Herniated
disc and sciatic
The column vertebrae are formed with 7 cervical vertebrae,
12 thoracic, 5 lumbars, 5 sacral and 3 coccygeus. Between each vertebra there
is a disc formed with the annulus fibrosus and nucleus pulposus giving movement
to the back, support and cushion the body´s weight.
The lower back is more prevalent to have a herniated disc
having to support more weight than the other vertebrae and because it has a
high mobility in flexion. The area of least resistance offered by the fibrous
annulus is the posterior part. The nucleus is slightly delayed with respect to
the geometric centre of the disc. This situation together with the bending
movement causes the nucleus to exert more pressure on the back of the annulus.
Over the years, annulus wear down and nucleus can to go out.
Usually, the herniated disc is not symptomatology but if nucleus affects the
sciatic nerve we can feel symptoms. The most important symptom of sciatica is
lumbosacral radicular leg pain that follows a dermatomal pattern radiating
below the knee and into the foot and toes (1, 2).
 |
| Lumbar vertebrae |
(Information extracted from: Jacobs, Wilco CH, et al. "Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review." European Spine Journal 20.4 (2011): 513-522)
The prevalence of sciatic symptoms
reported in the literature varies considerably ranging from 1.6% in the general
population to 43% in a selected working population (3). Although the prognosis
is good in most patients (4), a substantial proportion (up to 30%) continues to
have pain for 1 year or longer (5, 6).
The goal of this study was to assess
the effects of surgery versus conservative therapy (including epidural
injections) for patients with sciatica due to lumbar disc herniation.
In total, five studies were
identified. One study compared early surgery with prolonged conservative care
followed by surgery if needed (7); three studies compared surgery with usual
conservative care (8,9,10), and one study compared surgery with epidural
injections (11).
Early
surgery versus prolonged conservative care
1.
Relief of leg pain was faster for patients
assigned to early surgery. Intention to treat analysis
showed statistically significant more
leg pain relief in favour of early surgery as compared with prolonged conservative
care at 3 months. There was no significant overall difference between the two
groups in disability scores during the first year. The median time to recovery
was 4 weeks for early surgery and 12 weeks for prolonged conservative treatment
(7).
Surgery
versus usual conservative care
2. Both
patient and observer ratings demonstrated that discectomy was significantly
better than conservative treatment at 1 year. After 1 year, 24 of the 66
patients (36%) in the conservative care group versus 39 of the 60 patients
(65%) in the surgery group reported a good outcome. No significant differences
in outcomes were reported at 4 and 10 years follow-up (9).
3. Overall,
no significant differences were found for leg pain or back pain, and subjective
disability throughout the 2 years of follow up. Visual analog scale leg pain
scores, however, improved more rapidly in the discectomy group first 6 weeks (8).
4. Confirmed
disc herniation showed that both the surgery as well as the conservative
treatment group improved substantially over 2 years of leg pain and/or back pain
(10).
Surgery
versus epidural steroid injections
5. Patients
undergoing discectomy had the most rapid decrease in their symptoms. The
decrease in leg pain in the discectomy group was significantly greater than in
the epidural steroid injection group at 3 and 6 month follow-up intervals, but
not beyond 1 year. There were no significant differences between groups for
back pain throughout the follow-up (11).
 |
| Epidural steroid injection |
Conclusions
In general, there is evidence that
early surgery in patients with sciatica provides for a better short-term relief
of leg pain as compared to prolonged conservative care. But no significant
differences were found between surgery and usual conservative care in any of
the clinical outcomes after 1 and 2 years.
Bibliography
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Rozenberg S, Koes B (2010) Sciatica. Best Pract Res Clin Rheumatol 24:241–252
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Sciatica: what the rheumatologist needs to know. Nat Rev Rheumatol 6:139–145
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Sciatica: review of epidemiological studies and prevalence estimates. Spine
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den Hout WB, Brand R, Eekhof JA, Tans JT, Thomeer RT, Koes BW (2007) Surgery versus prolonged conservative
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J, Malmivaara A (2006) Effectiveness of microdiscectomy for lumbar disc
herniation: amrandomized controlled trial with 2
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9. Weber H (1983) Lumbar disc
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JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo
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prospective, randomized study. J Bone Joint Surg Am 86-A:670–679
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