TNF-α blockade for herniated intervertebral disc-induced sciatica: a way forward at last?

Extract

¹University of Manchester Rheumatic Diseases Centre, Hope Hospital, Salford ²Laboratory Medicine Academic Group, University of Manchester, Manchester, UK

Following the recognition that diagnostic triage is fundamental to the delivery and organization of services for low back pain (LBP) patients [1, 2], physiotherapy-led LBP triage and treatment clinics have proliferated. Although such developments have improved the speed and accessibility of such services to LBP patients, they have also meant that many rheumatologists now rarely see LBP patients. This especially applies to those with suspected herniated intervertebral discs (HIDs), who would usually be triaged surgically. Although representing only a small portion of the spectrum of degenerative disc disease problems [3], HIDs are still a common cause of back and radicular pain, and the natural history dictates that symptoms gradually resolve spontaneously, with a good functional outcome in most cases [4]. However, in some patients back and especially sciatic symptoms fail to resolve sufficiently quickly, or at all, so prompting decompressive surgery. Despite radiologically targeted and technically well executed surgery, sciatic symptoms (without radiological evidence of recurrent HID) do not always resolve, and surgical ‘failure’ rates range from 3–14% in some studies [5–9] to as high as 36% in others [10]. This degree of variation probably reflects between-study differences in outcome assessment methods, but clearly a substantial minority of HID patients do fare badly. In some patients surgery initially cures radicular symptoms, only for these to recur and progress as part of the feared ‘post-surgical back pain syndrome’.