Whilst low back pain (LBP) is the number one cause of disability worldwide, a small number of patients will suffer associated leg pain, generally due to a herniated intervertebral lumbar disc – commonly known as ’sciatica’. Responsible for less than five percent of all low-back presentations, lower limb pins and needles, tingling, numbness or weakness associated with sciatica is frequently more severe than LBP, with patients often expressing a degree of hopelessness associated with the condition. Approximately 70% of patients with sciatica will recover within a few weeks to a few months, yet others will report ongoing pain and disability for 12 months or more.
Recently, our group, lead by myself and Dr Paulo Ferreira from the Arthritis and Musculoskeletal Group at the University of Sydney’s Faculty of Health Sciences published two systematic reviews and meta-analyses in the European Spine Journal and Spine, focusing on optimal management strategies related to sciatica. The first review addressed the comparison between surgery and physical activity-based interventions, by statistically pooling evidence from twelve randomised trials (1978 participants), including six trials specifically addressing lumbar disc herniation, which is the focus for the bodyandmind blog (the remaining trials in this review focused on other causes of sciatica). In the short-term, greater symptom relief and improvement were associated with surgery for leg pain, back pain and disability outcomes over physical activity-based interventions. However, the size of the effect in the short-term was relatively small, ranging from 9 points for disability (4 studies, 825 patients), 16 points for leg pain (4 studies, 825 patients) and 12 points for LBP (3 studies, 416 patients) on a 0 to 100 scale and it is questionable whether it is clinically worthwhile. At long-term follow-up, results showed no differences between the two modalities up to and including greater than 2-years follow-up.
In a follow up study we asked whether advice to stay active or structured exercise was more beneficial in the management of sciatica, with five randomised trials included in the meta-analysis (604 participants). Overall, long-term results suggest that supervised exercise programs provide similar results to advice for leg pain and disability outcomes. However, exercise provided a small, superior effect for leg pain over advice – 11 points on a 0 to 100 scale (5 studies, 587 patients) in the short-term and it is again questionable whether this is clinically worthwhile. Supervised exercise in this review consisted of lower limb isometrics and core stability training.
So what do these findings tell us? With respect to the first review, practitioners should carefully consider the risks and costs associated with spinal surgery when making recommendations about treatment options for sciatica. Apart from the obvious risks associated with surgery, almost a quarter of patients with sciatica will need a reoperation within 10 years due to recurrent disc herniation or other complications. That being said, surgery was found to be cost effective in the long term and this can be attributed to fewer recurrences, less permanent disability benefits and absenteeism. Management decisions will depend on symptom severity, pain tolerance and treatment preferences, along with other factors such as patients’ expectations with treatments. Along this line, and given the non-significant findings between advice to remain active and structured exercise, practitioners have the opportunity to optimize the format and delivery of the advice they provide to their patients. This comes on the back of patients acknowledging that good communication, information sharing, support, and empathy from their practitioner was critical to their recovery and more likely resulted in a favourable outcome. Moreover, evidence shows therapists are not well versed in communicating this form of therapy, when compared to their ‘hands on’ treatment or exercise prescription. In addition, while it is logical to assume that advice is more cost-effective compared to exercise (i.e., waiting time for health care utilization, consultation frequency, and costs for exercise therapy visits), further economical analyses are warranted to provide firm conclusions. Finally, while there was a lack of high-quality evidence in both meta-analyses, this new updated information will nonetheless be of interest to patients, practitioners, insurers, and policy makers.
About Matt Fernandez
Matt completed his Masters in Chiropractic and Sports Science degrees at Macquarie University and the University of New South Wales respectively. Currently enrolled fulltime at the University of Sydney, Faculty of Health Sciences, Matt is a PhD candidate within the Arthritis and Musculoskeletal Research Group and is supervised by Dr Paulo Ferreira. Matt’s PhD focuses on the efficacy of treatments for sciatica and the effects of back pain on chronic diseases such cardiovascular disease and mental illness, utilising twin studies.
References
Fernandez M, Ferreira ML, Refshauge KM, Hartvigsen J, Silva IR, Maher CG, Koes BW, Ferreira PH. Surgery or physical activity in the management of sciatica: a systematic review and meta-analysis. Eur Spine J. 2015 Jul 26. [Epub ahead of print]
Fernandez M, Hartvigsen J, Ferreira ML, Refshauge KM, Machado AF, Lemes ÍR, Maher CG, Ferreira PH. Advice to Stay Active or Structured Exercise in the Management of Sciatica A Systematic Review and Meta-analysis. Spine (Phila Pa 1976). 2015 Jul 10. [Epub ahead of print]