Sciatica and Associated Depression
References
Koes, B., van Tulder, M., & Peul, W. (2007). Diagnosis and treatment of sciatica. BMJ,
334(7607), 1313-1317. http://dx.doi.org/10.1136/bmj.39223.428495.be
6 pages – sciatica and depression – essay – 10 pages
References
Koes, B., van Tulder, M., & Peul, W. (2007). Diagnosis and treatment of sciatica. BMJ,
334(7607), 1313-1317. http://dx.doi.org/10.1136/bmj.39223.428495.be
6 pages – sciatica and depression – essay – 10 pages
Sciatica Pathology.
Sciatica is a common ailment characterized by radiation of leg pain and disabilities related to the pain (Koes, van Tulder, & Peul, 2007). Diagnosis is based on history, physical examination, and testing; imaging is used in the event there is a suspicion surgery may be indicated.
Etiology and Risk Factors.
It is estimated that sciatica related to disc problems affected approximately 2.2 percent of the population (Younes et al., 2006). The development of sciatica is associated with age (adults between 45 and 64 years of age), height (taller people have higher risk), smoking, lifestyle stress, occupations that involve frequent lifting while twisting, and driving.
Symptoms.
Patient report of radiating pain in a dermatomal pattern, possible low back pain, and sensory symptoms promotes suspicion of sciatica (Koes, van Tulder, & Peul, 2007). Physical examination employs the straight leg raising test (Lasègue's sign). To differentiate between non-specific low back pain and sciatica, the physician looks for low back pain that is less than pain in only one leg, pain radiation and numbness to the foot or toes, leg pain induced with straight leg raising and pain limited to one nerve root.
Diagnostic Imaging.
Imaging is indicated only if there may be the need for surgical intervention based on history and physical examination; if there is a suspicion of infection, malignancy or other causes that disc herniation or if the patient does not respond to conservative treatment after 6 to 8 weeks, magnetic resonance imaging (MRI) may be preferred over computed tomography due to less radiation or better visualization of soft tissues (Goving, 2004). Diagnosis of lumbar disc herniation cannot be made from imaging (Jarvik, 2002).
Treatment.
It is generally accepted that treatment should be conservative in nature for the first 6 to 8 weeks (Koes, van Tulder, & Peul, 2007). Initial treatment is focused on reduction of pain with analgesics or taking pressure off the nerve root. Patient education is important for compliance with recommended therapy. Use of nonsteroidal anti-inflammatory drugs, analgesics, muscle relaxers, traction, intramuscular injections of steroids or have not been shown to be definitively effective or ineffectivein relieving sciatica symptoms. Further research is needed.
Nonopioid medication. In a review of 122 relevant studies, nonopioid drugs were found to statistically improve symptoms (Lewis et al., 2015).
Opioid medication. In a review of 122 relevant studies, opioid drugs were found to be inferior to other treatment therapies (Lewis et al, 2015).
Epidural injections. Steroid injections into the dura matter of the spinal cord may be effective in symptom relief (Vroomen, de Krom, Slofstra, & Knottnerus, 2000). In a review of 122 relevant studies, epidural injection was found to statistically improve symptoms (Lewis et al., 2015).
Disc surgery. Surgery on discs has been shown to provide faster relief of leg pain over more conservative therapy, but no differences are demonstrated after two years (Koes, van Tulder, & Peul, 2007). In a review of 122 relevant studies, disc surgery was found to statistically improve symptoms (Lewis et al., 2015). Intervention is removal of disc herniation and eventually part of the foraminal stenosis to eliminate leg pain, but not back pain. Cauda equine syndrome requires immediate surgery.
Spinal manipulation. In a review of 122 relevant studies, spinal manipulation was found to statistically improve symptoms (Lewis et al., 2015).
Acupuncture. In a review of 122 relevant studies, acupuncture was found to statistically improve symptoms (Lewis et al., 2015).
Bed rest. Passive bed rest therapy has been found to be inferior to more active treatments and therefore is no longer recommended (Koes, van Tulder, & Peul, 2007). In a review of 122 relevant studies, bed rest was found to be inferior to other treatment therapies (Lewis et al, 2015).
Exercise therapy. Evidence shows movement is more beneficial than bedrest (Health Council of the Netherlands, 1999).
Education/advice used alone. In a review of 122 relevant studies, education alone was found to be inferior to other treatment therapies (Lewis et al, 2015).
Percutaneous discectomy. In a review of 122 relevant studies, percutaneous discectomy was found to be inferior to other treatment therapies (Lewis et al, 2015).
Prognosis.
The prognosis is favorable for most sciatica patients, but 20 percent to 30 percent continue to experience symptoms after one year (Koes, van Tulder, & Peul, 2007).
Depression Associated with Sciatica
Cross-sectional surveys have been conducted for decades demonstrating that anxiety, depression, and chronic pain frequently occur at the same time. Moods that are symptomatic of anxiety and depression are aggravated or initiated by pain. A study in 2006 followed 395 members of a sciatica group that received both surgical and nonsurgical intervention over a 10 year span (Max et al., 2006). The participants in the study showed a significant relationship between depressive symptoms and pain.
Use of the Calgary-Cambridge Guide to the Interview
Start of the consultation. Before meeting with the patient, familiarize yourself with the patient’s history to attempt to anticipate possible problems (Kurtz et al., 2003).
Gathering information. Proper preparation for the interview allows the creation of anticipatory responses and the formulation of appropriate questions to gather additional information. This may be done through examination, gathering a history, taking samples, and observation (Kurtz et al., 2003) non-verbal cues to message communication occur 80 percent of the time as opposed to 20 percent of the time as verbal statements (Gask, 2002). Ask open-ended questions, then move to closed ones. Listen closely without interrupting or leading the answers. A request for a detailed narrative of the problems may reveal additional information. Clarify statements and use non-technical terms to be sure the patient understands the question.
Building the relationship. Greeting the client, confirming his name, introducing oneself, stating the purpose of the interview, and asking permission promotes rapport with the patient and family (Kurtz et al., 2003). Start the interview with casual conversation and give a personal experience if possible.
Closing the interview with explanation and planning. Explain the reason for the symptoms and offer reassurance about expected prognosis (Koes, van Tulder, & Peul, 2007). Provide recommendations for activity, lifestyle, diet, and other needs. Review medications in easy-to-understand terms. Remind of dates for follow up appointments and provide with a written reminder. Make arrangements for consultations if needed. Be sure the patient understands what has preceded in the interview and close with thanks and genuine concern .
Reflections
The patient is a regular client of the clinic, but I have never met him before. From the patient’s records, I found that he has a history of a persistent cough, severe low back pain, and numbness in one leg. He has a recent diagnosis of sciatica. I reviewed his tests and consultations and felt confident I could conduct the interview in an informed fashion. The notes on the chart told me of his frustration and possible depression and I was prepared to confront that behavior. I created possible responses to his inquiries regarding his diagnosis, treatment, and prognosis.
I created a safe and professional environment by being friendly and responsive to the patient’s questions. I introduced myself, confirmed the patient’s name and that of his wife, stated the purposed of the interview, and asked permission to conduct it. I did not rush the visit. In order to establish rapport, I started the interview with the information from the chart that the patient worked as a driver. I told him that my uncle works as a driver and states he sometimes has low back pain. I empathized with the discomfort the patient was experiencing. I made eye contact, used the names of the patient and his wife, and used gestures such as nodding to show I was listening closely. The patient was accompanied by his wife, who was as upset as the patient with the pain he was experiencing and I included her input in the interview, but confirmed her comments with the patient. I did not interrupt or lead the patient on his answers to my questions.
I observed the signs of his reaction to his pain. He was angry, flushed, his heart rate and blood pressure were elevated, and he was crying. The doctor attempted to comfort him and prescribed more potent pain medication. This calmed the patient and his wife to some extent. The doctor allowed me to question the patient concerning his recent symptoms and I examined his throat and felt his lymph glands for signs of infection; none were detected. The doctor suggested the cough may be in response to his crying and suggested an expectorant for a few days and then evaluating the result.
I asked open-ended questions such as, “How is the pain right now?”, “How long do you need to be sitting before it becomes noticeably worse”, and “How do you feel emotionally about the challenges you are facing with your sciatica?”. I asked for a detailed narrative of the patient’s and the wife’s version of his medical problems by saying, “Can you walk me through your history with your present problems?”. Although it was possible additional information would come to light, none was detected. In addition, I clarified statements with questions such as “Do I understand that . . .” and “Wanted to do what?”.
As far as patient education, I explained the cause of the patient’s symptoms and offered reassurance about his prognosis. He was advised to stay active and maintain daily activities with only a few hours of bed rest as needed. The patient was provided with Tylenol with codeine and was cautioned on possible side effects. A consultation was made with his orthopedic doctor for a follow up appointment and appointment card given to the patient’s wife.
At the end of the interview, I asked if there were any other concerns the couple had today. Throughout the interview, I kept my conversational skills at the level of the couple. Overall, I felt the interview was productive for the doctor and me and reassuring and educational for the patient and his wife. All topics were covered and documented for future reference. I believe my skills as an interviewer improved with this practice.
References
Gask, L. (2002). ABC of psychological medicine: The consultation. BMJ, 324(7353), pp.1567-
1569.
Govind, J. (2004). Lumbar radicular pain. Australian Family Physician, [online] 33, pp.409-12.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/15253601.
Health Council of the Netherlands, (1999). Health Council of the Netherlands: management of
the lumbosacral radicular syndrome (sciatica). Publication no. 1999/18. [online]
Available at: https://www.gezondheidsraad.nl/en/publications/optimale-
gezondheidszorg/management-of-the-lumbosacral-radicular-syndrome-sciatica [Accessed
15 May 2016].
Jarvik, J. (2002). Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Annals of
Internal Medicine, 137(7), p.586.
Koes, B., van Tulder, M. and Peul, W. (2007). Diagnosis and treatment of sciatica. BMJ,
334(7607), pp.1313-1317.
Kurtz, S., Silverman, J., Benson, J. and Draper, J. (2003). The Enhanced Calgary-Cambridge
Guide to the Medical Interview 2012. [online] Available at:
http://medicine.cf.ac.uk/media/filer_public/2013/08/29/calgary-
cambridge_guide_to_medical_interview_2012.pdf [Accessed 15 May 2016].
Lewis, R., Williams, N., Sutton, A., Burton, K., Din, N., Matar, H., Hendry, M., Phillips, C.,
Nafees, S., Fitzsimmons, D., Rickard, I. and Wilkinson, C. (2015). Comparative clinical
effectiveness of management strategies for sciatica: systematic review and network meta-
analyses. The Spine Journal, 15(6), pp.1461-1477.
Max, M., Wu, T., Atlas, S., Edwards, R., Haythornthwaite, J., Bollettino, A., Hipp, H.,
McKnight, C., Osman, I., Crawford, E., Pao, M., Nejim, J., Kingman, A., Aisen, D.,
Scully, M., Keller, R., Goldman, D. and Belfer, I. (2006). A clinical genetic method to identify mechanisms by which pain causes depression and anxiety. Molecular Pain, 2(1), p.14.
Vroomen, P., de Krom, M., Slofstra, P. and Knottnerus, J. (2000). Conservative Treatment of
Sciatica: A Systematic Review. Journal of Spinal Disorders, 13(6), pp.463-469.
Younes, M., Béjia, I., Aguir, Z., Letaief, M., Hassen-Zrour, S., Touzi, M. and Bergaoui, N.
(2006). Prevalence and risk factors of disk-related sciatica in an urban population
in Tunisia. Joint Bone Spine, 73(5), pp.538-542.
Objectives: Break down the visit in difference parts/recognize need for flexibility
Observe different methods of obtaining information and how to include in negotiating a treatment plan’
Prioritizing complaints and how to deal with uncertainty
Importance of record keeping and continuity of care
How the illness affects the patient, the family, and the role of the Family Doctor
Preventative medicine, identification of risk factors, skills for motivational change
Sensitivity for insight for compliance with medication and recommendations.
Reflection for teaching and insight purposes, differential diagnoses, and management.
Define the view, content, and context of the interview, the roles, advantages and disadvantages of
doctor-centered and patient-centered approaches
