checking lower limb reflexes, dermatome and myotome assessment, upper motor neuron tests such as the plantar response and specialized neural tension tests such as the passive straight leg raise (SLR) and slump tests.
5. A positive crossover sign occurs when raising the straight leg on the affected side reproduces not only the typical pain in the affected leg but causes pain to radiate down the seemingly unaffected leg as well. This finding of bilateral sciatica suggests pathology located in the midline, a central disc herniation.
True sciatica from a herniated lumbar disc is when the leg pain is the dominant symptom over back pain. Lancinating, constant, radicular pain down the posterior leg along the path of the sciatic nerve is the hallmark symptom. Activity, prolonged sitting or Valsalva maneuvers such as coughing or bearing down aggravate sciatic pain. A patient may prefer to stand because sitting is intolerable.
Neurogenic Claudication from spinal stenosis is distinctive from herniated lumbar disc sciatica. Unlike classic sciatica, lumbar spinal stenosis neural tension tests are often negative and the neurological assessment may be normal; however, the more classic sciatic presentation, may be present in spinal stenosis if a focal nerve root is also compressed.
To distinguish piriformis syndrome from sciatica, muscle tenderness with deep gluteal palpation and specialized piriformis stretch tests such as the FAIR, Pace and Beatty maneuvers may be helpful.
Greater trochanteric bursitis, meralgia paresthetica, and cluneal nerve entrapment are conditions that can cause pain in a distribution that is similar to the sciatic nerve, but without involving the nerve directly.
Identifying any posterior thigh pain when the leg is elevated above 60 or 70 degrees as sciatica is a common diagnostic error. Unless the leg pain produced is identical to the patient’s chief complaint on history, the test is negative.
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Related Terms: Back Health, sciatica, leg dominant pain, nerve compression, straight leg raise

Management of Lumbar Radiculopathy Secondary to Lumbar Intervertebral Disc Herniation

Teaser: 

Patrick Thornley, MD, MSc, FRCSC,1, Christopher S. Bailey, MD, MSc, FRCSC,2,

1 London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, Ontario, Canada.
2 London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, Ontario, Canada.

CLINICAL TOOLS

Abstract: Lumbar intervertebral disc herniations (IVH) carry a high lifetime prevalence and are the most common cause of sciatica. The vast majority of symptomatic lumbar IVH improve with conservative management though adjuncts such as physiotherapy and epidural steroid injections may play a role in short-term symptom relief. For patients with unresponsive lumbar IVH, discectomy reliably improves symptoms more rapidly than continued conservative care, though there is inconsistent evidence that clinical differences between operative and conservative care are no different at one-year after symptom onset.
Key Words: lumbar radiculopathy, intervertebral disc herniation; lumbar intervertebral disc herniation; lumbar disc herniation; sciatica.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

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1. The natural history of lumbar intervertebral disc herniations causing lumbar radiculopathy is favourable with conservative care in the vast majority of patients.
2. Advanced imaging for patients with lumbar radiculopathy is indicated only in the setting of “red flag” neurologic symptoms or a concerning clinical history for infection, neoplastic or traumatic etiology or the absence of symptom improvement after six-weeks of conservative care.
3. Long-term follow-up demonstrates most patients with lumbar intervertebral disc herniation causing lumbar radiculopathy achieve comparable clinical improvement with surgery or conservative management, with surgery leading to earlier symptom resolution.
4. The high-quality evidence for surgery is weak given the high cross over rate but observational studies show a benefit of surgery after failed non-operative care.
1. The diagnosis is made on the patient’s history including leg dominant pain and confirmed by the physical examination.
2. A combination of a detailed motor and sensory neurologic examination, including supine straight leg raise in addition to cross leg straight leg raise, increases the clinical sensitivity and specificity of a diagnostic examination for lumbar radiculopathy.
3. Analgesics should be used to manage function and not just to reduce pain, taking into account response to the specific analgesic on an individual basis including the known side effect profiles.
4. Microdiscectomy surgery for patients with refractory lumbar radiculopathy lasting greater than four months can lead to a significant reduction in leg pain compared to continued conservative management.
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Related Terms: Back Health, lumbar radiculopathy, intervertebral disc herniation, lumbar intervertebral disc herniation, Lumbar disc herniation, sciatica

Current Management of Symptomatic Lumbar Disc Herniation

Teaser: 

Parham Rasoulinejad, MD, FRCSC, MSc, 1 Jennifer C. Urquhart, PhD,2 Christopher S. Bailey, MD, FRCSC, MSc, 2

1Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Assistant Professor, Dept. of Surgery, University of Western Ontario, London, ON.
2Research Associate, Division of Orthopaedic Surgery, London Health Sciences Center, and Lawson Health Research Institute, London, ON.
3Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Associate Professor, Dept. of Surgery, University of Western Ontario, London, ON.

CLINICAL TOOLS

Abstract: Lumbar disc herniation is a common cause of low back pain and radiculopathy (sciatica). Diagnosis is initially made based on history and physical examination and ruling out red flags, particularly surgical emergencies such as Cauda Equina Syndrome. A trial of conservative treatment consisting of physical rehabilitation and oral medication is usually successful for back dominant pain. When persistent radiculopathy indicates lumbar discectomy the diagnosis must be confirmed by imaging but, due to very high rates of asymptomatic disc herniation, imaging cannot replace clinical diagnosis. For disabling leg dominant pain discectomy results in faster recovery but has a similar long-term outcomes compared to conservative treatment.
Key Words: lumbar disc herniation, lower back pain, sciatica, radiculopathy.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Pre-test CME Quiz Post-test CME Quiz
Lumbar disc herniation is common and frequently asymptomatic.
Lumbar disc herniation may result in back pain. Much less frequently, when the adjacent nerve root is involved it can cause radiculopathy (sciatica).
Under most circumstances, the symptoms of lumbar disc herniation can be managed conservatively with physical rehabilitation and oral medications.
Red flags and surgical emergencies such as Cauda Equina Syndrome must be considered and should lead to urgent imaging and surgical referral.
Imaging, particularly MRI, has high rates of false positives and should only be used to confirm a diagnosis made based on history and physical examination.
For disabling persistent radiculopathy with good radiological correlation, surgical intervention in the form of a discectomy can be considered.
Lumbar disc herniation (LDH) is common and in most cases asymptomatic. Findings on MRI of lumbar disc herniation are not predictive of future back related disability. MRI findings should be interpreted along with history and physical exam findings to determine the appropriate diagnosis.
LDH can result in back pain and, when the adjacent nerve root is involved, radicular leg pain. The first line of treatment for back dominant pain should be education, lifestyle modification, mechanical therapy and oral medications in the form of acetaminophen, non-steroidal anti-inflammatories.
Radicular leg dominant pain may require opioids and/or epidural corticosteroid injections. The majority of patients will improve without further intervention.
For persistent symptoms of sciatica, surgical intervention can be considered. Lumbar discectomy is the most common procedure performed and has good to excellent outcomes.
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Related Terms: Back Health, Lumbar disc herniation, low back pain, sciatica, radiculopathy

Passive Straight Leg Raise Test: Definition, Interpretation, Limitations and Utilization

Passive Straight Leg Raise Test: Definition, Interpretation, Limitations and Utilization

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

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Teaser: 

Dr. Hamilton Hall, MD, FRCSC, is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.
Greg McIntosh, MSc, completed his Masters in Epidemiology from the University of Toronto's Faculty of Medicine. He is currently the Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.

Abstract
This article highlights the myths and misunderstandings surrounding the straight leg raise (SLR) test for sciatica. Unfortunately, neither intra- nor inter-observer reliability of the passive SLR test has ever been agreed upon. In addition, there is poor consensus about what constitutes a positive SLR test in terms of pain location, leg elevation limitation or clinical significance. Until there are stricter performance standards and uniform agreement, researchers and clinicians should interpret the test with caution. We believe a true positive SLR should be the reproduction or exacerbation of the typical leg dominant pain in the affected limb at any degree of passive elevation. Those with only increased back pain or any leg pain other than that presenting as the chief complaint should be regarded as false positives.
Key Words: low back pain, straight leg raise, sciatica, irritative test.

Related Terms: Back Health, low back pain, sciatica, straight leg raise, irritative test

Managing Leg Dominant Pain

Managing Leg Dominant Pain

Teaser: 

Yoga Raja Rampersaud, MD, FRCSC,1 Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,2 Hamilton Hall, MD, FRCSC,3

1Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Immediate Past President Canadian Spine Society, Toronto, ON.
2Associate Professor, Department of Family and Community Medicine, University of Toronto, Medical Director, Sport CARE, Women’s College Hospital, Toronto, ON.
3Professor, Department of Surgery, University of Toronto; Medical Director, Canadian Back Institute; Executive Director, Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: Leg dominant pain suggests direct nerve root involvement: radicular, not referred symptoms. Constant pain associated with positive neurological findings usually results from an acute disc herniation. Symptoms are the result of mechanical compression but principally reflect an inflammatory response, properly designated sciatica. Intermittent leg dominant pain triggered by activity in extension and relieved by rest in flexion probably represents neurogenic claudication: nerve root ischemia secondary to spinal stenosis. Except for acute cauda equina syndrome, acute sciatica is initially managed with scheduled rest, adequate medication, and time. Non-responsive cases may require surgery. Surgery also shows superior outcomes for disabling neurogenic claudication.
Key Words:leg dominant pain, sciatica, neurogenic claudication, cauda equina syndrome, surgery.

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True spine-generated, leg dominant pain is consistently reproduced by particular spinal movements or positions.
No imaging investigation is required for a patient presenting an unequivocal clinical picture and exhibiting steady predictable improvement.
Of the four back pain syndromes, only neurogenic claudication is consistently best treated by surgery.
In contrast to the back dominant cases, in sciatica there is a definite role for short-acting narcotics or psychotropic drugs for uncontrolled pain.
Criteria for Surgical Referral
Emergency Referral The symptoms of Cauda Equina Syndrome are: - Urinary retention followed by insensible urinary overflow. - Unrecognized fecal incontinence. - Loss or decrease in saddle/perineal sensation. Acute Cauda Equina Syndrome is a surgical emergency.
Consider Elective Referral Failure to respond to a trial of conservative care: - Unbearable constant leg dominant pain. - Worsening nerve irritation tests (SLR or femoral nerve stretch). - Expanding motor, sensory or reflex deficits. - Recurrent disabling sciatica. - Disabling neurogenic claudication.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Arthritis, Back Health, Musculoskeletal Disease, Osteoporosis, Pain, neurogenic claudication, surgery, leg dominant pain, sciatica, cauda equina syndrome