Management of sciatica

About 80% of people will have an episode of low back pain in their lifetime, according to Bone and Joint Canada. For some, it will be sciatica, a lumbar radiculopathy that involves radiating pain caused by the compromise of the sciatic nerve or its nerve roots between L4 and S3.In the majority of cases, sciatica will go away within four to six weeks after conservative management. For up to 10% of patients, the pain will continue for a longer period, with select patients requiring surgery.Assessment and investigationThere are no specific Canadian guidelines for assessing and treating sciatica, although there’s guidance on low back pain in general. A National Institute for Health and Care Excellence (NICE) guideline on sciatica in people over 16 years old was published in 2020, and a review of various guidelines appeared in a 2023 issue of the Archives of Physical Medicine and Rehabilitation.When it comes to investigating radicular pain, if a patient is also experiencing urinary or fecal incontinence or saddle anesthesia, send them to the emergency department immediately. Signs of weakness such as a foot drop also require urgent action. For other patients, watch for red flags such as malignancies or trauma to the spine or nerve.Patients with low back pain usually do not need imaging, Choosing Wisely notes. Imaging may be required if a physician suspects a serious underlying pathology, or if it’s needed to plan for an intervention, such as surgery. A nerve conduction study may be helpful for patients with unrelenting pain, said Dr. Scott Cook, a physiatrist and pain specialist at Grand River Hospital in Kitchener, Ont.When assessing patients for sciatica, a common misdiagnosis is hip osteoarthritis, said Dr. Jeremie Larouche, chief of spine surgery at Sunnybrook Health Sciences Centre in Toronto. Radiating pain that is reproducible with internal hip rotation is rarely sciatica, he said. An X-ray can confirm if the pain is from a mechanical irritation that’s coming from the hip.Multi-modal management that includes education about painManagement of sciatica should include physiotherapy, exercise, help with smoking cessation and achieving or maintaining a healthy weight. Massage is another option. Exercise in the water may be easier for some patients because it isn’t load-bearing, Dr. Cook noted.Patients will also need counselling or psychological support to help them live with pain. “Having cognitive strategies to help manage things can be important. You’re alone with your thoughts more often than not, so having those tools to help manage this is an important part of the toolbox,” Dr. Cook said.Education on pain is an essential piece for any type of pain. This can help patients understand the need for movement, how to return to daily activities and what lifestyle changes are beneficial.“No matter what, even if the patient has surgery, a large portion of those patients will continue to have some sort of pain. They may get 75% better, but the majority of them will not get 100% better,” explained Dr. Jill Osborn, an anesthesiologist and physician director of the interventional and chronic pain program and co-director of the neuromodulation program at St. Paul’s Hospital in Vancouver.Patients can access a number of pain education resources across Canada. This includes the Power Over Pain Portal, which has resources on physical activity, mental health, nutrition and other areas of pain management. Pain B.C. has numerous resources, including a podcast. Some regions have courses on pain management, like one in the Waterloo, Ont., region.Tell patients they need to take an active involvement to manage pain and reduce the risk of future episodes of sciatica, Dr. Osborn advised.Pharmaceutical managementInitial pharmaceutical management of sciatica can include anti-inflammatories or neuropathic medication such as gabapentin or duloxetine, Dr. Osborn noted.The Canadian Pain Society’s 2014 consensus statement on pharmaceutical management of chronic neuropathic provides a step-by-step approach for pharmaceutical management. Canadian Family Physician also published a review of the guidelines for primary care in 2017.Inform patients that the medication doesn’t work right away andmay take a few weeks, Dr. Osborn said. “It takes a little time for the medications to work. Everybody wants everything to work immediately,”While opioids are considered second-line treatment, they may be needed for some cases of acute sciatic pain, Dr. Cook said.Advanced interventionsIf conservative management in primary care isn’t providing relief, consider referring the patient to a pain clinic. There, interventions may include steroid injections guided by fluoroscopy or ultrasound. For radicular pain, the specialist may opt for epidural nerve blocks with steroids.The goal of the injections is to treat the pain so the patient can work on other areas of managing pain, such as exercise and getting adequate sleep.Steroid injections need to be limited so they don’t cause further breakdown of the joints. Dr. Osborn’s clinic usually does no more than three injections per year in one area. “There really isn’t any research out there saying what is the safe number of injections,” she said.Expect variability in how much the injections help. “The pain relief is really individual between patients,” Dr. Osborn explained. “If they’re getting three to six months of pain relief then I stay at that level.” If patients only get two weeks of relief, then a different intervention is needed.If patients have imaging that matches their symptoms, pain specialists may offer radiofrequency ablation or neurostimulation.“The interesting thing about spine imaging is it doesn’t necessarily reflect the symptomatology,” Dr. Osborn explained. “You can look at some people’s backs and they look horrible and they have no pain. And then other people have lots of pain and there is nothing on their spine that indicates that there’s been compression of the nerve.” That’s why a physical exam is extremely important.Radiofrequency ablation involves applying a heated probe to the dorsal root ganglion, where the sensory nerve cells sit, Dr. Cook said. It stuns the sciatic nerve but doesn’t injure it in the hope that patients get longer-lasting benefit.Neurostimulation, using implanting electrodes in the spine is another option, albeit expensive and not yet often used in Canada. Dr. Osborn noted that cost-benefit analyses suggest that the expense of the intervention, depending on the device used, is recovered through other cost savings in three to 10 years.SurgerySome provinces or healthcare regions in Canada have assessment clinics to determine if patients are candidates for surgery. This includes the Rapid Access Clinics for Low Back Pain in Ontario.In general, other interventions are used before surgery. If surgery is indicated, timing matters when it comes to outcomes.“The sweet spot to be seen and assessed by a surgeon, for the vast majority of cases, is people who have symptoms that last more than three months that haven’t gotten better on their own, but definitely before 12 months where the outcome isn’t as good if they have chronic compression,” Dr. Larouche said.He noted that referrals are often rejected because of insufficient information so suggests making sure the patient has imaging and a neurological assessment before referring them to a surgeon.Ninety per cent of the time, surgical treatment for sciatica is a microdiscectomy. “We make a small incision, we take away a bit of the bone to get to where the disc is, we move the nerve out of the way and we take out the fragment of the disc that’s herniated,” Dr. Larouche explained.European and other centres are exploring endoscopic microdiscectomy as an alternative to open microdiscectomy. This involves a small shaving tool that surgeons use on the herniated disc. A randomized control trial published in the British Medical Journal in 2022 found the endoscopic procedure was non-inferior to open microdiscectomy for sciatica when it came to patient-reported and other outcomes.

Management of sciatica

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