Radiculopathy (sciatica, cervical radiculopathy) Flashcards
Which investigation is most useful for radiculopathy?
MRI
A 42 year old man complains of low back pain dating back 2-3 years. Symptoms have become more severe and he is now experiencing pain radiating down the back of the right leg to the ankle, with numbness of the lateral side of his foot. Which nerve root is likely affected?
L5
Where does the spinal cord end?
L1
What are the signs and symptoms of cauda equina syndrome?
Severe narrowing of the spinal canal compressing the nerves –>
- Sciatic symptoms
- Leg weakness
- Leg numbness
- Perianal./perineal numbness
- Weakness of the anal sphincter
- Bowel/bladder disturbance
Define radiculopathy.
Radiculopathy is a neurological state in which conduction is limited or blocked along a spinal nerve or its roots — it is differentiated from radicular pain*, although they commonly occur together
*Radicular pain is usually caused by compression of the nerve root due to cervical disc herniation or degenerative spondylotic changes, but radicular symptoms can also occur without evident compression (for example, due to inflammation of the nerve).
What are the general clinical features of radiculopathy?
- Pain/’electrical’ sensations at the level of the compression
- Numbness
- Dull reflexes
- LMN weakness
- Eventual wasting of muscles innervated by that nerve roots
What do UMN signs below the level of root compression suggest?
UMN signs below the level of affected root suggest cord compression
What is polyradiculopathy?
When more than one nerve root is compressed
Define sciatica.
Sciatica describes radiating leg pain caused by inflammation or compression of the lumbosacral nerve roots (L4–S1) forming the sciatic nerve.
What are the clinical features of sciatica?
- Sudden/slow onset
- Unilateral leg pain radiating below the knee to the foot or toes.
- Low back pain — if present, which is less severe than any leg pain.
- Numbness, tingling (paraesthesia) in the distribution of a nerve root.
- Weakness or reflex changes, or both in a myotomal distribution.
- A positive result in a straight leg raise test
What are the causes of nerve root compression in sciatica?
- A herniated intervertebral disc — in about 90% of cases; usually due to age-related degenerative changes, but rarely it can be caused by trauma
- Spondylolisthesis
- Spinal stenosis.
- Infection e.g. discitis, vertebral osteomyelitis, spinal epidural abscess
- Cancer - usually due to metastatic disease of the spine rather than primary tumour
What are the risk factors for sciatica?
- Old age
- Genetic influlence- these are a more important cause of disc degeneration than mechanical causes
- Smoking
- Obesity
- Occupational factors — for example, whole body vibration, strenuous physical activity
- General health and comorbidities
What is the prognosis with sciatica?
Half of people recover spontaneously within 6 weeks
A quarted experience transient episodes with recurrence
Worse prognosis if workplace contributing factors persist or if there are psychosocial factors like low mood.
What are the red flags for patients with sciatica?
- Bowel/bladder dysfunction (most commonly urinary retention).
- Progressive neurological weakness.
- Saddle anaesthesia.
- Bilateral radiculopathy.
- Incapacitating pain.
- Unrelenting night pain.
- Use of steroids or intravenous drugs.
What are some differential diagnoses for sciatica?
- Cauda equina syndrome
- Spinal fracture
- Cancer
- Infection
What is the management of sciatica?
- Admit or refer urgently to spinal surgery service if red flag symptoms present +/- MRI
Conservative:
- Physiotherapist for manual therapy e.g. massage
- Psychological therapies e.g. CBT
- Group exercise programme
Medical:
- Simple analgesia
- Do not offer gabapentinoids, other antiepileptics, oral corticosteroids, or benzodiazepines for managing sciatica as there is no overall evidence of benefit and there is evidence of harm. Do not offer opioids.
Safety net: seek follow up if symptoms worsen, persist for over 2 weeks, severe pain has not subsided within 1 week, if new symptoms develop, or if symptoms recur
What general advice should be given about sciatica?
- Stay active - bed rest not recommended
- Resume normal activities
- Return to work ASAP - work adjustments may help
- A modest increase in pain on resuming activities does not indicate that damage has occurred.
- Application of heat may relieve pain
Define spondylolisthesis.
Spondylolisthesis — when a proximal vertebra moves forward relative to a distal vertebra.
What are the complications of sciatica?
- Chronicity
- Diability, poor quality or life, increased use of healthcare resources
- Time off work, reduced productivity, and loss of employment
Which cancers are responsible for more than 80% of cases of metastatic bone disease?
Spine is the most common site for these metastases.
Breast, prostate, lung
How is a straight leg raise test for sciatica done?
With the person lying supine, the hip is flexed gradually with the knee extended. Pain reproduced below 60 degrees of hip flexion on the ipsilateral side indicates a positive test.
What investigations are used to diagnose sciatica?
- Examination - a positive result in a straight leg raise test
- STarT Back Screening Tool is a nine item questionnaire - used in GP to assess risk of chronicity so that appropriate level of support can be given
- Routine imaging is not required but consider if infection, malignany or inflammation suspeced. Then do FBC, ESR, CRP, blood cultures, urinalysis.
Should you offer traction, TENS or PENS for sciatica?
Do not offer:
- foot orthotics,
- belts or corsets,
- rocker sole shoes,
- traction,
- acupuncture,
- ultrasound,
- transcutaneous electrical nerve simulation (TENS),
- or percutaneous electrical nerve simulation (PENS),
…for people with sciatica
In what instances should you refer sciatica to a specialist?
- Pain at 2-6 weeks
- Non-tolerable pain at 6 weeks
- Acute and severe sciatica - for consideration of epidural corticosteroid/local anaesthetic injection
- When non-surgical treatment has not worked —> consider spinal decompression
