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Lumbar Radiculopathy

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Other Names

  • Sciatica
  • Sciatic Back Pain
  • Radicular back pain
  • Lumbosacral Radiculopathy
  • Sacral radiculopathy

Background

  • This page refers to back pain with radicular features radiating down one or both legs

History

  • Needs to be updated

Epidemiology

  • Prevalence estimated to be between 3% - 5% of the population (need citation)
  • Incidence of low back pain with radicular symptoms ranges from 12% to 40%[1]
  • Typically affects men in their 40s, women in their 50s and 60s[2]
  • Males > Females[3]

Pathophysiology

Causes of nondisc sciatica[4]
Illustration of the lumbosacral plexus[5]
The course of the sciatic nerve in the lower limb[6]

General

  • Typically subacute radicular back pain down into the lower extremity from a wide variety of causes
  • Symptoms include radiating pain, numbness/tingling, weakness, and gait abnormalities across a spectrum of severity
  • Patients often present with a predictable pattern across a specific dermatome or myotome[7]

Terminology

  • 'Lumbosacral radiculopathy' refers to constellation of symptoms that occur with compression of the lumbosacral nerve roots
  • 'Sciatica' refers to pain in the distribution of the sciatic nerve
  • The terms sciatica, lumbosacacral radiculopathy often used interchangeably, although they are technically distinct
  • Piriformis Syndrome refers to impingement of the sciatic nerve and is considered a separate clinical entity

Etiology: Lumbar Radiculopathy

  • The symptoms of lumbar radiculopathy are secondary to other etiologies including:
  • Compression can occur at the following locations:
    • Within the thecal sac
    • As the nerve root exits the thecal sac within the lateral recess
    • As the nerve root traverses the neural foramina
    • After the nerve root as exited the foramina

Etiology: Sciatica

  • The Sciatic Nerve is made up of nerve roots L4 to S2
    • It is the largest nerve in the body
  • Compression most commonly occurs due to compression from herniated disc
    • May also be due to spinal stenosis, spondylolisthesis and other causes of radiculopathy
  • In about 15% of individuals, the nerve goes through the Piriformis muscle
    • Thus Piriformis Syndrome is a separate cause of sciatic nerve pain
    • Piriformis muscle only responsible for about 6-8% of cases[8]
    • There is some literature to support the Obturator Internus as a cause of sciatica often attributed to the piriformis muscle[9]
  • Natural history of sciatica
    • May be suddenly or slowly, with or without a clear triggering cause
    • Aching and sharp components from lower buttock proceeding dorsolateral into the thigh

Anatomy of the Lumbosacral Plexus

  • Anterior rami of L1 to L4 and S1 to S4 located in lumbar region
  • Coalesce to form the lumbosacral plexus
  • Responsible for supplying the skin, musculature of the pelvis and lower extremities

Anatomy of the Sciatic Nerve

Risk Factors

  • Increasing age
  • Physically demanding occupations including
    • Military service

Differential Diagnosis

Differential Diagnosis Back Pain

Clinical Features

Illustration of straight leg raise test with positive Lasegue sign[10]

History

  • Patients report lower back pain that radiates into the lower extremity
    • Low back pain is not always present, especially in true sciatica
  • Typically, this follows a dermatomal pattern
  • Patient may endorse numbness, tingling, weakness
  • Patients with sciatica often complain of gluteal or pain radiating down the posterior leg
  • L4 compression: pain is anterolateral thigh (can mimic hip disease)
  • L5 compression: pain in the dorsolateral thigh
  • S1 compression: pain in posterior thigh
  • Typically unilateral
  • Symptoms may be worse with valsalva (coughing, sneezing, straining, etc)

Physical Exam: Physical Exam Back

  • Paresthesia can be in a dermatomal distribution of a nerve root
    • Sensory symptoms, signs not prominent
  • Weakness is seen in less than half of patients
  • Foot drop may be present in severe L5 radiculopathy
  • Downward tilted pelvis if gluteal weakness present in S1 radiculopathy
  • In most cases, neuro exam is normal
  • Patients may have diminished reflexes, sensation or strength

Special Tests

Evaluation

Sciatic nerve compression by a paralabral cyst. Coronal PD image (A) of the right hip shows the right sciatic nerve (arrows) draped over the cyst (asterisk). Sequential axial T2 FS images depict posterior and lateral displacement of the sciatic nerve by the cyst (arrow, B). Note communication of the cyst with the hip joint at the posterior chondrolabral junction (arrow, C).[11]
T2-weighted magnetic resonance imaging (MRI) of the lumbar spine. Sagittal image showed a cyst in the ventrolateral epidural space of the 5 th lumbar vertebral (L5) level that communicated with the adjacent 4 th lumbar and 5 th lumbar intervertebral disc (arrow).[12]
  • In the absence of red flags, imaging isn't necessary initially
    • Consider imaging after 4-8 weeks of lack of improvement with conservative therapy

Radiographs

MRI

  • Imaging modality of choice
    • Can show compression of the nerve root
    • Make sure MRI findings correlate with physical exam
  • Can add contrast if concerned about tumor, infection or prior surgery

CT

  • CT with myelogram is acceptable alternative in patients who can not undergo an MRI

EMG/NCS

  • Can aid diagnosis by revealing a topographic distribution of muscular denervation corresponding to a nerve root
  • The role of EMG in sciatica has not been established and some guidelines do not require testing

Diagnostic Block

  • In cases of uncertain etiology, a diagnostic nerve block may be considered[13]

Classification

  • Needs to be updated

Management

Lumbar Support Cushion

Nonoperative

  • Indications
    • Generally considered first line management
    • Symptoms improve or resolve with conservative management in the vast majority of cases
  • Patient Education
  • Maintaining activity and exercise
    • Strict rest has been shown to be an ineffective treatment[14]
  • Physical Therapy
    • Can recommend things like yoga, tai chi
  • McKenazie Exercises
    • Home based exercise program aimed at treating cervical and lumbosacral back pain
    • Shown to provide some relief in acute lumbar radiculopathy[15]

Medications

  • NSAIDS
  • Oral Corticosteroids should be considered
  • Rarely Opiates, which most guidelines recommend avoiding
  • Tumor necrosis factor inhibitors
    • In experimental studies, negative or limited positive effects on pain[16]

Complementary and Alternative Medicine (CAM)

Procedures

Operative

  • Indications
    • Failure of conservative measures to provide adequate relief, minimum of 1-2 months
    • No clear consensus on who is a surgical candidate
    • SPORT Trial recommended using the SF36 index (benefit-cost ratio of lumbar fusion) and ODI (Oswestry Disability Index) disability score[22]
  • Technique
    • Depends on etiology
    • Discetomy
    • Laminectomy
    • Lumbar fusion

Rehab and Return to Play

Rehabilitation

  • Emphasis on core stabilization and strengthening[23]
  • Correct inflexibilities, strength deficits
  • Improve postural awareness
  • Directional preference exercises (back-movement exercises in a direction that causes the locus of pain to move proximally, toward the mid-back, where it is better tolerated)
  • Motor-control exercises (also known as specific stabilization exercises)focus on enhancing control of the transversus abdominis and multifidus muscles
  • Strengthening of other core muscles
  • Stretching
  • General fitness exercises

Return to Play

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Outcomes are similar among surgical and non-surgical patients[22]

Complications

  • Chronic pain

See Also

Internal

External

References

  1. ↑ Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010 Dec;24(6):769-81.
  2. ↑ Tarulli, Andrew W., and Elizabeth M. Raynor. "Lumbosacral radiculopathy." Neurologic clinics 25.2 (2007): 387-405.
  3. ↑ Jordon, Jo, Kika Konstantinou, and John O'Dowd. "Herniated lumbar disc." BMJ clinical evidence 2009 (2009).
  4. ↑ Pande, Anil, et al. "Piriformis Syndrome and Variants–A Comprehensive Review on Diagnosis and Treatment." Journal of Spinal Surgery 8.4 (2021): 7-14.
  5. ↑ Liyew, Worku Abie. "Clinical presentations of lumbar disc degeneration and lumbosacral nerve lesions." International journal of rheumatology 2020.1 (2020): 2919625.
  6. ↑ Sehmbi, Herman, and Ushma Jitendra Shah. "Ultrasound-guided approaches to sciatic nerve block." International Journal of Perioperative Ultrasound & Applied Technologies 2.3 (2013): 135.
  7. ↑ Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. 2007 May;25(2):387-405.
  8. ↑ Hallin RP. Sciatic pain and the piriformis muscle. Postgrad Med. 1983;74(2):69‐72.
  9. ↑ Meknas K, Christensen A, Johansen O. The internal obturator muscle may cause sciatic pain. Pain. 2003;104(1–2):375‐380.
  10. ↑ Almoallim, Hani, et al. "Approach to Musculoskeletal Examination." Skills in Rheumatology (2021): 17-65.
  11. ↑ Delaney, Holly, Jenny Bencardino, and Zehava Sadka Rosenberg. "Magnetic resonance neurography of the pelvis and lumbosacral plexus." Neuroimaging Clin N Am 24.1 (2014): 127-150.
  12. ↑ Kim, Sae Young. "Radiculopathy caused by discal cyst." The Korean Journal of Pain 27.1 (2014): 86-89.
  13. ↑ Mondelli, M., et al. "Clinical findings and electrodiagnostic testing in 108 consecutive cases of lumbosacral radiculopathy due to herniated disc." Neurophysiologie Clinique/Clinical Neurophysiology 43.4 (2013): 205-215.
  14. ↑ Vroomen, PC, de Krom, MC, Wilmink, JT, Kester, AD, Knottnerus, JA. Lack of effectiveness of bed rest for sciatica. N Engl J Med 1999;340:418-423
  15. ↑ Halliday, Mark H., et al. "A randomized controlled trial comparing the McKenzie method to motor control exercises in people with chronic low back pain and a directional preference." Journal of Orthopaedic & Sports Physical Therapy 46.7 (2016): 514-522.
  16. ↑ Genevay, Stéphane, et al. "Adalimumab in severe and acute sciatica: A multicenter, randomized, double‐blind, placebo‐controlled trial." Arthritis & rheumatism 62.8 (2010): 2339-2346.
  17. ↑ Ropper, Allan H., and Ross D. Zafonte. "Sciatica." New England Journal of Medicine 372.13 (2015): 1240-1248.
  18. ↑ Bronfort, Gert, et al. "Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation." Annals of internal medicine 161.6 (2014): 381-391.
  19. ↑ Wegner, Inge, et al. "Traction for low‐back pain with or without sciatica." Cochrane Database of Systematic Reviews 8 (2013).
  20. ↑ Buchmuller, A., et al. "Value of TENS for relief of chronic low back pain with or without radicular pain." European Journal of Pain 16.5 (2012): 656-665.
  21. ↑ Carette, Simon, et al. "Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus." New England Journal of Medicine 336.23 (1997): 1634-1640.
  22. ↑ 22.0 22.1 Weinstein, James N., et al. "Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial." Jama 296.20 (2006): 2441-2450.
  23. ↑ Kennedy, David J., and Maureen Y. Noh. "The role of core stabilization in lumbosacral radiculopathy." Physical Medicine and Rehabilitation Clinics 22.1 (2011): 91-103.
Created by:
John Kiel on 11 June 2020 23:08:58
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Last edited:
23 September 2024 12:38:12
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