Sciatica in primary care – a case discussion

It is estimated that 60% of the adult population will experience low pain throughout their lifetime (Campbell and Colvin, 2013). Low back pain is a global common health problem which poses a significant financial economic burden. Hill et al. (2011) reports 60% of patients presenting with low back pain also report leg pain, this includes sciatica symptoms. The current economic financial burden associated with low back pain is estimated £12 billion per year (NICE, 2016). This article will discuss a case study of a patient (Mrs A) (see appendix one) who presented with symptoms of lumbar radiculopathy, commonly labelled as sciatica (National Institute for Heath and Care Excellence, (NICE) 2022) and was reviewed by a community trainee enhanced clinical practitioner (tECP), previously referred to as community matrons. The patient has provided verbal consent to be utilized as a case study and has been assured their name and details will remain anonymous. The aetiology, epidemiology and pathophysiology of sciatica will be explored with the support of current based evidence. The process of formulating a diagnosis through concise history taking, performing a clinical examination and investigations including diagnostic tests will be discussed and critically evaluated leading to a conclusion (Balogh, Miller and Ball, 2015), a clinical management plan and considerations for future practice.

Definition of sciatica

The sciatic nerve is defined as a collection of two nerves, the common fibular and tibial nerves, originating from the L4-S3 of the sacral plexus, leaving via the greater sciatic foramen and traveling down the posterior gluteal region and posterior thigh (Dupont et al, 2018). Sciatica, also known as lumbar radicular pain, describes leg pain and/or paraesthesia caused by inflammation or compression of the lumbosacral nerve roots, that together form the sciatica nerve (Jensen, Kongsted and Kjaer, 2019, Goldsmith, Howard Williams and Wood, 2019, Davis and Vasudevan, 2019). Dependent on the duration and symptoms, sciatica can be categorised as acute or chronic, chronic referring to the symptoms that have become persistent and have been present for a period of longer than twelve weeks (Bailey et al. 2020).

The duration of symptoms may alter the chosen treatment plans; acute symptoms primarily aim to be self-managed whereas the chronic conditions may require medical intervention (Kumar, 2011). In relation to the case study, Mrs A demonstrated acute sciatica with a two-week history of symptoms (Kumar,2011). Unilateral sciatica affects one leg and bilateral sciatica is characterised if the pain radiates down both legs. Mrs A reported sciatica radiating down one leg. Davis, Maini and Vasudervan (2022) emphasise the importance of a thorough history and physical examination, the opinion supported by the clinician.

Risk factors

The risk factors associated with developing sciatica within one's lifetime include smoking, obesity and occupational factors; namely frequent heavy lifting, or the use of vibrating equipment/machinery (Jensen et al. 2019, NICE, 2020 and Park and Singh 2021). Park and Singh, (2021) highlight additional risk factors to include age and noted a peak prevalence within those aged 45–65 years and indicate a genetic relation to disc degeneration. Sciatica is rarely seen in those under 20 years of age (NICE, 2020). NICE (2020a) state the occurrence of sciatica to be more prevalent in the patients fifth decade.

Prevalence

Following literature review, Konstantinou and Dunn (2008) notes that prevalence estimates of sciatica vary considerably ranging from 1.6–43%. The authors report this may be due to differences in study populations, data collection methods and definitions. Inman and Thomson (2019) report that sciatica symptoms are associated with around 10% of low back pain episodes. NICE (2020) state that 13–40% of the population will experience sciatica during their lifetime. Davis, Maini and Vasudevan (2022) report no evidence to suggest sciatica to be more prevalent in male or females.

History

The initial assessment occurred face to face with the patient and the tECP within a community setting. To ensure a patient centred approach and the provision of a high-quality service a positive interaction between patient and tECP is essential. Verbal consent was obtained from the patient prior to commencing the assessment. A clinical history involving gaining information relating to the patients’ medical history, past medical history, family history, social history, allergies, medications, and risks associated to the individual's medical conditions was undertaken (Nichol, Sundjaja and Nelson, 2022). Further questions were presented to the patient to determine the patients’ symptoms, perceptions, and to initiate considerations of potential diagnoses. Ensuring a holistic history, details of the onset of symptoms, the severity and characteristics of the symptoms were obtained, alongside the clinicians underlying knowledge of the disease pathology and progression a final diagnosis and management and treatment plans were generated. Communication between patient and health care professional is essential for the provision of care and recovery (Kwame and Petrucka, 2021), with the aim to improve specific health care outcomes, patient education of the condition and the prevention of recurring symptoms. Evidence suggests that 80% of diagnoses can be made from the history alone (Summerton, 2008).

Clinical subjective assessment

The patient presented to the tECP with a two-week history of low back pain with pain travelling down her left leg. The clinician's role is to obtain information of the patient symptoms, gathering concise details in relation to site of pain, the severity and factors that aggravate and ease the symptoms. Kinirons and Ellis (2006) report true sciatica involves pain that radiates into the buttocks, down into the thigh, lateral aspect of the lower limb, into the ankle then foot, resulting in a reduction in extension of toes. Pain is experienced in the lower spinal region and is predominately unilateral, a well-known characteristic is that the radiating pain will be ipsilateral to the affected limb (Davis, Maini and Vasudevan, 2022). Ailianou et al, (2012) suggests sciatic pain can be intermittent or constant and the severity of the pain can be exacerbated by a change in posture. With relation to the case study, pain was described specifically as radiating from lower back to knee and affecting the left lower limb only. On questioning, Mrs A's pain was aggravated when weight bearing and mobilising, thus supporting this evidence.

Sensory function

With reference to the case study, normal sensory function was affected and a tingling sensation in feet and toes were described. Laroche and Perrot (2013) supports with research that many patients with sciatica have sensory involvement, one fifth of patients experiencing numbness, with approximately 70% of patients describing a pins and needles sensation in the affected limb. An additional sensory symptom reported by Davis and Vasudevan (2019) is the feeling of heaviness of the affected limb.

It is possible that sciatica symptoms can overlap with serious spinal pathologies. The presence of red flags symptoms needs to be investigated to rule out pathologies such as cauda equina or malignancies. See table one for possible causes of ‘red flag’ symptoms. (Della-Giustina, 2013). The Red flag symptoms that can be suggestive of cauda equina include saddle anaesthesia and bilateral radiculopathy (NHS England, 2016), none of the red flag signs were reported by Mrs A throughout her assessment.

Clinical objective assessment

Following the taking of clinical history, a physical assessment was completed, and vital signs taken (see appendix one). NICE (2022) recommend the physical assessment to comprise of a musculoskeletal and a neurological assessment. The tECP completed a musculoskeletal assessment of Mrs A's gait, observed and assessed range of movement of Mrs A's lumbar spine and hip, palpation of Mrs A's lumbar spine and hip and consequently performed an assessment of the lower limb dermatomal nerve pattern (figure 1) and the application of a neurological tests.

Clinical tests

Deville et al. (2000) states if a patient experiences unilateral leg pain and obtains a positive result on one or more neurological test used to diagnosis nerve root tension or neurological discrepancy the diagnosis of sciatica is justified. Clinical tests commonly used to support the diagnosis of sciatica include the straight leg raise test (SLR) (figure 2) and the slump test (figure 3) (Gore and Nadkami, 2014). Nee, Coppieters and Boyd (2022) identify that a high proportion of clinical guidelines suggest the SLR is an assessment tool commonly used for the diagnosis of sciatica. In response to the symptoms described by Mrs A and the clinical findings during assessment, the SLR test was performed and produced a positive result. Das and Nadi (2022) suggest a positive SLR if radiating leg pain is reproduced. On the contrary Mistry et al. (2020) suggest there is minimal evidence to support that the SLR test can detect compression of a nerve root. The SLR test can indicate other pathologies, including hamstring, gluteus maximus tightness or neurological pain which could be indicative of lumbar disc herniation (Ropper and Zafonte, 2015). The Slump test is perceived as a more sensitive test and is used to detect a change in mechanical sensitivity of the nervous system (Flynn, Cleland and Whitman, 2008). A positive Slump test would be indicative of the presence of radiculopathy when the SLR test is negative (Majlesi et al. 2008). Further, it has been identified that additional research is required to support the sensitivity and specificity of these clinical tests (Pesonen et al, 2021). Majlesi et al. (2008) document the slump test to be a variant of the SLR test and suggest the Slump test is more appropriate to support diagnosis of lumbar disc herniations, in comparison the SLR test may be more beneficial in the diagnosis of nerve irritation or compression. Sensory tests, such as light touch and pin prick can also be completed to establish neurological integrity. Motor tests including functional tests and reflexes can support the diagnosis of neurological conditions. On reflection, completion of the Slump test and reflexes with Mrs A would have supported the elimination of alternative diagnoses.

Differential diagnoses

Sciatica symptoms can be mirrored by other health conditions. Sciatica is diagnosed through thorough history taking and physical assessment. Causes that can irritate one or more of the nerve roots and mimic sciatica symptoms in the lumbosacral spine include; slipped discs – the dislodgment of the soft tissue between each vertebrae, leading to lower limb sensation changes and pain, however may involve lower back pain when performing certain movements, depending on the location of the herniated disc, spondylolisthesis, the displacement of a vertebra, which may require an x-ray or scan to diagnose, infection including discitis or vertebral osteomyelitis, and secondary cancer may all result in sciatica symptoms (NICE 2020). If further investigations including blood tests, scans are arranged, these differential diagnoses can be established and inevitably rule out the diagnose of sciatica.

Common misinterpretations of sciatica include Piriformis Syndrome. Evidence suggests Piriformis Syndrome is responsible for up to 6% of sciatica cases (Brandon, Hicks, Lam and Varacallo, 2022). Piriformis Syndrome is a neuromuscular disorder which occurs when the piriformis muscle compresses the sciatic nerve. Patients will present with sciatica symptoms; the health care professional must subsequently differentiate the origin of the radiating pain to determine it primary cause. In Piriformis Syndrome the pain may occur along the L5 and S1 dermatome pathways (Hopayian and Danielyan, 2017). Evidence suggests the Flexion, Adduction and Internal Rotation (FAIR) test to be specific and sensitive clinical test to support the detection and diagnosis of irritation caused by the piriformis muscle (Slipman et al.1999). Fishman et al. 2002 suggest a positive result of the FAIR test when sciatica symptoms are reproduced. The FAIR test was performed on Mrs A and did not reproduce the sciatica symptoms.

Lumbar disc degeneration is defined as wear and tear of the lumbar spine intervertebral discs and predominately occur at L3-L4 and L4-S1 (David et al. 2010). Degeneration of the lumbar spine may result in osteophytes, disc bulging and consequently compression and irritation on corresponding nerves (Liyew, 2020) There is a direct correlation with vertebral disc degeneration and increasing patient age. Evidence suggests degenerative lumbar spine is more prevalence in elderly females (Wang et al. 2010). Clinical presentations of lumbar degeneration include muscular weakness and radiating pain (Liyew, 2020). Following an x-ray of Mrs A's lumbar spine, pelvis and hip, no fractures were detected however lumbar degenerative changes were reported.

Diagnostic imaging

NICE (2016) states that imaging is not an essential diagnostic tool for sciatica and is not routinely offered. Imaging would therefore only be considered an option to support diagnosis if there concerns regarding serious pathology or red flag symptoms had been detected. As no red flag symptoms were identified during the subjective or objective assessment of Mrs A, further diagnostic imaging was not offered at this time.

Treatment options

The STarT back screening tool has been was developed by Keele University in 2021 to systemically identify the correct treatment for patients experiencing low back pain. The tool is comprised of nine questions designed to group patients into categories depending on their level of risk of a poor outcome. This then allows the clinicians to adapt the management plan to the appropriate patients. Mrs A scored 4 with the STarT back tool and therefore deemed as medium risk of chronicity.

NICE (2016) guidelines recommend treatment focused initially on education of self-management and encouraging normal activities. Mrs A and her daughter were informed of the sciatica diagnosis by the tECP and early intervention of medication and exercises were encouraged. Mrs A was also informed to monitor any changes or deterioration to her condition including red flag symptoms to ensure if these symptoms occurred to seek further urgent medical intervention.

Non-pharmacological treatment

Self-management interventions include the use of hot and cold packs to reduce discomfort and decrease inflammation, encouraging regular changes of position and avoiding periods of prolonged static positions. Referral to physiotherapy is also endorsed to educate the patient on strengthening and stretching exercises and manual therapy including spinal manipulation and soft tissue massage. NICE (2020) supports the advice of regular exercise and encourage the healing process and reduce intensity of neuropathic pain.

Physiotherapy is recognised as an essential component of resolving sciatica symptoms and prevention of reoccurring symptoms. Information can be provided to enhance the patients understanding of the pathology of sciatica and manage expectations of recovery. Evidence suggests that conservative management is favourable, however educating patients has not been specifically investigated in controlled trials. Initial decisions regarding the treatment for sciatica is based upon the patient's history and clinical examination. Luijsterburg et al. (2007) performed a systemic review and concluded that conservative treatment did not fundamentally improve the symptoms of sciatica. On the contrary, Jensen et al. (2019) report patients symptoms improved over time with conservative treatment or exercises, physiotherapy and pain management strategies. Davis and Vasudevan (2019) support that sciatica symptoms improve within four to six weeks with non-surgical management, however, many experience underlying or recurring sciatica pain in the long term. If severe neurological deficits have occurred, the recovery period will be extended. Due to Mrs A's symptoms being of an acute nature, conservative treatment of advice and physiotherapy were offered foremost.

Tailored exercise programme

NICE (2016) clinical guidelines suggest an exercise programme as a non-invasive treatment option, a health care professional can provide an individualised exercise programme to strengthen, mobilise, and stabilise the surrounding structures and reduce symptom reoccurrences. The use of equipment, supports and orthotics is deemed not appropriate for the reduction of sciatica symptoms (NICE 2016). Fernandez et al. (2015) completed a systemic review discussing physical activity and surgical options in the management of sciatica and document that leg pain reduced following manual therapy. Mrs A was issued with an exercise programme focusing on increasing core muscle strength and improving her lumbar spine range of movement. Each exercise was initially demonstrated and performed with supervision of a physiotherapist.

Outcome measures

Outcome measures are useful tools to monitor patients progress, the Numeric Rating Scale (NRS) was used during this case study to measure Mrs A's pain. The NRS is a pain screening tool to assess severity of pain at a given time using a 0–10 scale (Sharma et al. 2017). Scoring from zero - “no pain” and 10 describing the “worst imaginable pain possible”. Mrs A rated her pain at 2/10 at rest and 8/10 on movement. The treatment objective is to reduce the pain score. The Timed Up and Go (TUG) (figure 4) was the second outcome measure used during assessment of Mrs A. the TUG is an extensively used physical outcome measure used to assess mobility, balance and falls risk in the elderly population. During the TUG test the patient must stand from their chair, mobilise 3 metres, turn round, mobilise back to their chair and sit themselves down while timed by the health care professional. Mrs A completed the TUG test in 21 seconds, a study completed by Rose, Jones and Luccese (2002) would identify Mrs A to be at risk of falls as time taken was greater than 13.5 seconds. Stenhagen, Nordell and Elmstahl (2013) suggest the TUG cannot be used exclusively to assess the falls risk due to the number of additional factors that can cause falls. On reflection, further outcome measures could have been performed including the Clinical Frailty Scale and ones to further investigate the functional effect of sciatica on Mrs A's quality of life, these outcome measures are known as patient reported outcome measures.

Pharmaceutical treatment options

Nonsteroidal anti-inflammatory drugs (NSAID's) are commonly prescribed for treatment of sciatica. NICE (2020) encourage clinicians to prescribe a low dosage with effective use and for the minimum time possible due to adverse side effects. An article A Cochrane review written by Rasmussen-Barr et al. (2016) states that NSAID's are no more effective than placebo or other drugs at reducing sciatica pain. There is, however, significant evidence suggesting extensive use of NSAIDS can have serious consequences including gastrointestinal ulcers and haemorrhages (Shah, Fitzgerald and Murray, 1999). Pinto, Verwoerd and Koes (2017) states there is lack of evidence to support the prescription of paracetamol, benzodiazepines and opioids. NICE (2020) guidelines advise health care professionals not to prescribe opioids including benzodiazepines and gabapentin and pregabalin for the management of chronic sciatica symptoms. This is based on lack of evidence and considerations for long term risk on quality of life. Mrs A was not prescribed opioids and was taking regular paracetamol for the management of pain relief.

The consideration of surgery namely spinal decompression would only be deemed an option if non-surgical treatment, medication, physiotherapy and spinal injection therapy had been unsuccessful, or the symptoms were having a detrimental effect on the patient's quality of life.

Conclusion

When diagnosing sciatica there requires a comprehensive understanding of the pathophysiology, the anatomy involved, a concise history taking and an awareness of red flags symptoms. Enhancing health professionals’ knowledge may lead to improved and timely diagnosis and interventions to inevitably improve the patients’ journey. Educating and empowering patients and health care professionals regarding the symptoms and management of sciatica, aims to vastly improve their management techniques and prevent further recurrences for the patient. There are many causes of sciatica and therefore a multidisciplinary approach is beneficial. It is noted however, that there is limited evidence supporting patients’ preference to treatment. Broader investigation of this would enhance future practise and support patients’ self-management and education being the favoured clinical course.