L5 radiculopathy; secondary to progressive degenerative change occurring in the lower Lx & mechanical dysfunction, resulting in DNE (dynamic nerve entrapment)
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- 59 y.o., car mechanic
- Lower Lx spine (L>R) into the lateral aspect of L thigh to the anterior shin & into the toes - Insidiously 2 months ago |
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Back pain
- Deep ache & stiff - 5/10 - Constant pain - Stiffness is worse in the morning & at the end of the day after work Leg pain - Feels like "pinched nerve" - Shooting pain - Feeling of "dead leg" - 8/10 - Pain depends on what he's doing |
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-Getting worse
-AF: standing, working overhead - RF: Sitting down (slouched) diminished leg pain, sleeping on side (firm bed helps) - AA: Work; is careful with ADL |
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Extra
- High BP - Motorbike accident 10 years ago resulted in a painful L shoulder (resolved itself) - Surgery at age 3 for pyloric stenosis - Naproxen takes the edge off (GP prescribed) - 1 cigar / day - Drinks 1 bottle of wine every day - Doesn't exercise now due to pain - Mother passed due to cancer - Stools are a bit loose atm (needs further investigations; consider risk of bowel cancer due to age) |
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- High BP
- Posture/stance: hypolordotic Lx spine; kyphotic Tx spine - Gait: reduced arm swing bilaterally; reduced Tx movement (very rigid) |
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ROM
- AROM Lx: extension limited & painful in LB & down leg into shin - PROM hip: full & pain free bilaterally |
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- SLR: 90° bilaterally, muscle stretch @ end point
- Active SLR: same as SLR - Percussion & vibration Lx: negative (-ve) - Trigger points: in ES, glut. max. & glut. med. bilaterally - Spinal palpations: L T11-L2 restricted; L L4-S1 restricted & tender; L SI restricted |
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Kemps
- Purpose: assess Lx spine facet joint pain - Findings: L +ve w/ L leg pain into shin; R -ve |
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Single leg hyperextension
- Purpose: SI & Lx nerve root irritation - Findings: -ve bilaterally |
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Slump's
- Purpose: detect altered neurodynamics or neural tissue sensitivity - Findings: pulling in LB (L>R) |
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Faber's
- Purpose: diagnose hip pathology by attempting reproducing pain - Findings: -ve bilaterally |
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SI distraction
- Purpose: provocation of the SIJ - Findings: -ve |
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Modified Thomas
- Purpose: measures the angle of femur abduction relative to pelvis - Findings: tight bilaterally (L>R) |
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Gaenslen's
- Purpose: diagnose SIJ lesion, pubic symph. instability, L4 nerve root lesion - Findings: -ve bilaterally |
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McGill's
- Purpose: assess radiographic Lx instability - Findings: both -ve |
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Pheasant
- Purpose: indicates an unstable spine segment - Findings: increased pain in Lx |
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Nerve tension
- Findings: tibial -ve; fibular -ve; sural -ve |
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Working diagnosis
- L5 radiculopathy - Most likely 2° to progressive degenerative change occurring in the lower Lx & mechanical dysfunction, resulting in DNE (dynamic nerve entrapment) |
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- Insidious onset + LB stiffness + pt's age = suggest degenerative change (predisposing cause of the problem)
- Supporting evidence: +ve Kemp's (reproducing pain), -ve Slump's & SLR |
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- Increased pain on Pheasant's test likely due to extension intolerance &/or facet pain associated with degenerative change
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→ Most pts w/ radicular pain have associated LBP, &/or Hx of LBP
- Typical presentation: LBP that progresses to leg pain, w/ leg pain later being more painful than LBP (peripheralisation) |
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→ Radicular pain that is 2° to IVF encroachment; leg pain may
- Relieved: sitting & bringing the knees to the chest (anything that flexes Lx & increases the IVF space) - Aggravated: standing & walking |
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→ Radicular pain 2° to disc herniation
- Aggravated: prolonged sitting |
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2 categories of "mechanical" (ortho neurological) nerve root syndromes (can coexist)
1. Spondylosis & related degenerative change: must be more specific & identify whether there's lateral entrapment or central stenosis (LSS) 2. Disc herniation: (lateral entrapment) should identify whether it's likely to be a fixed nerve entrapment (FNE) or dynamic nerve entrapment (DNE) |
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Differentials for LBP w/ leg pain
- Cauda equina syndrome (CES) - Lx central stenosis syndrome (LSS) - Disc herniation - Spinal stenosis - Sciatica - Lx radiculopathy - Spondylolisthesis - SIJ dysfunction - Piriformis Syndrome |
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Red flags for pts w/ radicular leg pain
- Bowel/bladder dysfunction - Progressive unilateral / bilateral neurological deficits (e.g. major motor weakness [e.g. knee flexion]) - Saddle anaesthesia - Bilateral radiculopathy - Severe unremitting pain - Unrelenting night pain - Sensory changes around rectum - Major trauma (or mild trauma aged 70+) - Point tenderness over a vertebra - Erectile dysfunction - Unexplained weight loss |
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How to screen for cauda equina syndrome (CES)?
⏺ Symptoms: - LBP - Bilateral leg radiculopathy (sharp shooting pain or dull ache that radiates down the legs) - Saddle anaesthesia - Bladder/bowel incontinence - Lower extremity motor & sensory loss ⏺ Imaging: - MRI & CT screening for compression / damage of cauda equina - Cauda Equina Screening Tool (CEST): set questions to assess risk of CES - Electromyography (EMG): measures electrical activity of muscles & nerves, detecting nerve damage |
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How to screen for bowel cancer?
⏺ Screening starts at 45 y.o. - gFOBT(fecal occult blood test): checking for blood in stool - Sigmoidoscopy: scope in lower colon - Colonoscopy: scope an entire colon - Capsule endoscopy: swallow pill-sized camera |
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Understand the pathophysiology of the mechanical & chemical pathophysiology processes that occur in lateral nerve entrapment
⏺ Lateral nerve entrapment: - Peripheral nerve becomes compressed or entrapped by surrounding structures - Can occur due to anatomical abnormalities, trauma, inflammation, or repetitive motion - Sx & SSx: pain, numbness, tingling, muscle weakness, & loss of function in area supplied by affected nerve ⏺ Mechanical pathophysiology: - Compression: can disrupt the normal function of the nerve, causing pain &/or abnormal sensations - Tension: tension/stretching of nerve, resulting in irritation & dysfunction; can arise from muscle imbalances repetitive movements that place strain on the nerve - Ischaemia: prolonged compression or tension on the nerve can compromise its blood supply, leading to reduced O2 & nutrient delivery; Ischaemia (lack of blood flow) can cause nerve damage & contribute to development of symptoms ⏺ Chemical pathophysiology: - Inflammation: compression irritation can trigger inflammatory response (cytokines & prostaglandins) in surrounding tissue; chemicals further irritate nerve & contribute to amplifying pain / other symptoms - Chemical irritation: chemicals (histamine, substance P, bradykinin) released from damaged tissues, directly stimulate pain receptors in the nerve; resulting in pain & sensitivity - Neurotoxicity: metabolic disturbances lead to accumulation of toxic substances within the nerve tissue; can further damage the nerve cells & exacerbate symptoms |
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Biopsychosocial issues for this pt
⏺ Biological factors: - Genetics: mother passed from cancer - Physiology: loose stools, however appears healthy ⏺ Psychological factors: - Mental health: feeling anxious (due to episodic leg pain) - Coping mechanisms: 1 cigar + 1 bottle of wine / day - Beliefs & attitudes: N/A ⏺ Social factors: - Socioeconomic: own shop/garage - Support system: Wife + 4 healthy children - Cultural background: N/A |
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