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Lumbar Radicular Pain

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Lumbar Radicular Pain Back pain • THEME Lumbar radicular pain Although commonly referred to as ‘sciatica’, the term BACKGROUND Radicular pain is caused by lumbar radicular pain (LRP) is anatomically more irritation of the sensory root or dorsal root correct. Lumbar radicular pain is a form of neuralgia ganglion of a spinal nerve. The irritation causes due to an irritation of the sensory root or the dorsal root ectopic nerve impulses perceived as pain in the ganglion (DRG) of a spinal nerve. In contrast, sciatic distribution of the axon. neuralgia specifically refers to pain in the distribution of The pathophysiology is more than just mass the sciatic nerve due to pathology of the nerve itself.1 effect: it is a combination of compression sensitising the nerve root to mechanical By definition, radicular pain involves a region beyond the stimulation, stretching, and a chemically spine. In individuals presenting both with spinal pain and LRP, mediated noncellular inflammatory reaction. it is paramount that the characteristics and distribution of each Jay Govind, pain should be defined and diagnosed separately, as it is likely MBChB, DPH (OH), OBJECTIVE This article discusses the clinical MMed, FFOM (RACP), they arise from different anatomical structures and are caused features, assessment and management of lumbar is VMO, Royal radicular pain (LRP). by different pathomechanisms. In LRP, ectopic impulses gen- Newcastle Hospital, erated in the DRG are perceived as pain arising in the territory and research officer, DISCUSSION Lumbar radicular pain is sharp, innervated by the affected axon. Somatic pain (nociception) is Department of Clinical shooting or lancinating, and is typically felt as a Research, evoked by noxious stimulation of nerve endings; somatic narrow band of pain down the length of the leg, Bone and Joint Institute, referred pain is a function of interneuronal convergence within Royal Newcastle both superficially and deep. It may be associated the spinal cord. Neuropathic pain is evoked by ectopic Hospital, University of with radiculopathy (objective sensory and/or 1 Newcastle, motor dysfunction as a result of conduction block) impulses generated in the axons of a peripheral nerve. New South Wales. and may coexist with spinal or somatic referred Radicular pain should not be confused with radicu- pain. In more than 50% lopathy. Radiculopathy is objective loss of sensory and/or of cases, LRP settles with simple analgesics. motor function as a result of conduction block; the fea- Significant and lasting pain relief can be achieved tures of which might include numbness, motor loss, with transforaminal epidural steroid injection. wasting, weakness, and loss of reflexes. Each can occur Surgery is indicated for those patients with simultaneously or independent of each other.2 Any lesion progressive neurological deficits or severe LRP that affects the integrity of the lumbosacral nerve root refractory to conservative measures. can cause LRP, radiculopathy or both (Table 1). Pathophysiology Lumbar radicular pain is caused by more than a simple mass effect. With the advent of computerised tomog- raphy (CT) and magnetic resonance imaging (MRI), studies have confirmed that patients whose symptoms of sciatica had resolved still showed the same mass effect.3,4 Additionally, disc herniations or protrusions evident on CT or MRI may not be associated with either low back pain or LRP.5 Ectopic impulses, and hence perception of pain, Reprinted from Australian Family Physician Vol. 33, No. 6, June 2004 409 Theme: Lumbar radicular pain • inflammation of DRG, and/or Table 1. Causes of radicular pain2 • possible ischaemic damage to DRG. There are two distinctive, but not mutually exclusive • Disc herniation (commonest cause) pathomechanisms for LRP. • Spinal stenosis Nerve roots subjected to sustained compression for • Synovial cysts protracted periods may become sensitised to mechani- • Infection cal stimulation. The resulting patho-anatomical changes • Infestation including focal demyelination, intraneural oedema, • Tumour impaired microcirculation, Wallerian degeneration, • Vascular abnormalities partial axonal damage with or without neuroma in conti- nuity, have the potential to generate ectopic impulses from the affected nerve.2 Table 2. Distinguishing features of LRP and somatic referred pain2 Studies have also confirmed that while pain may corre- late with the size of disc herniation, and limitation of straight Feature Radicular pain Somatic referred pain leg raising may correlate with pain, straight leg raising does not correlate with the size of disc herniation.6 This implies Distribution Entire length of lower limb Anywhere in lower limb that tension in a sensitised nerve root is most likely cardinal BUT BUT mechanism of pain rather than the effects of simple com- below knee > above knee proximal > distal pression. Pattern Narrow band Wide area A complementary explanation implicates a chemically Travelling Relatively fixed in location mediated noncellular inflammatory reaction – ‘chemical Quasi segmental but not Quasi segmental but not radiculitis’ – implying irritation of the nerve root by per- dermatomal dermatomal ineural spread of nucleus pulposus, which might occur Not distinguishable by segment Not distinguishable by segment through a disc rupture. Nucleus pulposus is inflammato- Boundaries difficult to define genic and leukotactic.7,8 Quality Shooting, lancinating, Dull, aching, like an expanding like an electric shock pressure Clinical features Depth Deep as well as superficial Deep only, lacks any cutaneous Distinguishing between radicular pain and somatic pain quality (local or referred) is essential to the diagnosis. Radicular pain is often perceived in the territory innervated by the affected nerve root, eg. in the lower extremity when Table 3. Conditions mimicking radicular L4/5/S1 nerve roots are involved, and in the anterior pain2 thigh in the case of L2/3. Implicitly, pain does not follow the corresponding dermatomes and it is the sensory • Spinal cord tumours loss that indicates the affected segment. Lumbar radic- • Diabetic neuropathy ular pain travels through the lower limb along a narrow • The prodromal phase of herpes zoster band usually not more than 5–8 cm wide, and when • Tabes dorsalis experimentally reproduced, the perceived pain is qualita- • Direct contusion of the sciatic nerve tively sharp, shooting or lancinating.9 It can be • Polyarthritis nodosa experienced superficially and deeply. • Gluteal injections In contrast, somatic referred pain is often felt deeply • Prolonged sitting as a dull aching pain. Radicular pain and somatic referred • Penetrating wounds pain are not mutually exclusive. They can co-exist. • Methyl methacrylate neuropathy following Radicular pain may be superimposed on a background of hip replacement somatic referred pain. Hence, careful scrutiny is essential to distinguish whether the patient is describing somatic may be generated as a result of: referred pain, radicular pain or a combination of both. • mechanical deformation of DRG Although not absolute, certain features may assist • mechanical stimulation of previously damaged in distinguishing between somatic pain and radicular nerve roots pain (Table 2). Conditions that can mimic radicular pain 410Reprinted from Australian Family Physician Vol. 33, No. 6, June 2004 Theme: Lumbar radicular pain without affecting the nerve roots are shown in Table 3. herniation. Studies may be indicated to exclude a more distal nerve damage, verify suspected muscle weak- Clinical examination ness by needle electromyogram, and to assess Clinical examination does not diagnose the cause of LRP, pre-operative baseline muscle status in cases of recur- but can establish the presence or absence of radiculopathy. rent disc operation.11 Although lumbar disc herniation is the commonest cause of LRP, there are no distinctive features either in Treatment the history or physical examination that would implicate Generally bed rest is no more effective than watchful the intervertebral disc as the cause of pain. Definitive waiting. Depending on the severity and response to diagnosis can only be made by imaging studies. The medication, the early resumption of daily activities straight leg raise clinical test has the best sensitivity, should be encouraged. but a low specificity with an average likelihood ratio of Clinical studies have shown that neither piroxicam,10 1.5. Complementary testing procedures including dorsi- indomethacin,12 nor oral dexamethasone,13 offer greater flexion of the foot, impaired ankle reflex, sensory deficit analgesia than placebo. For severe pain, opioids can be and muscle atrophy, have modest to poor sensitivities used judiciously. and specificities. In younger and middle aged patients, The efficacy of physical modalities including manipu- the pretest probability of disc herniation is high, lation and traction remains controversial,11 and there is whereas in the elderly, foraminal stenosis or spinal no compelling evidence to encourage their utilisation. stenosis is more likely. Injection techniques such as botulinum toxin, prolotherapy, or facet joint injections are irrational The natural history and illogical. On average, patients with LRP can expect a dramatic Epidural steroid injection reduction in the severity of pain with treatment limited to simple analgesics. At 12 months, at least 50% of Epidural steroids are not indicated for the treatment patients can expect to be free of leg pain, but at least of low back pain. The efficacy of steroid injection
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