Sciatic Pain

THE problem of sciatic pain is a complex one. Justification for this paper lies in the belief that it is insufficiently understood and that on the whole there is a widespread laxity in accurate diagnosis, with the inevitable corollary that treatment may be inappropriate or inadequate. There is no need to emphasise the frequency of such pain. Most cases are treated by the general practitioner, but many are referred to general physicians, surgeons, orthopedists, or neurologists, or to those who specialise in various forms of physiotherapy. What matters from the point of view of the patient is that anyone undertaking treatment should have a comprehensive appreciation of the problem and be capable of carrying out the treatment indicated or at least of referring him to someone who can. Before trying to be constructive, it would be as well to give reasons for dissatisfaction with the usual state of affairs. In the first place, the term "sciatica" is loosely used for almost any pain down the back of the lower limb. It implies that the sciatic nerve is directly involved in some pathological process. Actually in a majority of cases this is not so, and the pain is referred from some structure in the posterior ilio-lumbar-sacral region. It would be better to say that the patient has pain down the thigh and leg, for that at least is true, and in actual fact may represent all that is known, rather than imply prematurely that the precise cause of the pain is understood. No harm is done if it is realised that "sciatica" is not a diagnosis, but unfortunately all too often the matter is not carried further. The patient is labelled "sciatica," put to bed in the acute stage, given warmth, analgesics, and possibly a counter-irritant, until he is fit for some form of physiotherapy. Sometimes it is mentioned that an injection of oxygen or saline into or around the nerve sheath may be beneficial, and occasionally it is recommended that an epidural injection is worth trying and may give marked relief. Many, however, are not aware of the precise indications and details of technique of such procedures. If the patient does not improve by the end of a few weeks, or as we all know, sometimes months, he is referred for a specialist opinion-usually to a neurologist or orthopaedist-where disorders in these two specialities are excluded or treated. If that fails, he is likely to be sent hopefully once more for physiotherapy, or possibly, and a little ashamedly, in the case of a woman with predominant backache, to that haven for one who has done the rounds of the departments of a general hospital-gynaeecological O.P.s, or if of dubious mental balance, to that other haven-the psychological department. Most of us will remember being taught the first thing to do in sciatica is to exclude all possible forms of pressure on the nerve, especially neoplastic, and5