Abstract
Background
Sciatica is a common symptom for many people with degenerative lumbar spine diseases. It is by far the most common symptom of disc herniation. However, disc herniation is not the only cause of sciatica. Other degenerative lumbar spine diseases can provoke Sciatica. To date, few studies have analysed the cause of sciatica in particularly in elderly patients.
Material and methods
We analysed retrospectively records of patients aged between 35 and 55 (first group) and between 65 and 85 (second group) visited in our departments for sciatica between December 2009 and November 2018.
Results
In elderly patients, disc herniation from upper levels (L2-L3 and L3-L4) is more common than younger people. Sciatica as a result of exclusive disc herniation reduces with age. Foramen stenosis produces sciatica in elderly patients more than twice as high in younger patients. Statistically, more patients needed to surgery in elderly patients in comparison with younger population.
Conclusion
Sciatica in elderly patients takes a different clinical aspect in comparison with younger population. The clinical picture associates pain less severe but more persistent, more resistant to treatment. It is caused in less than 50% by disc herniation.
Keywords: Lumbar disk herniation, Low back pain, Lumbar spine degenerative disease, Spine surgery, Spine degenerative diseases
1. Introduction
The prevalence of symptomatic lumbar disc herniation is about 1–3%.1, 2, 3, 4, 5, 6, 7, 8, 9,11, 12, 13, 14, 15,17 The incidence of disc herniation decreases with aging.2, 3, 4, 5,10, 11, 12, 13, 14,16,17 Although sciatica mostly affects young adults, it is not prerogative of the youth population. Sciatalgia is frequent mainly between 35 and 55 years. In this age group, the cause of sciatica originates from disc herniation in 95%. In 5% of the cases, the causes are of non-discal origin: cordonnal, central, troncular or plexular sciatica. The way that sciatica due to herniated disc occurs is relatively fast. It may often be preceded or accompanied by acute low back pain. with or without trigger factor. Disc herniation occurs less frequently as it grows older. in this age category (after 65 year), the clinical situation is, however, slower. Sciatica is preceded longer by chronic low back pain and paresthesias or unilateral intermittent claudication. In reality, though, these clinical stereotypical situations do not happen that often. In everyday clinical practice, we receive elderly patients with abrupt sciatica. In this paper, we compare statistics, mode of occurrence, evolution and proposed treatment for disc herniation in two age brackets −35 to 55 years and 65 to 85 years-.
2. Material and methods
We conducted a retrospective chart review of patients seen in our departments for sciatica between December 2009 and November 2018. Among them, some patients had sciatica due to disc herniation or foramen stenosis or recess stenosis. 5.51% of patients were excluded from the study because sciatica was generated by any other cause. 5263 patients were either the age of 35 and 55 or between 65 and 85.3622 patients (68.82%) were between the ages of 35 and 55 and 1641 patients (31.18%) were between 65 and 85 years of age. Average patient age was 41.6 years old (range: 35–55 years) and average patient age for the second group was 75 (range: 65–85 years). in the 35- to 55-year-old age bracket, there were 1086 women and 2536 men. the male-female ratio was 2.33/1. In the second range age, we found 574 women and 1067 men. the male-female ratio was therefore, 1.86/1. All the patients had their lumbar spine MR imaging at least once.
3. Results
In the 35–55 age category, the mean duration of symptoms was 8 months compared with 18.7 months in the 65–85 age bracket. In the first range age, 1815 patients (50.11%) underwent epidural infiltrations without surgery. 909 (25.10%) patients were operated without infiltrating and 611 (16.87%) patients underwent surgery after unsuccessful infiltrating. In the second range age, 1401 (85.37%) patients underwent epidural infiltrations without surgery. 129 (7.86%) patients were operated without infiltrating and 798 (48.63%) patients underwent surgery after unsuccessful infiltrating. Table 1 demonstrates disc herniation distribution across levels and Table 2 shows causes of sciatica in the two age groups.
Table 1.
Disc herniation distribution across levels.
| Age groups | 35–55 |
65–85 |
|
|---|---|---|---|
| Level | |||
| Herniation level | L1-L2 | 3 (0.08%) | 1 (0.06%) |
| L2-L3 | 6 (0.17%) | 16 (0.99%) | |
| L3-L4 | 146 (4.03%) | 311 (19%) | |
| L4-L5 | 1664 (45.91%) | 722 (44%) | |
| L5-S1 | 1803 (49.78%) | 590 (36%) | |
| Total number of P. | 3622 | 1641 |
Table 2.
Causes of sciatica in the two age groups.
| Age groups | 35–55 | 65–85 |
|---|---|---|
| D.H. | 2427 (67%) | 673 (41.01%) |
| F.S. | 651 (17.97%) | 459 (27.97%) |
| R.S. | 72 (1.98%) | 33 (2.01%) |
| D.H.+F.S. | 325 (8.97%) | 279 (17%) |
| F.S.+R.S. | 68 (1.93%) | 115 (7%) |
| D.H.+R.S. | 73 (1.88%) | 66 (4.02%) |
| D.H.+R.S.+F.S. | 6 (0.16%) | 16 (0.97%) |
Abreviation: DH = Disc Herniation. F.S. = Foraminal stenosis. R.S. = Recess Stenosis.
4. Discussion
Following conclusions may be drawn concerning our study: With regard to disc level, we found a high rate of disc herniation at the level of L3-L4 (19%) in Group B. While for Group A (younger patients) this rate is 4%. Tamir et al. have come to the same conclusion.18 Sedighi et al. indicate 10% of disc herniation at the level of L3-L4.19 Strömqvist et al. reached broadly the same conclusions as we did: 20% of L3-L4 disc herniation in elderly patients over 65 while they do not specify an upper age limit.20 At any rate, there are few studies that approach this level. Nevertheless, an important aspect is the fact that incidence rate increases with age. This increase has occurred, in our study, to the detriment of L5-S1 level. In this level, incidence rate reduced from 49% to 36% in Group A et Group B respectively. Incidence rate at the level of L4-L5 remained much the same. Detailed analysis and comparison between two groups shows that sciatica as a result of exclusive disc herniation reduces with age (67% in Group A versus 41% versus Group B) (Tab le2). Foramen stenosis produces sciatica in elderly patients more than twice as high in younger patients (Tab 2). The results of our study indicate 17.97% of sciatica caused by Foramen stenosis in Group A versus 27.97% in Group B. As regards the treatment, the results of our study are more difficult to interpret. As a matter of fact, it appears that the trend toward conservative treatment in elderly patients continues to build in our series. As a general principle, the procedure of choice is conservative treatment and infiltration as far as possible. Despite this reluctance, ultimately, 48% of patient have been operated in Group B after unsuccessful conservative treatment and infiltration. All in all, 56.49% of patients have been operated in elderly group versus 41.97% in younger group. These findings, which appear paradoxical are related to the fact that primary cause of sciatica in elderly patients is foraminal and recess stenosis and not soft disc herniation.
In summary, in comparison to elderly patient, young adults respond better to conservative treatment. In elderly patients, L3-L4 disc herniation is more common than young patients.
Compliance with ethical standards
The authors declare that there is no conflict of interest.
Doctor Keyvan MOSTOFI declares that he has no conflict of interest.
Dr Babak GHARAEI MOGHADDAM declares that he has no conflict of Interest.
Dr Morad PEYRAVI declares that he has no conflict of Interest.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jcot.2019.07.011.
Contributor Information
Keyvan Mostofi, Email: keyvan.mostofi@yahoo.fr.
Morad Peyravi, Email: moradpeyravi@yahoo.de.
Babak Gharaei Moghaddam, Email: babakgharai@yahoo.com.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
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