A diagnostic study in patients with sciatica establishing the importance of localization of worsening of pain during coughing, sneezing and straining to assess nerve root compression on MRI

Verwoerd, Annemieke; Mens, Jan; Barzouhi, Abdelilah el; Peul, Wilco C.; Koes, Bart W.; Verhagen, Arianne P.

doi:10.1007/s00586-016-4393-8

Cited by 19 publications

(11 citation statements)

References 8 publications

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“…The term sciatica is used inconsistently, by clinicians and patients for different types of leg/back pain and should be avoided. 24 The diagnosis of radicular pain relies on clinical findings including a history of dermatomal leg pain, leg pain worse than back pain, worsening of leg pain during coughing, sneezing or straining 25 and straight leg raise test.…”

Section: Radicular Pain and Radiculopathymentioning

confidence: 99%

What low back pain is and why we need to pay attention

Buchbinder¹,

Hartvigsen

Cherkin³

et al. 2018

The Lancet

3,170

2,394

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Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

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Section: Radicular Pain and Radiculopathymentioning

confidence: 99%

What low back pain is and why we need to pay attention

Buchbinder¹,

Hartvigsen

Cherkin³

et al. 2018

The Lancet

3,170

2,394

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“…Patients with clinical suspicion (by their general practitioner [GP] or the assessing physiotherapist) of serious spinal path ology (eg, cauda equina syndrome, fracture, spondylo arthropathy, malignancy, infection, or foot drop) or serious physical or mental comorbidities (as judged by their GP or the assessing physiotherapist) were excluded. The sciatica case definition for this trial was based on the assessing physiotherapist being at least 70% confident in their clinical diagnosis, 20,21 with at least one of the following being present: leg pain approximating a dermatomal distribu tion; leg pain worse than or as bad as back pain; leg pain worse with coughing, sneezing, or straining; sub jective sensory changes approximating a dermatomal distribu tion; objective neurological deficits indicative of nerve root compression; positive neural tension test; 22,23 and (specifi cally for spinal claudication or spinal steno sis) leg pain worse with weightbearing activities and better with sitting. Assessing physiotherapists recorded a specific clinical diagnosis of sciatica due to disc prolapse or stenosis.…”

Section: Implications Of All the Available Evidencementioning

confidence: 99%

Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial

Konstantinou

Lewis

Dunn

et al. 2020

The Lancet Rheumatology

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Background Sciatica has a substantial impact on individuals and society. Stratified care has been shown to lead to better outcomes among patients with non-specific low back pain, but it has not been tested for sciatica. We aimed to investigate the clinical and cost-effectiveness of stratified care versus non-stratified usual care for patients presenting with sciatica in primary care. MethodsWe did a two-parallel arm, pragmatic, randomised controlled trial across three centres in the UK (North Staffordshire, North Shropshire/Wales, and Cheshire). Eligible patients were aged 18 years or older, had a clinical diagnosis of sciatica, access to a mobile phone or landline number, were not pregnant, were not currently receiving treatment for the same problem, and had no previous spinal surgery. Patients were recruited from general practices and randomly assigned (1:1) by a remote web-based service to stratified care or usual care, stratified by centre and stratification group allocation. In the stratified care arm, a combination of prognostic and clinical criteria associated with referral to spinal specialist services were used to allocate patients to one of three groups for matched care pathways. Group 1 was offered brief advice and support in up to two physiotherapy sessions; group 2 was offered up to six physiotherapy sessions; and group 3 was fast-tracked to MRI and spinal specialist assessment within 4 weeks of randomisation. The primary outcome was self-reported time to first resolution of sciatica symptoms, defined as "completely recovered" or "much better" on a 6-point ordinal scale, collected via text messages or telephone calls. Analyses were by intention to treat. Health-care costs and cost-effectiveness were also assessed. This trial is registered on the ISRCTN registry, ISRCTN75449581.

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“…We also asked the assessing physiotherapists to record a specific diagnosis of disc prolapse or stenosis for the sciatic symptoms. At least one of the following signs and symptoms contributing to the clinical diagnosis of sciatica 7,39,40 had to be present: leg pain approximating a dermatomal distribution; leg pain worse than, or as bad as, back pain; leg pain worse with coughing/sneezing/ straining; subjective sensory changes approximating a dermatomal distribution; objective neurological deficits indicative of nerve root compression; positive neural tension test; and (specifically for spinal claudication/spinal stenosis) leg pain worse with weight-bearing activities and better with sitting. Patients were excluded if the assessing physiotherapist thought that the leg pain was a result of causes other than sciatica (e.g.…”

Section: Baseline Assessment Eligibility Screening and Informed Consentmentioning

confidence: 99%

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT

Foster

Konstantinou

Lewis

et al. 2020

Health Technol Assess

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Background Sciatica has a substantial impact on patients and society. Current care is ‘stepped’, comprising an initial period of simple measures of advice and analgesia, for most patients, commonly followed by physiotherapy, and then by more intensive interventions if symptoms fail to resolve. No study has yet tested a model of stratified care in which patients are subgrouped and matched to different care pathways based on their prognosis and clinical characteristics. Objectives The objectives were to investigate the clinical effectiveness and cost-effectiveness of a stratified care model compared with usual, non-stratified care. Design This was a two-parallel group, multicentre, pragmatic, 1 : 1 randomised controlled trial. Setting Participants were recruited from primary care (42 general practices) in North Staffordshire, North Shropshire/Wales and Cheshire in the UK. Participants Eligible patients were aged ≥ 18 years, had suspected sciatica, had access to a mobile phone/landline, were not pregnant, were not receiving treatment for the same problem and had not had previous spinal surgery. Interventions In stratified care, a combination of prognostic and clinical criteria associated with referral to spinal specialist services was used to allocate patients to one of three groups for matched care pathways. Group 1 received advice and up to two sessions of physiotherapy, group 2 received up to six sessions of physiotherapy, and group 3 was fast-tracked to magnetic resonance imaging and spinal specialist opinion. Usual care was based on the stepped-care approach without the use of any stratification tools/algorithms. Patients were randomised using a remote web-based randomisation service. Main outcome measures The primary outcome was time to first resolution of sciatica symptoms (six point ordinal scale, collected via text messages). Secondary outcomes (at 4 and 12 months) included pain, function, psychological health, days lost from work, work productivity, satisfaction with care and health-care use. A cost–utility analysis was undertaken over 12 months. A qualitative study explored patients’ and clinicians’ views of the fast-track care pathway to a spinal specialist. Results A total of 476 patients were randomised (238 in each arm). For the primary outcome, the overall response rate was 89.3% (88.3% and 90.3% in the stratified and usual care arms, respectively). Relief from symptoms was slightly faster (2 weeks median difference) in the stratified care arm, but this difference was not statistically significant (hazard ratio 1.14, 95% confidence interval 0.89 to 1.46; p = 0.288). On average, participants in both arms reported good improvement from baseline, on most outcomes, over time. Following the assessment at the research clinic, most participants in the usual care arm were referred to physiotherapy. Conclusions The stratified care model tested in this trial was not more clinically effective than usual care, and was not likely to be a cost-effective option. The fast-track pathway was felt to be acceptable to both patients and clinicians; however, clinicians expressed reluctance to consider invasive procedures if symptoms were of short duration. Limitations Participants in the usual care arm, on average, reported good outcomes, making it challenging to demonstrate superiority of stratified care. The performance of the algorithm used to allocate patients to treatment pathways may have influenced results. Future work Other approaches to stratified care may provide superior outcomes for sciatica. Trial registration Current Controlled Trials ISRCTN75449581. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 49. See the NIHR Journals Library website for further project information.

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A diagnostic study in patients with sciatica establishing the importance of localization of worsening of pain during coughing, sneezing and straining to assess nerve root compression on MRI

Cited by 19 publications

References 8 publications

What low back pain is and why we need to pay attention

What low back pain is and why we need to pay attention

Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT

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