Review Note

Causes:

• Lumbar Disk Herniation:
  • Most commonly occurs at L4-L5 or L5-S1.
  • Less commonly seen in thoracic or high lumbar regions.
• Degenerative Changes:
  • In intervertebral discs or vertebral bodies.
• Osteophytes.
• Other Factors:
  • Compressing structures such as tumors or cysts.

Clinical Symptoms:

• Leg Pain > Lumbar Pain:
• Positive straight leg raise test (stretches the nerve root).

• Dermatomal Distribution:
  • Paresthesias.
  • Motor weakness and loss of reflexes.
• Symptoms:
  • Increase in sitting and bending positions; improve with bed rest.
• Sciatica:
• Sharp or burning pain radiating down from the buttocks along the course of the sciatic nerve (posterior and lateral aspect of the leg to the foot and ankle).
• Mostly attributable to L5-S1 radiculopathy.

Red Flags:

• Unexpected Weight Loss:
  • May indicate tumor metastasis in the vertebral column (commonly from breast, prostate, lung, thyroid).
• Trauma:
  • Is there a fracture in the vertebral column?
• Neurological Symptoms:
  • Signs of cauda equina syndrome (sensory loss/paresthesia in the genital area, bladder and bowel dysfunction, leg muscle weakness) require hospitalization, urgent MRI, and surgery within 24-48 hours! (Delayed intervention may hinder recovery of neurological function).
• Age >50 or <20 Years:
  • Possible indication of tumor.
• Fever:
  • May suggest spondylodiscitis (inflammation in the intervertebral disc in the epidural area), severe infections leading to bone destruction, or vertebral osteomyelitis.
• Intravenous Drug Use:
  • Potential for septic conditions (epidural abscess).
• Anticoagulant Use:
  • Can lead to hematoma.
• Night Pain:
  • Typical for oncological patients.
• No Response to Painkillers:
  • MRI should be performed to identify more severe underlying causes.

Treatment:

• Depends on the Underlying Cause.
• Conservative Management:
  • Physiotherapy and continuous daily activities.
  • Pain medications – NSAIDs, paracetamol.
  • Local heat application.
  • Muscle relaxants.
  • Local steroid injections.
• Surgical Management:
  • Discectomy (for disc protrusion).
  • Indications:
    • Cauda equina symptoms!!
    • Significant or progressive neurological deficit.
    • Massive radicular pain unmanageable by conservative therapy.
• Other Options:
  • E.g., intravenous antibiotics for infections, tumor resection, or chemotherapy/radiation.