For the full versions of these articles see bmj.

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CLINICAL REVIEW

Diagnosis and treatment of sciatica

B W Koes,1 M W van Tulder,2 W C Peul3

1
Department of General Practice, Sciatica affects many people. The most important from vehicles.2 3 w2 Evidence for an association
Erasmus MC, University Medical symptoms are radiating leg pain and related disabil- between sciatica and sex or physical fitness is
Center Rotterdam, PO Box 2040, ities. Patients are commonly treated in primary care conflicting.2 3 w2
3000 CA Rotterdam, Netherlands
2 but a small proportion is referred to secondary care
EMGO Institute, VU University
Medical Center, Amsterdam, and may eventually have surgery. Many synonyms How is sciatica diagnosed?
Netherlands for sciatica appear in the literature, such as lumbosacral Sciatica is mainly diagnosed by history taking and
3
Department of Neurosurgery, radicular syndrome, ischias, nerve root pain, and nerve physical examination. By definition patients mention
Leiden University Medical Center, root entrapment. radiating pain in the leg. They may be asked to report
Leiden, Netherlands
In about 90% of cases sciatica is caused by a her- the distribution of the pain and whether it radiates
Correspondence to: B W Koes
[email protected] niated disc with nerve root compression, but lumbar below the knee and drawings may be used to evaluate
stenoses and (less often) tumours are possible causes. the distribution. Sciatica is characterised by radiating
BMJ 2007;334:1313-7
doi:10.1136/bmj.39223.428495.BE
The diagnosis of sciatica and its management varies pain that follows a dermatomal pattern. Patients may
considerably within and between countries—for exam- also report sensory symptoms.
ple, the surgery rates for lumbar discectomy vary Physical examination largely depends on neurologi-
widely between countries.w1 A recent publication con- cal testing. The most applied investigation is the
firmed this large variation in disc surgery, even within straight leg raising test or Lasègue’s sign. Patients
countries.1 This may in part be caused by a paucity of with sciatica may also have low back pain but this is
evidence on the value of diagnostic and therapeutic usually less severe than the leg pain. The diagnostic
interventions and a lack of clear clinical guidelines or value of history and physical examination has not
reflect differences in healthcare and insurance systems. been well studied.4 No history items or physical exam-
This review presents the current state of science for the ination tests have both high sensitivity and high speci-
diagnosis and treatment of sciatica. ficity. The pooled sensitivity of the straight leg raising
test is estimated to be 91%, with a corresponding
Who gets sciatica? pooled specificity of 26%.5 The only test with a high
Exact data on the incidence and prevalence of sciatica specificity is the crossed straight leg raising test, with
are lacking. In general an estimated 5%-10% of patients a pooled specificity of 88% but sensitivity of only 29%.5
with low back pain have sciatica, whereas the reported Overall, if a patient reports the typical radiating pain in
lifetime prevalence of low back pain ranges from 49% one leg combined with a positive result on one or more
to 70%.w2 The annual prevalence of disc related sciatica neurological tests indicating nerve root tension or neu-
in the general population is estimated at 2.2%.2 A few rological deficit the diagnosis of sciatica seems justi-
personal and occupational risk factors for sciatica have fied. Box 2 shows the signs and symptoms that help
been reported (box 1), including age, height, mental to distinguish between sciatica and non-specific low
stress, cigarette smoking, and exposure to vibration back pain.

What is the value of imaging?

Sources and selection criteria Diagnostic imaging is only useful if the results influ-
ence further management. In acute sciatica the diagno-
We identified systematic reviews in the Cochrane
Library evaluating the effectiveness of conservative and
sis is based on history taking and physical examination
surgical interventions for sciatica. Medline searches up and treatment is conservative (non-surgical). Imaging
to December 2006 were carried out to find other may be indicated at this stage only if there are indica-
relevant systematic reviews on the diagnosis and tions or “red flags” that the sciatica may be caused by
treatment of low back pain. Keywords were sciatica, underlying disease (infections, malignancies) rather
hernia nuclei pulposi, ischias, nerve root entrapment, than disc herniation.
systematic review, meta-analysis, diagnosis, and Diagnostic imaging may also be indicated in patients
treatment. In addition we used our personal files for
with severe symptoms who fail to respond to conserva-
other references, including publications of recent
randomised clinical trials. Finally we checked the tive care for 6-8 weeks. In these cases surgery might be
availability of clinical guidelines. considered and imaging used to identify if a herniated
disc with nerve root compression is present and its

BMJ | 23 JUNE 2007 | VOLUME 334 1313

 CLINICAL REVIEW

Box 1 | Risk factors for acute sciatica3 w2 within 12 months.12 About 50% of patients with acute
sciatica included in placebo groups in randomised
Personal factors
 Age (peak 45-64 years)
trials of non-surgical interventions reported improve-
ment within 10 days and about 75% reported improve-
 Increasing risk with height
ment after four weeks.13 In most patients therefore the
 Smoking
prognosis is good, but at the same time a substantial
 Mental stress
proportion (up to 30%) continues to have pain for
Occupational factors one year or longer.12 13
 Strenuous physical activity—for example, frequent
lifting, especially while bending and twisting What is the efficacy of conservative treatments for
 Driving, including vibration of whole body
sciatica?
Conservative treatment for sciatica is primarily aimed
at pain reduction, either by analgesics or by reducing
pressure on the nerve root. A recent systematic review
Box 2 | Indicators for sciaticaw5
found that conservative treatments do not clearly
 Unilateral leg pain greater than low back pain
improve the natural course of sciatica in most patients
 Pain radiating to foot or toes or reduce symptoms.14 Adequately informing patients
 Numbness and paraesthesia in the same distribution
about the causes and expected prognosis may be an
 Straight leg raising test induces more leg pain important part of the management strategy. However,
 Localised neurology—that is, limited to one nerve root educating patients about sciatica has not been specifi-
cally investigated in randomised controlled trials.
Box 3 summarises the evidence of effectiveness for
location and extent. It is important as part of the deci- commonly available conservative treatments for scia-
sion to operate that the clinical findings and symptoms tica, including injection therapy. Strong evidence of
correspond well with the scan findings. This is espe- effectiveness is lacking for most of the available inter-
cially relevant because disc herniations identified by ventions. Little difference in effect on pain and func-
computed tomography or magnetic resonance ima- tional status has been shown between bed rest and
ging are highly prevalent (20%-36%) in people without advice on staying active.15 As a result of this finding,
symptoms who do not have sciatica.6 w3 In many bed rest—for a long time the mainstay of treatment
people with clinical symptoms of sciatica no lumbar for sciatica—is no longer widely recommended.w2 w4
disc herniations are present on scans.7 8 At present no Analgesics, non-steroidal anti-inflammatory drugs,
one type of imaging method shows a clear advantage and muscle relaxants do not seem to be more effective
over others. Although some authors favour magnetic than placebo in reducing symptoms. Evidence for
resonance imaging above other imaging techniques opioids and various compound drugs is lacking. A sys-
because computed tomography has a higher radiation tematic review reported that no evidence exists for
dose or because soft tissues are better visualised,9 10 evi- traction, non-steroidal anti-inflammatory drugs, intra-
dence shows that both are equally accurate at diagnos- muscular steroids, or tizanidine being superior to
ing lumbar disc herniation.11 Radiography for the placebo.13 This review suggested that epidural injec-
diagnosis of lumbar disc herniation is not recom- tions of steroid might be effective in patients with acute
mended because discs cannot be visualised by x sciatica.13 However, a more recent systematic review of
rays.11 a larger number of randomised trials reported that
there was no evidence of positive short term effects of
What is the prognosis? corticosteroid injections and that the long term effects
In general the clinical course of acute sciatica is favour- were unknown.14 The same systematic review reported
able and most pain and related disability resolves that active physical therapy (exercises) seemed not to
within two weeks. For example, in a randomised trial be better than inactive (bed rest) treatment and other
that compared non-steroidal anti-inflammatory drugs conservative treatments, such as traction, manipula-
with placebo for acute sciatica in primary care 60% of tion, hot packs, or corsets).14
the patients recovered within three months and 70%
What is the role of surgery in sciatica?
Surgical intervention for sciatica focuses on removal of
Box 3 | Levelsofevidenceforconservativetreatmentsfor disc herniation and eventually part of the disc or on
sciatica
foraminal stenosis, with the purpose of eliminating
 Bed rest (trade-off) the suspected cause of the sciatica. Treatment is
 Staying active, in contrast to bed rest (likely to be aimed at easing the leg pain and corresponding symp-
beneficial) toms and not at reducing the back pain. Consensus is
 Analgesics or non-steroidal anti-inflammatory drugs,
that a cauda equina syndrome is an absolute indication
acupuncture, epidural steroid injections, spinal
for immediate surgery. Elective surgery is the choice
manipulation, traction therapy, physical therapy,
behavioural treatment, multidisciplinary treatment for unilateral sciatica. Until recently only one relatively
(unknown effectiveness) old randomised trial was available that compared sur-
gical intervention with conservative treatment for

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 CLINICAL REVIEW

selected patients with sciatica as a result of lumbar disc

Box 4 | Clinical guideline for diagnosis and treatment of
prolapse that fails to resolve with conservative care. A
sciatica from Dutch College of General Practicew4
recent review came to the same conclusion.18 The
Diagnosis Cochrane review further concluded that the long
 Check for red flag conditions, such as malignancies, term effects of surgical intervention are unclear and
osteoporotic fractures, radiculitis, and cauda equina that evidence on the optimal timing of surgery is also
syndrome lacking.17
 Take a history to determine localisation; severity; loss
of strength; sensibility disorders; duration; course;
Randomised controlled trials not yet included in
influence of coughing, rest, or movement; and
consequences for daily activities
systematic reviews
 Carry out a physical examination, including
Two additional randomised controlled trials have been
neurological testing—for example, straight leg raising published comparing disc surgery with conservative
test (Lasègue’s sign) treatment. One trial (n=56) compared microdiscect-
 Carry out the following tests in cases with a omy with conservative treatment in patients who had
dermatomal pattern, or positive result on straight leg had sciatica for six to 12 weeks.19 Overall, no signifi-
raising test, or loss of strength or sensibility disorders: cant differences were found for leg pain, back pain, and
reflexes (Achilles or knee tendon), sensibility of subjective disability over two years of follow-up. Leg
lateral and medial sides of feet and toes, strength of pain, however, seemed to initially improve more
big toe during extension, walking on toes and heel rapidly in patients in the discectomy group. The large
(left-right differences), crossed Lasègue’s sign
spine patient outcomes research trial (a randomised
 Imaging or laboratory diagnostic tests are only
trial) and related observational cohort study was car-
indicated in red flag conditions but are not useful in
ried out in the United States.20 21 Patients with sciatica
cases of suspected disc herniation
for at least six weeks and confirmed disc herniation
Treatment
were invited to participate in either a randomised trial
 Explain cause of the symptoms and reassure patients
or an observational cohort study. Patients in the trial
that symptoms usually diminish over time without
specific measures were randomised to disc surgery or to conservative
 Advise to stay active and continue daily activities; a care. Patients in the cohort study received disc surgery
few hours of bed rest may provide some symptomatic or conservative care based on their preference. In the
relief but does not result in faster recovery randomised trial (n=501) both treatment groups
 Prescribe drugs, if necessary, according to four steps: improved substantially over two years for all primary
(1) paracetamol; (2) non-steroidal anti-inflammatory and secondary outcome measures. Small differences
drugs; (3) tramadol, paracetamol, or non-steroidal were found in favour of the surgery group, but these
anti-inflammatory drug in combination with codeine; were not statistically significant for the primary out-
and (4) morphine come measures. Only 50% of the patients randomised
 Refer to neurosurgeon immediately in cases of cauda to surgery received surgery within three months of
equina syndrome or acute severe paresis or inclusion compared with 30% randomised to conser-
progressive paresis (within a few days)
vative care. After two years of follow-up 45% of
 Refer to neurologist, neurosurgeon, or orthopaedic
patients in the conservative care group underwent sur-
surgeon for consideration of surgery in cases of
gery compared with 60% in the surgery group.20
intractable radicular pain (not responding to
morphine) or if pain does not diminish after 6-8 weeks The observational cohort included 743 patients.
of conservative care Both groups improved substantially over time, but
the surgery group showed significantly better results
for pain and function compared with the conservative
patients with sciatica.16 This study showed that surgical group. The authors did mention caution in interpreting
intervention had better results after one year, whereas the findings because of potential confounding by indi-
after four and 10 years of follow-up no significant dif- cation and because outcome measures were self
ferences were found.16 reported.21
A Cochrane review summarised the available ran-
domised clinical trials evaluating disc surgery and
chemonucleolysis.17 In chemonucleolysis the enzyme Additional educational resources
chymopapain is injected in the discus with the purpose BMJ Clinical Evidence (www.clinicalevidence.org)—Up
of shrinking the nucleus pulposus. The review reported to date evidence for clinicians on the benefits and
better results with disc surgery than with chemonucleo- harms of treatments for a variety of disorders
lysis in patients with severe sciatica of relatively long Cochrane Back Review Group (www.cochrane.iwh.on.
duration varying from more than four weeks to more ca)—Activities of review group responsible for writing
than four months. Chemonucleolysis was more effec- systematic Cochrane reviews on the efficacy of
treatments for low back pain and sciatica
tive than placebo. Indirectly therefore the review sug-
Low back pain: guidelines for its management (www.
gested that disc surgery is more effective than placebo.
backpaineurope.org)—Recently issued guidelines for
On the basis of data from three trials the authors con- the management of low back pain and sciatica from the
cluded that evidence is considerable that surgical dis- European Commission Research Directorate General
cectomy provides effective clinical relief for carefully

BMJ | 23 JUNE 2007 | VOLUME 334 1315

 CLINICAL REVIEW

vative, with a strong focus on patient education, advice

A patient’s perspective (A)
to stay active, continuing daily activities, and adequate
After an episode of lumbago during a vacation I continuously had low back pain and treatment for pain. In this phase imaging has no role.
tingling feet for about nine months. Then suddenly my right foot started to hurt badly Referral to a medical specialist—for example, neuro-
and after a while the pain became so severe that I was unable to leave my house. The
specialist ordered an MRI (magnetic resonance imaging) scan and it revealed a large
logist, rheumatologist, spine surgeon—is indicated in
lumbar disc herniation. Since it only got worse after that I decided to have surgery. patients whose symptoms do not improve after conser-
After the operation I recovered quickly and the back pain and leg pain were completely vative treatment for at least 6-8 weeks. In these referred
gone. I soon was able to go back to work and rebuild my social life. Unfortunately after cases surgery may be considered. Immediate referral is
a couple of months the low back pain and the other symptoms returned, although not indicated in cases with a cauda equina syndrome.
as severe as before surgery. A new MRI scan now revealed two small disc herniations Acute severe paresis or progressive paresis are also rea-
and two bad intervertebral discs. The specialist told me that it was too early for a sons for referral (within a few days).
second operation.
Now it is unclear to me what the doctor can do about it and I don’t even know which
measures I can take myself. The constant back and leg pain are greatly interfering with
Promising developments
my work and my social life. I sometimes feel like an elderly person because of my More evidence based information has become avail-
physical limitations. I try to stay positive, but it is hard to cope with the uncertainty. able on the efficacy of surgical care compared with con-
C Penning, aged 32, Rotterdam servative care for patients with sciatica. Although
evidence is limited, initial findings suggest no impor-
tant differences in long term (one or two years) effect
The results indicate that both conservative care and between these two approaches. This finding may be
disc surgery are relevant treatment options for patients partly explained by patients who initially received con-
with sciatica of at least six weeks’ duration. Surgical servative care later undergoing disc surgery. In all
intervention may provide quicker relief of symptoms available studies it seems that a substantial proportion
compared with conservative care, but no large differ- of patients improve over time. This holds true for
ences have been found in success rate after one or two patients undergoing surgery or receiving conservative
years of follow-up. Patients and doctors may thus care. Patients undergoing disc surgery are more likely
weigh the benefits and harms of both options to make to get quicker relief of leg symptoms than patients
individual choices. This is especially relevant because receiving conservative care. If symptoms do not
patients’ preference for treatment may have a direct improve after 6-8 weeks patients may opt for disc sur-
positive influence on the magnitude of the treatment gery. Those who are hesitant about surgery and can
effect. cope with their symptoms may opt for continued con-
servative care. Patient preference is therefore an
important feature in the decision process.
What are the recommendations in clinical guidelines? Since the mid-1990s a switch has occurred in the
Although in many countries clinical guidelines are management of sciatica from passive treatments, such
available for the management of non-specific low as bed rest, to a more active approach, with patients
back pain this is not the case for sciatica.22 Box 4 being advised to continue their daily activities as
shows the recommendations for sciatica (lumbosacral much as possible.
radicular syndrome) in clinical guidelines recently
issued by the Dutch College of General Practice.w4 Future research
After excluding specific diseases on the basis of red More information is needed on the importance of clin-
flags, sciatica is diagnosed on the basis of history taking ical signs and symptoms for the prognosis of sciatica
and physical examination. Initial treatment is conser- and the response to treatment. This includes the
value of size and location of the disc herniation, visible
nerve root compression, sequestration, and the results
A patient’s perspective (B) of history taking and physical and neurological exam-
My complaints started about four months ago with pain in the lower back. Soon after inations. Subgroup analysis in a Finnish trial showed
the pain radiated into my legs, for which I went to my general practitioner. His analysis that discectomy was superior to conservative treat-
was no herniated disc. A muscle relaxant in combination with referral to a ment in patients with disc herniation at L4-5.23 No
physiotherapist would reduce the symptoms. Three weeks of physiotherapy followed
strong evidence exists for or against the efficacy of
by several treatments by a chiropractor did not provide any symptom relief. In fact the
symptoms became worse—especially during walking and standing. Lying down and many of the available conservative treatments. Much
cycling were much better tolerated. Additional complaints were reduced strength in the progress can be achieved here. Questions remain
left leg, not being able to stand on the heel or toes, a cold feeling in the lower leg at the about the efficacy of analgesics for sciatica and the
end of the day, while in the morning it felt like standing in a bunch of needles. value of physical therapy and of patient education
About one month ago a neurologist diagnosed a herniated disc on the right side based and counselling. No trial has yet evaluated the effec-
on an MRI scan that was taken. However, this could not explain the symptoms in the tiveness of behavioural treatment and multidisciplin-
left leg. The symptoms in the left leg could be due to spinal stenosis. The complaints ary treatment programmes.
were not severe enough to recommend surgery and the neurologist told me that a
Tumour necrosis factor α has been identified in ani-
substantial improvement was to be expected within a period of 3-4 months. His advice
was to continue normal daily activities as much as possible. At present (one month mal and human studies as one factor in the develop-
later) I feel some improvement of my symptoms. ment of sciatica.23 24 The first randomised trial
J Vreuls, aged 49, The Hague evaluating a tumour necrosis factor α antagonist in
patients with sciatica did not find a positive result.25

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8 Modic MT, Obuchowski NA, Ross J, Brant-Zawadzki MN, Grooff PN,

SUMMARY POINTS Mazanec DJ, et al. Acute low back pain and radiculopathy: MR
imaging findings and their prognostic role and effect on outcome.
Most patients with acute sciatica have a favourable Radiology 2005;237:597-604.
prognosis but about 20%-30% have persisting problems 9 Govind J. Lumbar radicular pain. Aus Fam Phys 2004;33:409-12.
after one or two years 10 Awad JN, Moskovich R. Lumbar disc herniations: surgical versus
nonsurgical treatment. Clin Orthop Relat Res 2006;443:183-97.
The diagnosis is based on history taking and physical 11 Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with
examination emphasis on imaging. Ann Intern Med 2002137:586-97.
12 Weber H, Holme I, Amlie E. The natural course of acute sciatica with
Imaging is indicated only in patients with “red flag” nerve root symptoms in a double blind placebo-controlled trial of
conditions or in whom disc surgery is considered evaluating the effect of piroxicam (NSAID). Spine 1993;18:1433-8.
Passive (bed rest) treatments have been replaced with more 13 Vroomen PCAJ, Krom MCTFM de, Slofstra PD, Knottnerus JA.
Conservative treatment of sciatica: a systematic review. J Spinal Dis
active treatments 2000;13:463-9.
Consensus is that initial treatment is conservative for about 14 Luijsterburg PAJ, Verhagen AP, Ostelo RWJG, Os TAG van, Peul WC,
6-8 weeks Koes BW. Effectiveness of conservative treatments for the
lumbosacral radicular syndrome: a systematic review. Eur Spine J
Disc surgery may provide quicker relief of leg pain than 2007 Apr 6;(Epub ahead of print).
conservative care but no clear differences have been found 15 Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated Cochrane
after one or two years review of bedrest for low back pain and sciatica. Spine
2005;30:542-6.
16 Weber H. Lumbar disc herniation. A controlled prospective study with
ten years of observation. Spine 1983;8:131-40.
17 Gibson JN, Waddell G. Surgical interventions for lumbar disc
Contributors: BWK wrote the first draft. MWvT and WCP critically appraised prolapse. Cochrane Database Syst Rev 2007 Jan 24;(1):CD001350.
and improved the manuscript. BWK is guarantor. 18 Van Tulder MW, Koes B, Seitsalo S, Malmivaara A. Outcome of
invasive treatment modalities on back pain and sciatica: an
Competing interests: None declared.
evidence-based review. Eur Spine J 2006;15:S82-92.
Provenance and peer review: Commissioned; peer reviewed. 19 Osterman H, Seitsalo S, Karppinen J, Malmivaara A. Effectiveness of
microdiscectomy for lumbar disc herniation. Spine
1 Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ 2006;31:2409-14.
trends and regional variations in lumbar spine surgery: 1992-2003. 20 Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Hanscom B,
Spine 2006;31:2707-14. Skinner JS, et al. Surgical vs nonoperative treatment for lumbar disk
2 Younes M, Bejia I, Aguir Z, Letaief M, Hassen-Zroer S, Touzi M, et al. herniation: the spine patient outcomes research trial (SPORT): a
Prevalence and risk factors of disc-related sciatica in an urban randomized trial. JAMA 2006;296:2441-50.
population in Tunisia. Joint Bone Spine 2006;73:538-42. 21 Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson
3 Miranda H, Viikari-Juntera E, Martikainen R, Takala E, Riihimaki H. ANA, et al. Surgical vs nonoperative treatment for lumbar disk
Individual factors, occupational loading, and physical exercise as herniation: the spine patient outcomes research trial (SPORT)
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4 Vroomen PCAJ, Krom MCTFM de, Knottnerus JA. Diagnostic value of 22 Koes BW, Tulder MW van, Ostelo R, Burton AK, Waddell G. Clinical
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Mazanec DJ. Contrast-enhanced MR imaging in acute lumbar Bowman C, et al. The treatment of disc herniation-induced sciatica
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CORRECTIONS AND CLARIFICATIONS

Improved effectiveness of partner notification for Drug eluting stents: What fuels public policy?
patients with sexually transmitted infections: During the preparation of this letter by Mark H Wilson
systematic review (BMJ 2007;334:599-600, 24 Mar, doi: 10.1136/
In this research article by Sven Trelle and colleagues (BMJ bmj.39150.648762.BE), we wrongly marked up the
2007;334:354-7; doi: 10.1136/bmj.39079.460741.7C) position and email address of the author. His correct
two errors were missed in the full version (on bmj.com). affiliation is director of medical ethics
The absolute risk ratio if 10% of patients managed with ([email protected]).
simple patient referral had persistent or recurrent
infections would be 2.7% [not 3.7%] and the number
needed to treat 37 [not 27]. Short Cuts Extra: INR easily monitored at home
Cover picture In this item by Harvey Marcovitch about the use of
In the 26 May issue of the BMJ we put a picture of a portable coagulometers (BMJ 2007;334:928, 5 May,
roundworm on the cover of the printed journal, beside the doi: 10.1136/bmj.39191.635637.AD) the penultimate
words “Anaemia in developing countries.” As we should sentence should have read: “Paired results were
have known, it is not roundworms, but hookworms, that highly correlated (r=0.91), and only three (5%) of the
occur with iron deficiency anaemia (as the editorial in that home tests differed from laboratory results by >15%
issue pointed out). [not >20%].”

BMJ | 23 JUNE 2007 | VOLUME 334 1317