Sciatica: Sciatica: When to image. When to image. When to refer.When to refer.

Juanita Halls M.D.Juanita Halls M.D.

Internal MedicineInternal Medicine

October 10, 2007October 10, 2007

No financial disclosuresNo financial disclosures

ObjectivesObjectives

Understand when to perform imaging Understand when to perform imaging on patients presenting with sciaticaon patients presenting with sciatica

Understand when to refer patients with Understand when to refer patients with sciatica to a spine surgeonsciatica to a spine surgeon

Case 1Case 1

58 yo healthy female presents January, 58 yo healthy female presents January, 2007 with 6 week history of achy LBP, 2007 with 6 week history of achy LBP, R>L with episodes of pain shooting down R>L with episodes of pain shooting down back of thighs to calves and occasional back of thighs to calves and occasional numbness in footnumbness in footNo preceding injury, heavy lifting, etcNo preceding injury, heavy lifting, etcNo weakness, bladder or bowel dysfnNo weakness, bladder or bowel dysfnNo systemic sx e.g. fever/sweats/weight No systemic sx e.g. fever/sweats/weight lossloss

PMHPMH

Hypertension on lisinopril/HCTZHypertension on lisinopril/HCTZ

s/p hysterectomys/p hysterectomy

Takes MVI and Calcium/vitamin DTakes MVI and Calcium/vitamin D

Otherwise healthy, non-smokerOtherwise healthy, non-smoker

Screening: Screening: – Routine PE 10/06Routine PE 10/06– mammogram 10/05, ordered 10/06 but not done mammogram 10/05, ordered 10/06 but not done – Flex sig negative 1999, FOBT negative 10/06 Flex sig negative 1999, FOBT negative 10/06

(colonoscopy not covered by insurance)(colonoscopy not covered by insurance)

ExamExam

No spinal tenderness or deformityNo spinal tenderness or deformity

Mild decrease extension with painMild decrease extension with pain

Mild decrease flexion without painMild decrease flexion without pain

Positive SLR bilaterally at 60Positive SLR bilaterally at 60oo

DTR: 2+ knee and 1+ ankle bilaterallyDTR: 2+ knee and 1+ ankle bilaterally

Motor: 5/5 in LEMotor: 5/5 in LE

Sensory: IntactSensory: Intact

ImagingImaging

L/S spine films: multilevel degenerative L/S spine films: multilevel degenerative disk and joint diseasedisk and joint disease

No labs doneNo labs done

Dx/ RxDx/ Rx

““Sciatica with no worrisome symptoms and Sciatica with no worrisome symptoms and negative spine X-ray”negative spine X-ray”

Home exercisesHome exercisesPT referralPT referralIce or heatIce or heatNo liftingNo liftingNaproxen and Tylenol #3Naproxen and Tylenol #3RTC 2 months, sooner if not improvingRTC 2 months, sooner if not improving

2 months later2 months later

Had cancelled PT because pain resolved Had cancelled PT because pain resolved with home exercises and Naproxenwith home exercises and Naproxen

Now 3 week history of increased right Now 3 week history of increased right sided LBP radiating to right footsided LBP radiating to right foot

Paresthesia of right ankleParesthesia of right ankle

No weakness or bladder/bowel dysfnNo weakness or bladder/bowel dysfn

↑ ↑ with sitting and at nightwith sitting and at night

ExamExam

No spinal tendernessNo spinal tenderness

SLR negative on left, positive at 60SLR negative on left, positive at 60oo on right on right

DTR: symmetricalDTR: symmetrical

Motor: 5/5Motor: 5/5

PlanPlan

MRI offered but patient declinedMRI offered but patient declined

Diclofenac (was having side effects with Diclofenac (was having side effects with naproxen)naproxen)

PT referralPT referral

Spine clinic referralSpine clinic referral

4 weeks later 4 weeks later (3 months after initial presentation)(3 months after initial presentation)Seen in Spine clinic:Seen in Spine clinic:– Pain had gotten better, now worse again and Pain had gotten better, now worse again and

interfering with sleepinterfering with sleep– No systemic symptomsNo systemic symptoms

Exam:Exam:– No change except minimal tendernessNo change except minimal tenderness– Positive SLR/Lasegue maneuverPositive SLR/Lasegue maneuver

DX: Probable HNPDX: Probable HNPPlan: MRIPlan: MRI

2 Weeks later2 Weeks later(3 ½ months after presentation)(3 ½ months after presentation)

MRI competed and I am paged by the MRI competed and I am paged by the Spine clinic physician late Friday afternoonSpine clinic physician late Friday afternoon

MRI case 1MRI case 1

MRI Case 1MRI Case 1

MRI readingMRI reading

Large osseous mass involving right iliac Large osseous mass involving right iliac wing and central and right portions of S1 wing and central and right portions of S1 and S2 vertebra with soft tissue extension and S2 vertebra with soft tissue extension obliterating right L5, S1 and S2 neural obliterating right L5, S1 and S2 neural foramen.foramen.

Second osseous mass in body of T12Second osseous mass in body of T12

Most likely represents metastatic diseaseMost likely represents metastatic disease

10 days later10 days later

CT guided biopsy:CT guided biopsy:– Large B cell lymphomaLarge B cell lymphoma

Low Back PainLow Back Pain

Low back painLow back pain– 84% of adults experience LBP84% of adults experience LBP– 2.5% of medical visits2.5% of medical visits– Total cost in US: $100 Billion per yearTotal cost in US: $100 Billion per year– <5% have serious pathology<5% have serious pathology– 5% have sciatica5% have sciatica

Annual incidence of sciatica is 5 per 1000Annual incidence of sciatica is 5 per 1000

Definition of sciaticaDefinition of sciatica

Pain, numbness, tingling in distribution of Pain, numbness, tingling in distribution of sciatic nerve sciatic nerve

Radiation down posterior or lateral leg to Radiation down posterior or lateral leg to foot or anklefoot or ankle

If radiation below knee – more likely If radiation below knee – more likely radiculopathy with impingement of nerve radiculopathy with impingement of nerve rootroot

Etiology of sciaticaEtiology of sciatica

MechanicalMechanical– Pyriformis syndromePyriformis syndrome– HNPHNP– SpondylolisthesisSpondylolisthesis– Compression fractureCompression fracture

Neoplastic (0.7% of LBP)Neoplastic (0.7% of LBP)

Infectious (0.01% of LBP)Infectious (0.01% of LBP)

Questions to askQuestions to ask

Is there evidence of systemic disease?Is there evidence of systemic disease?

Is there evidence of neurological Is there evidence of neurological compromise?compromise?

Clues on history to suggest Clues on history to suggest systemic diseasesystemic disease

Hx of cancer Hx of cancer NoNo

Age > 50Age > 50 YesYes

Unexplained weight lossUnexplained weight loss NoNo

Duration > 1 monthDuration > 1 month YesYes

Night time painNight time pain YesYes

Unresponsive to conservative rxUnresponsive to conservative rx +/-+/-

Pain not relieved by lying downPain not relieved by lying down +/-+/-

ExamExam

Back examBack exam– ROMROM– Palpate for tendernessPalpate for tenderness– SLRSLR– Neuro examNeuro exam

If suspicious historyIf suspicious history– Breast or prostate examBreast or prostate exam– Lymph node examLymph node exam

Testing for lumbar nerve root compromise

Straight leg raisingStraight leg raising

Passive lifting of the leg with the knee extended produces pain radiating down the posterior or lateral aspect of the leg, distal to the knee and usually into the foot.

Dorsiflexion of the foot (Lasegue's test) will exacerbate these symptoms

SLR with Lasegue testSLR with Lasegue test

Sensitivity/specificity for radiculopathy, in patients with sciatica*

Finding     Sensitivity, percent

Specificity, percent + LR

Negative LR

Motor examination:

Weak ankle dorsiflexion

Ipsilateral calf wasting

Sensory examination:

Leg sensation abnormal

Reflex examination:

Abnormal ankle jerk

Other tests:

Straight-leg raising maneuver

Crossed straight-leg raising maneuver

54 89 4.9

29 94 5.2

16 86 NS

48 89 4.3

73-98 11-61 NS

23-43 88-98 4.3

Imaging indicationsImaging indications

Progression of neurological findingsProgression of neurological findingsConstitutional symptomsConstitutional symptomsHx of traumatic onsetHx of traumatic onsetHx of malignancyHx of malignancy<18 or > 50<18 or > 50Infection risk (IVDU, immunocompromise, Infection risk (IVDU, immunocompromise, fever)fever)OsteoporosisOsteoporosis

Imaging – L/S spine filmsImaging – L/S spine films

If risk factor or no better in 4-6 weeksIf risk factor or no better in 4-6 weeksMay be able to detect:May be able to detect:– Tumor Tumor (sensitivity 60%)(sensitivity 60%)– InfectionInfection (sensitivity 82%)(sensitivity 82%)– SpondyloarthropathySpondyloarthropathy– SpondylolisthesisSpondylolisthesis

Also consider Labs: ESR and/or CRP if Also consider Labs: ESR and/or CRP if risk for infectionrisk for infectionIf negative: conservative rx for 4-6 weeksIf negative: conservative rx for 4-6 weeks

Imaging - MRIImaging - MRI

If progressive neurological deficit, high If progressive neurological deficit, high suspicion of cancer or infection, or 12 suspicion of cancer or infection, or 12 weeks of persistent painweeks of persistent pain

May be able to detect:May be able to detect:– TumorTumor (sensitivity 83-93%)(sensitivity 83-93%)– InfectionInfection (sensitivity 96%)(sensitivity 96%)– HNPHNP (sensitivity 60-100%)(sensitivity 60-100%)– Spinal stenosis (sensitivity 90%)Spinal stenosis (sensitivity 90%)

Malignancy and sciaticaMalignancy and sciatica

O.7% of LBP due to malignancyO.7% of LBP due to malignancy

Non-Hodgkin’s lymphomaNon-Hodgkin’s lymphoma– 10% have CNS involvement10% have CNS involvement– Sciatica is uncommon and occurs lateSciatica is uncommon and occurs late– Very rare for sciatica to be presenting featureVery rare for sciatica to be presenting feature

Case 2Case 2

49 yo healthy female presents February, 49 yo healthy female presents February, 2007 with recurrent LBP radiating to right 2007 with recurrent LBP radiating to right buttock and shooting to posterior thigh and buttock and shooting to posterior thigh and lateral calf.lateral calf.Numbness of bottom of footNumbness of bottom of footNo weakness, bladder or bowel dysfnNo weakness, bladder or bowel dysfnNo systemic sx e.g. fever/sweats/weight lossNo systemic sx e.g. fever/sweats/weight loss↑ ↑ prolonged sitting, getting up, bendingprolonged sitting, getting up, bending↓ ↓ walking, lying downwalking, lying down

Previous historyPrevious history

4 months previous had ER visit for acute 4 months previous had ER visit for acute LBP radiating to right buttock after bending LBP radiating to right buttock after bending over in Yoga class and treated with PT over in Yoga class and treated with PT and pain medsand pain meds

2 months previous after 6-7 PT sessions 2 months previous after 6-7 PT sessions reported “much better”reported “much better”

PMH: No meds, non-smokerPMH: No meds, non-smoker

ExamExam

DTR’s 2+ at knee and ankleDTR’s 2+ at knee and ankle

Motor 5/5 in LEMotor 5/5 in LE

No spinal tendernessNo spinal tenderness

SLR negative bilaterallySLR negative bilaterally

TreatmentTreatment

PTPT

If not improving, get MRI and/or refer to If not improving, get MRI and/or refer to spine clinicspine clinic

5 weeks later5 weeks later

No better and MRI ordered and referred to No better and MRI ordered and referred to spine clinicspine clinic

MRI Case 2MRI Case 2

MRI Case 2MRI Case 2

MRI readingMRI reading

L5-S1 disk protrusion contacting right S1 L5-S1 disk protrusion contacting right S1 nerve rootnerve root

Spine clinic visit next daySpine clinic visit next day

Hx: same plus pain increases with cough/sneezeHx: same plus pain increases with cough/sneeze

Exam:Exam:– Tender inferior to right piriformis muscleTender inferior to right piriformis muscle– ↓ ↓ sensation to light touch right S1, PP normalsensation to light touch right S1, PP normal– DTR: 2+ knees and left ankle, 1+ right ankleDTR: 2+ knees and left ankle, 1+ right ankle– Negative SLRNegative SLR– Prone press up – pain in buttockProne press up – pain in buttock

Dx: Radiculopathy with HNP L5-S1Dx: Radiculopathy with HNP L5-S1

Spine clinic treatmentSpine clinic treatment

Right S1 diagnostic and therapeutic Right S1 diagnostic and therapeutic transforaminal steroid injectiontransforaminal steroid injection

PT and/or chiropracterPT and/or chiropracter

OxycodoneOxycodone

NeurontinNeurontin

8 weeks later8 weeks later (3 months after initial presentation)(3 months after initial presentation)

s/p 2 injections, PT, Chiropracters/p 2 injections, PT, Chiropracter

Still severe pain and now weakness right Still severe pain and now weakness right leg with stairsleg with stairs

Referred to spine surgeonReferred to spine surgeon

Spine surgeonSpine surgeon

Exam:Exam:– SLR positive/ Lasegue positive on rightSLR positive/ Lasegue positive on right– DTR: 1+ left ankle 0 right ankleDTR: 1+ left ankle 0 right ankle

““You should have been here within 6 weeks You should have been here within 6 weeks of onset of sciatica symptomsof onset of sciatica symptoms””

Recommends: L5-S1 microdiskectomyRecommends: L5-S1 microdiskectomy– Outpatient procedure with epiduralOutpatient procedure with epidural– 95% get relief of pain95% get relief of pain– 3% risk of re-herniation3% risk of re-herniation

When to refer to spine surgeonWhen to refer to spine surgeon

Cauda equina syndromeCauda equina syndrome

Neuro motor deficitNeuro motor deficit

Persistent severe sciatica after Persistent severe sciatica after conservative treatmentconservative treatment

Timing of referral for diskectomyTiming of referral for diskectomy

Optimal timing is not clearOptimal timing is not clear

No consensus on how long conservative No consensus on how long conservative treatment should be triedtreatment should be tried

Sciatica improves within 3 months in 75% Sciatica improves within 3 months in 75% of patients (95% at one year)of patients (95% at one year)

Surgery vs Prolonged Conservative Surgery vs Prolonged Conservative Treatment for SciaticaTreatment for Sciatica

Peul, et al NEJM May 31, 2007Peul, et al NEJM May 31, 2007283 patients with 6-12 wk of severe sciatica and 283 patients with 6-12 wk of severe sciatica and HNP on MRIHNP on MRIRandomized to:Randomized to:– early surgery (microdiskectomey) vs early surgery (microdiskectomey) vs – conservative therapy with surgery if neededconservative therapy with surgery if neededPrimary outcomes:Primary outcomes:– Subjective pain and disability scoresSubjective pain and disability scores– Perceived recoveryPerceived recovery

Outcomes of studyOutcomes of studySurgery grp: Surgery grp: 89% surgery at mean 89% surgery at mean

2.2 weeks2.2 weeksConservative grp: 36% surgery at mean Conservative grp: 36% surgery at mean

4½ months4½ monthsAt 1 year: no difference in pain or disability At 1 year: no difference in pain or disability score or perceived recovery (95% in both grps)score or perceived recovery (95% in both grps)Pain relief and perceived recovery faster in Pain relief and perceived recovery faster in surgery groupsurgery groupMedian time to full recovery 4 vs 12 weeksMedian time to full recovery 4 vs 12 weeksMax difference in pain score <20 mm on 100 Max difference in pain score <20 mm on 100 mm scalemm scale

Peul, et al. New Engl J Med, 2007;356:2245-56

Peul, et al. New Engl J Med, 2007;356:2245-56

Peul, et al. New Engl J Med, 2007;356:2245-56

Conclusions of studyConclusions of study

Advantage of early surgery is faster relief of Advantage of early surgery is faster relief of pain and faster perceived recovery timepain and faster perceived recovery time

Not blinded study (patient expectation bias)Not blinded study (patient expectation bias)

Did not look at any objective outcomes e.g. Did not look at any objective outcomes e.g. days of work lostdays of work lost

SPORT studySPORT studySurgical vs Nonoperative Treatment Surgical vs Nonoperative Treatment

for Lumbar Disk Herniationfor Lumbar Disk HerniationWeinstein, et al JAMA November, 2006Weinstein, et al JAMA November, 2006

501 pts with radiculopathy and HNP for at 501 pts with radiculopathy and HNP for at least 6 weeksleast 6 weeks

Open diskectomy vs conservative rxOpen diskectomy vs conservative rx

Surgery grp: 60% (50% within 3 months)Surgery grp: 60% (50% within 3 months)

Conserv grp: 45% (30% within 3 months)Conserv grp: 45% (30% within 3 months)

No difference in subjective pain and No difference in subjective pain and disability scoresdisability scores

BOTTOM LINEBOTTOM LINE

Risk of serious problem (e.g. cauda equina, Risk of serious problem (e.g. cauda equina, neurological deterioration) is very small so neurological deterioration) is very small so most patients do not need urgent surgerymost patients do not need urgent surgery

Main benefit of surgery is faster perceived Main benefit of surgery is faster perceived recovery and resolution of disabling painrecovery and resolution of disabling pain

No data on days of lost productivityNo data on days of lost productivity

No other strong reason to advocate for No other strong reason to advocate for surgery except patient preferencesurgery except patient preference

Bottom lineBottom line

Offer surgery to patients who:Offer surgery to patients who:– Not able to cope with the painNot able to cope with the pain– Find natural course of recovery to slowFind natural course of recovery to slow– Want to minimize time to recovery from painWant to minimize time to recovery from pain

Questions for patient:Questions for patient:– How badly do you feel?How badly do you feel?– How urgently do you wish to achieve relief at How urgently do you wish to achieve relief at

“cost” of having surgery?“cost” of having surgery?

Follow up Case 1Follow up Case 1

Treated with CHOP plus RitoxanTreated with CHOP plus Ritoxan

s/p 6 cycless/p 6 cycles

PET and CT scans pendingPET and CT scans pending

Follow up Case 2Follow up Case 2

4 months s/p microdiskectomy4 months s/p microdiskectomy

Back to work one month after surgery and Back to work one month after surgery and doing welldoing well

ReferencesReferences1.1. Jarvik, JG and Deyo, RA. Diagnostic evaluation of low Jarvik, JG and Deyo, RA. Diagnostic evaluation of low

back pain with emphasis on imaging. Ann Intern back pain with emphasis on imaging. Ann Intern Med.2002;137:586-597.Med.2002;137:586-597.

2.2. Stadnik, et al. Annular tears and disk herniation: Stadnik, et al. Annular tears and disk herniation: Prevalence and contrast enhancement on MR images in Prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology the absence of low back pain or sciatica. Radiology 1998;206:49-55.1998;206:49-55.

3.3. O’Neill, et al. Sciatica caused by isolated non-Hodgkin's O’Neill, et al. Sciatica caused by isolated non-Hodgkin's lymphoma of the spinal epidural space: A report of two lymphoma of the spinal epidural space: A report of two cases. Br J Rheum 1991;30:385-86.cases. Br J Rheum 1991;30:385-86.

4.4. Peul, et al. Surgery versus prolonged conservative Peul, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:2245-56.treatment for sciatica. N Engl J Med 2007;356:2245-56.

5.5. Weinstein, et al. Surgical vs nonoperative treatment for Weinstein, et al. Surgical vs nonoperative treatment for lumbar disk herniation. SPORT trial. JAMA lumbar disk herniation. SPORT trial. JAMA 2006;296:2441-50.2006;296:2441-50.