Spine ICF - Lumbar Radiculopathy: LBP with Radiating Pain (That Does Not Centralize)

ICF classification

• Pain extends distal to the knee —> indicates nerve root involvement

• Neurological symptoms present:

  • Sensory (paresthesia, numbness)

  • Motor (weakness)

  • Reflex changes

• Symptoms are not modified (centralized) w repeated movements

Common causes

• Primary issue: Nerve root compression

  • Disc herniation in posterolateral direction

  • Osteophyte formation

  • Spondylolisthesis

  • All 3 are caused by disc degeneration and lead to spinal stenosis

    • Reduces available space for nerve roots

Clinical presentation

• Characteristics of pain

  • Sharp, shooting pain that travels below the knee

    • Paresthesia - abnormal skin sensations such as pins and needles

    • Numbness

  • Often unilateral

    • Because pathologies usually favor one side and as a result, compress a single nerve root

    • If bilateral - cauda equina syndrome (red flag)

  • Neuropathic

    • Pain arises from nerve compression and follows dermatomal pattern

• Weakness and loss of reflexes in legs

Diagnosis

• Acute LBP + radiating pain

  • Acute LBP + radiating pain @ involved LE

  • LE paresthesia, numbness, and/or weakness

  • Symptoms aggravation:

    • Initial-mid range spinal mobility

    • LE tension/slr/slump tests

  • Signs of

    • Nerve root involvement

    • Potential deficits

      • Decreased sensory, strength, and reflex

• Subacute LBP + radiating pain

  • Subacute/recurring mid/LBP + associated radiating pain

  • Symptoms:

    • Aggravate at mid range

    • Worsen at end range

    • LE tension/slr/slump tests

  • Potential deficits

    • Decreased sensory, strength, and reflex

• Chronic LBP + radiating pain

  • Chronic LBP + radiating pain

    • Chronic/recurring mid/LBP + associated radiating pain

    • Symptoms aggravation

      • Sustained end-range LE tension/SLR/slump tests

    • Potential deficits

      • Decreased sensory, strength, and reflex

Neuro screen

• Radiculopathy = effects at nerve root level

  • Dermatomes

    • Checking sensation

    • Bilaterally

      • Different?

    • “Does this feel different?”

  • Myotomes

    • Check test action

    • Bilaterally

      • Different?

    • “Don’t let me move you”

  • Deep tendon reflex (DTR)

    • Patellar

      • L3

    • Achilles

      • S1

    • Bilaterally

      • Different?

Special tests

• = provocative in nature

• Looking for: symptom reproduction

• Neurodynamics

  • Impinged nerves will have altered movement in the body

• Neural tissue sensitivity

  • Root compression » inflammation

    • Increased excitability

  • Hyperalgesia

• Tests include:

  • Slump test

  • SLR test

  • Cross-SLR test

Slump test

• Provocative assessment of neurodynamics/neural sensitivity

• Positive test at any S&S reproduction

• Sn = 0.84, Sp = 0.83

Straight leg raise

• Test of lumbosacral neural tissue mechanosensitivity

  • Aka: are radicular s&s d/t n root compression

  • Pooled: Sn = 0.91, Sp = 0.26

• Procedure:

  • Therapist slowly flexes hip

    • Maintain extended knee

  • Check for s/s

    • + reproduction of s/s

    • At 30 deg or less = strong correlation

  • Increase provocation

    • +DF

    • + Hip adduction

    • + Cervical flexion

• Cross SLR

  • = SLR test of contralateral (unaffected) side

  • Pooled: Sn = 0.29, Sp = 0.88

Treatment

• Surgical

  • Once conservative treatment fails

  • Very similar results to non-surgical!

  • Non-surgical

    • Physical therapy

      • Exercise and conditioning

        • Active stabilize

      • Manual therapy

        • Segment mobs

        • Nerves w decreased mobility

    • Education

      • Positions that alter pain

    • Traction

Traction

• Longitudinal force on joint, increasing joint space

  • Relieves pressure on nerve root

    • Widen IV foramina

    • Reduction in disc displacement

      • Negative pressure “sucks back” as ligs tighten pushing back in

    • Stretches spinal muscles

• Positional distraction

  • = more accessible alternative

    • Less equipment

  • Isolates spinal level to affected IVF

    • Combo: flexion, lateral flex + rot

    • Maximizes neuroforamen space