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Diagnosis and treatment of sciatica 

B W Koes, M W van Tulder and W C Peul 
BMJ doi:10.1136/[Link] 2007;334;1313-1317 Updated information and services can be 
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CLINICAL For the full versions of these articles see [Link] 

REVIEW 
Diagnosis and treatment of sciatica 
B W Koes,1 M W van Tulder,2 W C Peul3 
Sciatica  affects  many  people.  The  most  important  symptoms  are  radiating  leg  pain  and  related  disabil-  ities.  Patients  are 
commonly  treated  in  primary  care  but  a  small  proportion  is  referred  to  secondary  care  and  may  eventually have surgery. Many 
synonyms  for  sciatica  appear  in  the  literature,  such  as  lumbosacral  radicular  syndrome,  ischias,  nerve  root  pain,  and nerve root 
entrapment. 
In  about  90% of cases sciatica is caused by a her- niated disc with nerve root compression, but lumbar stenoses and (less often) 
tumours are possible causes. The diagnosis of sciatica and its management varies considerably within and between countries—for 
exam-  ple,  the  surgery  rates for lumbar discectomy vary widely between countries.w1 A recent publication con- firmed this large 
variation  in  disc  surgery,  even  within  countries.1  This  may  in  part be caused by a paucity of evidence on the value of diagnostic 
and  therapeutic  interventions  and  a  lack  of  clear  clinical  guidelines  or  reflect  differences  in  healthcare  and  insurance  systems. 
This review presents the current state of science for the diagnosis and treatment of sciatica. 
Who gets sciatica? Exact data on the incidence and prevalence of sciatica are lacking. In general an estimated 5%-10% of 
patients with low back pain have sciatica, whereas the reported lifetime prevalence of low back pain ranges from 49% to 
70%.w2The annual prevalence of disc related sciatica in the general population is estimated at 2.2%.2 A few personal and 
occupational risk factors for sciatica have been reported (box 1), including age, height, mental stress, cigarette smoking, and 
exposure to vibration 1Department of General Practice, from Erasmus MC, University Medical 
vehicles.23 w2 Evidence for an association between sciatica and sex or physical fitness is Center Rotterdam, PO Box 
2040, 3000 CA Rotterdam, Netherlands 
conflicting.23 w2 
2EMGO Institute, VU University Medical Center, Amsterdam, Netherlands 
How is sciatica diagnosed? Sciatica is mainly diagnosed by history taking and 3Department of Neurosurgery, 
physical examination. By definition 
patients mention Leiden University Medical Center, Leiden, Netherlands Correspondence to: B W Koes [Link]@[Link] 
radiating pain in the leg. They may be asked to report the distribution of the pain and whether it radiates below the knee and 
drawings may be used to evaluate the distribution. Sciatica is characterised by radiating BMJ 2007;334:1313-7 
doi:10.1136/[Link] 
pain that follows a dermatomal pattern. Patients may also report sensory symptoms. 
Physical  examination  largely  depends on neurologi- cal testing. The most applied investigation is the straight leg raising test or 
Lasègue’s  sign. Patients with sciatica may also have low back pain but this is usually less severe than the leg pain. The diagnostic 
value  of  history  and  physical  examination  has  not been well studied.4 No history items or physical exam- ination tests have both 
high  sensitivity  and  high  speci-  ficity.  The  pooled  sensitivity  of  the  straight  leg  raising  test  is  estimated  to  be  91%,  with  a 
corresponding  pooled  specificity  of  26%.5  The  only  test  with  a  high  specificity  is  the  crossed  straight  leg  raising  test,  with  a 
pooled  specificity  of 88% but sensitivity of only 29%.5 Overall, if a patient reports the typical radiating pain in one leg combined 
with  a  positive  result  on  one  or  more  neurological  tests  indicating  nerve  root  tension  or  neu-  rological  deficit  the  diagnosis  of 
sciatica  seems  justi-  fied.  Box  2  shows  the  signs  and  symptoms  that  help  to  distinguish  between  sciatica  and  non-specific  low 
back pain. 
What is the value of imaging? 
Sources and selection criteria We identified systematic reviews in the Cochrane Library evaluating the effectiveness of 
conservative and surgical interventions for sciatica. Medline searches up to December 2006 were carried out to find other 
Diagnostic imaging is only useful if the results influ- ence further management. In acute sciatica the diagno- sis is based on 
history taking and physical examination and treatment is conservative (non-surgical). Imaging may be indicated at this stage only 
if there are indica- relevant systematic reviews on the diagnosis and 
tions or “red flags” that the sciatica may be caused by treatment of low 
back pain. Keywords were sciatica, 
underlying disease (infections, malignancies) rather hernia nuclei 
pulposi, ischias, nerve root entrapment, systematic review, meta-analysis, diagnosis, and treatment. In addition we used our 
personal files for other references, including publications of recent randomised clinical trials. Finally we checked the availability 
of clinical guidelines. 
than disc herniation. 
Diagnostic  imaging  may  also  be  indicated  in  patients  with  severe  symptoms who fail to respond to conserva- tive care for 6-8 
weeks.  In  these cases surgery might be considered and imaging used to identify if a herniated disc with nerve root compression is 
present and its 
BMJ | 23 JUNE 2007 | VOLUME 334 1313 
 
CLINICAL REVIEW 
Downloaded from [Link] on 24 August 2007 Box 1| Risk factors for acute sciatica3 w2 
within 12 months.12 About 50% of patients with acute 
Personal factors Age (peak 45-64 years) Increasing risk with height Smoking Mental stress Occupational factors 
sciatica included in placebo groups in randomised trials of non-surgical interventions reported improve- ment within 10 days and 
about 75% reported improve- ment after four weeks.13 In most patients therefore the prognosis is good, but at the same time a 
substantial proportion (up to 30%) continues to have pain for one year or longer.12 13 Strenuous physical activity—for example, 
frequent 
lifting, especially while bending and twisting 
What is the efficacy of conservative treatments for Driving, including 
vibration of whole body 
sciatica? Conservative treatment for sciatica is primarily aimed at pain reduction, either by analgesics or by reducing 
Box 2 | Indicators for sciaticaw5 Unilateral leg pain greater than low back pain Pain radiating to foot or toes Numbness and 
paraesthesia in the same distribution 
pressure on the nerve root. A recent systematic review found that conservative treatments do not clearly improve the natural 
course of sciatica in most patients or reduce symptoms.14 Adequately informing patients about the causes and expected 
prognosis may be an Straight leg raising test induces more leg pain 
important part of the management strategy. However, Localised 
neurology—that is, limited to one nerve root 
educating patients about sciatica has not been specifi- cally investigated in randomised controlled trials. 
Box 3 summarises the evidence of effectiveness for location and 
extent. It is important as part of the deci- 
commonly available conservative treatments for scia- sion to operate 
that the clinical findings and symptoms 
tica, including injection therapy. Strong evidence of correspond well 
with the scan findings. This is espe- 
effectiveness is lacking for most of the available inter- cially relevant 
because disc herniations identified by 
ventions. Little difference in effect on pain and func- computed 
tomography or magnetic resonance ima- 
tional status has been shown between bed rest and ging are highly 
prevalent (20%-36%) in people without 
advice on staying active.15 As a result of this finding, symptoms 
who do not have sciatica.6 w3 In many 
bed rest—for a long time the mainstay of treatment people with 
clinical symptoms of sciatica no lumbar 
for sciatica—is no longer widely recommended.w2 w4 disc 
herniations are present on scans.7 8 At present no 
Analgesics, non-steroidal anti-inflammatory drugs, one type of 
imaging method shows a clear advantage 
and muscle relaxants do not seem to be more effective over others. 
Although some authors favour magnetic 
 than placebo in reducing symptoms. Evidence for resonance imaging 
above other imaging techniques 
opioids and various compound drugs is lacking. A sys- because 
computed tomography has a higher radiation 
tematic review reported that no evidence exists for dose or because 
soft tissues are better visualised,9 10 evi- 
traction, non-steroidal anti-inflammatory drugs, intra- dence shows 
that both are equally accurate at diagnos- 
muscular steroids, or tizanidine being superior to ing lumbar disc 
herniation.11 Radiography for the 
placebo.13 This review suggested that epidural injec- diagnosis of 
lumbar disc herniation is not recom- 
tions of steroid might be effective in patients with acute mended 
because discs cannot be visualised by x 
sciatica.13 However, a more recent systematic review of rays.11 
a larger number of randomised trials reported that there was no evidence of positive short term effects of What is the prognosis? 
corticosteroid injections and that the long term effects In general the 
clinical course of acute sciatica is favour- 
were unknown.14The same systematic review reported able and 
most pain and related disability resolves 
that active physical therapy (exercises) seemed not to within two 
weeks. For example, in a randomised trial 
be better than inactive (bed rest) treatment and other that compared 
non-steroidal anti-inflammatory drugs 
conservative treatments, such as traction, manipula- with placebo for 
acute sciatica in primary care 60% of 
tion, hot packs, or corsets).14 the patients recovered within three 
months and 70% 
What is the role of surgery in sciatica? 
Box3 |Levelsofevidenceforconservativetreatmentsfor sciatica Bed rest (trade-off) 
Surgical intervention for sciatica focuses on removal of disc herniation and eventually part of the disc or on foraminal stenosis, 
with the purpose of eliminating the suspected cause of the sciatica. Treatment is Staying active, in contrast to bed rest (likely to 
be 
beneficial) Analgesics or non-steroidal anti-inflammatory drugs, 
acupuncture, epidural steroid injections, spinal manipulation, traction therapy, physical therapy, behavioural treatment, 
multidisciplinary treatment (unknown effectiveness) 
aimed  at  easing  the  leg  pain  and  corresponding  symp-  toms  and  not  at  reducing the back pain. Consensus is that a cauda equina 
syndrome  is  an  absolute  indication  for  immediate  surgery.  Elective  surgery  is  the  choice  for  unilateral  sciatica.  Until  recently 
only one relatively old randomised trial was available that compared sur- gical intervention with conservative treatment for 
1314 BMJ | 23 JUNE 2007 | VOLUME 334 
 
CLINICAL REVIEW Downloaded from [Link] on 24 August 2007 Box 4 | Clinical guideline for diagnosis and treatment of 
selected sciatica from Dutch College of General Practicew4 
BMJ | 23 JUNE 2007 | VOLUME 334 1315 patients with sciatica as a result of lumbar disc prolapse that fails to resolve with 
conservative care. A recent review came to the same conclusion.18 The Diagnosis 
Cochrane review further concluded that the long Check for red flag 
conditions, such as malignancies, 
term effects of surgical intervention are unclear and osteoporotic 
fractures, radiculitis, and cauda equina syndrome Take a history to determine localisation; severity; loss 
that evidence on the optimal timing of surgery is also lacking.17 
of strength; sensibility disorders; duration; course; influence of coughing, rest, or movement; and consequences for daily 
activities Carry out a physical examination, including 
neurological testing—for example, straight leg raising test (Lasègue’s sign) Carry out the following tests in cases with a 
dermatomal pattern, or positive result on straight leg 
Randomised controlled trials not yet included in systematic reviews Two additional randomised controlled trials have been 
published comparing disc surgery with conservative treatment. One trial (n=56) compared microdiscect- omy with conservative 
treatment in patients who had had sciatica for six to 12 weeks.19 Overall, no signifi- raising test, or loss of strength or sensibility 
disorders: 
cant differences were found for leg pain, back pain, and reflexes 
(Achilles or knee tendon), sensibility of 
subjective disability over two years of follow-up. Leg lateral and medial 
sides of feet and toes, strength of big toe during extension, walking on toes and heel (left-right differences), crossed Lasègue’s 
sign Imaging or laboratory diagnostic tests are only 
indicated in red flag conditions but are not useful in cases of suspected disc herniation Treatment Explain cause of the symptoms 
and reassure patients 
that symptoms usually diminish over time without specific measures Advise to stay active and continue daily activities; a 
few hours of bed rest may provide some symptomatic relief but does not result in faster recovery 
pain, however, seemed to initially improve more rapidly in patients in the discectomy group. The large spine patient outcomes 
research trial (a randomised trial) and related observational cohort study was car- ried out in the United States.20 21 Patients with 
sciatica for at least six weeks and confirmed disc herniation were invited to participate in either a randomised trial or an 
observational cohort study. Patients in the trial were randomised to disc surgery or to conservative care. Patients in the cohort 
study received disc surgery or conservative care based on their preference. In the randomised trial (n=501) both treatment groups 
Prescribe drugs, if necessary, according to four steps: 
(1) paracetamol; (2) non-steroidal anti-inflammatory 
improved substantially over two years for all primary and secondary outcome measures. Small differences drugs; (3) tramadol, 
paracetamol, or non-steroidal 
were found in favour of the surgery group, but these anti-inflammatory 
drug in combination with codeine; and (4) morphine 
were not statistically significant for the primary out- come measures. Only 50% of the patients randomised Refer to 
neurosurgeon immediately in cases of cauda 
equina syndrome or acute severe paresis or progressive paresis (within a few days) Refer to neurologist, neurosurgeon, or 
orthopaedic 
surgeon for consideration of surgery in cases of intractable radicular pain (not responding to morphine) or if pain does not 
diminish after 6-8 weeks of conservative care 
to  surgery  received  surgery  within  three  months  of  inclusion  compared  with  30%  randomised  to  conser-  vative  care.  After two 
years  of  follow-up  45%  of  patients  in  the  conservative  care  group  underwent  sur-  gery  compared  with  60%  in  the  surgery 
group.20 
The observational cohort included 743 patients. Both groups improved substantially over time, but the surgery group showed 
significantly better results for pain and function compared with the conservative patients with sciatica.16 This study showed that 
surgical 
group. The authors did mention caution in interpreting intervention 
had better results after one year, whereas 
the findings because of potential confounding by indi- after four and 
10 years of follow-up no significant dif- 
cation and because outcome measures were self ferences were 
found.16 
reported.21 A Cochrane review summarised the available ran- domised 
clinical trials evaluating disc surgery and chemonucleolysis.17 In chemonucleolysis the enzyme 
Additional educational resources chymopapain is injected in the 
discus with the purpose 
BMJ Clinical Evidence ([Link])—Up of 
shrinking the nucleus pulposus. The review reported 
to date evidence for clinicians on the benefits and better results 
with disc surgery than with chemonucleo- 
harms of treatments for a variety of disorders lysis in patients with 
severe sciatica of relatively long 
Cochrane Back Review Group ([Link]. duration 
varying from more than four weeks to more than four months. Chemonucleolysis was more effec- tive than placebo. Indirectly 
therefore the review sug- gested that disc surgery is more effective than placebo. On the basis of data from three trials the authors 
con- cluded that evidence is considerable that surgical dis- cectomy provides effective clinical relief for carefully 
ca)—Activities of review group responsible for writing systematic Cochrane reviews on the efficacy of treatments for low back 
pain and sciatica Low back pain: guidelines for its management (www. [Link])—Recently issued guidelines for the 
management of low back pain and sciatica from the European Commission Research Directorate General 
 
CLINICAL REVIEW 
Downloaded from [Link] on 24 August 2007 A patient’s perspective (A) After an 
episode of lumbago during a vacation I continuously had low back pain and tingling feet for about nine months. Then suddenly 
my right foot started to hurt badly and after a while the pain became so severe that I was unable to leave my house. The specialist 
ordered an MRI (magnetic resonance imaging) scan and it revealed a large lumbar disc herniation. Since it only got worse after 
that I decided to have surgery. After the operation I recovered quickly and the back pain and leg pain were completely 
vative, with a strong focus on patient education, advice to stay active, continuing daily activities, and adequate treatment for pain. 
In this phase imaging has no role. Referral to a medical specialist—for example, neuro- logist, rheumatologist, spine surgeon—is 
indicated in patients whose symptoms do not improve after conser- vative treatment for at least 6-8 weeks. In these referred gone. 
I soon was able to go back to work and rebuild my social life. Unfortunately after 
cases surgery may be considered. 
Immediate referral is a couple of months the low back pain and the other symptoms returned, although not 
indicated in cases with a cauda equina 
syndrome. as severe as before surgery. A new MRI scan now revealed two small disc herniations and two bad intervertebral 
discs. The specialist told me that it was too early for a second operation. 
Acute severe paresis or progressive paresis are also rea- sons for referral (within a few days). 
Now it is unclear to me what the doctor can do about it and I don’t even know which measures I can take myself. The constant 
back and leg pain are greatly interfering with my work and my social life. I sometimes feel like an elderly person because of my 
physical limitations. I try to stay positive, but it is hard to cope with the uncertainty. 
Promising developments More evidence based information has become avail- able on the efficacy of surgical care compared with 
con- C Penning, aged 32, Rotterdam 
servative  care  for  patients  with  sciatica.  Although  evidence  is  limited,  initial  findings  suggest no impor- tant differences in long 
term  (one  or  two  years)  effect  between  these  two  approaches.  This  finding  may  be  partly  explained  by  patients  who  initially 
received con- servative care later undergoing disc surgery. In all available studies it seems that a substantial proportion of patients 
improve  over  time.  This  holds  true  for  patients  undergoing  surgery  or  receiving  conservative  care.  Patients  undergoing  disc 
surgery  are  more  likely  to  get  quicker  relief  of  leg  symptoms  than  patients  receiving  conservative  care.  If  symptoms  do  not 
improve  after  6-8  weeks  patients  may  opt  for  disc  sur-  gery.  Those  who  are  hesitant  about  surgery  and  can  cope  with  their 
symptoms may opt for continued con- servative care. Patient preference is therefore an important feature in the decision process. 
Since  the  mid-1990s  a  switch  has  occurred  in  the  management  of sciatica from passive treatments, such as bed rest, to a more 
active approach, with patients being advised to continue their daily activities as much as possible. 
Future research More information is needed on the importance of clin- ical signs and symptoms for the prognosis of sciatica and 
the response to treatment. This includes the value of size and location of the disc herniation, visible nerve root compression, 
sequestration, and the results A patient’s perspective (B) 
of history taking and physical and 
neurological exam- My complaints started about four months ago with pain in the lower back. Soon after 
inations. Subgroup analysis in a Finnish 
trial showed the pain radiated into my legs, for which I went to my general practitioner. His analysis was no herniated disc. A 
muscle relaxant in combination with referral to a physiotherapist would reduce the symptoms. Three weeks of physiotherapy 
followed by several treatments by a chiropractor did not provide any symptom relief. In fact the symptoms became 
worse—especially during walking and standing. Lying down and cycling were much better tolerated. Additional complaints were 
reduced strength in the left leg, not being able to stand on the heel or toes, a cold feeling in the lower leg at the 
that discectomy was superior to conservative treat- ment in patients with disc herniation at L4-5.23 No strong evidence exists for 
or against the efficacy of many of the available conservative treatments. Much progress can be achieved here. Questions remain 
about the efficacy of analgesics for sciatica and the end of the day, while in the morning it felt like standing in a bunch of 
needles. 
 value of physical therapy and of patient 
education About one month ago a neurologist diagnosed a herniated disc on the right side based 
and counselling. No trial has yet 
evaluated the effec- on an MRI scan that was taken. However, this could not explain the symptoms in the left leg. The symptoms 
in the left leg could be due to spinal stenosis. The complaints were not severe enough to recommend surgery and the neurologist 
told me that a substantial improvement was to be expected within a period of 3-4 months. His advice was to continue normal 
daily activities as much as possible. At present (one month later) I feel some improvement of my symptoms. 
tiveness of behavioural treatment and multidisciplin- ary treatment programmes. 
Tumour  necrosis  factor  α  has  been  identified  in  ani-  mal  and  human studies as one factor in the develop- ment of sciatica.23 
24 The first randomised trial 
J Vreuls, aged 49, The Hague 
evaluating a tumour necrosis factor α antagonist in patients with sciatica did not find a positive result.25 
1316 BMJ | 23 JUNE 2007 | VOLUME 334 
The  results  indicate  that  both  conservative  care  and  disc  surgery  are  relevant  treatment  options for patients with sciatica of at 
least  six  weeks’  duration.  Surgical intervention may provide quicker relief of symptoms compared with conservative care, but no 
large  differ-  ences  have  been  found  in  success  rate  after  one  or two years of follow-up. Patients and doctors may thus weigh the 
benefits  and  harms  of  both  options  to  make  individual  choices.  This  is  especially  relevant  because  patients’  preference  for 
treatment may have a direct positive influence on the magnitude of the treatment effect. 
What are the recommendations in clinical guidelines? Although in many countries clinical guidelines are available for the 
management of non-specific low back pain this is not the case for sciatica.22 Box 4 shows the recommendations for sciatica 
(lumbosacral radicular syndrome) in clinical guidelines recently issued by the Dutch College of General Practice.w4 After 
excluding specific diseases on the basis of red flags, sciatica is diagnosed on the basis of history taking and physical examination. 
Initial treatment is conser- 
 
CLINICAL REVIEW Downloaded from [Link] on 24 August 2007 SUMMARY POINTS 
8 Modic MT, Obuchowski NA, Ross J, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al. Acute low back pain and 
radiculopathy: MR 
Most patients with acute sciatica have a favourable 
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have persisting problems 
9 Govind J. Lumbar radicular pain. Aus Fam Phys 2004;33:409-12. 
after one or two years The diagnosis is based on history taking and physical 
10 Awad JN, Moskovich R. Lumbar disc herniations: surgical versus nonsurgical treatment. Clin Orthop Relat Res 
2006;443:183-97. 11 Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with examination 
emphasis on imaging. Ann Intern Med 2002137:586-97. Imaging 
is indicated only in patients with “red flag” conditions or in whom disc surgery is considered 
12 Weber H, Holme I, Amlie E. The natural course of acute sciatica with 
nerve root symptoms in a double blind placebo-controlled trial of evaluating the effect of piroxicam (NSAID). Spine 
1993;18:1433-8. Passive (bed rest) treatments have been replaced with more active treatments 
13 Vroomen PCAJ, Krom MCTFM de, Slofstra PD, Knottnerus JA. 
Conservative treatment of sciatica: a systematic review. J Spinal Dis 2000;13:463-9. Consensus is that initial treatment is 
conservative for about 
14 Luijsterburg PAJ, Verhagen AP, Ostelo RWJG, Os TAG van, Peul 
WC, 6-8 weeks Disc surgery may provide quicker relief of leg pain than 
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15 Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated 
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CORRECTIONS AND CLARIFICATIONS 
Improved effectiveness of partner notification for 
Drug eluting stents: What fuels public policy? patients with sexually 
transmitted infections: 
During the preparation of this letter by Mark H Wilson systematic 
review In this research article by Sven Trelle and colleagues (BMJ 2007;334:354-7; doi: 10.1136/bmj.39079.460741.7C) two 
errors were missed in the full version (on [Link]). The absolute risk ratio if 10% of patients managed with 
(BMJ 2007;334:599-600, 24 Mar, doi: 10.1136/ [Link]), we wrongly marked up the position and email address 
of the author. His correct affiliation is director of medical ethics (healthresearch@[Link]). simple patient referral had 
persistent or recurrent infections would be 2.7% [not 3.7%] and the number needed to treat 37 [not 27]. 
Short Cuts Extra: INR easily monitored at home Cover picture 
In this item by Harvey Marcovitch about the use of In the 26 May 
issue of the BMJ we put a picture of a 
portable coagulometers (BMJ 2007;334:928, 5 May, roundworm on 
the cover of the printed journal, beside the 
doi: 10.1136/[Link]) the penultimate words “Anaemia 
in developing countries.” As we should 
sentence should have read: “Paired results were have known, it is not 
roundworms, but hookworms, that 
highly correlated (r=0.91), and only three (5%) of the occur with iron 
deficiency anaemia (as the editorial in that 
home tests differed from laboratory results by >15% issue pointed 
out). 
[not >20%].” 
BMJ | 23 JUNE 2007 | VOLUME 334 1317