Clinical Context

Sciatica is a common pain condition seen in primary care and specialist offices alike, and it carries a worse prognosis in recovery vs low back pain. The authors of the current study provide a brief review of research examining rates of recovery from sciatica. Overall, rates of recovery are fairly variable in comparing different results from different studies. However, in 2 large trials, the rates of recovery from sciatica after surgery were approximately 70% to 80% at 1 year, whereas the rate of recovery without surgery was only 56% to 60%. Moreover, patients treated without surgery did not experience substantial gains in the rate of recovery after 1 year.

Sciatica

A better understanding of which patients with sciatica are at risk for poor outcomes can help clinicians in medical decision making. The current study by Haugen and colleagues addresses this issue.

Study Synopsis and Perspective

Prognostic factors associated with nonsuccess in patients with sciatica and disc herniation are recently identified in those referred to secondary care. These factors include being male, smoking, and having comorbid health complaints, according to the findings of a prospective, observational study.

Anne J. Haugen, MD, with the Department of Rheumatology at the Østfold Hospital Trust in Fredrikstad, Norway, and colleagues reported their findings in the September 22 issue of BMC Musculoskeletal Disorders.

"The results indicate that the prognosis for sciatica referred to secondary care is not that good and only slightly better after surgery and that comorbidity should be assessed in patients with sciatica," the researchers write.

According to Dr. Haugen and colleagues, existing data on prognosis and success rates for patients with sciatica are variable and come largely from studies evaluating surgical outcomes. Their primary goal was to identify prognostic factors associated with nonsuccess at 1- and 2-year follow-up in patients treated both nonoperatively (ie, conservatively) and surgically.

The multicenter study included 466 patients with sciatica and lumbar disc herniation who were referred for secondary care from primary health services in 2005 and 2006. Disc herniation was confirmed with imaging, and referral to an orthopaedic surgeon was made by the back clinic if symptoms were "severe."

Prognostic factors recorded at inclusion included age, sex, smoking status, educational level, and work status. The researchers also recorded duration and severity of back and leg pain and previous episodes of sciatica.

Patients completed questionnaires and underwent clinical examination at baseline. Questionnaires were then completed at 3, 6, 12, and 24 months. The main outcome variable was the Maine-Seattle Back Questionnaire (MSBQ) score, which the study authors report as the best measure of success in sciatica. The MSBQ assesses disability and functional limitations because of back pain and sciatica, with a higher score indicating worse function. Nonsuccess was defined as an MSBQ score of 5 or greater.

The secondary outcome measure was the Sciatica Bothersomeness Index (SBI), which assesses sciatica symptoms. Nonsuccess was defined as an SBI score of 7 or greater. Patient-reported variables included evaluations of emotional distress, kinesiophobia, motor function, sciatica symptoms, and a comorbid subjective health complaints inventory.

The study authors reported a nonsuccess rate of 47% at 1 year and 39% at 2 years in patients treated conservatively, when using the primary outcome. They also reported a nonsuccess rate of 35% at 1 year and 39% at 2 years in the surgical group.

Nonsuccess defined by the secondary outcome was reported in 54% of patients treated nonsurgically at 1 year and 47% at 2 years. By contrast, the nonsuccess rate in the surgical group was 30% at 1 year and 33% at 2 years.

Prognostic factors associated with nonsuccess at 1 year were male sex, smoking, higher intensity of back pain, and abnormal reflexes on examination. At the 2-year follow-up, kinesiophobia and longer duration of back pain and sciatica were considered prognostic factors for nonsuccess. A high score on the comorbid subjective health complaints assessment was associated with nonsuccess at both 1- and 2-year follow-ups, whereas nonsuccess in men and in surgical patients are contradictory to previous findings.

"The current results suggest that the prognosis for sciatica patients referred to secondary care is not as good as previously reported and is only slightly better after surgery, and that comorbidity and kinesiophobia should be assessed in patients with sciatica, including surgical candidates," the researchers conclude.

These findings call for "a broader assessment of patients with sciatica than is afforded by the traditional clinical assessment in which mainly the physical symptoms and signs are investigated," they suggest. "The results of the present study may be used to identify subgroups of patients referred to hospital with an increased risk of poor prognosis for sciatica."

The study was funded by a grant from the Eastern Norway Regional Health Authority. The study authors have disclosed no relevant financial relationships.

BMC Musculoskelet Disord. Published online September 22, 2012.

Source Medscape.org

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