Systematic Review Study of Current Sciatica Clinical Treatment Protocols and Recommend Revisions

By: Dr’s. Carlos M. Barrera, DC, MPH(c) and Mardochee K. Augustin, DC

Introduction:

Sciatica is a leading MSK (Musculoskeletal) complaint that brings thousands of Americans to visit medical institutions/professionals from emergency rooms, primary care, physical therapy, orthopedics, chiropractic clinics, urgent care, etc. The typical “sciatica patient” will report subjective symptoms of lower back pain, usually unilateral and pain traveling down the gluteal region on the posterior portion of the thigh. This paper tends to illustrate the management amongst disciplines of sciatica and review the role of inter professional teams in improving patient outcomes. MSK (Musculoskeletal) complaints attribute to the top three chief complaint reasons/visits to a doctor/provider (Barrera, Augustine, Et. Al, 2022). Musculoskeletal pain is described as pain and symptoms affecting the bones, joints, ligaments, tendons, and muscles (Cleveland clinic).

Objectives:

• Describe the etiology of sciatica 
• Describe the current clinical treatment protocols for sciatica
• Summarize the treatment options for a patient with sciatica 

Etiology: 

The sciatic nerve commonly causes symptoms by a structural impingement of the sciatic nerve which usually gets trapped in the piriformis muscle, which can also be called and/or associated with piriformis syndrome. In the geriatric population stenosis can also be the leading cause of sciatica symptoms. 

Subjective/Symptoms:

Patients with a chief complaint of sciatica will usually describe a pain in the lumbar spine unilaterally and traveling through the gluteal region down along the posterior thigh. The pain is described as a burning sensation deep in the buttock region.

Objective:

Objectively the provider may perform various physical exams, neurological testing and orthopedic testing including SLR (straight leg raises), Slump test, Bragard's test, Sicard's Test SICARDS and Cluster of Laslett. They may find a possible orthopedic testing; SLR where there is pain reproduced between 30 to 70 degrees of hip flexion and experienced primarily in the back. Neurologically they may find decreased motor strength and muscle stretching or previously known as DTR (deep tendon reflexes). Physical exam wise, there should be no reproduction of any abdominal complaint. 

Assessment:

Sciatica or M54. 3 (sciatica, unspecified side), The international classification of diseased-10 code for reimbursement is described as a disease of the musculoskeletal system and connective tissue and other dosopathies. There must be high evidence-based medicine standards/findings to confirm this diagnosis. When considering your differential diagnosis, include herniated discs, nerve root impingement, tumors, and Potts disease. 

Plan/Current treatment protocol: 

(Adapted from: Jama Network. (n.d.). Retrieved April 11, 2023, from https://jamanetwork.com/journals/jama/article-abstract/2782184 )

 Current treatment protocols include patient education, medical therapies, spinal manipulation, injections, and surgery. The goal of treating sciatica is to decrease pain and increase mobility. There are various ways to treat sciatic: Pharmacotherapy: Patients with sciatica can be treated with various pharmaceuticals such as muscle relaxants, NSAIDS, opioids, corticosteroids injections in a local region on the body, these treatments tend to not have any real long-term effect and provide temporary pain relief. OTC (over the counter, not prescribed) medications are usually recommended initial to treat the inflammation and swelling These include Advil, Motrin, naproxen. A typical corticoid steroid injection can provide pain relief for about 3 months. Patients typically have 3-4 shots a year. Chiropractic treatment for sciatica is an option. Spinal manipulation can help reduce nerve irritability responsible for symptoms to sciatica such as shooting nerve pain, muscle spasm, and. inflammation. However, it must be done without pain. There is limited research which shows spinal manipulation can aid in sciatica. Research has shown that spinal manipulation can aid in low back pain, but sciatica was not mentioned in any literature. There are other ways a chiropractor can help in the treatment of sciatica. This includes soft tissue manipulation to loosen muscles especially in the event of muscle spasm which is a symptom of sciatica. There is application of ice/cold therapy that can aid in reducing inflammation. Ultrasound is another modality that chiropractors can use to help treat sciatica. This reduces muscle stiffness and the pain that typically accompanies it. Acupuncture treatment for sciatic has been shown to be positive. According to one study acupuncture can help reduce the pain that is associated with sciatica. The theory behind the effectiveness of acupuncture in treating sciatic is that it stimulates inhibitory nerve fibers for a short period of time reducing transmission of pain signal to the brain. Bed rest is not recommended, on the contrary; pain free movement is encouraged. Practicing good posture is encouraged along with avoidance of activities that may incite pain. Exercise is encouraged to strengthen the core, gentle stretching of lumbar, glutes and hamstrings to decrease pain as well to increase range of motion. Surgery: If in the event pharmaceuticals or physical therapy provide no real improvement in pain after 6-8 weeks surgery must be considered. Surgery also is recommended when the patient has a loss of bladder and bowl control. Severe and unrelenting pain is also a reason for surgery. There could be structural abnormalities at play as well. These can include disc herniation, epidural hematoma, or abscess, and possible a tumor. One study found that sciatica surgery may speed up recovery. According to it surgery has similar effects to one year of conservative care. There are various types of surgery that treat sciatica. One is to remove a bone spur from a herniated disc that is pressing on the nerve. There are two surgical options; microdiscectomy which is a minimally invasive procedure to remove fragments of a herniated disk pressing on a nerve and laminectomy; which is a procedure where the lamina that pressing on the sciatic nerve is removed.

Conflict of interest disclosures: None Reported. 

Funding: None Reported.

References:

Horsley, L. (2008, June 1). ACP guidelines for the diagnosis and treatment of low back pain. American Family Physician. Retrieved April 19, 2023, from https://www.aafp.org/pubs/afp/issues/2008/0601/p1607.html 

JN;, D. R. A. W. (n.d.). Low back pain. The New England journal of medicine. Retrieved April 19, 2023, from https://pubmed.ncbi.nlm.nih.gov/11172169/ 

Foundation, A. B. I. M. (2021, August 11). American Chiropractic Association: Choosing wisely. Choosing Wisely | Promoting conversations between providers and patients. Retrieved April 19, 2023, from https://www.choosingwisely.org/societies/american-chiropractic-association/ 

Adrian C. Traeger, P. D. (2021, July 20). Patient information: Low back pain. JAMA. Retrieved April 19, 2023, from https://jamanetwork.com/journals/jama/article-abstract/2782184 

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