Sciatica
Julie Adkins and Jill C. Cash
Definition
A.Sciatica is a sharp or burning pain, usually associated with numbness, that radiates down the posterior or lateral leg that can result in neurosensory and/or motor deficits. Sciatica indicates abnormal function of the lumbosacral nerve roots or one of the nerves in the lumbosacral plexus.
Incidence
A.The prevalence of sciatica in the general population is 40%, though only 1% have any neurosensory or motor deficits. The most common cause of sciatica is herniated discs, 95% of which occur at the L4 to L5 or L5 to S1 level.
Pathogenesis
A.Pressure on the nerve from a herniated disc, bony osteophytes, a compression fracture, or any other extrinsic pressure (e.g., pelvic mass or epidural process, wallet sciatica
) causes progressive sensory, sensorimotor, or sensorimotor visceral loss. Typically, sciatica affects only one side of the body.
Predisposing Factors
A.Inflexibility.
B.Obesity.
C.Trauma.
D.Bony osteophytes.
Common Complaints
A.Pain around the buttock area.
B.Pain often associated with numbness traveling down the lateral or posterior leg.
C.Numbness.
D.Paresthesia.
Other Signs and Symptoms
A.Difficulty walking with affected leg.
B.Positive straight leg raises, positive Patrick’s sign.
C.Decreased sensation.
Subjective Data
A.Elicit onset of symptoms, duration, and what makes pain better or worse.
B.Inquire about previous episodes of pain or trauma.
C.Have the patient point to the area of pain, numbness, or tingling.
D.Are symptoms unilateral or bilateral?
E.Question the patient about loss of bowel or bladder control or other deficits and/or changes.
F.Does the patient notice leg weakness or difficulty walking?
Physical Examination
A.Check pulse and blood pressure.
B.Inspect gait and movement of back and extremities.
C.Palpate spinous processes.
D.Examine flexion and extension of spine. Assess sensation, deep tendon reflexes (DTRs), muscle strength, and motor weakness of lower extremities.
E.Examine neurologic function of back and lower extremity:
1.Straight leg raising sign is positive.
2.Dorsiflexion of ankle is positive.
3.Check for loss of sensation in radicular pattern. Light touch pinprick and two point discrimination are not present.
4.Look for decrease or loss of DTRs.
5.Check muscle strength of lower extremities.
6.Check motor weakness.
7.Check for cauda equina syndrome, indicated by urinary retention, radicular symptoms, and saddle anesthesia.
Cauda equina syndrome is a surgical emergency, characterized by bowel and bladder dysfunction; saddle anesthesia at the anus, perineum, or genitals; and widespread or progressive loss of strength in the legs or gait disturbances.
F.Percuss for tenderness over the spinous processes.
Diagnostic Tests
A.Radiography, when red flags for fracture, cancer, or infection are present.
B.CT scan or MRI, when cauda equina, tumor, infection, or fracture is suspected; MRI is test of choice for patients with prior back surgery.
Differential Diagnoses
A.Sciatica of unknown etiology.
B.Lumbosacral strain.
C.Herniated disc.
D.Bony osteophytes, spinal stenosis.
E.Compression fracture.
F.Neoplasm of spine.
G.Pelvic mass.
H.Epidural process causing progressive sensory, sensorimotor, or sensorimotor visceral loss.
I.Meralgia paresthetica.
Plan
A.General interventions: Care for these patients should evolve over a three-step process:
1.Step 1 (2–4 days):
a.Bed rest for severe radiculopathy only.
b.Limit walking and standing to 30 to 40 minutes each day.
c.Recommend application of heat or cold packs to site as needed.
2.Step 2 (7–14 days):
a.Reevaluate neurologic and back exam; tell the patient Let pain be your guide
when resuming normal daily activities.
b.Have him or her perform gentle stretching exercises.
c.Encourage walking on flat surfaces.
d.Educate him or her regarding proper care of the back, with regard to exercises, posture, and so forth.
e.
See Section III: Patient Teaching Guide Back Stretches.
f.Physical therapy may be implemented at this time if no significant improvement is noted.
3.Step 3 (2–3 weeks):
a.Reevaluate the patient, noting degree of improvement with exam.
b.Continue muscle toning and reconditioning exercises.
c.If improvement is noted, gradually increase physical activities.
d.Reinforce healthy care of the back.
e.Continue physical therapy until the patient can perform exercises without assistance or until released by the physical therapist.
B.Pharmaceutical therapy:
1.Nonsteroidal anti-inflammatory drugs (NSAIDs) as needed: Naproxen (Naprosyn) 500 mg initially, followed by 250 mg every 6 to 8 hours.
2.Acetaminophen may also be used as needed, especially if the patient is not able to tolerate
ibuprofen.
3.For more severe pain not relieved by NSAIDs, consider acetaminophen (Tylenol) with codeine for short duration. Narcotics should not be used for more than 2 weeks.
4.Muscle relaxants: Muscle relaxants should not be used for more than 2 weeks:
a.Cyclobenzaprine (Flexeril) 10 mg one to three times daily:
b.Muscle relaxants place patients at risk for drowsiness. Warn the patient not to mix medications with alcohol because it may potentiate the medication.
Follow-Up
A.Initial follow-up is needed in 1 to 2 weeks.
Consultation/Referral
A.If cauda equina syndrome is suspected, prompt referral to a physician is necessary.
B.If bilateral sciatica is associated with vertebral collapse, osteoporosis, neoplasia, and/or vascular disease, consult with a physician.
Individual Considerations
A.Pregnancy:
1.Sciatica pain is common due to physiologic changes of the pelvis as pregnancy progresses to term. Avoid use of NSAIDs. Physical therapy may be used as indicated.
B.Adults:
1.For adults older than 50 years, presenting with no prior history of backache, consider differential diagnosis of neoplasm. Most common metastasis is secondary to the primary site of breast or prostate, or to multiple myeloma. Pain is most prominent in recumbent position and rarely radiates into buttock or leg.
C.Geriatrics:
1.Bilateral sciatica is associated with vertebral collapse, osteoporosis, neoplasia, and/or vascular disease. Refer the patient to a physician immediately.
2.Use caution when prescribing medication to the elderly because of the risk for drowsiness and potential falls.
3.Implement education of proper body mechanics during activities of daily living (ADLs) and exercise. Avoid heavy lifting, twisting, or prolonged sitting/standing.
4.Exercises to prevent recurrences and spinal health (sciatica prevention) include back flexion stretches, lower back stretch, calf stretch, and low-impact exercise. See www.livestrong.com/article/333512-spine-stretch-and-sciatica-exercises-for-the-elderly/ for a full description of these age-friendly exercises.