Sciatica: When to image. When to refer. - PowerPoint PPT Presentation

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Sciatica: When to image. When to refer.

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Dorsiflexion of the foot (Lasegue's test) will exacerbate these symptoms. SLR with Lasegue test ... Weak ankle dorsiflexion. Ipsilateral calf wasting. Sensory ... – PowerPoint PPT presentation

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


1
Sciatica When to image. When to refer.
  • Juanita Halls M.D.
  • Internal Medicine
  • October 10, 2007

2
  • No financial disclosures

3
Objectives
  • Understand when to perform imaging on patients
    presenting with sciatica
  • Understand when to refer patients with sciatica
    to a spine surgeon

4
Case 1
  • 58 yo healthy female presents January, 2007 with
    6 week history of achy LBP, RgtL with episodes of
    pain shooting down back of thighs to calves and
    occasional numbness in foot
  • No preceding injury, heavy lifting, etc
  • No weakness, bladder or bowel dysfn
  • No systemic sx e.g. fever/sweats/weight loss

5
PMH
  • Hypertension on lisinopril/HCTZ
  • s/p hysterectomy
  • Takes MVI and Calcium/vitamin D
  • Otherwise healthy, non-smoker
  • Screening
  • Routine PE 10/06
  • mammogram 10/05, ordered 10/06 but not done
  • Flex sig negative 1999, FOBT negative 10/06
    (colonoscopy not covered by insurance)

6
Exam
  • No spinal tenderness or deformity
  • Mild decrease extension with pain
  • Mild decrease flexion without pain
  • Positive SLR bilaterally at 60o
  • DTR 2 knee and 1 ankle bilaterally
  • Motor 5/5 in LE
  • Sensory Intact

7
Imaging
  • L/S spine films multilevel degenerative disk
    and joint disease
  • No labs done

8
Dx/ Rx
  • Sciatica with no worrisome symptoms and negative
    spine X-ray
  • Home exercises
  • PT referral
  • Ice or heat
  • No lifting
  • Naproxen and Tylenol 3
  • RTC 2 months, sooner if not improving

9
2 months later
  • Had cancelled PT because pain resolved with home
    exercises and Naproxen
  • Now 3 week history of increased right sided LBP
    radiating to right foot
  • Paresthesia of right ankle
  • No weakness or bladder/bowel dysfn
  • ? with sitting and at night

10
Exam
  • No spinal tenderness
  • SLR negative on left, positive at 60o on right
  • DTR symmetrical
  • Motor 5/5

11
Plan
  • MRI offered but patient declined
  • Diclofenac (was having side effects with
    naproxen)
  • PT referral
  • Spine clinic referral

12
4 weeks later (3 months after initial
presentation)
  • Seen in Spine clinic
  • Pain had gotten better, now worse again and
    interfering with sleep
  • No systemic symptoms
  • Exam
  • No change except minimal tenderness
  • Positive SLR/Lasegue maneuver
  • DX Probable HNP
  • Plan MRI

13
2 Weeks later(3 ½ months after presentation)
  • MRI competed and I am paged by the Spine clinic
    physician late Friday afternoon

14
MRI case 1
15
MRI Case 1
16
MRI reading
  • Large osseous mass involving right iliac wing and
    central and right portions of S1 and S2 vertebra
    with soft tissue extension obliterating right L5,
    S1 and S2 neural foramen.
  • Second osseous mass in body of T12
  • Most likely represents metastatic disease

17
10 days later
  • CT guided biopsy
  • Large B cell lymphoma

18
Low Back Pain
  • Low back pain
  • 84 of adults experience LBP
  • 2.5 of medical visits
  • Total cost in US 100 Billion per year
  • lt5 have serious pathology
  • 5 have sciatica
  • Annual incidence of sciatica is 5 per 1000

19
Definition of sciatica
  • Pain, numbness, tingling in distribution of
    sciatic nerve
  • Radiation down posterior or lateral leg to foot
    or ankle
  • If radiation below knee more likely
    radiculopathy with impingement of nerve root

20
Etiology of sciatica
  • Mechanical
  • Pyriformis syndrome
  • HNP
  • Spondylolisthesis
  • Compression fracture
  • Neoplastic (0.7 of LBP)
  • Infectious (0.01 of LBP)

21
Questions to ask
  • Is there evidence of systemic disease?
  • Is there evidence of neurological compromise?

22
Clues on history to suggest systemic disease
  • Hx of cancer No
  • Age gt 50 Yes
  • Unexplained weight loss No
  • Duration gt 1 month Yes
  • Night time pain Yes
  • Unresponsive to conservative rx /-
  • Pain not relieved by lying down /-

23
Exam
  • Back exam
  • ROM
  • Palpate for tenderness
  • SLR
  • Neuro exam
  • If suspicious history
  • Breast or prostate exam
  • Lymph node exam

24
Testing for lumbar nerve root compromise
25
Straight 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

26
SLR with Lasegue test
27
LR
28
Imaging indications
  • Progression of neurological findings
  • Constitutional symptoms
  • Hx of traumatic onset
  • Hx of malignancy
  • lt18 or gt 50
  • Infection risk (IVDU, immunocompromise, fever)
  • Osteoporosis

29
Imaging L/S spine films
  • If risk factor or no better in 4-6 weeks
  • May be able to detect
  • Tumor (sensitivity 60)
  • Infection (sensitivity 82)
  • Spondyloarthropathy
  • Spondylolisthesis
  • Also consider Labs ESR and/or CRP if risk for
    infection
  • If negative conservative rx for 4-6 weeks

30
Imaging - MRI
  • If progressive neurological deficit, high
    suspicion of cancer or infection, or 12 weeks of
    persistent pain
  • May be able to detect
  • Tumor (sensitivity 83-93)
  • Infection (sensitivity 96)
  • HNP (sensitivity 60-100)
  • Spinal stenosis (sensitivity 90)

31
Malignancy and sciatica
  • O.7 of LBP due to malignancy
  • Non-Hodgkins lymphoma
  • 10 have CNS involvement
  • Sciatica is uncommon and occurs late
  • Very rare for sciatica to be presenting feature

32
Case 2
  • 49 yo healthy female presents February, 2007 with
    recurrent LBP radiating to right buttock and
    shooting to posterior thigh and lateral calf.
  • Numbness of bottom of foot
  • No weakness, bladder or bowel dysfn
  • No systemic sx e.g. fever/sweats/weight loss
  • ? prolonged sitting, getting up, bending
  • ? walking, lying down

33
Previous history
  • 4 months previous had ER visit for acute LBP
    radiating to right buttock after bending over in
    Yoga class and treated with PT and pain meds
  • 2 months previous after 6-7 PT sessions reported
    much better
  • PMH No meds, non-smoker

34
Exam
  • DTRs 2 at knee and ankle
  • Motor 5/5 in LE
  • No spinal tenderness
  • SLR negative bilaterally

35
Treatment
  • PT
  • If not improving, get MRI and/or refer to spine
    clinic

36
5 weeks later
  • No better and MRI ordered and referred to spine
    clinic

37
(No Transcript)
38
MRI Case 2
39
MRI Case 2
40
MRI reading
  • L5-S1 disk protrusion contacting right S1 nerve
    root

41
Spine clinic visit next day
  • Hx same plus pain increases with cough/sneeze
  • Exam
  • Tender inferior to right piriformis muscle
  • ? sensation to light touch right S1, PP normal
  • DTR 2 knees and left ankle, 1 right ankle
  • Negative SLR
  • Prone press up pain in buttock
  • Dx Radiculopathy with HNP L5-S1

42
Spine clinic treatment
  • Right S1 diagnostic and therapeutic
    transforaminal steroid injection
  • PT and/or chiropracter
  • Oxycodone
  • Neurontin

43
8 weeks later (3 months after initial
presentation)
  • s/p 2 injections, PT, Chiropracter
  • Still severe pain and now weakness right leg with
    stairs
  • Referred to spine surgeon

44
Spine surgeon
  • Exam
  • SLR positive/ Lasegue positive on right
  • DTR 1 left ankle 0 right ankle
  • You should have been here within 6 weeks of
    onset of sciatica symptoms
  • Recommends L5-S1 microdiskectomy
  • Outpatient procedure with epidural
  • 95 get relief of pain
  • 3 risk of re-herniation

45
When to refer to spine surgeon
  • Cauda equina syndrome
  • Neuro motor deficit
  • Persistent severe sciatica after conservative
    treatment

46
Timing of referral for diskectomy
  • Optimal timing is not clear
  • No consensus on how long conservative treatment
    should be tried
  • Sciatica improves within 3 months in 75 of
    patients (95 at one year)

47
Surgery vs Prolonged Conservative Treatment for
Sciatica
  • Peul, et al NEJM May 31, 2007
  • 283 patients with 6-12 wk of severe sciatica and
    HNP on MRI
  • Randomized to
  • early surgery (microdiskectomey) vs
  • conservative therapy with surgery if needed
  • Primary outcomes
  • Subjective pain and disability scores
  • Perceived recovery

48
Outcomes of study
  • Surgery grp 89 surgery at mean 2.2 weeks
  • Conservative grp 36 surgery at mean 4½
    months
  • At 1 year no difference in pain or disability
    score or perceived recovery (95 in both grps)
  • Pain relief and perceived recovery faster in
    surgery group
  • Median time to full recovery 4 vs 12 weeks
  • Max difference in pain score lt20 mm on 100 mm
    scale

49
Peul, et al. New Engl J Med, 20073562245-56
50
Peul, et al. New Engl J Med, 20073562245-56
51
Peul, et al. New Engl J Med, 20073562245-56
52
Conclusions of study
  • Advantage of early surgery is faster relief of
    pain and faster perceived recovery time
  • Not blinded study (patient expectation bias)
  • Did not look at any objective outcomes e.g. days
    of work lost

53
SPORT studySurgical vs Nonoperative Treatment
for Lumbar Disk Herniation
  • Weinstein, et al JAMA November, 2006
  • 501 pts with radiculopathy and HNP for at least 6
    weeks
  • Open diskectomy vs conservative rx
  • Surgery grp 60 (50 within 3 months)
  • Conserv grp 45 (30 within 3 months)
  • No difference in subjective pain and disability
    scores

54
BOTTOM LINE
  • Risk of serious problem (e.g. cauda equina,
    neurological deterioration) is very small so most
    patients do not need urgent surgery
  • Main benefit of surgery is faster perceived
    recovery and resolution of disabling pain
  • No data on days of lost productivity
  • No other strong reason to advocate for surgery
    except patient preference

55
Bottom line
  • Offer surgery to patients who
  • Not able to cope with the pain
  • Find natural course of recovery to slow
  • Want to minimize time to recovery from pain
  • Questions for patient
  • How badly do you feel?
  • How urgently do you wish to achieve relief at
    cost of having surgery?

56
Follow up Case 1
  • Treated with CHOP plus Ritoxan
  • s/p 6 cycles
  • PET and CT scans pending

57
Follow up Case 2
  • 4 months s/p microdiskectomy
  • Back to work one month after surgery and doing
    well

58
References
  1. Jarvik, JG and Deyo, RA. Diagnostic evaluation
    of low back pain with emphasis on imaging. Ann
    Intern Med.2002137586-597.
  2. Stadnik, et al. Annular tears and disk
    herniation Prevalence and contrast enhancement
    on MR images in the absence of low back pain or
    sciatica. Radiology 199820649-55.
  3. ONeill, et al. Sciatica caused by isolated
    non-Hodgkin's lymphoma of the spinal epidural
    space A report of two cases. Br J Rheum
    199130385-86.
  4. Peul, et al. Surgery versus prolonged
    conservative treatment for sciatica. N Engl J
    Med 20073562245-56.
  5. Weinstein, et al. Surgical vs nonoperative
    treatment for lumbar disk herniation. SPORT
    trial. JAMA 20062962441-50.
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