Epidemiology Lumbosacral radicular syndrome

Epidemiology Lumbosacral radicular syndrome

Lumbosacral radicular syndrome The lumbosacral radicular syndrome is characterized by radicular pain, with or without other irritation symptoms (paraesthesia) and neurological symptoms of the affected nerve root(s). Typical of radicular pain is that it radiates into a leg, is localized in the area of ​​one of the main spinal cord nerve roots of the lumbosacral spine (“dermatome pattern”), radiating into the lower leg and gives a sharp pain. The patient can usually point out the location of the pain accurately.5
Incidence The incidence increases with age and is highest (16 per 1,000 patients per year) in the age group of 45 to 64 years. After 65 years the incidence is around 11 per 1000 persons per year.1,2
Prevelance The prevalence in the general practice is 15 per 1000 patients and shows the same trend towards age as does the incidence rate.1,2
Sex LRS is almost as often diagnosed in In men as in women.1,2
Age LRS is rare in young adulthood.1,2
Pain location Back, leg and lower leg, sometimes also radiates into feet and/or toe(s)5
Pain sensation / Symptoms Sharp pain, paraesthesia. The neurological symptoms may include disorders of sensibility (“deaf”, “cold” spots), loss of strength or reflex abnormalities. Although LRS often gives low back pain, it is not characteristic for LRS and allow the leg complaints to be present in foreground. Usually the nerve roots of L5 and S1 are affected in LRS and the pain radiates to the lower leg. If the pain radiation is limited to gluteal region, thigh or groin, there may be more of the rare high lumbar radicular syndrome (L1 to L4).5
Prognosis Although the prognosis of the LRS for leg pain is favorable, a significant proportion of patients remain having back pain in varying degrees.6,7
History of injury Usually a LRS caused by a herniated disc. In some cases an LRS involves a narrowing of the spinal cord or lateral recesses, usually by degenerative changes, or the symptoms are the result of a collapse fracture or spondylolisthesis.8,9,10
Affected levels Usually in LRS the nerve roots of L5 or S1 roots affected, In a disc herniation – the main cause of LRS – in about 90% of cases are the disci L4-L5 and L5-S1 (each about 45%). At this height the static and kinetic forces of the spine are the biggest. The L3-L4 disc rarely degenerates (5% of the herniated disc), and L2-L3 and L1-L2 almost never degenerate.3,4
Literature
  1. Van der Linden MW, Westert GP, De Bakker DH, Schellevis FG. Tweede Nationale Studie naar ziekten en verrichtingen in de huisartspraktijk: klachten en aandoeningen in de bevolking en in de huisartspraktijk. Utrecht/Bilthoven: NIVEL/RIVM, 2004.
  2. Nachemson AL, Waddell G, Norlund AI. Epidemiology of neck and low back pain. In: Nachemson AL, Jonsson E, editors. Neck and back pain: the scientific evidence of causes, diagnosis and treatment. Philadelphia: Lippincott, Williams & Wilkins, 2000.
  3. Van Woerkom TCAM, Tavy DLJ. Aandoeningen van wortels en ruggenmerg. In: Hijdra A, Koudstaal PJ, Roos RAC, redactie. Neurologie. Maarssen: Elsevier gezondheidszorg, 2003.
  4. Kuks JBM, Snoek JW, Oosterhuis HJGH. Klinische neurologie. Houten: Bohn Stafleu Van Loghum, 2003.
  5. Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone, 1998.
  6. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine 1983;8:131-40.
  7. Habbema JD, Braakman R, Blaauw G, Slebus FG, Singh R. De toestand van patiënten een jaar na operatie wegens een lumbosacraal radiculair syndroom. Ned Tijdschr Geneeskd 1989;133:2615-9.
  8. Bartels RH, Frenken CW. Lumbale spinale stenose. Ned Tijdschr Geneeskd 1993;137:529-32.
  9. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990;72:403-8.
  10. O’Duffy JD. Spinal stenosis: development of the lesion, clinical classification and presentation. In: Frymoyer JW, editor. The adult spine: principles and practice. New York: Raven Press, 1997.

 

Info2 Herniated Disc
Age 30-50
Pain pattern  
Location Back, leg (unilateral)
Origin Acute
Standing Pain –
Sitting Pain +
Bending Pain +
SLR +
X-ray

Diagnose Lumbar herniation3

  Lumbar discus (L5-S1)
History  Quick movements in flexion, rotation, lateroflexion, extension 
Pain Lumbar, referred pain posterior side of the feet(radicular)Extension pain+
Inspection Scoliosis possibleMuscle hypertonic
Active ROM Lateroflexion, rotation, possibly decreased Range of Motion. 
Resistance Pain minimal, unless a protrusion is present
Special tests L5-S1 myotomes possibly involvedSLR en slump possibly positive
Sensation L5-S1 dermatomes possibly involved
Reflexes L5-S1 reflexes possibly involved 
Joint play Muscle hypertonic
  1. David J. Magee, Orthopedic Physical Assesment, Fifth Edition, 2008 by Saunders, an imprint of Elsevier Inc.p527
  2. David J. Magee, Orthopedic Physical Assesment, Fifth Edition, 2008 by Saunders, an imprint of Elsevier Inc.p.610

 

Physical examination

Alarming signals for Hernia nucleus pulposi:– Positive staight leg raising test, bragard and neri

– Positive well leg raise

– Positive slump test

– Sensitivity disorders

– Motor kenn muscles failure

Active range of motion of the lumbar spine1
Flexion 40 to 60 degrees
Extension 20 to 35 degrees
Lateral flexion 15 to 20 degrees

 

Lumbar nerve syndromes2
Nerve Dermatome Muscle weakness Reflexes/ tests Paresthesia
L1 Back, trochantor, groin No No Groin, after posture that causes pain
L2 Back, anterior side thigh till knee Psoas, hip add. No Anterior side of the thigh
L3 Upper part of the buttock, anterior aspect thigh and thigh, medial aspect lower leg Psoas, quadriceps, thigh Knee reflex, prone knee bending, pain in SLR Knee, anterior lower leg
L4 Inner buttock area, lateral side of thigh, leg, dorsum of the feet, big toe. Tibialis anterior, extensor hallucis SLR limited, neck flexion, pain, weak knee, lateroflexion limited Medial side of the calf and ankle
L5 Buttock, posterior side of lower leg and lateral thigh, lateral aspect leg, dorsum of feet, digits 1,2,3 Extensor hallucis, peroneals, gluteus medius, enkel dorsaalflex, hamstrings, calf SLR limited on 1 side, crossed SLR, neck flexion, SLR limited lateral side of the leg, medial 3 toes
S1 Buttock, posterior side of lower leg Calf, hamstrings, gluteus, peronei, plantair flexors SLR limited Lateral two toes, lateral side of feet, lateral side knee, plantair aspect of the feet, lateral side of the leg, knee, heel
S2 Same as S1 Same as S1 except peronei Same as S1 Lateral side of the leg, knee, heel
S3 groin, medial thigh till knee No No No
S4 Perineum, genitals, apex sacrum Blatter, rectum, No Saddle area, genitals, anus, impotence
Comment: Manipulation and tractions are contraindications as S4 or massive posterior disc placement causing bilateral sciatica and S3 pain

 

Myotomes3
Nerves Tests Muscles involved
L1-L2 Hip flexion Psoas, iliacus, sartorius, gracilis, pectineus, adductor longus, adductor brevis
L3 Knee flexion Quadriceps, adductor longus, magnus, and brevis
L4 Ankle dorsaalflexion Tibialis anterior, quadriceps, tensor faciae latae, adductor magnus, obturator externus, tibialis posterior
L5 Toe extension Extensor hallucis longus, extensor digitorum longus, gluteus medius and minimus, obturator internus, semimembranosus, semitendinosus, peroneus tertius, popliteus
S1 Ankle plantair flexion, ankle eversion, hip extension, knee flexion Gastrocnemius, soleus, gluteus maximus, obturator internus, piriformis, biceps femoris, semitendinosus, popliteus, peroneus longus and brevis, extensor digitorum brevis
S2 Knee flexion Biceps femoris, piriformis, soleus, gastocnemius, flexor digitorum longus, flexor hallucis longus, intrinsic foot muscles
S3 Intrinsic foot muscles (except abductor hallucis), flexor hallucis brevis, flexor digitorum brevis, extensor digitorum brevis
Literature
  1. David J. Magee, Orthopedic Physical Assessment, Fifth Edition, 2008 by Saunders, an imprint of Elsevier Inc.p533
  2. David J. Magee, Orthopedic Physical Assessment, Fifth Edition, 2008 by Saunders, an imprint of Elsevier Inc.p.550
  3. David J. Magee, Orthopedic Physical Assessment, Fifth Edition, 2008 by Saunders, an imprint of Elsevier Inc.p.551

 

Evidence Based Practice

Utility scoresUtility 1: Evidence strongly supports the use of this test
Utility 2: Evidence moderately supports the use of this test

Utility 3: Evidence minimally supports or does not support the use of this test

Tests for Hernia or lumbar radiculopathy
Tests Study Methodological results
Well leg raise (looks like straight leg raise)
(utilitiy score 1)
Knuttson (1)  – sensitivity 25%
– specificity 95%
– LR+ 5
– LR- 0.79
Hakelius & Hindsmarsh (2)  – sensitivity 28%
– specificity 88%
– LR+ 2.33
– LR- 0.82
Spangfort (3)  –  sensitivity 23%
– specificity 88%
– LR+ 1.91
– LR- 0.86
Kosteljanets et al (4) – sensitivity 24%- specificity 100%
Slump test
(utility score 2)
Stankovic et al. (5) – sensitivity 83%
– specificity 55%
– LR+ 1.82
– LR- 0.32
Straight leg raise
(utility score 2)
Knuttson (6)  – sensitivity 96%
– specificity 10%
– LR+ 1.06
– LR- 0.40
Spangfort (7)  – sensitivity 97%
– specificity 11%
– LR+ 1.08
– LR- 0.27
Kerr et al. (8)  – sensitivity 98%
– specificity 44%
– LR+ 1.75
– LR- 0.05
Vroomen et al. (9) – sensitivity 97%
– specificity 57%
– LR+ 2.23
– LR- 0.05
Literature (1) Knuttson B. Somparative value of electromyography, myelographic, and clinical-neurological examinations in diagnosis of lumbar root comprssion syndrome. Acta Ortho Scand. 1951;(Suppl 49): 19-49
(2) Hakelius A, Hindmarsh J. The comparative reliability of preoperative diagnostic methods in lumbar disc surgery. Acta Orthop Scand. 1972;43:234-238
(3) Spangfort EV. The lumbar dics herniation: a computer aided analysis of 2504 operations. Acta Orthop Scand. 1972;11(Supl 142):1-93
(4) Kosteljanetz M. Bang F, Schmidt-O.son S. The clinical significance of straight leg raising (lasegue’s sign) in the diagnosis of prolapsed lumbar dixc. Spine. 1988;13:393-395
(5) Stankovic R, Johnell O, Maly P, Willner S. Use of lumbar extension, slump test, physical and neurological examination in the evaluation of patients with suspected herniated nucleus pulposus: aprospective clinical study. Man Ther. 1999;4(1:25-32
(6) Knuttson B. Comparative value of electromyographic, myelographic, and clinical-neurological examinations in diagnosis of lymbar root compresiion syndrome. Acta Ortho Scand.1961;(Suppl 49):19-49
(7) Spangfort EV. The lumbar dics herniation: a computer aided analysis of 2504 operations. Acta Orthop Scand. 1972;11(Supl 142):1-93
(8) Kerr RSC, Cadoux-Hudson TA, Adams CBT. The value of accurate clinical assessment in the surgical nanagement of the lumbar disc protrusion. J. Neurol Neurosurg Psychiatr. 1988;51:169-173
(9) Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knotternus JA, Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J. Neurol Neruosrug Psychiatry. 2002;72(5):630-634

 

 

 

 

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