Clinical

History

 The onset of symptoms in patients with lumbosacral radiculopathy is often sudden and
includes LBP. Some patients state the preexisting back pain disappears when the leg pain
begins.
 Sitting, coughing, or sneezing may exacerbate the pain, which travels from the buttock
down to the posterior or posterolateral leg to the ankle or foot.

Radiculopathy in roots L1-L3 refers pain to the anterior aspect of the thigh and typically does not
radiate below the knee, but these levels are affected in only 5% of all disc herniations.

Physical

A comprehensive physical examination of a patient with acute LBP should include an in-depth
evaluation of the neurologic and musculoskeletal systems.

 The neurologic examination should always include an evaluation of sensation, strength,

and reflexes in the lower extremities. This portion of the examination allows the
examiner to detect sensory or motor deficits that may be consistent with an associated
radiculopathy or cauda equina syndrome. Often, an assessment of the L5 reflex (medial
hamstrings) is helpful. Also, in L5 radiculopathy, the presence of weakness in foot
invertors should raise the additional suspicion of a peroneal nerve palsy. When
differentiating between an L3 radiculopathy versus a femoral neuropathy, weakness in
the hip adductors in addition to the quadriceps group would indicate an L3 radiculopathy.
In an isolated femoral neuropathy, only the quadriceps group would show weakness.
 Provocative maneuvers, such as the straight-leg raising test or the slump test, may
provide evidence of increased dural tension, indicating underlying nerve root pathology.
Attempts at pain centralization through postural changes (ie, lumbar extension) may
suggest a discogenic etiology for pain and may also assist in determining the success of
future treatment strategies.
 The musculoskeletal evaluation should include an assessment of the lower extremity
joints, as pain referral patterns may be confused with focal peripheral involvement. For
example, a patient with anterior thigh and knee pain may actually have a degenerative hip
condition rather than an upper lumbar radiculopathy. By assessing lower extremity
flexibility, hip rotation, muscular balance, and ligamentous stability, the evaluating
physician might be alerted to the patient's predisposition toward an acute LBP episode.

.Physical Examination
You may be asked to stand, walk or lie down on the exam table during the physical examination.
In a lying position, your physician will raise each of your legs to demonstrate flexibility and
 strength in your low back and legs. The following table is a summary for the examination
performed and possible findings:

Nerve Root
Possible Exam Findings with Nerve Root Compression
Involved

L2 Decreased hip flexor strength

Decreased patellar reflex

Sensation loss of the anterior thigh
L3
Weakness in quadriceps muscle
Pain in the area of the anterior thigh

Sensory loss of the anterior lateral or medial foot

Possible decreased patellar tendon reflex
L4
Weakness of the quadriceps
Pain in the area of the anterior leg

Sensory loss in the dorsum of the foot and great toe

L5 Weakness of the anterior tibialis, great toe (extensor hallicus longus), and hip abductors
Pain down the side of the leg

Decreased Achilles reflex

Sensory loss of the lateral foot and the small toe
S1
Weakness of the gastrocnemius, gluteus maximus, plantar flexor, and great toe
Pain down the back of the leg into the bottom or side of the foot

PHYSICAL
THERAPY — Physical therapy may be indicated for
patients with acute back pain who have failed to improve and return
to work within a few days, and for patients with chronic low back
pain. Studies evaluating the effectiveness of physical therapy,
compared to individual exercise, advice, or pain management, are
reviewed separately. (See "Subacute and chronic low back pain:
Physical therapy may include modality treatments, mobilization,
manipulation, exercise and patient education.

 — Physical therapy modalities include

heat, cold, and ultrasound. Evidence for effectiveness of these
measures is limited. A systematic review has found that heat wrap
therapy can provide short-term pain relief for acute and subacute
back pain.

Acute injury is best managed with the RICE program: rest, ice,
compression, and elevation. Ice packs include frozen gel packs and
frozen bags of peas. If many areas are needed, dishtowels can be
moistened and frozen, then applied as needed. Ice should be applied
for up to 20 minutes, and repeated every few hours.

EXERCISE
THERAPY — In the patient who is recovering from
acute low back pain, or who has a history of chronic or recurrent
pain, a program of regular exercises, loss of excess weight, and
modification of activities should be initiated. An exercise program
for a sedentary or older person should begin with low stress aerobic
activities (walking, swimming, stationary bike with rest breaks) to
improve physical stamina.

Patients are said to have a directional preference if their

distal symptoms centralize with movement in a specific direction
(ie, flexion or extension, lateral shift, or rotation). A randomized
trial showed improved response for patients assigned to exercises
adapted toward their directional preference, compared to general
exercises or exercises in opposition to their directional preference
which exacerbated symptoms.

Herniated lumbar
disc — Patients with a herniated disc may use the
following exercises:
The 90/90 rest position for patients with low back pain is achieved by lying on a flat surface
and flexing both hips and knees to 90 degrees.

The posterior pelvic tilt is a basic maneuver in back rehabilitation. The abdominal and gluteal
muscles are contracted to flatten the lumbar spine. This position is held for 5 to 10 seconds
and can be repeated frequently.

The elbow prop exercise is performed during the early phase of progression in a back
extension program. The position is held for 30 to 60 seconds as tolerated. When less acutely
painful, further extension can be instituted by pressing the top half of the body up with arms,
keeping elbows straight. The legs and pelvis are kept against floor.
Standing lumbar extension is a useful technique for postural correction. Subjects should be
encouraged to perform this exercise frequently, especially after being in a flexed posture for a
period of time.

Sit with one leg/foot to the side of the bed, with the other leg off the side of the bed. Bend
forward, reaching the hands toward the foot. Hold for 10 to 30 seconds. The stretch is felt in
the posterior trunk, thigh, and calf. Turn around, and repeat with the other leg out straight.
Grasping a chinning bar placed in a doorway, the subject "relaxes" into a sitting position. The
weight of the lower body stretches the musculature and soft tissues about the lumbar spine.
The subject should spend a minute or two repetitively holding this position as long as grasping
permits

This exercise strengthens abdominal muscles. It should be performed on a firm surface with
knees bent. The subject raises the trunk no more than 6 inches from the surface. Arms may
be folded across chest or stretched forward as shown. Hold position for ten to twenty seconds
and breathe. Repeat six to ten repetitions
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