Core Training
Sciatica
S
ciatica is a common medical Several causes of sciatica exist, although as a single trunk, travelling distally in the
complaint that is associated with lumbosacral disc herniation with nerve root posterior compartment of the thigh. The
significant personal morbidity compression is by far the most common, sciatic nerve provides sensory innervation
and economic burden. It refers to accounting for approximately 90% of to the skin of the foot and leg, and motor
radiating pain in the buttock or leg cases (Koes et al, 2007). Investigation innervation to the posterior compartment
along the course of the sciatic nerve, and may and management of the disease varies of the thigh and all the compartments of
be associated with radicular sensory, motor considerably, likely a reflection of variation the leg (Figure 2).
or tendon reflex abnormalities. However, in health-care systems and a lack of clear
the term is often misused to describe non- clinical guidelines, but the majority of cases What causes sciatica?
specific leg and back symptoms. Synonyms can be managed in the primary care setting. Sciatica can result from irritation of the
available in the literature, such as lumbosacral sciatic nerve anywhere along its length and
radicular syndrome and sciatic neuralgia, are Anatomy of the sciatic nerve may have underlying spinal or non-spinal
better descriptions of the disease, but are The sciatic nerve is the largest nerve in the causes (Table 1). Most commonly, sciatica
infrequently used. body. It arises from the fourth and fifth is caused by compression of a nerve root
lumbar and first three sacral nerve roots, by a herniated lumbosacral disc, usually
Figure 1. Anatomy of the lumbosacral plexus. which join in the lumbosacral plexus at the L4–L5 or L5–S1 levels (Figure
to form the peroneal and tibial nerves 3). Degenerative spinal disease causing
L4 (Figure 1). These leave the pelvis through spondylolisthesis (Figure 4) or lumbar
Lumbosacral trunk the greater sciatic foramen, ensheathed stenosis, infection and tumours are other
L5 Figure 2. Sciatic nerve innervation.
Superior gluteal nerve
Interior gluteal S1 Muscular innervation of Muscular innervation of
nerve posterior thigh and leg lateral and anterior leg
Cutaneous innervation
Nerve to S2
obturator internus Tibial nerve Common fibular nerve Anterior view Posterior view
Nerve to S3 L4
quadratus femoris L5
S1
S4
Sciatic nerve S2
S3
S5
Common
peroneal nerve C1 Sciatic nerve*
Tibial nerve Pudendal nerve
Biceps femoris
(long head)
Posterior cutaneous nerve of thigh Semitendinosus Biceps femoris
Posterior
femoral
(short head)
Adductor magnus cutaneous
Semimembranosus nerve
Mr Euan RB Stirling is Orthopaedic Registrar
Gastrocnemius Plantaris
in the Department of Trauma and Gastrocnemius
Common fibular
nerve
Orthopaedics, Royal Berkshire Hospital, Popliteus
Reading Soleus Fibularis Tibialis
Tibialis anterior
Mr Mohammed S Patel is Orthopaedic longus
Flexor posterior
Registrar in the Department of Trauma and digitorum Extensor Extensor
Orthopaedics, University Hospitals of longus Flexor Fibularis digitorum hallucis
Leicester, Leicester LE5 4PW hallucis brevis longus longus
longus Tibial nerve
Mr Philip J Sell is Consultant Spinal Surgeon Fibularis tertius
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Abductor hallucis
in the Department of Trauma and Flexor digitorum brevis Extensor
Orthopaedics, University Hospitals of Flexor hallucis brevis
All other muscles of
digitorum
the sole
Leicester, Leicester Lumbricalis brevis
Correspondence to: Mr MS Patel *Sciatic nerve formed by tibial and common
(shaqs@[Link]) fibular nerves wrapped by common sheath
C180 British Journal of Hospital Medicine, November 2016, Vol 77, No 11
What You Need To Know About
Figure 3. Different types of disc herniation. Figure 4. Lateral plain radiograph showing a L4/
Table 1. Causes of sciatica L5 spondylolisthesis. Forward displacement of
Spinal causes Herniated lumbosacral Normal disc one vertebral body on another has the potential
intervertebral disc to ‘pinch’ the exiting nerve roots. However, this
Nucleus Annulus can be asymptomatic, being a coincidental
Degenerative spinal disease pulposus fibrosus finding on imaging.
(foraminal or central
stenosis) Cauda Spinal
equina nerve
Spondylolisthesis root
(degenerative or traumatic)
Tumour and infection
Typical locations of
Spinal cysts disc herniation
Non-spinal causes Pelvic tumour L4 vertebral body
Pregnancy and delivery
L5 vertebral body
Piriformis syndrome
Iatrogenic injury L4/5 spondylolisthesis
Primary nerve tumours
Posterolateral Central
possible causes of root compression. Non- Usual location, most Involves multiple nerve roots.
commonly involving Predominantly causes low back
spinal sciatica can result from disturbance one nerve root (the pain more than leg pain.
to the nerve in the pelvic cavity, buttock, lower one) May cause incontinence of the
gluteal region or posterior thigh. Lesions bladder and bowel
in the course of the nerve such as
schwannoma, neurofibroma and ganglion
Foraminal
are uncommon but should be considered,
particularly if imaging of the lumbar spine Occurs in 8 – 10% of the cases. of bilateral symptoms should stimulate
is unhelpful. The symptomatology of sciatic Involves the exiting nerve further enquiry into possible symptoms of
pain is complex, and thought to result from cauda equina syndrome, in particular any
a combination of both direct nerve root disturbance in bowel and bladder sphincter
compression and also local inflammatory function or perianal sensation.
effects (Andrade et al, 2011). Pain may be accompanied by disturbance
smoking have been identified to be associated in sensory or motor function. Dermatomal
Who gets sciatica with sciatica, although the causal role for paraesthesia or numbness may be reported
and what are the risk factors? some is questionable (Koes et al, 2007).
The reported prevalence of sciatica
Figure 5. Morphology of different types of disc
varies greatly. A systematic review of What are the symptoms and signs? herniation.
epidemiological studies and prevalence Sciatica has various modes of presentation
estimates provide figures of between 1.6% from an acute onset of symptoms to a more
Degeneration Prolapse Extrus
and 43% for a selection of lifetime, period indolent course, and this may reflect disc
and point prevalence (Konstantinou and morphology of a subligamentous, extruded
Dunn, 2008), reflecting differences in the or sequestered material (Figure 5). History
definition of sciatica, method of diagnosis and physical examination, primarily through
and the populations studied. neurological testing, are central to diagnosis.
Sciatica can present at any age but is most Pain may be reported to have aching and
common in the fourth and fifth decades sharp components.
DegenerationIt is the distribution,
Prolapse Extrusion Sequestration
(Konstantinou and Dunn, 2008). Evidence which radiates to the leg in a radicular
for an association between sex and prevalence pattern in keeping with the affected spinal
of sciatica is conflicting. There is some quality nerve root, that increases the likelihood of
developing evidence that disc degeneration diagnosis of nerve pain. Typically, sciatic pain
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has a largely genetic basis but this has not yet is unilateral, reflecting the most common
been defined for herniated nucleous pulposus underlying pathology of posterolateral disc
producing radicular pain. Modifiable risk herniation (Figure 3). Bilateral sciatica can
factors including occupation, prolonged occur with central disc herniation, lumbar
exposure to vibration, mental stress and stenosis or spondylolisthesis. A history
British Journal of Hospital Medicine, November 2016, Vol 77, No 11 C181
Core Training
but is not a prominent feature while motor of clinical and radiological findings. This However, evidence increasingly suggests
weakness is present in less than 50% of cases. is particularly important as there is a high that patient subgroups with different
Reflexes may be altered, with reduction prevalence of false-positive findings detected prognostic profiles exist, and therapy may
or loss of ankle jerk reflex with S1 root on imaging in asymptomatic individuals therefore become increasingly targeted.
compression, or knee jerk reflex with L4 (Jensen et al, 1994). Sciatica with co-existent disabling lower
root compression. Thorough neurological Radiographs have limited value but do back pain (el Barzouhi et al, 2014) and
examination, although often unremarkable, permit an assessment of bone anatomy. They female gender are associated with poorer
is therefore vital. Rapid assessment of may show evidence of spondylolisthesis, outcome at 1 year, while the latter is also
motor power of the primary anti-gravity infection or tumour but lack sensitivity and associated with slower symptom recovery
muscle groups through ability to heel walk, specificity, so are not routinely performed. (Peul et al, 2008a). Psychological factors are
tip-toe walk and knee dip is of particular Computed tomography and magnetic also thought to be important in recovery.
importance, as a deficit in these actions may resonance imaging have similar sensitivities Early treatment of sciatica focuses on
result in long-term functional disability, and and specificities for diagnosis of herniated reduction of pain symptoms through
may therefore alter the management plan. intervertebral discs, but magnetic resonance analgesia and physical therapy, although the
The straight-leg-raise (Lasègue’s) test is imaging provides better visualization of precise role of both is unclear. Multi-modal
the most common special test performed soft tissues and is also more sensitive for therapy with anti-inflammatories, simple
in the assessment of a patient with sciatica, infection and malignancy (Jarvik and Deyo, analgesics and neuropathic pain medication
and helps determine if the pain is caused 2002), and is the modality of choice unless may be more effective than single modality
by disc compression of a nerve root. In a contraindicated. treatment. Evidence is often confounded
positive test, pain is reproduced on passive by combining investigations for treatment
elevation of the extended leg as the nerve root What are the management options? of lower back pain with that of sciatica.
is stretched further over the herniated disc. The natural history of sciatica is generally Activity is often limited by discomfort,
It has high sensitivity of 92% but is non- favourable; symptoms resolve with but there is no significant difference in
specific (van der Windt et al, 2010), with a conservative measures within 2 weeks in symptoms or function in patients who rest
positive test frequently elicited as a result of one third of patients, and within 3 months or remain active, and the latter is therefore
gluteal or hamstring tightness. Simultaneous in three quarters of patients (Vroomen recommended where possible (Hagen et al,
dorsiflexion of the foot or hallux intensifies et al, 2002). Early good quality pain 2005). Various exercise regimens have been
the symptoms, and also increases sensitivity. control and reassurance regarding the trialled but currently there is no evidence
Crossed straight-leg-raise testing, where the favourable natural history should therefore for superiority of one over another (Longo
non-symptomatic leg is elevated, eliciting be provided. A period of observation and et al, 2015). Perhaps of greatest importance
pain in the affected leg when positive, is review is recommended in the first 6 weeks, is timely and comprehensive patient
more specific (90% pooled specificity) but assuming no red flag symptoms are present. counselling with cognitive and affirmative
far less sensitive (28%) (van der Windt et reassurance regarding the favourable clinical
al, 2010). A variant of these, the slump test, course with spontaneous resolution of
Table 2. Red flag symptoms for
has also been shown to have high sensitivity symptoms (Koes et al, 2007).
urgent imaging investigation
(84%) and specificity (83%) for lumbar disc Patients who fail to improve with
herniation (Majlesi et al, 2008). It involves Suspected spinal cord neurology conservative measures may receive an
progressive spinal and hip flexion while in a epidural injection or a nerve root block,
Impending cauda equina syndrome
seated position in order to apply traction to sometimes called a transforaminal
the nerve roots, reproducing symptoms of Major motor radiculopathy epidural. Systematic review evidence for
pain in a positive test. this treatment is conflicting. Short-term
Suspected spinal infection
benefit of improved pain symptoms may
How is sciatica investigated? Past history of cancer be gained by infiltration of local anaesthetic
In typical cases, a thorough history and Recent unexplained weight loss
and steroid around the affected nerve root.
examination in the primary care setting However, there is no evidence for long-term
forms the basis of the diagnosis. Imaging Objectively unwell with spinal pain improvement compared with placebo and it
and/or specialty spinal review is not indicated Raised inflammatory markers does not reduce the need for future surgical
as an emergency unless there is progressive intervention (Luijsterburg et al, 2007).
neurology or red flags suggestive of serious Possible immunosuppression with new spinal Surgical management of discogenic sciatica
spine pathology (Table 2). Investigation pain focuses on decompression of the affected
may also be required in patients with severe Prolonged steroid use nerve root and removal of the herniated disc
symptoms that are bothersome and have material with the aim of relief of leg pain and
© 2016 MA Healthcare Ltd
failed to follow the usual favourable natural Known osteoporosis, with new severe spinal recovery of any altered neurological function.
history after 6–8 weeks, when invasive pain Patients with concurrent back pain
interventions may start to be considered. In Age <15 years or >60 years should be counselled that surgery is not
these cases imaging is used to determine the performed to alleviate these symptoms.
From NHS England National Pathfinder Projects (2014)
local neuroanatomy to confirm concordance Various techniques have been developed
C182 British Journal of Hospital Medicine, November 2016, Vol 77, No 11
What You Need To Know About
Figure 6. Flowchart of natural history of Symptom recovery
sciatica. Following discectomy for sciatica, pain KEY POINTS
relief occurs first, followed by recovery in ■■ Sciatica refers to radiating pain in the
motor function and finally by improvement buttock or leg, usually below the knee.
Symptom onset
in sensation. Persistent minor dermatomal ■■ It may be associated with radicular
dysfunction after surgical treatment is not sensory, motor or tendon reflex
Conservative Recovery uncommon. abnormalities.
management Symptom resolution
in one-third of About 75% of patients with mild to ■■ It is most commonly caused by
(analgesia and compression of a nerve root by a
reassurance) patients within moderate motor weakness will recover
2 weeks function within the first year following herniated lumbosacral disc.
surgery. However, failure of recovery has not ■■ The investigation of choice is magnetic
been shown to have any detrimental effect on resonance imaging.
Persisting Recovery function or quality of life. BJHM ■■ The natural history of the disease is
symptoms Symptom resolution
one of spontaneous resolution, with
in three quarters Conflict of interest: none.
of patients within 75% of patients having full resolution of
3 months symptoms by 3 months.
Andrade P, Visser-Vandewalle V, Philippens M,
Daemen MA, Steinbusch HW, Buurman WA, ■■ Initial management involves reassurance
Hoogland G (2011) Tumor necrosis factor-α and good quality multi-modal pain
Epidural injection
or nerve root Surgical levels correlate with postoperative pain severity control.
in lumbar disc hernia patients: opposite clinical
block intervention effects between tumor necrosis factor receptor 1 ■■ Referral to a spine specialist is indicated
and 2. Pain 152(11): 2645–52 (doi: 10.1016/j. for patients with bothersome or intrusive
pain.2011.08.012) persistent symptoms of more than
el Barzouhi A, Vleggeert-Lankamp CL, Lycklama à 6 weeks’ duration.
to decompress the nerve roots, but an in- Nijeholt GJ, Van der Kallen BF, van den Hout
depth description is beyond the scope of this WB, Koes BW, Peul WC; Leiden–The Hague ■■ Following surgery, leg pain improves first,
article. Complications including dural tear Spine Intervention Prognostic Study Group followed by recovery in motor function
(2014) Influence of low back pain and prognostic and finally by improvement in sensation.
with CSF leak, nerve root damage, infection value of MRI in sciatica patients in relation to
and epidural haematoma are uncommon back pain. PLoS One 9(3): 1–8 (doi: 10.1371/ ■■ Emergency surgery is only indicated in
but significant, and patients must be [Link].0090800) cases of cauda equina syndrome.
Hagen KB, Jamtvedt G, Hilde G, Winnem MF
made aware of these during discussion of (2005) The updated Cochrane review of bed rest
management options. Surgical treatment of for low back pain and sciatica. Spine 30(5): 542–6
non-discogenic sciatica likewise focuses on (doi: 10.1097/[Link].0000154625.02586.95) uploads/2015/01/Pathfinder-Low-back-and-
Jarvik JG, Deyo RA (2002) Diagnostic evaluation of [Link] (accessed 17 October 2016)
treatment of the underlying cause. Figure 6 low back pain with emphasis on imaging. Ann Peul WC, Brand R, Thomeer RTWM, Koes BW
presents a flow chart of the possible natural Intern Med 137(7): 586–97 (doi: 10.7326/0003- (2008a) Influence of gender and other prognostic
history and management pathway of patients 4819-137-7-200210010-00010) factors on outcome of sciatica. Pain 138(1):
Jensen MC, Brant-Zawadzki MN, Obuchowski 180–91 (doi: 10.1016/[Link].2007.12.014)
with sciatica. N, Modic MT, Malkasian D, Ross JS Peul WC, van den Hout WB, Brand R, Thomeer
The evidence for surgery in the treatment (1994) Magnetic resonance imaging of the RTWM, Koes BW (2008b) Prolonged
of sciatica remains ambiguous. Peul et al lumbar spine in people without back pain. conservative care versus early surgery in patients
N Engl J Med 331(2): 69–73 (doi: 10.1056/ with sciatica caused by lumbar disc herniation:
(2008b) compared early surgery with an NEJM199407143310201) two year results of a randomised controlled trial.
intended period of 6 months of conservative Koes BW, van Tulder MW, Peul WC (2007) BMJ 336(7657): 1355–8 (doi: 10.1136/bmj.
management in 283 patients with a 6–12- Diagnosis and treatment of sciatica. BMJ a143)
334(7607): 1313–17 (doi: 10.1136/ Vroomen PC, de Krom MC, Knottnerus JA (2002)
week history of sciatica. Early surgery was [Link]) Predicting the outcome of sciatica at short-term
shown to be of benefit by providing more Konstantinou K, Dunn KM (2008) Sciatica: review follow-up. Br J Gen Pract 52(475): 119–23
immediate relief of pain symptoms (P=0.05). of epidemiological studies and prevalence van den Hout WB, Peul WC, Koes BW, Brand R,
estimates. Spine 33(22): 2464–72 (doi: 10.1097/ Kievit J, Thomeer RT; Leiden-The Hague Spine
Many (62 of 142) of the conservatively BRS.0b013e318183a4a2) Intervention Prognostic Study Group (2008)
managed cohort subsequently went on Longo DL, Ropper AH, Zafonte RD (2015) Sciatica. Prolonged conservative care versus early surgery in
to have surgery. However, no significant N Engl J Med 372(13): 1240–8 (doi: 10.1056/ patients with sciatica from lumbar disc herniation:
NEJMra1410151) cost utility analysis alongside a randomised
difference in pain or disability was found Luijsterburg PA, Verhagen AP, Ostelo RW, van Os controlled trial. BMJ 336(7657): 1351–4 (doi:
at 1 and 2 years follow up. Early surgical TA, Peul WC, Koes BW (2007) Effectiveness 10.1136/[Link])
treatment also has the benefit of restoring of conservative treatments for the lumbosacral van der Windt DA, Simons E, Riphagen II et
radicular syndrome: a systematic review. Eur Spine al (2010) Physical examination for lumbar
function more quickly, allowing an earlier J 16(7): 881–99 (doi: 10.1007/s00586-007-0367- radiculopathy due to disc herniation in patients
return to work and reducing associated 1) with low-back pain. Cochrane Database Syst
costs (van den Hout et al, 2008). Surgery Majlesi J, Togay H, Unalan H, Toprak S (2008) The Rev (2): CD007431 (doi: 10.1002/14651858.
© 2016 MA Healthcare Ltd
sensitivity and specificity of the Slump and the CD007431)
is performed on an elective basis; the only Straight Leg Raising tests in patients with lumbar
absolute indication for immediate surgery disc herniation. J Clin Rheumatol 14(2): 87–91 Further reading
is cauda equina syndrome, with the aim of (doi: 10.1097/RHU.0b013e31816b2f99) European Seventh Framework Programme Research
NHS England National Pathfinder Projects (2014) Project on Intervertebral Disc Degeneration and
preservation of bowel and bladder sphincter National Pathway of Care for Low Back and Back Pain – Genodisc. [Link]/
function. Radicular Pain. [Link] genodisc/[Link] (accessed 19 July 2015)
British Journal of Hospital Medicine, November 2016, Vol 77, No 11 C183