Sciatica: When to image. When to refer.

1. Sciatica: When to image.  When to refer. Juanita Halls M.D. Internal Medicine October 10, 2007

2. No financial disclosures

3. Objectives Understand when to perform imaging on patients presenting with sciatica Understand when to refer patients with sciatica to a spine surgeon

4. Case 1 58 yo healthy female presents January, 2007 with 6 week history of achy LBP, R>L with episodes of pain shooting down back of thighs to calves and occasional numbness in foot No preceding injury, heavy lifting, etc No weakness, bladder or bowel dysfn No systemic sx e.g. fever/sweats/weight loss

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

6. 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

7. Imaging L/S spine films: multilevel degenerative disk and joint disease No labs done

8. Dx/ Rx �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

9. 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

10. Exam No spinal tenderness SLR negative on left, positive at 60o on right DTR: symmetrical Motor: 5/5

11. Plan MRI offered but patient declined Diclofenac (was having side effects with naproxen) PT referral Spine clinic referral

12. 4 weeks later (3 months after initial presentation) Seen in Spine clinic: Pain had gotten better, now worse again and interfering with sleep No systemic symptoms Exam: No change except minimal tenderness Positive SLR/Lasegue maneuver DX: Probable HNP Plan: MRI

13. 2 Weeks later(3 � months after presentation) MRI competed and I am paged by the Spine clinic physician late Friday afternoon

14. MRI case 1

15. MRI Case 1

16. 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

17. 10 days later CT guided biopsy: Large B cell lymphoma

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

19. 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

20. Etiology of sciatica Mechanical Pyriformis syndrome HNP Spondylolisthesis Compression fracture Neoplastic (0.7% of LBP) Infectious (0.01% of LBP)

21. Questions to ask Is there evidence of systemic disease? Is there evidence of neurological compromise?

22. Clues on history to suggest systemic disease Hx of cancer No Age > 50 Yes Unexplained weight loss No Duration > 1 month Yes Night time pain Yes Unresponsive to conservative rx +/- Pain not relieved by lying down +/-

23. Exam Back exam ROM Palpate for tenderness SLR Neuro exam If suspicious history Breast or prostate exam Lymph node exam

25. Straight leg raising Passive lifting of the leg with the knee extended produces pain radiating down the posterior or lateral aspect of the leg, distal to the knee and usually into the foot. Dorsiflexion of the foot (Lasegue's test) will exacerbate these symptoms

26. SLR with Lasegue test

28. Imaging indications Progression of neurological findings Constitutional symptoms Hx of traumatic onset Hx of malignancy <18 or > 50 Infection risk (IVDU, immunocompromise, fever) Osteoporosis

29. Imaging � L/S spine films If risk factor or no better in 4-6 weeks May be able to detect: Tumor (sensitivity 60%) Infection (sensitivity 82%) Spondyloarthropathy Spondylolisthesis Also consider Labs: ESR and/or CRP if risk for infection If negative: conservative rx for 4-6 weeks

30. Imaging - MRI If progressive neurological deficit, high suspicion of cancer or infection, or 12 weeks of persistent pain May be able to detect: Tumor (sensitivity 83-93%) Infection (sensitivity 96%) HNP (sensitivity 60-100%) Spinal stenosis (sensitivity 90%)

31. Malignancy and sciatica O.7% of LBP due to malignancy Non-Hodgkin�s lymphoma 10% have CNS involvement Sciatica is uncommon and occurs late Very rare for sciatica to be presenting feature

32. Case 2 49 yo healthy female presents February, 2007 with recurrent LBP radiating to right buttock and shooting to posterior thigh and lateral calf. Numbness of bottom of foot No weakness, bladder or bowel dysfn No systemic sx e.g. fever/sweats/weight loss ? prolonged sitting, getting up, bending ? walking, lying down ?? Severity of pain?? Severity of pain

33. Previous history 4 months previous had ER visit for acute LBP radiating to right buttock after bending over in Yoga class and treated with PT and pain meds 2 months previous after 6-7 PT sessions reported �much better� PMH: No meds, non-smoker

34. Exam DTR�s 2+ at knee and ankle Motor 5/5 in LE No spinal tenderness SLR negative bilaterally

35. Treatment PT If not improving, get MRI and/or refer to spine clinic More rx??More rx??

36. 5 weeks later No better and MRI ordered and referred to spine clinic

38. MRI Case 2

39. MRI Case 2

40. MRI reading L5-S1 disk protrusion contacting right S1 nerve root

41. Spine clinic visit next day Hx: same plus pain increases with cough/sneeze Exam: Tender inferior to right piriformis muscle ? sensation to light touch right S1, PP normal DTR: 2+ knees and left ankle, 1+ right ankle Negative SLR Prone press up � pain in buttock Dx: Radiculopathy with HNP L5-S1

42. Spine clinic treatment Right S1 diagnostic and therapeutic transforaminal steroid injection PT and/or chiropracter Oxycodone Neurontin

43. 8 weeks later (3 months after initial presentation) s/p 2 injections, PT, Chiropracter Still severe pain and now weakness right leg with stairs Referred to spine surgeon

44. Spine surgeon Exam: SLR positive/ Lasegue positive on right DTR: 1+ left ankle 0 right ankle �You should have been here within 6 weeks of onset of sciatica symptoms� Recommends: L5-S1 microdiskectomy Outpatient procedure with epidural 95% get relief of pain 3% risk of re-herniation Lasegue??Lasegue??

45. When to refer to spine surgeon Cauda equina syndrome Neuro motor deficit Persistent severe sciatica after conservative treatment

46. Timing of referral for diskectomy Optimal timing is not clear No consensus on how long conservative treatment should be tried Sciatica improves within 3 months in 75% of patients (95% at one year)

47. Surgery vs Prolonged Conservative Treatment for Sciatica Peul, et al NEJM May 31, 2007 283 patients with 6-12 wk of severe sciatica and HNP on MRI Randomized to: early surgery (microdiskectomey) vs conservative therapy with surgery if needed Primary outcomes: Subjective pain and disability scores Perceived recovery

48. Outcomes of study Surgery grp: 89% surgery at mean 2.2 weeks Conservative grp: 36% surgery at mean 4� months At 1 year: no difference in pain or disability score or perceived recovery (95% in both grps) Pain relief and perceived recovery faster in surgery group Median time to full recovery 4 vs 12 weeks Max difference in pain score <20 mm on 100 mm scale

52. Conclusions of study Advantage of early surgery is faster relief of pain and faster perceived recovery time Not blinded study (patient expectation bias) Did not look at any objective outcomes e.g. days of work lost

53. SPORT studySurgical vs Nonoperative Treatment for Lumbar Disk Herniation Weinstein, et al JAMA November, 2006 501 pts with radiculopathy and HNP for at least 6 weeks Open diskectomy vs conservative rx Surgery grp: 60% (50% within 3 months) Conserv grp: 45% (30% within 3 months) No difference in subjective pain and disability scores

54. BOTTOM LINE Risk of serious problem (e.g. cauda equina, neurological deterioration) is very small so most patients do not need urgent surgery Main benefit of surgery is faster perceived recovery and resolution of disabling pain No data on days of lost productivity No other strong reason to advocate for surgery except patient preference

55. Bottom line Offer surgery to patients who: Not able to cope with the pain Find natural course of recovery to slow Want to minimize time to recovery from pain Questions for patient: How badly do you feel? How urgently do you wish to achieve relief at �cost� of having surgery?

56. Follow up Case 1 Treated with CHOP plus Ritoxan s/p 6 cycles PET and CT scans pending

57. Follow up Case 2 4 months s/p microdiskectomy Back to work one month after surgery and doing well

58. References Jarvik, JG and Deyo, RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med.2002;137:586-597. Stadnik, et al. Annular tears and disk herniation: Prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology 1998;206:49-55. O�Neill, et al. Sciatica caused by isolated non-Hodgkin's lymphoma of the spinal epidural space: A report of two cases. Br J Rheum 1991;30:385-86. Peul, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:2245-56. Weinstein, et al. Surgical vs nonoperative treatment for lumbar disk herniation. SPORT trial. JAMA 2006;296:2441-50.