Overdiagnosis or misdiagnosis
The sciatica epidemic
The other day i had a patient with pain in lower back and spreading into the left leg. She promptly went to her “ortho” (weird isn’t it we have family orthopaedician) and was diagnosed as having “sciatica”. That was done easily as she had pain in the leg and back. The patient was prescribed pain-relieving medications, but unfortunately, like many others, she did not experience any significant improvement. She was referred to a “specialist” in a star hospital. A repeat MRI was requested and promptly shown in the MRI her “problem”.
See here “ the disc is compressing the nerve”
“Yes sir”
”well we need to correct it ASAP get on that gurney”
Like many patients who are understandably hesitant about undergoing spinal surgery, she decided to seek a second opinion and ended up in my clinic. I did not see any sciatica, I diagnosed her as having Non- specific Low back pain (NSLBP). I'm certain that this story is not unique – it's a scenario that many patients encounter. I want to highlight the increase in misdiagnosis or overdiagnosis of sciatica in clinical practice. I am not sure which nomenclature fits best, but I will assume this is misdiagnosis problem.
What’s are the features of sciatica?
As we all know, sciatica occurs when the sciatic nerve is compressed, leading to radiculopathy characterized by symptoms such as sensory and motor weakness along with severe pain. This pain is often described as burning or pricking, although it can encompass various sensations. Notably, the presence of saddle sensory weakness is considered a red flag, necessitating specialist care, possibly from a neurosurgeon. Please note that this is not an exhaustive medical textbook description; rather, these are the essential features.
Sciatica is becoming increasingly prevalent in our daily practice, even though it is relatively uncommon compared to non-specific low back pain (NSLBP). But I am not sure many patients who are diagnosed with sciatica have the above mentioned symptoms. That is they don’t fit the diagnosis criteria but are labeled as having sciatica. When a patient presents with both leg and back pain, it's often hastily assumed to be sciatica. Subsequently, they are sent for an MRI to confirm this hypothesis, with the expectation that the disc is out ( “herniated” which somehow makes the diagnosis sound more sophisticated).
Allow me to clarify the reasons why this process can lead to misdiagnosis or overdiagnosis.
A comprehensive history and physical examination are essential for accurately diagnosing radiculopathy. It's important to remember that pain in the lower back can radiate to other areas, including the lower limb, even without nerve compression (say referred pain). It's crucial to differentiate between NSLBP and sciatica. However, when we reflexively order MRIs for everyone experiencing back and lower limb pain as a diagnostic test, we end up "discovering" more cases of disc prolapse and sciatica. This is primarily a matter of probability. Essentially, we have shifted the diagnostic criteria from clinical assessment to relying solely on imaging and the presence of pain in the back and leg, overlooking the crucial factor—whether it is indeed a radiculopathy. This is has led to overdiagnosis or misdiagnosis of sciatica.
I hear patients being diagnosed as having sciatica over the phone, across the table without examination, just by seeing a MRI. However, even if you have assumed it to be sciatica- the MRI is hardly required if the patient is not going for surgery.
Read a book and use your organ between the ears you lazy, greedy idiot.
But what harm does it make to be thorough with a MRI?
From psychological to physical aspects, the effects of overdiagnosis are observed in numerous medical conditions- from diabetes to early cancer detection.
The persistent anxiety experienced by patients, often leading to increased disability.
Leading to many people saying:
“what spinal surgery, I have a major disease” - this is sad especially if it is misdiagnosed
“ I have l4 l5 issue for the last 5 years”. (well this is not only for sciatica)
“I have sciatica and told not to bend or lift heavy objects”
“I use less of my bike as it can aggravate my back” and by the way fuck global warming I am driving my car”
“I never venture out without this belt”
These have led to abuse of MRI, needless intervention from over medication (probably a gabapentin kind of drugs) and “surgeries”.
Well the cost of health care for a simple disease runs into the risk of going into lakhs, (well who care)
And then there are PTs- who via then the magic of pulling the vertebrae apart to relieve the pressure, and relieve the symptoms- I am talking about the table we all have in our clinic. Then there are countless low value care from extension exercises to manual therapy (including magic points). And special mention to nerve mobilization guys-😂 just sit down. Even if the diagnosis is right these PT method are pretty useless so….
so what should be done if we have a confirmed diagnosis via a proper examination. Well nothing much. Ask your patient to be active, do some exercise- any exercise will be good. Be empathetic- as the pain will be unbearable. And stop giving useless advice from stopping driving to flexion.
PS- it seems early screening for cancer rarely reduces outcomes and whole body check up is good if you have a clinical lab.