PREVALANCE AND MANAGEMENT OF SCIATICA IN A TERITIARY CARE HOSPITAL: A PROSPECTIVE OBSERVATIONAL STUDY

1. Sree Chaitanya Institute of Pharmaceutical Sciences, Karimnagar, Telangana, 505001. 2. Narsaraopet Institute Of Pharmaceutical Sciences, Narsaraopet, Andhrapradesh, 522601. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 February 2020 Final Accepted: 12 March 2020 Published: April 2020


Tests for sciatic nerve root compression: Straight Leg Raising (SLR) Test:
Raise the affected leg with the knee in extended position (while preventing knee flexion on the normal side), pain at 40degrees or less denotes positivity and it is suggestive of nerve compression.

Bragard Test:
Gentle dorsiflexion of the ankle precipitates further tension the nerve root on reaching the limit in straight leg raise test.

Lasegue Test:
First the thigh is lifted ti 90degrees with knee bent. The knee is then gradually extended. If the nerve sheath is present will experience pain in the back of the thigh or leg and the pain radiates to the back.

Bowstring Sign:
After performing the Lasegue`s test, apply firm pressure with the thumb over the posterior tibial nerve in the middle of the popliteal fossa over the hamstring tendon. Now, the posterior tibial nerve is stretched like a bowstring a cross the popliteal fossa causing pain locally and radiation to the back.

Flip Test:
The patient is seated on the edge of the couch with the hips and knees flexed to 90degrees. Gently extend the knee. When there is root irritation, the patient will flip backwards to relieve the tension on the nerve root. In the absence of root compression, full extension of the knee is possible. . [6] Investigations: Plain X-Ray: In a case of chronic disc prolapsed, the affected disc space may be narrowed and there may be slipping of the vertebral margin posteriorly.

Myelography:
Following myelographic features suggest disc prolapse. 1. Complete or incomplete block to the flow of dye at the level of a disc.
2. An indentation of the dye column.

Root Cut Off Sign:
Normally the dye fills up the nerve root sheath. In cases where a lateral disc prolapsed is pressing on the nerve root, the sheath may not be filled.

CT Scan:
Normally, in an axial cut section, the posterior border of a disc appears concave. In a case where there is disc prolapsed, it will appear flat or convex. There will be loss of pre-thecal fat shadow normally seen between the posterior margin of the disc and theca.

MRI scan:
It shows the prolapsed disc, theca, nerve roots very clearly.

Electromyography(EMG):
Findings of denervation, localized to the distribution of a particular nerve root, helps in localizing the offending disc in cases with the multiple disc prolapse. This test is rarely required.

Treatment: Principles of Treatment:
Aim of treatment is to achieve remission of symptoms, mostly possible by conservative means. Cases who do not respond to conservative treatment for 3-6 weeks, and those presenting with cauda equine syndrome may require operative intervention.

Conservative treatment:
This consists of the following:

Rest:
It is most important in the treatment of a prolapsed disc. Rest on a hard bed is necessary for 2-3 weeks. [5] Medications: Pain Medications: It is a protective mechanism to which the body responds to harmful stimulus. Medications Used To Treat Pain Include: Analgesics -Ex: Acetaminophen-650mg, Tramadol-50-100mg.

Muscle relaxants:
Diazepam, Cyclobenzaprine, Clonazepam, Baclofen can be used to treat pain associated with muscle spasms and spasticity.

Anticonvulsants:
It can be used to relieve nerve pain as in trigeminal neuralgia. It can be used to reduce the swelling and inflammation of the nerves. Eg: Phenytoin-300mg, Clonazepam-1mg, Gabapentin-600-1200mg, Pregabalin-150-600mg.

Epidural Steroid Injections:
This procedure, usually performed under fluoroscopy, involves an injection of steroids and an analgesic numbing agent into the epidural space of the spine to reduce the swelling and inflammation of the nerves.

Facet Injections:
Facet injections are used for patients with low back pain stemming from inflammation or irritation of the facet joint. They may be performed using a fluoroscope (X-ray), which directs a needle through the skin and muscles to the path of the sensory nerves located in the facet joints. At that point, a mixture of numbing medicine and cortisone is injected into the facet joint.

Narcotics (Opioids):
Narcotics are very powerful pain relievers that actually deaden a person"s perception of pain. They are used for a short period (2 to 4 weeks) after an acute injury or surgery. Eg: Codeine-30-60mg, Meperidine-300mg, Oxycodone-5-10mg. [3] Surgical treatment: Surgical intervention for sciatica focuses on removal of disc herniation and eventually part of the disc or on foraminal stenosis, with the purpose of eliminating the suspected cause of the sciatica. Consensus is that a cauda equina syndrome is an absolute indication for immediate surgery. Elective surgery is the choice for unilateral sciatica.  [5] Physiotherapy: This consists of

Hot Fomentation:
Heat dilates blood vessels, increasing the flow of oxygen and nutrients to the area, which assists in healing. Applying heat also stimulates sensory receptors in the skin, so the brain focuses less on the pain of sciatica.

Cold Packs:
A cold pack or ice application can reduce inflammation and numb sore tissue, alleviating some of the pain in the sciatic nerve. [7] Excercises For Sciatica: Stretches: Some simple exercises and stretches you can do at home can help ease pain from sciatica (pain in your buttocks, legs and feet) and improve your strength and flexibility. Others: 1. Lumbar traction 2. Transcutaneous electric nerve stimulation (TENS) 3. Acupuncture

Life style modifications:
Self care measures can help relieve the symptoms of sciatica and also prevent recurrence.

Cold And Hot Packs:
Use alternate cold and hot packs to reduce swelling and relieve discomfort.

Regular Exercise:
Improves flexibility and helps prevent age-related degenerative changes.

Lift Objects Safely:
Always lift from a squatting position. Never bend over and lift with a straight back.

Avoid Sitting Or Standing:
For extended periods. If you sit at work, take regular breaks to stand and walk around.

Use Proper Sleeping Posture:
Take pressure off your back by sleeping on your side or on your back with a pillow under your knees.

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Avoid Wearing High Heels: Shoes with heels that are more than 1½ inches high shift your weight forward, throwing the body out of alignment.

Do Abdominal Crunches:
These exercises strengthen the abdominal muscles that help to support your lower back.

Stretch:
Sit in a chair and bend down toward the floor. Stop when you feel just slight discomfort, hold for 30 seconds, then release. Repeat six to eight times.

Walk/Swim:
Walking and swimming can help to strengthen your lower back.

Study Design:
A Prospective Observational Study.

Study Period:
This study was carried out for a period of 6 months.

Study Criteria: Inclusion criteria:
Participating patients that must have been diagnosed with sciatica or presented with any or all of the following symptoms such as radiating pain through the sciatic nerve distribution area, tenderness at the nerve stem, tingling and numbness. Positive Straight leg raise test.

Exclusion criteria:
Participants with back pain or low back pain but no symptoms of sciatica.

Source of Data:
Patient prescriptions and medical records were studied to obtain demographic details. Other information was asked verbally which includes lifestyle, working status, duration of condition, presence of other comorbid conditions (such as Thyroid problem), social habits (smoking, tobacco chewing etc.,). Data from X-rays, MRI and CT scans.

Ethical Committee Approval:
The protocol of the study including the introduction, objectives, data collection form and methodology was submitted for approval of ethical committee members, the study was approved by Institutional Ethical Committee of Sree Chaithanya Institute of Pharmaceutical Sciences.

Study Procedure:
All the patients who are diagnosed with SCIATICA. Patient: Data that can be collected includes demographic details (age, gender, and occupation), weight, height, social history (Smoking), past medical history (Trauma/any other surgeries),Duration of presenting pain, causes & predisposing factors, diagnostic reports (X-ray, MRI), Non-pharmacological, Pharmacological, Physiotherapy, Surgical treatment.

Data Collection Form:
Appropriate data collection form was designed to collect, document, analyse the data. Data collection form include the provision for collection of information related to all study parameters mentioned above like demographic details of patient ( name, age, sex,), social history, Comorbid conditions like thyroid problems. 276

Results:-
The study "A clinic based observational study on Sciatica was conducted in RENEE Hospital, Karimnagar. A total number of 712 patients who visited hospital to orthopedic department, in that 304 patients were diagnosed with Sciatica having the symptoms of low back ache and pain radiating to lower limbs are participated in the study. ]. This states that prevalence of sciatica is more in female patients than the male patients in our study population.

Distribution Of Patients According To Age Criteria:
The study population was divided in to various groups according to their age .   In the study population it was observed that the 167 patients with the duration of low back pain for less than 1 week is maximum[i.e.,54.3%) , followed by 88 patients[29.95%] with the duration of pain for 6 months and the number of patients with the duration of pain for more than 6 months is 49[16.11%] which is minimum.

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Overweight, smoking and history of trauma and thyroid problems seems to be the major risk factors in considerable number of patients. Out of 304 patients, 104 patients were having history of trauma (34.22%), followed by obesity (27.63%), then followed by smoking (25%) and thyroid (13.15%). A maximum prevalence is seen in the trauma and least prevalence is seen in thyroid patients.   Res. 8(04), 270-281 279

Distribution Of Patients According To Assessment Of Severity
In the study, out of 304 patients 228 patients (75%) were diagnosed with MRI scan, followed by 88 patients with the x-ray (25%).  In the study population it was observed that NSAIDS is prescribed for every patient suffering with sciatica. NSAIDS inhibits PG"S, TXA2, and Prostacyclin thereby reducing pain and inflammation. Every patient is prescribed with vitamin D and calcium supplement. Vitamin D helps body absorb calcium, so without enough vitamin D, there won"t be enough calcium. Without enough calcium, bones can weaken, potentially leading to bone and joint pain, or musculoskeletal pain. Patients with sciatica due to sciatic nerve damage are prescribed with methyl cobalamine injection. A vitamin B12 supplement boost helps to ease pain by encouraging body to thicken its protective coating around the nerves, so they don't "short circuit" and cause pain. In the study, majority of patients experiencing wound healing (7.89%) is maximum followed by patients who are having nerve root lesion (5.92%) then followed by flat back syndrome(3.9%). The patients suffering with cauda equine syndrome are very few.

Discussion:-
In this current study, total 712 cases were collected, among them 304 (42.7%) of the participants reported with sciatica. So, only 304 patients with sciatica are included and remaining cases were excluded. Out of 304 patients, 110 patients were males and remaining 194 patients were females. So in this study, the prevalence of sciatica was found to be more in female patients (63.82%) when compare to male patients (36.18%).
In this study population including both male and female, out of 304 patients 100 patients are between the age group of 40-49 years i.e, 32.69%. Maximum prevalence is seen in the 40-49 yrs age group patients. A low prevalence is seen in extreme age groups .Our results are not exactly but nearly comparable to LEENA KAILA-KANGAS etal, states that there is a chance of getting sciatica between 30-64 yrs of age in that physically demanding work in general is a risk factor for sciatica among men. [9] In this 304 patients, 104 patients were with the history of trauma, 84 patients were obese, 76 patients were smokers and remaining 40 patients were with thyroid problems. Maximum prevalence is seen in the trauma (34.22%) and least prevalence is seen in thyroid patients (13.15%). Our results are comparable with RAHMAN SHIRI etal , which states that smoking is a moderate risk factor for lumbar radicular pain and clinically verified sciatica. [10] In this study, total 304 patients 216 patients were with severe sciatica (71.05%), 52 patients were with moderate pain (17.11%) and remaining 36 patients were with mild pain (11.84%  Res. 8(04), 270-281 281 Total 304 patients are prescribed with NSAIDS, Muscle relaxants, Vitamin -D, Calcium supplement, and in this 150 patients are prescribed with Methyl cobalamine. According to LOUISKURITZKY etal , NSAIDS and muscle relaxants are used in treatment of low back pain. [11] In total 304 patients 35 patients had underwent surgery. About 22 patients underwent laminectomy. About 11 patients underwent microlumbar discectomy. There were no relevant studies showing correlation between surgeries.

Conclusion:-
Most patients with sciatica in tertiary care hospital were being treated with conservative management but less than half with surgery. Sciatica was observed mostly among males and was significantly correlated with risk factors. Based on the results of this study, it is concluded that, various risk factors are responsible for causing Sciatica, such as advancing age, trauma, thyroid problems. obesity, smoking, occupation related body postures. Among these, disc problem is the risk factor having highest impact on symptomatic Sciatica risk. And most oftenly it is due to disc herniation, bulging, or degeneration which may occurs by external factors like trauma or any other occupation related factors of the person. And the Second major risk factor with high impact on Sciatica is obesity which may further leads to spondylolisthesis. More over in the presence of more than one risk factors the progression to Sciatica is rapid. Mostly MRI can confirm the diagnosis of sciatica rather than the clinical symptoms to know the possible risk factor.
It is further concluded that the majority of case reports in hospital with Sciatica has already progressed to decompensate stage, frequently with complications such as Cauda equina syndrome, nerve root lesions and wound healing. Physiotherapy plays a key role in the management of sciatica.