Lumbar Radiculopathy | Sciatica
DEFINITION AND SYMPTOMS
Lumbar radiculopathy is a condition that consists of radiating pain from the lower back or buttock which travels down to the leg. This condition is often associated with numbness, tingling, and possibly weakness. The causes of lumbar radiculopathy can be a herniated disc, spinal stenosis, nerve impingement due to a bone spur, misaligned vertebrae (spondylolisthesis) or a combination of the above. Presentation could be acute or chronic and may involve one or both legs. Pain may start in the lower back or buttock and may develop into leg pain. It could have a mild presentation of leg heaviness, numbness, tingling and burning or could be severe electrical shooting pain as well as weakness and imbalance. Dependent on which nerve root is impinged upon, a different portion of the leg may be affected. Clinicians can determine which nerve root is impinged based on the pattern of pain, area of numbness, abnormal reflexes, and specific muscle weakness at the time of examination. The radiculopathy is named after the nerve root which is encroached. Most common radiculopathy is L4/5 and
L5/S1. Classic sciatica is a radiating back pain to the calf and the foot (S1 Radiculopathy).
If the first episode is acute and severe, patients often go to the emergency room. A clinical diagnosis is made based on x-rays, and physical examination. If there is no progressive neurological loss, further care is often deferred to the primary care physician and/or specialist in an outpatient setting. A spine specialist will examine the patient and determine proper workup. A thorough physical examination is performed by the spine specialists, which includes a range of motion examination, sensory testing, strength testing and evaluation of reflexes. If there are alarming signs of spinal cord compression, recommendation for further workup is made. The first diagnostic test is often an x-ray. The most accurate clinical test to identify a herniated disc is an MRI. Some patients are unable to have an MRI, in which case a CT scan and EMG test will help make a diagnosis.
If there are no alarming neurological deficits treatments such as, simple x-rays, 6-8 weeks of physical therapy, a short course of prednisone taper, spine manipulation, soft tissue treatments along with use of nonsteroidal antiinflammatory and muscle relaxants are recommended. In most cases, this conservative treatment results in substantial improvement in symptoms. After physical therapy treatment, the patient is re-examined to evaluate for any residual deficits or symptoms. If the pain subsides and function fully recovers, the patient is discharged with recommendations to continue a home exercise program and observe correct ergonomics. In some patients, the pain and dysfunction are not managed on oral medications or does not improve with physical therapy. In such cases, an x-ray guided lumbar epidural injection or selective nerve root injection can help reduce the inflammation in the nerve root and help with the recovery. The effect of an epidural injection may last several weeks to several months. If the symptom(s) return, such treatment could be repeated. In the acute phase of lumbar radiculopathy, sometimes mild opioid medication is prescribed to help with sleep and function. There is no indication for long-term use of narcotic medications for lumbar radiculopathy.
Persistent pain, bowel and bladder dysfunction, progressive weakness and frequent falls despite conservative care are among the indications for surgery. A careful risk assessment should be done by a primary care physician, spine surgeon and the patient before considering surgery. In most cases, the patient would benefit from laminectomy, discectomy, foraminotomy and in some cases spinal fusion. Surgery takes a few hours to complete, with a short course of inpatient hospitalization and a few weeks of outpatient rehabilitation after discharge from the hospital. Fusion is indicated if there is spine instability. Fusion has a longer course of recovery.