Bush, Keith; (1992) An investigation into the pathomorphological changes which accompany the resolution of sciatica. Doctoral thesis (M.D), UCL (University College London).

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Abstract

Sciatica due to lumbosacral nerve root compromise is thought of as one of the better defined lower back syndromes from a clinical point of view. Further, research has identified not only mechanical but also inflammatory factors in its aetiology. Nonetheless, its management remains controversial. This thesis reviews the trends in the management of sciatica and the patho-anatomical and pathophysiological evidence in support of these trends. Although there is good pathophysiological evidence to support the use of corticosteroids given epidurally in the management of sciatica, clinical evidence remains conflicting. However, it has been possible to demonstrate the efficacy of epidural local anaesthetic and corticosteroid in depot form in a prospective, randomised, placebo-controlled study. Subsequently, consecutive patients suffering from sciatica thought to be due to lumbosacral nerve root compromise, based on clinical and radiological evidence, were selected for further analysis. The serial placement of epidural steroids, usually via the caudal route but via the lumbar route and posterolateral route under x-ray control in resistant cases, was used as the mainstay of conservative management. Those patients not responding to this conservative regime were referred for decompressive surgery. The technological advantage of computed axial tomography has enabled repeated observation of disc herniations in symptomatic patients during recovery with conservative treatment methods. Blinded comparison of scans performed at twelve months interval has confirmed that partial or complete resolution of disc herniations does occur in a high proportion of patients whose sciatica resolves with conservative management. However, good clinical recovery was also noted in cases where no morphological change could be demonstrated. The available evidence suggests that a high proportion of intervertebral disc herniations have the potential to resolve spontaneously. It is therefore suggested that an aggressive course of conservative therapy, including serial epidural steroid and local anaesthetic injections where appropriate, is pursued before resorting to decompressive surgery.

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