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Lumbar Radiculopathy
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(Redirected from Sciatica)
Contents
Other Names
- Sciatica
- Sciatic Back Pain
- Radicular back pain
- Lumbosacral Radiculopathy
Background
- This page refers to back pain with radicular features radiating down one or both legs due to nerve compression
Definitions
- Lumbosacral radiculopathy refers to compression of a nerve root as it exits the lumbosacral column
- 'Sciatica' refers to pain in the distribution of the sciatic nerve
- The terms sciatica, lumbosacacral radiculopathy often used interchangeably, although they are technically distinct
History
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
- The term 'radiculopathy' refers to constellation of symptoms that occur with compression of the lumbosacral nerve roots
- This includes 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[4]
- The symptoms of lumbar radiculopathy are secondary to other etiologies including:
- Degenerative Disc Disease
- Spondylolisthesis
- Facet Joint Pathology
- Spinal Stenosis
- More rarely due to neoplasm, infection, trauma
- 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
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[5]
- There is some literature to support the Obturator Internus as a cause of sciatica often attributed to the piriformis muscle[6]
Risk Factors
- Increasing age
- Physically demanding occupations including
- Military service
Differential Diagnosis
- Fractures
- Neurological
- Musculoskeletal
- Autoimmune
- Infectious
- Pediatric
Clinical Features
- History
- Patients report lower back pain that radiates into the lower extremity
- 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
- Physical Exam: Physical Exam Back
- In most cases, neuro exam is normal
- Patients may have diminished reflexes, sensation or strength
- Special Tests
- Straight Leg Raise Test: patient supine, flex hip with knee extended and ankle dorsiflexed
Evaluation
- In the absence of red flags, imaging isn't necessary initially
- Consider imaging after 4-8 weeks of lack of improvement with conserative therapy
Radiographs
- Standard Radiographs Lumbar Spine, Standard Radiographs Sacroiliac Joint
- Screening tool for initial imaging modality
- Can reveal
- Degenerative changes
- Fractures
- Disc space narrowing
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
Diagnostic Block
- In cases of uncertain etiology, a diagnostic nerve block may be considered[7]
Classification
Management
Prognosis
- Outcomes are similar among surgical and non-surgical patients[8]
Nonoperative
- Generally considered first line management
- Patient Education
- Maintaining activity and exercise
- Physical Therapy
- Complementary and Alternative Medicine (CAM) including
- Medications
- NSAIDS
- Oral Corticosteroids should be considered
- Rarely Opiates
- McKenazie Exercises
- Home based exercise program aimed at treating cervical and lumbosacral back pain
- Shown to provide some relief in acute lumbar radiculopathy[9]
- Corticosteroid Injection
- May target epidural, facet joint, or transforaminal space depending on cause
- Can have diagnostic value as well
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[8]
- Technique
- Depends on etiology
- Discetomy
- Laminectomy
- Lumbar fusion
Rehab and Return to Play
Rehabilitation
- Emphasis on core stabilization and strengthening[10]
- Correct inflexibilities, strength deficits
- Improve postural awareness
Return to Play
- Needs to be updated
Complications
- Chronic pain
See Also
- Internal
- External
- Sports Medicine Review Back Pain: https://www.sportsmedreview.com/by-joint/back/
References
- ↑ 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.
- ↑ Tarulli, Andrew W., and Elizabeth M. Raynor. "Lumbosacral radiculopathy." Neurologic clinics 25.2 (2007): 387-405.
- ↑ Jordon, Jo, Kika Konstantinou, and John O'Dowd. "Herniated lumbar disc." BMJ clinical evidence 2009 (2009).
- ↑ Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. 2007 May;25(2):387-405.
- ↑ Hallin RP. Sciatic pain and the piriformis muscle. Postgrad Med. 1983;74(2):69‐72.
- ↑ Meknas K, Christensen A, Johansen O. The internal obturator muscle may cause sciatic pain. Pain. 2003;104(1–2):375‐380.
- ↑ 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.
- ↑ 8.0 8.1 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.
- ↑ 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.
- ↑ 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:
5 October 2022 23:57:30
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