|
INTRODUCTION
Sciatica clinically occurs in 4-6%of the U. S. population. 1
Herniated lumbar intervertebral disk and spinal stenosis are the common
causes of sciatica. Sciatica leads to impairment which accounts for significant
medical attention and cost with the use of a range of responses including
rest which may require hospitalization because of incapacitation, opiate
analgesics, non-steroidal antiinflammator y drugs, physical therapy, lumbar
epidural steroid injection, and ultimately surgery if the pain and impairment
does not resolve through natural history and is not mandated by cauda
equina syndrome or progressive neurologic deficit. The goal of evaluation
and management is to provide pain relief and minimize disability.
The primary care
physician often is the first point of patient contact and the orthopaedic
surgeon may be consulted. We conducted an observational investigation
of the role of an intravenous (i. v. )methylprednisolone protocol in the
management of acute sciatica caused by herniated lumbar intervertebral
disk and degenerative spinal stenosis.
METHODS
Sixty patients with acute sciatica were enrolled in the study on the basis
of a clinical diagnosis made solely on the criteria of history and physical
examination. Radiculopathy and/or root tension signs, especially the bowstring
test, 2
were used as the signs for including patients in the study. Methylprednisolone,
1 gram diluted in 250ml of normal saline, administered i. v. over 1. 5
hours, was used in all patients. The method was on the basis of a standard
protocol utilized in the treatment of multiple sclerosis. Patients were
examined at the time of presentation and follow-up. Informed consent was
obtained prior to treatment. Telephone interviews were used to obtain
follow-up data. Pain was registered on a 0-10 visual analogue scale.
RESULTS
Patients ranged in age from 29 to 92 years. Twenty-four patients (40%)were
male. Pain relief was noted in 80%of patients, of which 60%had marked
relief, 15%moderate, and 25%mild relief. Of those with relief, 75%had
recurrence of pain. 63%noted relief within 24 hours of treatment. The
most common side effects were a transient metallic taste during infusion
and transient sleep disturbance on the night following infusion.
DISCUSSION
The history of sciatica and the ruptured lumbar intervertebral herniated
disk has long been an interest of clinical research clinically in the
Harvard orthopaedic community, particularly at MGH. 3
We have been interested in the pathophysiology of the herniated disk and
examined alternative concepts of its formation and pathophysiology. 4
The fundamental objectives of a musculoskeletal operation is to relieve
pain, reduce deformity, and improve function. At the area of the lumbar
spine, the surgery focuses on decompression and stabilization through
arthrodesis. Mixter was concerned over the over-utilization and complications
of lumbar diskectomy for the management of low back pain and sciatica.
5 These
concerns are current to this day and have increased because of the socioeconomic
issues of technologies increasing in utilization and fiscal cost, while
the concepts of care are redefined from the traditional medical concern
directed toward the individual patient struck with pain and suffering
to concern for the cost effectiveness of an intervention and the "bottomline"
outcome to the entire medical delivery system. These contemporary conflicts
are discussed on a daily basis in our communities, hospitals, and medical
schools. It is a continuing interest at Harvard Medical School where teaching
medicine as well as the agenda of medical technology and the concepts
of ethics and caring are methodically examined.
It is within these
contemporary challenges that we undertook this study of a common clinical
condition, sciatica. The method provides some insight into the evaluation
and management of sciatica and addresses an alternative of acute care
based upon the simplicity of history and physical examination. It provides
medical students with a mixture of differential diagnoses and analytical
thinking while providing traditional care cost effectively to the patient,
provider, and the infrastructure of the reimbursement system.
Methylprednisolone
i. v. can provide transient relief of acute sciatica. It can be administered
solely on the basis of a clinical diagnosis made by history and physical
examination. Pain tends to recur within days so that the use of this intervention
is considered short term and is easily done in an ambulatory setting in
order to allow the continued activity of the patient, the avoidance of
narcotics with their adverse side effects, and acute hospitalization which
contributes to cost and prolonged impairment. Follow-up lumbar epidural
steroid injection is often used for more prolonged non-operative care
of the underlying disorder. The protocol is simple, easy to administer,
and is known to be free of the complications associated with prolonged
use of corticosteroids. Although not a cure for the underlying disorder,
the protocol can provide an effective acute response providing relief
to both the patient and the provider who is confronted with the problem
of what to do with his or her patient who has acute pain and impairment
requiring a timely response. Further research including a blinded, prospective
cohort study will be of value.
Stephen J. Lipson,
MD is a Clinical Professor in Orthopaedic Surgery at Harvard Medical
School.
Katherine Taft,
MSN, RNC is a Staff Nurse Practitioner, Beth Israel Deaconess Medical
Center, Boston, MA
Sonu S. Ahluwalia,
MD is a Clinical Fellow in Orthopaedic Surgery at Harvard Medical
School.
Address correspondence
to:
Stephen J. Lipson,
MD
Department of Orthopaedic Surgery
330 Brookline Avenue
Beth Israel Deaconess Medical Center
Boston, MA 02114
*The authors are
pleased to announce that this study will be presented at the International
Society for the Study of the Lumbar Spine meeting as a poster in June
2001, Edinburgh, Scotland.
|
