A low back pain condition characterised by pain radiating down the back and side of the leg, usually one side, often radiating below the knee and may affect the foot. Caused by a compression of a nerve (L5 or S1) in lower back by a disk bulge or related physiological changes.

Piriformis syndrome is often misdiagnosed when it presents as pain and numbness down the leg. Problems with various other muscles, ligaments, nerves and joints around the pelvis and low back, may cause the referral of pain in the back of the leg which may be misinterpreted as pain from a disc bulge. The sciatic nerve and other nerves in the legs can also be compromised at other sites as they travel through the leg (Peripheral/ Superficial Nerve Entrapment Syndromes).

Complications of severe pressure on the nerves in the lower back may include cauda equine syndrome (compression of the nervous system resulting in bladder and bowel dysfunction), which is a surgical emergency.

Diagnosis

Diagnosis of a trapped nerve in the lower back due to a disk bulge is derived from the patient’s history with positive orthopaedic and neurological exam findings and no indicators of potentially serious pathology. Imaging is only indicated in patients with a positive neurological exam or presence of a “red flag” [64-67].

Chiropractors perform a thorough history of complaint and examination (orthopaedic, neurological and chiropractic testing). Assessment may also include the use of diagnostic imaging including X-ray and MRI.

A diagnosis of sciatica may suggest the possibility that medical intervention is appropriate. Chiropractors frequently work alongside orthopaedic and neurosurgical colleagues in managing disc injuries and may refer back to the general practitioner for appropriate pain relief prescriptions and further assessmnent. Chiropractors recognise that not all disc injuries are suitable for spinal manipulation.

Evidence based summary for manual therapy [53]

Papers have shown support for the chiropractic management of sciatica [162-163].  One  included a meta-analysis which showed manipulation to be superior to inactive control, conventional care and intradiscal injections in terms of global effect. The evidence did not show strong support for the effectiveness of manipulation in terms of pain intensity alone.

A randomised double blind controlled trial looking at the chiropractic treatment of back pain and disk problems by Santilli et al. 2006 concluded that active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion. (Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J. 2006 Mar-Apr;6(2):131-7. Epub 2006 Feb 3.)

This has been reported as a moderate level of evidence for manipulation and suggested that it demonstrates manipulation to be superior to sham manipulation for sciatica/radiating leg pain in the short and long term.

A randomised controlled study by Dr. Gordon McMorland, and others published in 2010 found manipulation compared favourably with microdiskectomy for the treatment of sciatica (Dr G McMorland et al. Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study. JMPT. 2010 Vol33, Issue8, P 576-584.) All patients had previously failed other nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture.

Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted.

Other Evidence

There is other evidence (though not of the quality of double blinded randomised controlled trials) to support the chiropractic approach (of manipulation, mobilisation and exercise) as a safe and effective treatment intervention for mild-moderate disc lesions which may cause referred pain into the leg [91-93].

There is evidence for the benefits of exercise for people with herniated lumbar disks with nerve compression causing referred pain into the leg. All the participants had been considered as candidates suitable for surgery. With exercise therapy 50 out of 52 had “good” or “excellent” outcomes, with a 92% return to work, 90% returning to their previous field of work [94].

There is some evidence that patients with operable discs lesions find that manipulation can help with the partial or complete resolution of the mechanical factors [95].

Stude reports that there is radiological, clinical and laboratory evidence that disc herniation and other stenotic factors are reduced during flexion-distraction a commonly used chiropractic treatment [96].

Back-in-Action Clinical Comment

We often find in practise that patients complaining of low back and leg pain which we diagnose as a lumbar disc problem respond well to chiropractic. However a percentage of more severe cases do not respond to manual care and may be more suited to a surgical approach.

Chiropractors frequently work alongside orthopaedic and neurosurgical colleagues in managing disc injuries and may refer back to the general practitioner for appropriate pain relief prescriptions. Chiropractors recognise that not all disc injuries are suitable for spinal manipulation.

Chiropractors utilise a range of treatment and management interventions for referred pain in the back of the leg including manipulative therapy, mobilisation, massage, flexion-distraction, acupuncture techniques, exercise prescription (individually tailored self mobilisation, stretching and strengthening), therapeutic advice, patient education strategies and onward referral where indicated. We also find that to get the best results with people we not only need to free the mechanically restricted areas but help deal with the underlying causes – i.e. helping reduce the stress on that area of the body. Our approach often incorporates muscle release techniques, cranial work, diet and nutritional advice, functional neurological exercises, breathing techniques, acupuncture, cryotherapy (heat and/or ice), postural improvements, foot orthotics, ergonomic advice and relaxation counselling.

The treatments used depend upon the severity of the condition and any associated neurological symptoms.

In practise we also find that many patients who present with a radiating type leg pain actually may have on further investigation referred pain from muscles or joints around the pelvis and low back.