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Lumbar Radiculopathy

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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:
  • 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


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

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

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

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


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. Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. 2007 May;25(2):387-405.
  5. Hallin RP. Sciatic pain and the piriformis muscle. Postgrad Med. 1983;74(2):69‐72.
  6. Meknas K, Christensen A, Johansen O. The internal obturator muscle may cause sciatic pain. Pain. 2003;104(1–2):375‐380.
  7. 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. 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.
  9. 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.
  10. 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 November 2020 15:34:12
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