Sciatica: When to image When to refer

Sciatica: When to image When to refer
Presentation by:Juanita Halls M.D.
Internal Medicine


Objectives

* Understand when to perform imaging on patients presenting with sciatica
* Understand when to refer patients with sciatica to a spine surgeon

Case 1
PMH

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

Imaging

* L/S spine films: multilevel degenerative disk and joint disease
* “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
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
Exam

* No spinal tenderness
* SLR negative on left, positive at 60o on right
* DTR: symmetrical
* Motor: 5/5
Plan

* MRI offered but patient declined
* Diclofenac (was having side effects with naproxen)
* PT referral
* Spine clinic referral
4 weeks later (3 months after initial presentation)

* Seen in Spine clinic:
o Pain had gotten better, now worse again and interfering with sleep
o No systemic symptoms
* Exam:
o No change except minimal tenderness
o Positive SLR/Lasegue maneuver
* DX: Probable HNP
* Plan: MRI
2 Weeks later
(3 ½ months after presentation)
* MRI competed and I am paged by the Spine clinic physician late Friday afternoon
MRI case 1
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
10 days later

* CT guided biopsy:
o Large B cell lymphoma
Low Back Pain

* Low back pain
o 84% of adults experience LBP
o 2.5% of medical visits
o Total cost in US: $100 Billion per year
o <5% have serious pathology
o 5% have sciatica
+ Annual incidence of sciatica is 5 per 1000
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
Etiology of sciatica

* Mechanical
* Neoplastic (0.7% of LBP)
* Infectious (0.01% of LBP)

Questions to ask
* Is there evidence of systemic disease?
* Is there evidence of neurological compromise?
Clues on history to suggest systemic disease
Testing for lumbar nerve root compromise
Straight leg raising
Dorsiflexion of the foot (Lasegue's test) will exacerbate these symptoms
SLR with Lasegue test
Sensitivity/specificity for radiculopathy, in patients with sciatica
Imaging indications
Imaging – L/S spine films
Imaging - MRI
Malignancy and sciatica
Case 2
Previous history
Exam
Treatment
5 weeks later
MRI Case 2
MRI reading
Spine clinic visit next day
Spine clinic treatment
8 weeks later (3 months after initial presentation)
Spine surgeon
When to refer to spine surgeon
Timing of referral for diskectomy
Surgery vs Prolonged Conservative Treatment for Sciatica
Outcomes of study
Conclusions of study
SPORT study
Surgical vs Nonoperative Treatment for Lumbar Disk Herniation
BOTTOM LINE

Sciatica: When to image When to refer.ppt