Title: Sciatica: When to image. When to refer.
1Sciatica When to image. When to refer.
- Juanita Halls M.D.
- Internal Medicine
- October 10, 2007
2 3Objectives
- Understand when to perform imaging on patients
presenting with sciatica - Understand when to refer patients with sciatica
to a spine surgeon
4Case 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
5PMH
- 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)
6Exam
- 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
7Imaging
- L/S spine films multilevel degenerative disk
and joint disease - No labs done
8Dx/ 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
92 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
10Exam
- No spinal tenderness
- SLR negative on left, positive at 60o on right
- DTR symmetrical
- Motor 5/5
11Plan
- MRI offered but patient declined
- Diclofenac (was having side effects with
naproxen) - PT referral
- Spine clinic referral
124 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
132 Weeks later(3 ½ months after presentation)
- MRI competed and I am paged by the Spine clinic
physician late Friday afternoon
14MRI case 1
15MRI Case 1
16MRI 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
1710 days later
- CT guided biopsy
- Large B cell lymphoma
18Low 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
19Definition 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
20Etiology of sciatica
- Mechanical
- Pyriformis syndrome
- HNP
- Spondylolisthesis
- Compression fracture
- Neoplastic (0.7 of LBP)
- Infectious (0.01 of LBP)
21Questions to ask
- Is there evidence of systemic disease?
- Is there evidence of neurological compromise?
22Clues 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 /-
23Exam
- Back exam
- ROM
- Palpate for tenderness
- SLR
- Neuro exam
- If suspicious history
- Breast or prostate exam
- Lymph node exam
24Testing for lumbar nerve root compromise
25Straight 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
26SLR with Lasegue test
27LR
28Imaging indications
- Progression of neurological findings
- Constitutional symptoms
- Hx of traumatic onset
- Hx of malignancy
- lt18 or gt 50
- Infection risk (IVDU, immunocompromise, fever)
- Osteoporosis
29Imaging 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
30Imaging - 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)
31Malignancy 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
32Case 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
33Previous 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
34Exam
- DTRs 2 at knee and ankle
- Motor 5/5 in LE
- No spinal tenderness
- SLR negative bilaterally
35Treatment
- PT
- If not improving, get MRI and/or refer to spine
clinic
365 weeks later
- No better and MRI ordered and referred to spine
clinic
37(No Transcript)
38MRI Case 2
39MRI Case 2
40MRI reading
- L5-S1 disk protrusion contacting right S1 nerve
root
41Spine 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
42Spine clinic treatment
- Right S1 diagnostic and therapeutic
transforaminal steroid injection - PT and/or chiropracter
- Oxycodone
- Neurontin
438 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
44Spine 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
45When to refer to spine surgeon
- Cauda equina syndrome
- Neuro motor deficit
- Persistent severe sciatica after conservative
treatment
46Timing 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)
47Surgery 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
48Outcomes 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
49Peul, et al. New Engl J Med, 20073562245-56
50Peul, et al. New Engl J Med, 20073562245-56
51Peul, et al. New Engl J Med, 20073562245-56
52Conclusions 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
53SPORT 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
54BOTTOM 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
55Bottom 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?
56Follow up Case 1
- Treated with CHOP plus Ritoxan
- s/p 6 cycles
- PET and CT scans pending
57Follow up Case 2
- 4 months s/p microdiskectomy
- Back to work one month after surgery and doing
well
58References
- Jarvik, JG and Deyo, RA. Diagnostic evaluation
of low back pain with emphasis on imaging. Ann
Intern Med.2002137586-597. - 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. - 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. - Peul, et al. Surgery versus prolonged
conservative treatment for sciatica. N Engl J
Med 20073562245-56. - Weinstein, et al. Surgical vs nonoperative
treatment for lumbar disk herniation. SPORT
trial. JAMA 20062962441-50.