Introduction:
Low back pain with sciatica is one of the most common complaints for which patients seek medical advice, and the condition has considerable economic consequences in terms of healthcare resources and lost productivity. Most patients return to their normal activities within six months. For many patients, such as the one described below, a lengthy spell off work can have serious repercussions, and a rapid return to work is imperative.
Case presentation:
A man of 27 presented with low back pain of acute onset that was complicated by pain radiating down his right leg. The problem had coincided with a recent spell of gardening and had worsened progressively over the next few days, ultimately developing into numbness and tingling of the right foot. Although analgesics had controlled the pain, his foot had become noticeably weaker.
At this stage he had consulted his general practitioner:

He was found to be fit and healthy; he had no history of similar complaints. Physical examination showed that he had reduced forward flexion of the lumbar spine; straight leg raising was limited to 45 degrees on the right side. A sciatic stretch test on his right leg had positive results and responses to light touch and pin prick were reduced on the lateral side and over the dorsum of the right foot. Dorsiflexion of the right foot showed slight weakness (grade 4) and the right ankle jerk was reduced. His general practitioner prescribed anti-inflammatory drugs and bed rest for one week. Because of the patient's general concerns, it was decided to reassess the usual approach and evaluate evidence for the possible treatment options.
Question1: What would you prescribe to this patient at this stage?
Two weeks follow-up:
Two weeks later he presented at the rheumatology clinic with radicular pain that was aggravated by standing or sitting for any length of time. During this period and through his own initiative he had magnetic resonance imaging scan performed privately. His showed classic disc herniation on the right hand side at L5-S1. Physical examination confirmed the previous findings and did not show any warning sign or indications of progressive involvement. It was also apparent that he had a demanding work schedule and that any prolonged absence could have serious employment consequences. He wanted treatment that would allow him to return to normal activities as soon as possible. Fortunately the prognosis for patients with low back with radicular symptoms is good: 95% of patients return to normal activities within six months.

Although this information reassured the patient, it was clear that a speedy, recovery was his chief aim. Usual approach to patients with radicular pain is to encourage early mobilization and thereafter to use clinical judgement to select an appropriate treatment for each patient's circumstances.

Because of the patient's specific requirement to return to work as soon as possible, it was decided to reassess the usual approach and evaluate evidence for the possible treatment options.
Question2: What would you prescribe to this patient at this stage?
One year follow-up:
When last reviewed, approximately a year after the epidural injection, he had no residual neurological deficit, no sciatic pain but occasional mild low back pain on exertion that did not alter his usual life pattern including leisure activities.

Because of the patient's concerns about work ability, it was decided to reassess the usual approach and evaluate evidence for the possible treatment options.
Question3: What would you prescribe to this patient at this stage?
Ten year follow-up: He has been doing well until last year when he started having recurrent episodes of low back pain with occasional radiating pain down to the right leg exacerbated by exertion, walking, driving, when getting out of car, bed and armchair. For the last three months low back pain persisted despite three epidural injections and lumbar brace. Activities of daily living have been quite limited over the past month.

Physical examination showed that he had reduced forward and backward bending of the lumbar spine; straight leg raising was limited to 30 degrees on the right side. The right ankle jerk was reduced. There was no motor or sensory loss.

Plain X-rays of the lumbar spine revealed stage II degenerative L5-S1 inter-vertebral disc and stage I degenerative L4-L5 inter-vertebral disc.

MRI of the lumbar spine revealed L5-S1 right hand side posterior-lateral extruded disc in contact with S1nerve root and rupture of the inter-vertebral ligament. Because of the patient's concerns about pain and quality of life, it was decided to reassess the usual approach and evaluate evidence for choosing between treatment options.
Question4: What would you prescribe to this patient at this stage?
(*) Ash Samanta and Jo Beardsley Evidence based case report. Sciatica: which intervention? British Medical Journal 1999;319:302-3.