Lumbosacral radiculopathy

Description:

The Lumbosacral Radiculopathy (LR) – one of the heaviest options of vertebrogenny pain syndromes which is characterized by especially intensive and persistent pain which is usually followed by sharp restriction of mobility. Though about 5% of cases of a dorsodynia fall to the share of a radiculopathy, it is the most frequent reason of permanent disability. While at 90% of patients with an acute pain (at inclusion of all its options) it independently passes in spin during 6 weeks, not less than at 30% of patients with a radiculopathy pain remains longer.

Epidemiology.
PKR arises approximately at 3–5% of persons among the population. Incidence of men and women is approximately equal, however its peak at men is the share of age from 40 to 50 years, and women have from 50 to 60 years. The risk of development of a vertebrogenny radiculopathy is increased at those who do hard manual work, when smoking, the burdened family anamnesis. Regular physical activity can reduce risk of a radiculopathy, but at those who began to be engaged in it after an episode of a discogenic dorsodynia, the risk can increase.

Symptoms of the Lumbosacral radiculopathy:

Clinically PKR is characterized sharply or subacutely developing paroxysmal (shooting or penetrating) or a constant megalgia which at least incidentally irradiates in a distal zone of a dermatome (for example at reception of Lasega). The scelalgia usually is followed by a back pain, but young people can have it only in a leg. Pain can suddenly develop – after the sharp unprepared movement, rise in weight or falling. In the anamnesis such patients often have instructions on repeated episodes of a lyumbalgiya and a lumbar ishialgia. First pain can be stupid, aching, but gradually accrues, less often at once reaches the maximum intensity. If the radiculopathy is caused by disk hernia, pain, as a rule, amplifies at the movement, a natuzhivaniye, rise in weight, sitting in a deep chair, long stay in one pose, cough and sneezing, pressing on jugular veins and weakens at rest, in particular if the patient lies on a healthy side, having bent a sore leg in knee and coxofemoral joints.
At survey of spin it is often fixed in slightly bent situation. Quite often the scoliosis amplifying at a kpereda inclination, but vanishing in a prone position comes to light. It is most often caused by reduction of a square muscle of a waist. At lateral hernia scoliosis is sent to the healthy party, at paramedian – to the patient. The inclination of a kpereda is sharply limited and is carried out only at the expense of a hip joint. Also the inclination in the sick party is sharply limited. The expressed tension of juxtaspinal muscles decreasing in a prone position is noted.
Are characteristic sensitivity disturbance (painful, temperature, vibration, etc.) in the corresponding dermatome (in the form of paresthesias, hyper - or hypalgesias, allodynia, a hyperpathia), decrease or loss of the tendon jerks which are becoming isolated through the corresponding segment of a spinal cord, hypotonia and weakness of the muscles innervated by this root. As in lumbar department of a backbone approximately in 90% of cases hernia of a disk is localized at the L4-L5 and L5-S1 levels, in clinical practice L5 radiculopathy (about 60% of cases) or S1 (about 30% of cases) most often comes to light. At elderly people of hernia of intervertebral disks develop at higher level more often, in this regard at them radiculopathies of L4 and L3 are frequent.
Communication between the struck root and localization of hernia has difficult character and depends not only on disk hernia level, but also on the direction of protrusion. Hernias of lumbar disks most often happen paramedian and put pressure upon the root reaching through an intervertebral opening is one level lower. For example, at hernia of the disk L4-L5 L5 root most often will suffer. However if hernia of the same disk is directed more lateralno (towards the radicular channel), then will cause L4 root prelum if more medially – can lead to S1 root prelum (see the drawing). Simultaneous involvement of 2 roots on the one hand at hernia of 1 disk – an unusual occurrence, more often it is noted at hernia of the disk L4-L5 (in this case roots of L5 and S1 suffer).
Existence of symptoms of a tension and first of all a symptom of Lasega is typical, however this symptom is not specific to a radiculopathy. It is suitable for assessment of weight and dynamics of a vertebrogenny pain syndrome. The symptom of Lasega is checked, slowly (!) raising a direct leg of the patient up, expecting reproduction of radicular irradiation of pain. When involving roots of L5 and S1 pain develops or sharply amplifies at instep till 30-40 °, and at the subsequent bending of a leg it passes in knee and coxofemoral joints (otherwise it can be caused by pathology of a hip joint or has psychogenic character).
When performing reception of Lasega the back pain and a leg can arise also at a tension of juxtaspinal muscles or back muscles of a hip and shin. To confirm the radicular nature of a symptom of Lasega, the leg is raised to a limit above which there is pain, and then forcedly bend foot in an ankle joint that at a radiculopathy causes radicular irradiation of pain. Sometimes at medial hernia of a disk the cross symptom of Lasega when the back pain and a leg is provoked by a raising of a healthy leg is observed. When involving a root of L4 the "front" symptom of a tension – Wasserman's symptom is possible: it is checked at the patient lying on a stomach, raising a direct leg up and unbending a hip in a hip joint or bending a leg in a knee joint.
At a root compression in the radicular channel (owing to lateral hernia, a hypertrophy of a joint facet or formation of osteophytes) pain often develops more slowly, gradually getting radicular irradiation (buttock-hip-shin-foot), quite often remains at rest, but accrues during the walking and stay in vertical position, but unlike hernia of a disk is facilitated when sitting. It amplifies at cough and sneezing. Symptoms of a tension are, as a rule, less expressed. Inclinations are limited less forward, than at median or paramedian hernia of a disk, and pain is more often provoked by extension and rotation. Paresthesias are often observed, decrease in sensitivity or muscular weakness is more rare.
Weakness of muscles at discogenic radiculopathies usually happens easy. But sometimes against the background of sharp strengthening of radicular pains there can sharply be expressed foot paresis (paralyzing a sciatica). Development of this syndrome is connected with ischemia of roots of L5 or S1 caused by a prelum of the vessels feeding it (radikuloishemiya). In most cases paresis safely regresses within several weeks.
The acute bilateral radicular syndrome (syndrome of a horse tail) arises seldom, usually owing to massive median (central) hernia of a nizhnepoyasnichny disk. The syndrome is shown by quickly accruing bilateral asymmetric onychalgias, numbness and a hypesthesia of a crotch, the lower sluggish paraparesis, an urination delay, an incontience a calla. This clinical situation demands urgent consultation of the neurosurgeon.

Reasons of the Lumbosacral radiculopathy:

Hernia of an intervertebral disk is the most frequent reason of PKR. At young age in a type of more high intra disk pressure the pulpozny kernel gets between the damaged fibers of a fibrous ring easier that causes more frequent development of a discogenic radiculopathy. The hernias of intervertebral disks capable to compress a root are conditionally subdivided into 3 types: 1) lateral (are displaced towards an intervertebral opening); 2) paramedian (mediolateral); 3) median.
The radiculopathy is more often caused by a root prelum in the field of a lateral pocket or an intervertebral opening owing to formation of osteophytes in elderly people, a hypertrophy of joint facets, sheaves or other reasons. More rare reasons – tumors, infections, dismetabolichesky spondylopathies in total explain no more than 1% of cases of a radiculopathy.

Treatment of the Lumbosacral radiculopathy:

At most of patients with a discogenic radiculopathy against the background of conservative therapy it is possible to reach essential weakening and regress of a pain syndrome. A basis of conservative therapy of a radiculopathy, as well as other options of a dorsodynia, non-steroidal anti-inflammatory drugs (NPVP) which have to be applied from the first hours of development of a disease are, parenteral administration is more preferable than them. At megalgias use of a tramadol in a dose to 300 mg/days is possible. (7–14 days) the course of muscle relaxants (for example a tizanidina or a tolperazona) has to be an obligate component of treatment short.
Corticosteroids – the most effective remedy of suppression of inflammatory reaction, at the same time is more preferable than them the epidural introduction creating higher local concentration. Introduction of corticosteroids causes essential weakening of a pain syndrome though, apparently, does not influence the remote outcome of a radiculopathy. Efficiency of corticosteroids is higher lasting aggravation less than 3 months. It is possible to enter them at the level of the struck segment (a translaminar or transforaminalny way) or through a sacrococcygeal or I sacral opening. Translaminar access at which the needle is entered through juxtaspinal muscles (at paramedian access) or an interspinal sheaf (at median access) is safer, than trasforaminalny access at which the needle is entered through an intervertebral opening. Epiduralno is better to enter the corticosteroids forming depot in an injection site, for example hydrocortisone suspension (100 mg), the prolonged Methylprednisolonum drug (40 mg) or дипроспан. The corticosteroid is entered in one syringe with local anesthetic (for example from 0,5% novocaine solution). The volume of the solution entered interlaminarno usually makes up to 10 ml, transforaminalno – to 4 ml, in a sacrococcygeal and I sacral opening – to 20 ml. Depending on efficiency repeated injections are carried out at an interval of several days or weeks. Blockade of painful points and an inactivation of trigger points in the presence of the accompanying myofascial syndrome can be important. At a vertebrogenny radiculopathy there are no sufficient bases for use of diuretics or vasoactive drugs. Nevertheless use of a pentoksifillin is possible, considering its ability to have the braking effect on products of a factor of a necrosis of a tumor-a.
Considering the mixed character of a pain syndrome, influence not only on nociceptive, but also on a neuropathic component of pain is represented perspective. Still efficiency of the means which are traditionally applied at neuropathic pain, first of all antidepressants and antikonvulsant remains insufficiently proved. Only in single small researches the positive effect of a gabapentin, topiramat, lamotridzhin is shown. The early beginning of their use can be a condition of efficiency of these means. The positive effect is gained also at topical administration of plates with lidocaine.
The bed rest is often inevitable in the acute period, but has to be whenever possible minimized. At a radiculopathy, as well as at other options of a dorsodynia, more bystry return to daily activity can be the factor preventing synchronization of pain. At improvement of a state attach the remedial gymnastics, physiotherapeutic procedures and methods of the sparing manual therapy directed to mobilization and a relaxation of muscles that can promote increase in mobility in a backbone. Traditionally applied popular traction of lumbar department was inefficient in controlled researches. In some cases it provokes deterioration as causes stretching of not struck blocked segment (and a root decompression), and the segments located above and below.
Absolute indications to operational treatment is the prelum of roots of a horse tail with foot paresis, anesthesia of anogenitalny area, disturbance of functions of pelvic bodies. Increase of neurologic symptoms, for example weaknesses of muscles can also be the indication to operation. As for other cases, questions of expediency, optimum time and a method of operational treatment remain a discussion subject.
Recent large-scale researches showed that though early operational treatment undoubtedly leads to more bystry easing of pain, later half a year, year and two it has no advantages on the main indicators of a pain syndrome and degree of an invalidism before conservative therapy and does not reduce risk of synchronization of pain. It became clear that terms of performing surgery in general do not influence its efficiency. In this regard in uncomplicated cases of a vertebrogenny radiculopathy the solution of a question of operational treatment can be delayed on 6–8 weeks during which adequate (!) conservative therapy has to be carried out. Preservation of an intensive radicular pain syndrome, sharp restriction of mobility, resistance to conservative actions in these terms can be indications to an operative measure.
In recent years along with a traditional diskektomiya apply more sparing operative measure techniques; mikrodiskektomiya, laser decompression (vaporization) of an intervertebral disk, high-frequency ablation of a disk, etc. For example, laser vaporization is potentially effective at the radiculopathy connected with hernia of an intervertebral disk at preservation of integrity of a fibrous ring, its protrusion no more than on 1/3 sagittal sizes of the vertebral channel (about 6 mm) and at absence at the patient of motive frustration or symptoms of a compression of roots of a horse tail. Low-invasiveness of intervention expands a circle of indications to it. Nevertheless there is invariable a principle: optimum conservative therapy during not less than 6 weeks has to precede an operative measure.