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Sciatica

80 citationsUpdated Oct 2026
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For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Sciatica prognosis is difficult to define due to study heterogeneity [1], with outcomes in secondary care remaining modest and only slightly improved by surgical intervention [4]. Comorbidity assessment is essential for these patients [4]. Pathophysiologically, severe sciatica associated with lumbar disc herniation correlates with swelling of the affected nerve root within the dural tube [3]. While inflammation biomarkers such as TNFα and IL-6 do not significantly differentiate sciatica from referred leg pain [11], and the link between inflammation and symptoms remains inconclusive [13], nerve-root injection serves as a valuable diagnostic tool for recurrent cases or when standard methods fail [7].

Non-operative management in the acute phase (< 8 weeks) relies primarily on pain medication, as transforaminal epidural corticosteroids have shown negative results in randomized trials [2] and are not cost-effective compared to usual care [100]. Platelet-rich plasma epidural injection is recommended for single-level lumbar herniated nucleus pulposus due to its efficacy and safety [37]. Clinical decision-making in primary care is supported by specific referral algorithms [8] and ongoing evidence from the SCOPiC trial [5].

Operative intervention is indicated for chronic sciatica (4–12 months) caused by lumbar disc herniation, where early surgery is cost-effective and provides greater pain reduction at six months than conservative treatment [10, 19]. Tubular discectomy offers functional outcomes similar to conventional microdiscectomy but yields less favorable patient-reported pain and recovery scores [14]. For intraspinal synovial cysts, surgery results in complete resolution of sciatica at 18–25 months [9], while arthrodesis for Grade-III or IV isthmic spondylolisthesis achieves solid fusion and excellent relief of back pain and sciatica [22]. Patient selection for lumbosacral fusion requires persistent, disabling pain unrelieved by non-surgical treatment [43]. Current evidence lacks a definitive optimal treatment for lumbar disc-induced sciatica [6], necessitating further studies to identify candidates for early discectomy [45] and to assess the impact of activity restrictions post-discectomy [90].

Anatomy & Pathophysiology

Spinal Anatomy

The spinal column comprises 33 vertebrae divided into five distinct regions: 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 or 5 fused coccygeal vertebrae [51, 56, 59]. This configuration typically allows for 24 mobile segments [59]. A typical vertebra consists of an anterior body and a posterior arch that enclose the vertebral canal [59]. The vertebral body is a fairly cylindrical mass of bone connected by pedicles to the posterior arch, which consists of the lamina and spinous process [51]. The neural arch is composed of two pedicles laterally and two laminae posteriorly that are united to form the spinous process [59]. The spinal canal is created by the vertebral body anteriorly, the lamina posteriorly, and the pedicles laterally [51]. This canal extends throughout the length of the column and provides protection for the spinal cord, conus medullaris, and cauda equina [59].

Vertebral bodies function primarily to bear weight and transfer forces to the pelvis and hips, while the posterior elements provide protection to neural structures and function as a tension band [51]. Vertebral bodies bear 70% to 90% of the static axial load of the spine [55]. Facet joints support 10% to 20% of axial load in a standing, neutral alignment [55]. In extension, facet joints may bear up to 30% of the axial load, whereas in flexion, they may be burdened with up to 50% of the anterior shear load [55]. The lumbar spine has approximately 40° to 50° of lordosis [55]. The basic motion segment of the spine, the "functional spinal unit," consists of two vertebrae, the disk between them, and the facet joints and their capsules [55].

The intervertebral disk is composed of an inner nucleus pulposus and an outer ring termed the anulus fibrosus [56]. The nucleus pulposus serves as an osmotic pump to attract water and generate hydraulic pressure when subjected to significant loads [56]. The anulus fibrosus encapsulates the nucleus pulposus and provides mechanical support to contain nucleus pulposus pressure and constrain intervertebral rotations [56]. The intervertebral disk absorbs axial loads by deforming the nucleus pulposus to redistribute forces radially, which are resisted by the tensile properties of the anulus fibrosus [55]. The end plate is a bilayer of cartilage and bone that separates the disk from adjacent vertebrae [56].

The thoracic and lumbar levels are supplied by paired segmental arteries which originate directly from the aorta along its posterior surface [60]. The vascular supply of the spinal cord is primarily from the medullary branches of the segmental spinal arteries, which merge to feed the anterior spinal artery [60]. The anterior spinal artery is responsible for supplying approximately 80% of the vascular supply to the spinal cord [60]. The arteria medullaris magna (AMM), also known as the artery of Adamkiewicz, typically arises on the left side anywhere between the T8 and L1 level [60].

Nerve Anatomy

A typical mixed spinal nerve has three distinct components: motor, sensory, and sympathetic [61]. Motor root fibers arise from the anterior horn cells and innervate the skeletal muscles [61]. Sensory fiber cell bodies are located within the dorsal root ganglia with axons entering the posterolateral sulcus of the cord via several rootlets [61]. Pain and temperature fibers synapse in the substantia gelatinosa and cross to ascend in the dorsal spinothalamic tract [61]. Tactile fibers enter, synapse, and cross to ascend in the ventral spinothalamic tract [61]. The sympathetic component of all 31 mixed spinal nerves leaves the spinal cord along only 14 motor roots [61]. The cells of origin for the sympathetic component are in the intermediolateral cell column that extends throughout the thoracic and upper lumbar cord segments [61]. The area of skin supplied by the fibers of a single spinal root is called a dermatome [61]. Segmental dermatomal patterns are well preserved in the thoracic region but not in the limbs [61].

Neurological Associations: * L4 nerve root: Associated with the tibialis anterior muscle and the patellar reflex [57]. * L5 nerve root: Associated with toe extensors [57]. * S1 nerve root: Associated with peroneal muscles and the Achilles reflex [57].

Pathophysiology of Sciatica

Most patients with herniation of a lumbar disc and severe sciatica had swelling of the affected root in the dural tube, with a close relationship between sciatica severity and root swelling [3]. However, there is no experimental evidence showing that a herniated nucleus pulposus pressing on a lower lumbar-nerve root does in fact cause sciatica [32]. The pressure theory of pain has never been challenged or proved, and evidence suggests that pressure on nerve roots is not a common primary cause of sciatic pain [32].

In the typical disc syndrome, back pain is static or mechanical in nature, aggravated by activity and relieved by rest [17]. The improvement of back pain with rest may be due to a decrease in edema of the nerve root, adaptation of the root to its altered position, or physiological compression of the root [17]. Sciatica generally develops later in the course of the acute episode and sometimes not at all during the initial or early attacks [17]. Sciatica is usually unilateral, but even when bilateral, one limb is more painful than the other [17]. Sciatica alone, without back pain, is unusual, occurring in only 1 per cent of all patients in the series reported by Lansche and Ford [17]. The intensity of the pain seems to have no direct relationship to the size of the disc protrusion [17]. Sensory change in the foot, manifested by paresthesias or numbness, is quite common in the typical disc syndrome [17].

In case of a negative result in randomized controlled trials for acute sciatica treatment, pain medication will remain the mainstay of treatment in the acute stages [2]. The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain [23]. Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels [50].

The preserved biomechanical behavior in the upper lumbar segments underscores the particular vulnerability of the lumbosacral junction to mechanical deficits [72]. Pelvic rotation is an important method to compensate for the limited lumbar motion in patients with lumbar disc herniation [108]. Spinal musculature plays an important role in spinal sagittal imbalance in patients with lumbar disc herniation [114].

Gluteal Pain Mechanisms: * Dorsal Rami Compression: The principle mechanism of gluteal pain in lumbar disc hernia is compression or irritation of L5 or S1 dorsal rami, which produces pain by irritating the superior or medial cluneal nerve and referred pain from facet and sacroiliac joints [115]. * Proximal Sciatica: Proximal sciatica could also induce gluteal pain in patients with lumbar disc hernia [115]. * Gluteal Nerve Involvement: Fibers in the superior or inferior gluteal nerve could be compressed or irritated in lumbar disc herniation, inducing related gluteal pain [115].

Electromyogram-diagnosed chronic lumbar radiculopathy is highly associated with L4-S1 regional multifidus atrophy on magnetic resonance imaging [134]. The multifidus muscle plays a major role in stabilizing the neutral zone, and its atrophy and dysfunction reduce effective control of intervertebral motion, increasing the neutral zone and being associated with low back pain [134]. Denervation-related mechanisms contribute to multifidus degeneration in patients with chronic lumbar radiculopathy [134].

Classification

Diagnostic Accuracy and Clinical Examination

The accuracy of individual clinical index tests used to predict imaging findings of nerve root impingement in patients with chronic lumbar radiculopathy is low when applied in specialised care [25]. Clinicians' overall evaluation improves diagnostic accuracy slightly for chronic lumbar radiculopathy compared to individual clinical index tests [25]. A comprehensive systematic review of diagnostic accuracy studies evaluates clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine [16]. When clinical symptoms and signs are inconsistent with imaging findings, a detailed physical examination of the sciatic nerve is beneficial to avoid misdiagnosis [15].

Imaging and Anatomical Classification

The classification term 'disc bulges' is a source of confusion and disagreement among many practitioners [26]. The most commonly supported nomenclatures for lumbar disc herniation and nerve root compression have strong interobserver reliability [26]. A modified classification for migrated lumbar disc herniation has good reliability [47]. The experience level of spine surgeons does not affect the reliability of the modified classification for migrated lumbar disc herniation [47]. Computerized axial tomographic scanning of the thighs and pelvis can be helpful in evaluating the cause of sciatica of an extraforaminal etiology [18]. Textural features from T2-weighted magnetic resonance images can be applied in low back pain classification [111].

Pathophysiological and Biomarker Classification

There is a close relationship between sciatica severity and root swelling in patients with lumbar disc herniation [3]. There does not appear to be any experimental evidence showing that a herniated nucleus pulposus pressing on a lower lumbar-nerve root does in fact cause sciatica [32].

Clinical Subgrouping and Prognostic Classification

An algorithm was developed to support clinical decisions regarding early referral for primary care patients with sciatica [8]. The prognosis for sciatica referred to secondary care is not that good and only slightly better after surgery [4].

Clinical Presentation

History and Symptom Characteristics

The classic lumbar disc syndrome typically presents with dull, aching low-back pain that develops following a bending or lifting strain [17]. In this typical presentation, back pain is static or mechanical in nature, aggravated by activity or use of the back, and relieved at least partially by rest [17]. It is unusual for the pain to be non-intermittent during the initial episode [17]. While pain in the buttock or lower extremity may develop simultaneously with low-back pain, this concurrent onset is unusual [17]. Sciatica is usually unilateral; when bilateral, one limb is more painful than the other, though sciatic pain may occasionally alternate from one limb to the other [17]. Sciatica occurring without back pain is rare, present in only 1 per cent of patients in the series reported by Lansche and Ford [17]. The distribution of limb pain is often identical whether the disc protrusion occurs at the fourth lumbar or lumbosacral interspace [17]. Furthermore, the intensity of sciatic pain appears to have no direct relationship to the size of the disc protrusion [17].

Pathophysiology and Mechanisms

The improvement of pain with rest in the typical disc syndrome may result from a decrease in edema of the nerve root, adaptation of the root to its altered position, or physiological compression of the root [17].

Diagnostic Evaluation and Biomarkers

Magnetic resonance imaging is probably the diagnostic modality of choice when a lesion of the sciatic nerve is suspected [40]. However, findings on magnetic resonance scans were not predictive of the development or duration of low-back pain in asymptomatic subjects [23]. In the ATLAS cohort, no significant differences in serum levels of TNFα, IL-6, or any other biomarkers were observed between patients with sciatica and those with back pain with referred leg pain [11]. A combination of clinical features predicted the presence or absence of histologically confirmed inflammation in a sample of patients with lumbar disc herniation [39]. Clinicians' overall evaluation improves diagnostic accuracy slightly for chronic lumbar radiculopathy [25]. Additionally, negative discography in patients with probable symptoms of discogenic low back pain cannot absolutely exclude the diagnosis of discogenic pain [21].

Differential Diagnosis and Mimickers

Orthopaedic surgeons must distinguish lumbar radiculopathy from a myriad of mimicking pathologies, including musculoskeletal, neurogenic, immunogenic, and iatrogenic conditions [80]. Specific considerations include: * Nerve sheath tumors: These should be included in the differential diagnosis of neurogenic pain in the lower extremity [40]. * Atypical femoral fracture: This should be considered in older patients with lumbar canal stenosis undergoing long-term bisphosphonate therapy who present with thigh pain [38]. * Herpes zoster: Risk should be addressed whenever physicians encounter patients with sciatica, and vaccination should be considered especially for patients aged over 50 [41].

Prognosis and Management Context

In the event of a negative result in the trial of transforaminal epidural corticosteroids, pain medication will remain the mainstay of treatment in the acute stages of sciatica [2].

Investigations

MRI: Magnetic resonance imaging is the procedure of choice for screening patients with low back or sciatic pain following routine radiography [70]. It has supplanted CT myelography for lumbar and thoracic spine evaluation due to its noninvasive nature and lower cost [70]. MRI provides ideal evaluation of intervertebral discs, nerve roots, the posterior longitudinal ligament, intervertebral foramen, and the spinal cord [70]. It is superior to CT for identifying infections, tumors, and degenerative changes within discs [71], as well as for directly imaging neural structures and the nerve root in the foramen [71]. Specifically, MRI allows imaging of the nerve root in the foramen, which is difficult with postmyelography CT because contrast does not extend fully through the foramen [75].

Sagittal T2-weighted or gradient-echo images create a “myelographic” effect useful for evaluating subarachnoid space compromise [70]. Sagittal T1-weighted images should be examined to identify narrowing of the neuroforamina [70]. Far lateral disc herniations are best seen on selected axial images localized through disc levels [70]. Free disc fragments appear discontinuous with the intervertebral disc and usually have intermediate T1-weighted signal [70]. A positive MRI T2-weighted image of the lumbar disc with a high-intensity zone (HIZ) indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain [118]. The presence of an HIZ on a lumbar MRI T2-weighted image indicates abnormal disc morphology [120]. Lumbar endplate lesions (LEPLs) are common findings on lumbar MRIs in the general population, particularly in men [116]. Diffusion tensor imaging has been reported to demonstrate spinal cord impairment in early stage cervical spondylosis before it is visible on plain MRI scans [75].

CT: CT myelography is invasive and more costly than MRI [70]. It is reserved for patients with contraindications to MRI or equivocal MRI examinations [70]. CT is particularly useful in differentiating compression fractures from burst fractures and identifying features such as facet widening [73]. The primary disadvantage of CT imaging compared to MRI is that it does not provide as good a visualization of soft tissues [73].

Other Modalities: Ascending lumbar venography was as accurate as myelography (86 per cent) in localizing herniation of a lumbar disc in surgically proved cases [131]. Ultrasound imaging can be considered a useful tool to detect changes in the sciatic nerve due to disc herniation [107].

Clinical Correlation and Timing: MRI findings must be carefully correlated with the clinical impression because anatomy may be abnormal but asymptomatic [71]. Meaningful clinical information from MRI is obtained by posing specific questions regarding neural compression, instability, and deformity derived from history and physical examination [71]. The specific location of an abnormality should be suspected before MRI and confirmed with the study [71]. In a sample of patients with lumbar disc herniation, a combination of clinical features predicted the presence or absence of histologically confirmed inflammation [39]. MRI evidence of lumbar disc degeneration was found in 35% of patients aged 20 to 39 years and in 100% of patients older than 50 years [71]. MRI findings were not predictive of the development or duration of low-back pain in asymptomatic subjects [23].

The decision to obtain MRI is a clinical determination based on general criteria of diagnostic evaluation for symptoms of sciatica of approximately 6 weeks in duration [35]. In cases of severe pain or neurologic progression, MRI may be obtained substantially earlier than 6 weeks [35].

Diagnostic Pitfalls: If the clinical picture warrants it, exploration of the lumbar canal should be done even though the myelogram is negative [121]. Venous varix compression of the sciatic nerve should be considered if there is a lack of correlation between radiological findings and clinical picture or failure of response to treatment of assumed spinal etiology [113].

Prognostic Factors: Findings contribute new knowledge about patients' and clinicians' perspectives on the role of imaging and spinal specialist opinion in the management of sciatica [28].

Treatment

Non-Operative

Heterogeneity in available studies precludes firm conclusions regarding the prognosis of non-surgically treated sciatica [1]. In the acute stages, pain medication remains the mainstay of treatment, as randomized controlled trials have shown no relevant differences in outcome between study arms [2]. The overall incidence of regression among non-surgically treated symptomatic lumbar disc herniation patients is 63% [44]. Conservative management for lumbar stenosis involves a general practitioner providing information, reviewing pain medication efficacy, advising patients to stay active, and prescribing physical therapy consisting of active exercises, education, stretching, strengthening, and conditioning [87]. The goal of stretching and strengthening exercises is to decrease extension forces on the lumbar spine attributable to agonist muscle tightness or antagonist weakness [87]. Conditioning exercises include walking on a treadmill or level/inclined surfaces and riding a stationary bicycle to increase general fitness [87]. A maximum of 9 physical therapy sessions is allowed in the first 3 months of conservative management, with three additional booster sessions in the fourth, fifth, and sixth months [87]. Most lumbar spine pathologies in recreational athletes can be managed nonsurgically with excellent outcomes [49].

Injections and Interventions: Transforaminal epidural corticosteroids and local anesthetic are subjects of randomized controlled trial design for the treatment of acute sciatica [2]. Platelet-rich plasma (PRP) epidural injection is recommended for treating single-level lumbar disc herniation due to its efficacy and safety [37]. However, no significant differences in pain and functional improvements were observed between PRP and corticosteroid groups at follow-up time points in a systematic review of lumbar radicular pain [89]. Non-surgical spinal decompression is associated with a reduction in pain and an increase in disc height [99]. A combination of non-surgical spinal decompression therapy with routine physical therapy is more effective than routine physical therapy alone for improving pain, lumbar range of motion, back muscle endurance, functional disability, and physical role domain of quality of life in patients with lumbar radiculopathy following 4 weeks of treatment [105].

Operative

Indications: Surgical treatment of lumbar-disc lesions requires that pain be of sciatic nerve-root origin, persistent or recurrent, disabling, associated with neurological signs, and unrelieved by adequate non-surgical treatment [97]. Surgical treatment is a viable option with good outcomes for recreational athletes with lumbar spine pathologies who fail nonsurgical treatment or have neurological risk [49].

Surgical Approach / Technique: During surgical treatment of lumbar-disc lesions, the entire protruding or extruding nucleus pulposus and the degenerated portion of the disc are removed, but no attempt is made to remove the annulus [97]. Spine fusion for low backache and instability can be combined readily and effectively with removal of the nucleus pulposus [97]. Microdiscectomy was superior to nonoperative care for the treatment of chronic sciatica resulting from an L4-L5 or L5-S1 disc herniation at 2 years [31]. In patients with sciatica caused by lumbar disc herniation, tubular discectomy showed less favorable results in patient-reported pain and recovery compared to conventional microdiscectomy [14], although it was not different from conventional microdiscectomy in functional outcomes [14]. Percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) have similar clinical efficacy in treating L5–S1 disc herniation [84]. In situ arthrodesis without decompression for Grade-III or IV isthmic spondylolisthesis resulted in solid fusion and excellent relief of both back pain and sciatica [22]. The addition of dynamic stabilization to decompression does not yield significant benefits for degenerative lumbar spondylolisthesis [42].

Outcomes: Outcomes of operative management for sciatica due to lumbar disc herniation were superior to those of nonoperative management, with 81% of operated patients reporting much better or gone lower extremity pain compared to 56% of nonoperatively managed patients [29]. Operated patients for lumbar disc herniation had an 11-point improvement in the Roland score compared with a 5-point improvement for the nonoperative group [29]. For sciatica due to spinal stenosis, 78% of operatively managed patients had a marked reduction in lower extremity pain compared with 45% of nonoperatively managed patients [29]. Follow-up of 18 to 25 months after treatment for intraspinal synovial cyst causing sciatica revealed complete resolution of the sciatica in all patients [9].

Other Considerations: The evidence for spinal fusion or disc replacement in non-specific low back pain is poor, and lumbar disc replacement should not be performed [106]. Additional studies are needed to identify patients who may ultimately fail nonoperative treatment and would benefit from early discectomy [45].

Complications

Other Considerations: Long-term follow-up of cauda equina syndrome patients revealed that many continued to experience sexual issues, with reported rates ranging from 14% to 100% [36]. In the context of sciatica management, tubular discectomy resulted in a lower rate of recovery than conventional microdiscectomy [14]. Furthermore, tubular discectomy resulted in greater leg and back pain than conventional microdiscectomy for sciatica [14].

Recovery

Prognosis and Natural History: Heterogeneity in available studies makes it difficult to draw firm conclusions about sciatica prognosis [1]. The overall incidence of regression is 63% among non-surgically treated symptomatic lumbar disc herniation patients [44]. In older children and adolescents with lumbar intervertebral disc lesions, the prognosis is good and nearly all patients recover as a result of conservative treatment [137].

Surgical Outcomes: At 2 years, microdiscectomy was superior to nonoperative care for the treatment of chronic sciatica resulting from an L4-L5 or L5-S1 disc herniation [31]. In patients with sciatica caused by lumbar disc herniation, tubular discectomy was not different from conventional microdiscectomy in functional outcomes and showed less favorable results in patient-reported pain and recovery [14]. Follow-up ranging from eighteen to twenty-five months revealed complete resolution of the sciatica in all patients with intraspinal synovial cysts [9]. All arthrodeses for Grade-III or IV isthmic spondylolisthesis resulted in a solid fusion and excellent relief of both the back pain and the sciatica [22]. Seven percent of lumbar disc patients had a residive lumbar disc operation within five years of their first operation [133]. In patients with lumbar disc herniation surgery, all patient-reported outcomes improved from preoperative to the short-term follow-up, while no likely clinically important differences between the short- and long-term follow-up were seen [103]. In a prospective study of 331 patients using a new full-endoscopic technique for interlaminar operation of lumbar disc herniations, 82% reported no longer having leg pain and 13% had only occasional pain at 2 years [136].

Non-Surgical and Diagnostic Considerations: In case of a negative result in a randomized controlled trial of transforaminal epidural corticosteroids, pain medication will remain the mainstay of treatment in the acute stages of sciatica [2]. Nerve-root injection is a valuable method for patients with recurrent sciatica or when standard diagnostic methods fail [7]. In a primary care cohort, no significant differences in serum levels of TNFα, IL-6 or any other biomarkers were seen between patients with sciatica and those with back pain with referred leg pain [11]. Findings on magnetic resonance scans were not predictive of the development or duration of low-back pain [23]. The high-intensity zone (HIZ) sign indicated a part of the natural history of disc degeneration but was not an actual source of low back pain [46].

Key Evidence

  • [L1] At present, the heterogeneity of the available studies makes it difficult to draw firm conclusions about sciatica prognosis, and highlights the need for further research for this group of patients. [1] (10.1186/1471-2474-12-208)
  • [L1] In case of a negative result (no relevant differences in outcome between the three study arms), pain medication will remain the mainstay of treatment in the acute stages of sciatica. [2] (10.1186/s12891-017-1571-8)
  • [L4] Most patients with herniation of a lumbar disc and severe sciatica had swelling of the affected root in the dural tube, with a close relationship between sciatica severity and root swelling. [3] (10.2106/00004623-198870030-00007)
  • [L3] The results indicate that the prognosis for sciatica referred to secondary care is not that good and only slightly better after surgery and that comorbidity should be assessed in patients with sciatica. [4] (10.1186/1471-2474-13-183)
  • [L1] Results from this trial will contribute to the evidence base for management of patients with sciatica consulting in primary care. [5] (10.1186/s12891-017-1513-5)
  • [L2] Evidence is lacking concerning the optimal treatment of lumbar disc induced sciatica. [6] (10.1186/1471-2474-6-8)
  • [L3] The study developed an algorithm to support clinical decisions regarding early referral for primary care patients with sciatica. [8] (10.1186/s12891-019-2686-x)
  • [L4] Follow-up ranging from eighteen to twenty-five months revealed complete resolution of the sciatica in all patients. [9] (10.2106/00004623-198567060-00006)
  • [L1] Patients who underwent surgery for sciatica lasting 4 to 12 months caused by lumbar disk herniation had a greater reduction in pain at 6 months than those who received conservative treatment. [10] (10.1056/nejmoa1912658)
  • [L3] In this cohort, no significant differences in serum levels of TNFα, IL-6 or any other biomarkers were seen between patients with sciatica and those with back pain with referred leg pain. [11] (10.1186/s12891-019-2604-2)
  • [L1] Taking into account the overall risk of bias of the included studies there is insufficient evidence to draw firm conclusions regarding the relationship between inflammation and clinical symptoms in patients with sciatica. [13] (10.1186/s12891-019-2541-0)
  • [L1] In patients with sciatica caused by lumbar disc herniation, tubular discectomy was not different from conventional microdiscectomy in functional outcomes and showed less favorable results in patient-reported pain and recovery. [14] (10.2106/jbjs.9202.ebo443)
  • [L4] When clinical symptoms and signs are inconsistent with imaging findings, a detailed physical examination of the sciatic nerve is beneficial to avoid misdiagnosis. [15] (10.1186/s12891-021-04728-1)
  • [L1] This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. [16] (10.1186/s12891-017-1549-6)
  • [Case_report] Computerized axial tomographic scanning of the thighs and pelvis can be helpful in evaluating the cause of sciatica of an extraforaminal etiology. [18] (10.2106/00004623-198668090-00026)
  • [L3] Early surgery is cost-effective compared with nonoperative care in patients who have had chronic sciatica for 4 to 12 months. [19] (10.1097/corr.0000000000002001)
  • [L2] Negative discography in patients with probable symptoms of discogenic low back pain cannot absolutely exclude the diagnosis of discogenic pain. [21] (10.1007/s00402-011-1448-5)
  • [L4] All of the arthrodeses resulted in a solid fusion and excellent relief of both the back pain and the sciatica. [22] (10.2106/00004623-198971010-00011)
  • [L2] The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. [23] (10.2106/00004623-200109000-00002)
  • [L2] The accuracy of individual clinical index tests used to predict imaging findings of nerve root impingement in patients with chronic lumbar radiculopathy is low when applied in specialised care, but clinicians' overall evaluation improves diagnostic accuracy slightly. [25] (10.1186/1471-2474-14-206)
  • [L1] Although it appears that the most commonly supported nomenclatures have strong interobserver reliability, the classification term 'disc bulges' is a source of confusion and disagreement among many practitioners. [26] (10.1007/s11999-014-3674-y)
  • [L5] Findings contribute new knowledge about patients' and clinicians' perspectives on the role of imaging and spinal specialist opinion in the management of sciatica, and provide important insights for understanding the 'fast-track' pathway, as part of the stratified care model tested in the RCT. [28] (10.1186/s12891-020-03483-z)
  • [L3] [29] (10.2106/00004623-199906000-00002)
  • [L2] At 2 years, the present study showed that microdiscectomy was superior to nonoperative care for the treatment of chronic sciatica resulting from an L4-L5 or L5-S1 disc herniation. [31] (10.2106/jbjs.21.00448)
  • [L3] [35] (10.1186/1471-2474-11-275)
  • [L2] However, long-term follow-up of cauda equina syndrome patients revealed that many continued to experience sexual issues (14% to 100%). [36] (10.1186/s12891-025-08736-3)
  • [L1] Due to its efficacy and safety, the procedure is recommended in treating single level lumbar HNP. [37] (10.1186/s12891-023-06429-3)
  • [Case_report] Therefore, clinicians should consider AFF as a differential diagnosis in older patients with lumbar canal stenosis who are undergoing long-term bisphosphonate therapy and present with thigh pain. [38] (10.1186/s12891-022-05990-7)
  • [L3] In a sample of patients with lumbar DHR a combination of clinical features predicted the presence or absence of histologically confirmed inflammation. [39] (10.1186/s12891-020-03590-x)
  • [Case_report] Tumors of the nerve sheath should be included in the differential diagnosis of neurogenic pain in the lower extremity, and magnetic resonance imaging is probably the diagnostic modality of choice when a lesion of the sciatic nerve is suspected. [40] (10.2106/00004623-199304000-00016)
  • [L2] HZ risk should be addressed whenever physicians encounter patients with sciatica, and HZ vaccination should be considered especially for those aged over 50. [41] (10.1186/s12891-020-03847-5)
  • [L1] The addition of dynamic stabilization to decompression does not yield significant benefits. [42] (10.1186/s13018-025-06550-0)
  • [L1] The overall incidence of regression is 63% among non-surgically treated symptomatic lumbar disc herniation patients. [44] (10.1186/s12891-020-03548-z)
  • [L4] Additional studies to identify patients who may ultimately fail nonoperative treatment and would benefit from early discectomy would be beneficial. [45] (10.1016/j.spinee.2010.02.005)
  • [L3] HIZ sign indicated a part of the natural history of disc degeneration but was not an actual source of low back pain. [46] (10.1186/s13018-018-1010-z)
  • [L3] The modified classification has good reliability and its experience level of spine surgeons does not affect the reliability. [47] (10.1186/s13018-023-03688-7)
  • [L5] Most lumbar spine pathologies in recreational athletes can be managed nonsurgically with excellent outcomes, while surgical treatment is a viable option with good outcomes for those who fail nonsurgical treatment or have neurological risk. [49] (10.5435/jaaos-d-24-00979)
  • [L4] Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels. [50] (10.1186/s12891-025-09182-x)
  • [L3] The preserved biomechanical behavior in the upper lumbar segments underscores the particular vulnerability of the lumbosacral junction to mechanical deficits. [72] (10.1186/s12891-025-09238-y)
  • [L5] Orthopaedic surgeons must distinguish lumbar radiculopathy from a myriad of mimicking pathologies, including musculoskeletal, neurogenic, immunogenic, and iatrogenic conditions, to avoid misdiagnosis and delays in appropriate care. [80] (10.5435/jaaos-23-01-7)
  • [L3] PEID and PETD have similar clinical efficacy in treating L5–S1 disc herniation. [84] (10.1186/s13018-024-04543-z)
  • [L2] [87] (10.1186/1471-2474-12-57)
  • [L1] Although no significant differences in pain and functional improvements were observed between the PRP and corticosteroid groups at other follow-up time points, future studies are needed to assess the efficacy and safety of PRP versus corticosteroid injections in treating lumbar radicular pain by standardizing PRP preparation, extending follow-up durations, and increasing sample sizes. [89] (10.1186/s13018-025-05725-z)
  • [L2] This document describes the protocol for a randomised controlled trial to assess the impact of activity restrictions on clinical outcomes following lumbar discectomy, aiming to provide an evidence base for postoperative care. [90] (10.1186/s12891-017-1681-3)
  • [L3] Non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. [99] (10.1186/1471-2474-11-155)
  • [L1] Adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting. [100] (10.1186/s12891-024-07366-5)
  • [L3] All patient-reported outcomes improved from preoperative to the short-term follow-up, while no likely clinically important differences between the short- and long-term follow-up were seen within both groups. [103] (10.1302/0301-620x.101b12.bjj-2019-0621.r1)
  • [L2] It was concluded that a combination of non-surgical spinal decompression therapy with routine physical therapy is more effective, statistically and clinically, than routine physical therapy alone in terms of improving pain, lumbar range of motion, back muscle endurance, functional disability, and physical role domain of quality of life, in patients with lumbar radiculopathy, following 4 weeks of treatment. [105] (10.1186/s12891-022-05196-x)
  • [L5] The evidence for spinal fusion or disc replacement in non-specific low back pain is poor; spinal fusion should only be performed as part of a randomised controlled trial, and lumbar disc replacement should not be performed. [106] (10.1302/0301-620x.99b8.bjj-2017-0199.r1)
  • [L3] Ultrasound imaging can be considered as a useful tool to detect changes in the sciatic nerve due to disc herniation. [107] (10.1186/s12891-019-2814-7)
  • [L4] Pelvic rotation is an important method to compensate for the limited lumbar motion. [108] (10.1186/s12891-017-1572-7)
  • [L4] Textural features from T2-weighted magnetic resonance images can be applied in low back pain classification. [111] (10.1002/jor.24973)
  • [L5] It should be considered if there is lack of correlation between radiological findings and clinical picture or if there is a failure of response to treatment of assumed spinal etiology. [113] (10.1016/j.wneu.2018.06.058)
  • [L4] Spinal musculature plays an important role in spinal sagittal imbalance in patients with LDH. [114] (10.1186/s12891-016-1164-y)
  • [L5] [115] (10.1186/s12891-018-2147-y)
  • [L3] LEPLs are common findings on lumbar MRIs in the general population, particularly in men. [116] (10.1186/s12891-023-06379-w)
  • [L1] A positive MRI T2-weighted image of the lumbar disc with HIZ indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain. [118] (10.1186/s13018-023-04187-5)
  • [L1] The presence of an HIZ on a lumbar MRI T2-weighted image indicates abnormal disc morphology. [120] (10.1186/s13018-017-0523-1)
  • [L4] If the clinical picture warrants it, exploration of the lumbar canal should be done even though the myelogram is negative. [121] (10.2106/00004623-196042020-00001)
  • [L3] Ascending lumbar venography was as accurate as myelography (86 per cent) in localizing herniation of a lumbar disc in surgically proved cases. [131] (10.2106/00004623-197759020-00003)
  • [L3] Seven percent of the lumbar disc patients had a residive lumbar disc operation within five years of their first operation. [133] (10.1186/1471-2474-8-2)
  • [L3] [134] (10.1186/s12891-026-10084-9)
  • [L2] The results show that 82% reported no longer having leg pain, and 13% had only occasional pain. [136] (10.1055/s-2006-932172)
  • [L4] Lesions of the lumbar intervertebral discs may occur in older children and adolescents; the prognosis is good, and nearly all of the patients recover as a result of conservative treatment. [137] (10.2106/00004623-195032010-00009)

See Also

References

[1] Prognostic factors in non-surgically treated sciatica: A systematic review. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-208

[2] Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: design of a randomized controlled trial. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1571-8

[3] Swelling of the cauda equina in patients who have herniation of a lumbar disc. A possible pathogenesis of sciatica.. The Journal of Bone & Joint Surgery. 1988. DOI: 10.2106/00004623-198870030-00007

[4] Prognostic factors for non-success in patients with sciatica and disc herniation. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-183

[5] The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581). BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1513-5

[6] Prolonged conservative treatment or 'early' surgery in sciatica caused by a lumbar disc herniation: rationale and design of a randomized trial [ISRCT 26872154]. BMC Musculoskeletal Disorders. 2005. DOI: 10.1186/1471-2474-6-8

[7] Nerve-Root Injection: A METHOD FOR EVALUATING THE ETIOLOGY OF SCIATICA.. The Journal of Bone and Joint Surgery. American Volume. 1974.

[8] Subgrouping patients with sciatica in primary care for matched care pathways: development of a subgrouping algorithm. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2686-x

[9] Intraspinal synovial cyst causing sciatica.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567060-00006

[10] Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 Months. New England Journal of Medicine. 2020. DOI: 10.1056/nejmoa1912658

[11] Inflammatory biomarkers do not distinguish between patients with sciatica and referred leg pain within a primary care population: results from a nested study within the ATLAS cohort. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2604-2

[13] Inflammatory biomarkers in patients with sciatica: a systematic review. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2541-0

[14] Tubular Discectomy Resulted in Greater Leg and Back Pain and a Lower Rate of Recovery Than Conventional Microdiscectomy for Sciatica. The Journal of Bone & Joint Surgery. 2010. DOI: 10.2106/jbjs.9202.ebo443

[15] The diagnostic pitfalls of lumbar disc herniation---- malignant sciatic nerve tumour: two case reports and literature review. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04728-1

[16] Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1549-6

[17] Low-Back Pain and Sciatica: Diagnosis and Indications for Treatment.. The Journal of Bone and Joint Surgery. American Volume. 1968.

[18] Sciatica from a sciatic neurilemoma. A case report and review of the literature.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668090-00026

[19] Microdiscectomy Is More Cost-effective Than a 6-Month Nonsurgical Care Regimen for Chronic Radiculopathy. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000002001

[21] Diagnosis of discogenic low back pain in patients with probable symptoms but negative discography. Archives of Orthopaedic and Trauma Surgery. 2012. DOI: 10.1007/s00402-011-1448-5

[22] In situ arthrodesis without decompression for Grade-III or IV isthmic spondylolisthesis in adults who have severe sciatica.. The Journal of Bone & Joint Surgery. 1989. DOI: 10.2106/00004623-198971010-00011

[23] The Value of Magnetic Resonance Imaging of the Lumbar Spine to Predict Low-Back Pain in Asymptomatic Subjects. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200109000-00002

[25] Accuracy of physical examination for chronic lumbar radiculopathy. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-206

[26] How Should We Grade Lumbar Disc Herniation and Nerve Root Compression? A Systematic Review. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-014-3674-y

[28] Patients’ and clinicians’ perspectives on a ‘fast-track’ pathway for patients with sciatica in primary care: qualitative findings from the SCOPiC stratified care trial. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03483-z

[29] Relationship Between Rates and Outcomes of Operative Treatment for Lumbar Disc Herniation and Spinal Stenosis. The Journal of Bone & Joint Surgery. 1999. DOI: 10.2106/00004623-199906000-00002

[31] Discectomy Compared with Standardized Nonoperative Care for Chronic Sciatica Due to a Lumbar Disc Herniation. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.21.00448

[32] Whilst the so-caned disc syndrome is a well established clinical entity there does not appear to be any experimental evidence showing that a herniated nucleus pulposus pressing on a lower lumbar-nerve root does in fact cause sciatica.. 1958.

[35] Bias in the physical examination of patients with lumbar radiculopathy. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-275

[36] The implications of surgery on sexual dysfunction in patients with lumbar disc herniation with cauda equina syndrome: a systematic review. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08736-3

[37] “Platelet-Rich Plasma” epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06429-3

[38] Atypical femoral fracture mimicking lumbar radiculopathy in two patients taking bisphosphonate long-term: A case report. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05990-7

[39] Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03590-x

[40] Sciatica caused by a neurilemoma of the intrapelvic portion of the sciatic nerve. A case report.. The Journal of Bone & Joint Surgery. 1993. DOI: 10.2106/00004623-199304000-00016

[41] Herpes zoster in patients with sciatica. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03847-5

[42] Decompression, decompression plus fusion and decompression plus dynamic stabilization for degenerative lumbar spondylolisthesis: a network meta-analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06550-0

[43] Low Backache and Sciatica: Results of Surgical Treatment: PART I. SPINE FUSION ONLY.. The Journal of Bone and Joint Surgery. American Volume. 1964.

[44] The incidence of regression after the non-surgical treatment of symptomatic lumbar disc herniation: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03548-z

[45] Cost and use of conservative management of lumbar disc herniation before surgical discectomy. The Spine Journal. 2010. DOI: 10.1016/j.spinee.2010.02.005

[46] Factors associated with lumbar disc high-intensity zone (HIZ) on T2-weighted magnetic resonance image: a retrospective study of 3185 discs in 637 patients. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-1010-z

[47] Independent reliability and availability analyses of modified classification for migrated lumbar disc herniation. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03688-7

[49] Lumbar Spine Injuries in Recreational Athletes: A Review. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00979

[50] Prevalence of modic changes in patients with low back pain and association with degenerative spinal findings: a retrospective MRI study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09182-x

[51] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Spinal Anatomy > Osseous Anatomy.

[55] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Spinal Anatomy > Biomechanics.

[56] Orthopaedic Basic Science Fifth Edition Print Ebook. Biology and Mechanics of the Skeletal Extracellular Matrix > Anatomy.

[57] Miller S Review Of Orthopaedics. Genetics of musculoskeletal conditions and abnormalities are summarized in Table 1.27 > SURGICAL APPROACHES TO THE SPINE (Table 2.46).

[59] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTION OF THE PATELLOFEMORAL AND PATELLOTIBIAL LIGAMENTS WITH A SEMITENDINOSUS TENDON GRAFT > ANATOMY OF VERTEBRAL COLUMN.

[60] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Spinal Anatomy > Vascular Anatomy.

[61] Campbell S Operative Orthopaedics 4 Volume Set. PERIPHERAL NERVE INJURIES OF THE UPPER AND LOWER EXTREMITIES > ANATOMY OF THE SPINAL NERVES > COMPONENTS OF MIXED SPINAL NERVES.

[70] Campbell S Operative Orthopaedics 4 Volume Set. INTERVERTEBRAL DISC DISEASE.

[71] Campbell S Operative Orthopaedics 4 Volume Set. OVERVIEW OF LUMBAR AND THORACIC DISC DEGENERATION AND HERNIATION > MAGNETIC RESONANCE IMAGING.

[72] Fatigue-induced biomechanical decoupling at L4-S1 discs: mechanism of disc degeneration in chronic low back pain. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09238-y

[73] Rockwood And Green S Fractures In Adults. Imaging of Cervical Spine Fractures and Dislocations > Computed Tomography.

[75] Campbell S Operative Orthopaedics 4 Volume Set. POSTERIOR APPROACH TO THE LUMBAR SPINE, L1 TO L5 > MAGNETIC RESONANCE IMAGING.

[80] Mimickers of Lumbar Radiculopathy. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-23-01-7

[84] Percutaneous endoscopic transforaminal vs. interlaminar discectomy for L5–S1 lumbar disc herniation: a retrospective propensity score matching study. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04543-z

[87] Design of the Verbiest trial: cost-effectiveness of surgery versus prolonged conservative treatment in patients with lumbar stenosis. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-57

[89] Therapeutic interventions of platelet-rich plasma versus corticosteroid injections for lumbar radicular pain: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05725-z

[90] Lumbar microdiscectomy and post-operative activity restrictions: a protocol for a single blinded randomised controlled trial. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1681-3

[97] Low Backache and Sciatica: Results of Surgical Treatment: PART III. SURGICAL TREATMENT OF SPONDYLOLISTHESIS.. The Journal of Bone and Joint Surgery. American Volume. 1964.

[99] Restoration of disk height through non-surgical spinal decompression is associated with decreased discogenic low back pain: a retrospective cohort study. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-155

[100] Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07366-5

[103] Lumbar disc herniation surgery in adolescents and young adults. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b12.bjj-2019-0621.r1

[105] Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05196-x

[106] The surgical treatment of non-specific low back pain. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b8.bjj-2017-0199.r1

[107] The relationship of the shear wave elastography findings of patients with unilateral lumbar disc herniation and clinical characteristics. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2814-7

[108] Influences of lumbar disc herniation on the kinematics in multi-segmental spine, pelvis, and lower extremities during five activities of daily living. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1572-7

[111] T2‐weighted magnetic resonance imaging texture as predictor of low back pain: A texture analysis‐based classification pipeline to symptomatic and asymptomatic cases. Journal of Orthopaedic Research. 2021. DOI: 10.1002/jor.24973

[113] Sciatica Caused by Venous Varix Compression of the Sciatic Nerve. World Neurosurgery. 2018. DOI: 10.1016/j.wneu.2018.06.058

[114] Spinal sagittal imbalance in patients with lumbar disc herniation: its spinopelvic characteristics, strength changes of the spinal musculature and natural history after lumbar discectomy. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1164-y

[115] Possible pathogenic mechanism of gluteal pain in lumbar disc hernia. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2147-y

[116] The lumbar spinal endplate lesions grades and association with lumbar disc disorders, and lumbar bone mineral density in a middle-young general Chinese population. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06379-w

[118] The correlation between the lumbar disc MRI high-intensity zone and discogenic low back pain: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04187-5

[120] The correlation between the high-intensity zone on a T2-weighted MRI and positive outcomes of discography: a meta-analysis. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0523-1

[121] Correlation of the Myelogram with Clinical and Operative Findings in Lumbar Disc Lesions. The Journal of Bone & Joint Surgery. 1960. DOI: 10.2106/00004623-196042020-00001

[131] Ascending lumbar venography in lumbar-disc disease. The Journal of Bone & Joint Surgery. 1977. DOI: 10.2106/00004623-197759020-00003

[133] Reoperations after first lumbar disc herniation surgery; a special interest on residives during a 5-year follow-up. BMC Musculoskeletal Disorders. 2007. DOI: 10.1186/1471-2474-8-2

[134] Electromyogram diagnosed chronic lumbar radiculopathy is highly associated with L4-S1 regional multifidus atrophy on magnetic resonance imaging. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-10084-9

[136] A New Full-Endoscopic Technique for the Interlaminar Operation of Lumbar Disc Herniations Using 6-mm Endoscopes: Prospective 2-Year Results of 331 Patients. min - Minimally Invasive Neurosurgery. 2006. DOI: 10.1055/s-2006-932172

[137] INTERVERTEBRAL-DISC LESIONS IN CHILDREN AND ADOLESCENTS. The Journal of Bone & Joint Surgery. 1950. DOI: 10.2106/00004623-195032010-00009

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a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.