First-Of-Its-Kind Study Sciatica Prognosis Worse Than Expected

Roughly six out of ten patients seeking primary care for back pain also report back-related leg pain.1 That number includes both leg pain characterized by nerve root entrapment (sciatica) and referred leg pain without nerve. root involvement.

Both presentations predict worse outcomes compared to back pain without leg pain.2 Setting aside the strong potential for recurrence,3 we have previously reported that sciatica has a good prognosis, with the majority of pain complaints resolving within four weeks.4

This belief undergirds the guidance to provide a stepped approach to sciatica treatment (starting with analgesics and over time progressing to exercise therapy and then to other treatments including surgery if the symptoms persist).5

However, a recent study from the UK’s Research Institute for Primary Care & Health Sciences provides data challenging our old understanding of sciatica prognosis. This first-of-its-kind study is a prospective cohort analysis of more than 400 sciatica patients presenting to primary care. Kika Konstantinou and colleagues analysed the persistence of symptoms and predictive factors.6

One year after the initial primary care encounter, patients with back-related leg pain (mostly sciatica) went from:

• a baseline disability of 12.6 on a 23- point scale to 7.8

• a baseline back-pain intensity of 5.6 on a 10-point scale to 3.3

• a baseline leg-pain intensity of 5.2 to 2.4 Defining improvement as only a 30% reduction in the Roland-Morris Disability Questionnaire, only 55% of patients had improved their disability at 12 months.

Physiotherapy may have a role to play in improving these outcomes. In a randomised, controlled, double-blinded trial, researchers followed 180 consecutive patients with sciatica.7

Patients had symptoms that qualified them for surgery and were all referred by general practitioners, rheumatologists, and other doctors. The researchers divided patients into an active physiotherapy group and a cardiovascular exercise group. All patients continued care from their doctors and were not restricted in medication use. 

Over the course of eight weeks, patients in the active physiotherapy group received an average of five sessions with a physiotherapist. At one year follow-up, the active physiotherapy group experienced greater improvement in most measured outcomes including pain, functional status, and clinical findings.

The active physiotherapy group spent less time off work after one year, and they were 20% more likely to report sustained recovery.

Perhaps most telling is that the number of patients in the cardiovascular exercise group electing surgery within one year was five times greater than that with the active physiotherapy group. In the current study, Dr. Konstantinou et al. find the following factors predictive of longerlasting disability:

• longer leg pain duration

• patient assessment that the problem will last a long time

• higher pain intensity

• number of symptoms such as sleep disturbance, fatigue, and an inability to sit comfortably.

Depression was not predictive. Myotomal weakness predicted better outcomes. 

References

1. Hill JC, Konstantinou K, Egbewale BE, Dunn KM, Lewis M, van der Windt D. Clinical outcomes among low back pain consulters with referred leg pain in primary care. Spine. 2011 Dec 1;36 (25):2168-75.

2. Konstantinou K, Hider SL, Jordan JL, Lewis M, Dunn KM, Hay EM. The impact of low back-related leg pain on outcomes as compared with low back pain alone: a systematic review of the literature. The Clinical journal of pain. 2013 Jul 1;29(7):644-54.

3. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ. What low back pain is and why we need to pay attention. I. 2018 Jun 9;391(10137):2356-67.

4. van Tulder M, Peul W, Koes B. Sciatica: what the rheumatologist needs to know. Rheumatology. 2010; 6: 139-145.

5. Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal. 2015 Jun 1;15(6):1461- 77.

6. Konstantinou K, Dunn KM, Ogollah R, Lewis M, van der Windt D, Hay EM, ATLAS Study Team. Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. The Spine Journal. 2018 Jun 1;18(6):1030-40.

7. Nordin M, Belague F. Exercise may be beneficial for patients with chronic, severe sciatica who would normally qualify for surgery. Evid Based Med. 2013; 18 (2): 63-64.

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