APPROACH TO LOWER Dr PJ Wiese

BACK PAIN AND UFS

10/10/2022
RADICULOPATHY
INTRODUCTION
Lower back pain (LBP) is the most common musculoskeletal problem seen by
general practitioners and remains the most common cause of disability in US patients
<45 years of age. (2nd most common after a “cold”)
Radicular back pain is one of the common reasons for low back pain.
QUALITY OF LIFE
• Pain
• Depression
• Anxiety
• Stress
DEFINITIONS
• Acute lower back pain: an episode of lower back pain that resolves within 6 weeks
• Subacute lower back pain: pain persisting for 6 - 12 weeks
• Chronic lower back pain: persistent pain >12 weeks
• Nonspecific lower back pain: pain not attributed to recognizable or known pathology,
e.g. infection, fracture
• Acute lumbosacral radiculopathy: is a diffuse disease process that affects more than
one underlying nerve root, causing pain, loss of sensation, and motor function
depending on the severity of symptoms
 Patient with LBP

History and Physical

examination
Are there any serious
conditions suspected
Red flags
Yellow Flags

Diagnostic Testing

Discuss conservative
treatment options Assess response to
Phamacologic treatment
Non Pahrmacologic
HISTORY
When evaluating a patient with lower back symptoms, it may not be possible to
define a precise cause, because up to 85% of patients will be diagnosed with non-
specific lower back pain upon primary evaluation.
Important to look for evidence of specific etiologies and red flags of lower back pain.
HISTORY
• Duration of symptoms
• Location of pain and radiation, either axial or radicular low back pain
• Severity of pain (visual analog scale or numerical rating scale score)
• Characteristics:
• Burning
• Lancinating
• Aching
• Numb
• Electric shock sensation

• Circumstances that initiated the pain

• Functionality during work and activities of daily living (affect the degree of treatment)
RED FLAGS IN LOWER BACK
PAIN
• Patients <20 years and >55 years • Neurological impairment
• Not relieved on rest or posture • Bladder or bowel dysfunction
modification
• Severe morning stiffness as the primary
• Unchanged despite 2 - 4 weeks of complaint
treatment
• Inability to ambulate
• History of malignancy
• IV drug use
• Immunosuppressed status
• Thoracic dominant pain
• Fever/malaise/weight loss/ night sweats
• High fracture risk, e.g. osteoporosis
SURGICAL EMERGENCIES OF
BACK PAIN
• Rupture of AAA
• Epidural hemorrhage
• Ant spinal a. thrombosis
• Epidural Abscess
• Spinal cord tumors
• Cauda Equina Syndrome
YELLOW FLAGS
• Dissociation between verbal and non-verbal pain behavior
• Compensable cause of injury
• Psychological or emotional factors, e.g. depression, anxiety, abusive relationships
• Narcotic drug requests
• Repeated failure of both medical and surgical therapy
• Disability or inability to return to work (unwillingness
 PHYSICAL EXAMINATION
Inspection of the thoracolumbar spine:
• Posture and alignment: kyphosis, lordosis, or scoliosis

• Range of motion: Normal range of motion of the thoracolumbar spine is

90° of forward flexion, 30° of back extension, 60° of lateral rotation, and
25° of lateral flexion

• Skin evaluation : rashes, scars, swelling, and signs of trauma or

inflammation
 PHYSICAL EXAMINATION
Palpation
• Over the process can reveal localized tenderness which is seen in patients with
abscess, epidural tumor, and vertebral compression fractures
• Tenderness in the paraspinal region, which can be seen in patients with facet
arthropathy and myofascial-related pain
• Light palpation will help detect allodynia or hyperalgesia which will typically
indicate neuropathic pain
• Step-offs
• Spasms
DERMATOMES
THE PATRICK’S TEST
Evaluates hip and sacroiliac pathology, both of which are associated with lower back
pain.
With the patient in a supine position, the examiner should passively flex, abduct, and
externally rotate the hip. Pain in the groin area suggests hip pathology, while pain in
the back suggests sacroiliac joint pathology.
STRAIGHT LEG RAISE TEST
Conducted to determine any involvement of the lumbar nerve roots or hamstring muscle
in the lower back pain.
With the patient in a supine position, the examiner should lift the patient’s leg at the heel
while the knee is straight.
The hip should be flexed to an angle of 70° to 90°. This test produces tension in the
lumbar nerve roots.
A positive straight leg raise reproduces radicular pain experienced by the patient
radiating from his lower back or hip down to his ankle (the pain must occur in a
radicular pattern).
If pain remains localized to the posterior thigh area, it is most likely cause by tension on
the hamstrings.
STRAIGHT LEG RAISE TEST
 GAENSLEN’S TEST
Identify lower back pain related to the sacroiliac joints.
With the patient in the supine position, the hip joint should be
flexed maximally on one side and the opposite hip joint
extended, stressing both sacroiliac joints simultaneously.
This can be achieved by having the patient lift his knee to push
toward the chest while the other leg is allowed to fall over the
side of an examination table, and is pushed toward the floor,
flexing both sacroiliac joints.
The test is considered positive if pain related to the SI joint is
reproduced by this maneuver.
SCHOBAR’S TEST
RADICULOPATHY
 HISTORY AND PHYSICAL
EXAMINATION
RADICULOPATHY
L2, L3, and L4 lumbar radiculopathies are considered a group. This group has a marked
overlap of the innervation of the anterior thigh muscles.
An acute injury in the distribution of L2, L3, and L4 will most commonly present with the
patient experiencing radiating back pain to the anterior aspect of the thigh, which may
progress into their knee, and possibly radiate to the medial aspect of the lower leg, into the
foot.
On examination, patients can have weakness during knee extension, hip adduction, and or hip
flexion. There is often a loss of sensation over the anterior thigh along the area of pain. The
patient may show a reduced patellar reflex (L4).
Activities that can make the symptoms worse include coughing, leg straightening, or sneezing.
HISTORY AND PHYSICAL
EXAMINATION
In L5 radiculopathy, patients will often complain of acute back pain, which radiates
down the lateral leg into the foot.
On examination, there may be a reduction in muscle strength with big toe extension
(extensor hallucis longus), foot eversion, inversion, toe extension, and foot
dorsiflexion. Chronic L5 radiculopathy can cause atrophy of the extensor digitorum
brevis (the marker of L5 radiculopathy in EMG) and the tibialis anterior of the
anterior leg.
Severe L5 radiculopathy can affect the gluteus minimus and medius, causing
weakness in leg abduction.
HISTORY AND PHYSICAL
EXAMINATION
S1 radiculopathy will cause radiation of sacral or buttock pain into the posterior
aspect of the patient's leg, into the foot, or the perineum. On examination, there can
be weakness in plantar flexion. There can also be a loss of sensation along the
posterior leg and lateral aspect of the foot. The ankle reflex (S1) can also be lost or
diminished.
The marked motor deficit patterns characterized by an L5 or S1 radiculopathy help
aid in their diagnosis compared to other radiculopathies.
L5 and S1 nerve roots have their distinct innervations for sensation and muscle
strength testing.
HISTORY AND PHYSICAL
EXAMINATION
Examination findings helpful in diagnosing radiculopathy would include a patient's
inability to get up from a chair, history of a knee-buckling, and toe drag on
ambulation.
These exam findings suggest iliopsoas or quadriceps weakness, quadriceps, and
tibialis anterior weakness, respectively. Diminished deep tendon reflexes for L4, L5
are also useful to support a diagnosis of lumbar radiculopathy.
HISTORY AND PHYSICAL
EXAMINATION
A straight leg raising can be helpful in lumbosacral radiculopathy. The mechanism of
pain during a straight leg raise is increased dural tension placed upon the
lumbosacral spine during the test. Patients lay supine during the test. The physician
will flex the patient's quadriceps with the leg in extension as well as dorsiflex the
patient's foot on the symptomatic side. Pain or reproduction of paresthesia is
considered a positive test (Lasegue's sign). A Bowstring sign relieves this underlying
radicular pain with flexion of the patient's knee on the affected side. The straight leg
raising test is most helpful in the diagnosis of L4 and S1 radiculopathies
HISTORY AND PHYSICAL
EXAMINATION
A contralateral straight leg raising test is the passive flexion of the quadriceps with
the leg in extension and foot in dorsiflexion of the unaffected leg by the physician.
This test is positive when the unaffected leg reproduces radicular symptoms in the
patient's affected limb. However, the straight leg raising test is more sensitive but
less specific than the contralateral straight leg raising test.
HISTORY AND PHYSICAL
EXAMINATION
An internal hamstring reflex for L5 radiculopathy has also been shown to be a useful
test. Tapping either the semimembranosus or the semitendinosus tendons proximal to
the popliteal fossa elicits the reflex. When there is an asymmetry of the reflex
between legs, the presence of radiculopathy is suspected.[24]

In non-radicular back pain, the pain localizes to the spinal or paraspinal regions.
 Patient with LBP

History and Physical

examination
Are there any serious
conditions suspected
Red flags
Yellow Flags

Diagnostic Testing

Discuss conservative
treatment options Assess responce to
Phamacologic treatemnt
Non Pahrmacologic
DIAGNOSTIC TESTING
• Laboratory studies: ERS and/or CRP
• Electrodiagnostic testing (electromyography (EMG) and nerve conduction velocity
(NCV)
• X-ray: weight bearing radiographs of the lumbar spine (AP and lateral)
• CT
• MRI

Urgent utilization of neuroimaging is recommended for cases of severe acute

radiculopathy
DIAGNOSTIC TESTING: MRI/CT
MRI most useful imaging to identify underlying pathology and the need for surgical
intervention.
MRI can distinguish between inflammatory, malignant, or vascular disorders when
compared to a CT scan.
Recommendation is for an MRI with contrast unless otherwise contraindicated when
evaluating lumbar radiculopathy.
CT myelography visualizes a patient's spinal nerve roots in their passage through the
neuroforamina. CT myelography can be used to assess the underlying root sleeve. A
unique population for whom to recommend a CT myelogram is patients with surgical
spinal hardware.
DIAGNOSTIC TESTING: EMG
Accurate only after three weeks of persistent symptoms, they depend on fibrillation potentials after
an acute injury, which does not develop until two to three weeks following injury.
Origin of the pain is from the dorsal rami, such as the case of pain originating from the paraspinal
muscles, EMG can help make the diagnosis. An EMG helps establish the relationship between the
nerve root and muscle innervation. An EMG is usually not ordered until neuroimaging findings have
been negative and there are no signs of severe radiculopathies, such as muscular weakness on exam.
Help to localize specific nerve roots that are damaged.
Can also help distinguish between new and old nerve damage and support the presence of
demyelination at a nerve level leading to a conduction block
EMG is beneficial in helping to determine if denervation is either chronic or currently ongoing. An
example of this would be patients who have undergone previous spinal surgery but continue to have
significant radicular back pain following surgery
DIAGNOSTIC TESTING: CSF
Cerebrospinal fluid analysis is another useful test for a suspected neoplasm or
infectious cause or radiculopathy symptoms.
Recommendation for a lumbar puncture is progressive neurological symptoms,
negative or non-diagnostic neuroimaging, without known primary cancer, and failure
of prompt improvement.
IMPORTANT CAUSES OF
LOWER BACK PAIN
Systemic
Inflammatory
spondyloarthropathy
Metabolic bone diseases
Neoplasia, including myeloma
Infections of bone, disc or epidural
IMPORTANT CAUSES OF
LOWER BACK PAIN
Mechanical Neurological
Disc herniation Spinal canal stenosis Radiculopathy
Disc and segmental degradation, e.g. Myelopathy
facet arthropathy
Neuropathy
Soft-tissue injuries
Myopathy
Referred pain
Lumbosacral plexopathy
LUMBOSACRAL
RADICULOPATHY
Lumbosacral radiculopathy is very common.
Most cases of lumbosacral radiculopathy are self-limited.
The most common symptom in radiculopathy is paresthesia or back pain
radiating into the foot, with a positive straight leg raising test.

Muscle strength is often preserved in the case of radiculopathy because muscles

often receive innervation from multiple roots. Thus, muscle strength is often
only affected by severe cases of radiculopathy only.
ETIOLOGY
The most common origin is nerve root compression. It commonly results from either disc
herniation or spondylosis.
Herniation can be either an acute injury or secondary to chronic degeneration of the spine.
Disc herniation activates the pain fibers of surrounding tissues such as ligaments, vessels,
and dura mater.
Separately, spondylosis results in a narrowing of the spinal canal, neural foramen, or the
lateral recess. The most common cause of canal narrowing is degenerative arthritis of the
lumbar spine.
Other etiologies include inflammation, infection, trauma, vascular disease, and neoplasm.
Acute or chronic compression of the spinal nerve root can lead to underlying ischemia,
inflammation, or edema.
ETIOLOGY
The erosion of the intervertebral disc, intervertebral joints, and zygapophyseal joints
damages the spinal nerve roots. Osteophytes or herniation along the damaged areas
can cause direct impingement of the spinal cord and underlying spinal nerve roots. If
degeneration becomes severe enough, it can cause a misalignment of the spine.

The areas which are most susceptible to injuries are L4-L5 and L5-S1.
These levels are the areas that are responsible for the majority of the movement of the
lumbar spine. (90%)
PRESENTATION
L5 radiculopathy is the single most common lumbar radiculopathy.
72% paresthesia
35% radiation of pain in the lower limb
27% numbness.
Muscle weakness is present in up to 37%, absent ankle reflexes in up to 40%, and absent knee
reflexes in 18% of patients.
Disc herniation is the underlying etiology of less than 5% of patients with acute low back pain.
In patients presenting with a positive Romberg test with a wide-based gait, there is over a 90%
chance of possible lower spine syndrome.
Electromyography (EMG) has a sensitivity between 50 and 85% for radiculopathy.
TREATMENT / MANAGEMENT
There are three categories of radicular symptoms and signs:
• Mild: sensory loss and pain without motor deficits
• Moderate: sensory loss or pain with mild motor deficits
• Severe: sensory loss and pain with marked motor deficits.
Management of patients underlying symptoms will depend on the severity of the
radiculopathy.
TREATMENT / MANAGEMENT
Most cases of lumbosacral radiculopathy are self-limited.
Counseling is essential for patients with radicular symptoms since most cases are
mild and will resolve within six weeks after the onset of symptoms.
It is vital to discuss weight loss reduction considering that most patients with lumbar
radicular pain will have an elevated body mass index.
Spontaneous improvement following a disc herniation or lumbar spinal stenosis is
very high.
TREATMENT / MANAGEMENT

Primary treatment for lumbar radiculopathy will include conservative management

such as acetaminophen, nonsteroidal anti-inflammatories (NSAIDs), and activity
modification.
Opiate analgesia is only for patients with radiculopathy and severe pain who have
failed non-opiate analgesics.
Studies have shown that acetaminophen was more effective than placebo but less
effective than morphine for reducing pain in patients with lumbar-sacral
radiculopathy.
Muscle relaxants and benzodiazepines are not efficacious in patients with suspected
compression of the nerve root.
TREATMENT / MANAGEMENT

A randomized trial showed no significant difference in outcome for treatment with

bed rest versus watching and waiting.
There is no significant difference between bed rest versus physical therapy. A
systematic review showed no benefit of bed rest.
There is no convincing evidence in favor of physical therapy in the case of
lumbosacral radiculopathy.
It is recommended to delay physical therapy initiation until symptoms have persisted
for over three weeks duration
TREATMENT / MANAGEMENT
Experts have previously recommended systemic glucocorticoids to provide pain relief
in patients with acute radiculopathy. There is no evidence that systemic
glucocorticoids provide any benefit for radicular pain.
Disability scores were marginally better in the group receiving oral steroids versus
placebo.
Furthermore, if patients are prescribed NSAIDs alongside oral steroids, they may
require further protection against gastrointestinal bleeding with a daily proton pump
inhibitor.
TREATMENT / MANAGEMENT
Epidural steroid injections are beneficial for up to three months in duration in
patients with acute lumbar radiculopathy.
This benefit is modest yet clinically significant in the short term.
If a patient has not improved after six weeks of conservative management, they
would be eligible for an epidural glucocorticoid injection.
However, the outcomes are less favorable in a chronic setting.
TREATMENT / MANAGEMENT
On comparing surgical intervention versus conservative management, researchers
found that patients who underwent surgery such as discectomy had a more favorable
outcome after a short 12-week follow-up.
However, follow-up at one to two years showed similar outcomes between the
surgical and nonsurgical groups.
The patient should not consider surgical options until at least six weeks of symptoms
have passed
TREATMENT / MANAGEMENT
Controlled studies evaluating the efficacy of epidural etanercept injection have
conflicting results.
One study showed similar results between patients receiving saline and etanercept.
Other studies show that when compared to a placebo, there was significant pain relief
with etanercept compared to saline at a six-month follow-up.
Furthermore, additional studies have also demonstrated the benefits of etanercept are
similar to an epidural glucocorticoid injection.
TREATMENT / MANAGEMENT
Many studies have led to the following criteria for surgical selection:
(1) persistence of radicular symptoms for more than 6 to 8 weeks despite maximal medical therapy
(2) patient’s report of sensory changes or pain in a recognizable, anatomic, dermatomal distribution
(3) confirmation on physical examination of muscle weakness or depressed or absent deep tendon
reflexes in a recognizable, anatomic, myotomal distribution
(4) an MRI or equivalent radiographic finding in the anticipated location. Patients who fulfill these
criteria are likely to benefit from surgery.

These criteria do not apply, however, to patients who present acutely with serious neurologic
deficits, namely, moderate to severe weakness in the muscle group supplied by the compressed
root or with bladder or bowel dysfunction.
COMPLICATIONS
Lumbar radiculopathy is often self-limited but can be extremely painful. An
immediate complication that can arise from acute radicular pain is the loss of
function and decreased quality of life.
Emergent complications include cauda equina syndrome and severe lumbar
radiculopathy. Both of these complications often require emergent surgical
decompression.
Patients who do not improve within the six to twelve weeks following the onset of
pain can develop chronic pain.
Slowly progressing radicular symptoms can eventually lead to muscle atrophy as the
nerves innervating the lower extremity musculature are affected. Deconditioning can
occur over time.
PROGNOSIS
Most cases of lumbosacral radiculopathy are self-limited. Counseling is crucial for
patients with radicular symptoms since most cases are mild and will resolve within
six weeks. It is vital to discuss weight loss reduction, as the vast majority of these
patients will have an elevated body mass index.

Chances of spontaneous improvement following a disc herniation or lumbar spinal

stenosis are very high.

Concerns arise when a patient's symptoms worsen or are severe. Severe symptoms
warrant further imaging and/or emergent surgical intervention.
ENHANCING HEALTHCARE
TEAM OUTCOMES
The patient should follow up with primary care physicians one to two weeks
following the initial injury to monitor for progression of the nerve damage.
If symptoms worsen on follow-up or there is a concern for the development of
severe radiculopathy, referral to neurosurgery or hospitalization for possible spinal
decompression.
If radicular symptoms persist three weeks after injury, physical therapy referral can
be a consideration.
When symptoms persist for greater than six-week duration, imaging such as MRI or
CT scan are options for better visualization of the nerve roots.
ENHANCING HEALTHCARE
TEAM OUTCOMES
The patient should consult with a dietitian and eat a healthy diet and maintain a
healthy weight.
The pharmacist should encourage the patient to quit smoking, as this may help with
the healing process. Further, the pharmacist should educate the patient on pain
management and available options.
Persistent pain at six weeks' follow-up may warrant a referral to interventional pain
management or neurosurgery for an epidural steroid injection.
If mild to moderate symptoms continue at three months following the onset of
symptoms, referral for possible surgical intervention merits consideration as well.
THANK YOU