Cheatography
https://cheatography.com
L5 radiculopathy; secondary to progressive degenerative change occurring in the lower Lx & mechanical dysfunction, resulting in DNE (dynamic nerve entrapment)
Case
- 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 |
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 |
-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 |
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) |
Physicsl Examination Findings
- High BP
- Posture/stance: hypolordotic Lx spine; kyphotic Tx spine
- Gait: reduced arm swing bilaterally; reduced Tx movement (very rigid) |
ROM
- AROM Lx: extension limited & painful in LB & down leg into shin
- PROM hip: full & pain free bilaterally |
- 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 |
Clinical tests
Kemps
- Purpose: assess Lx spine facet joint pain
- Findings: L +ve w/ L leg pain into shin; R -ve |
Single leg hyperextension
- Purpose: SI & Lx nerve root irritation
- Findings: -ve bilaterally |
Slump's
- Purpose: detect altered neurodynamics or neural tissue sensitivity
- Findings: pulling in LB (L>R) |
Faber's
- Purpose: diagnose hip pathology by attempting reproducing pain
- Findings: -ve bilaterally |
SI distraction
- Purpose: provocation of the SIJ
- Findings: -ve |
Modified Thomas
- Purpose: measures the angle of femur abduction relative to pelvis
- Findings: tight bilaterally (L>R) |
Gaenslen's
- Purpose: diagnose SIJ lesion, pubic symph. instability, L4 nerve root lesion
- Findings: -ve bilaterally |
McGill's
- Purpose: assess radiographic Lx instability
- Findings: both -ve |
Pheasant
- Purpose: indicates an unstable spine segment
- Findings: increased pain in Lx |
Nerve tension
- Findings: tibial -ve; fibular -ve; sural -ve |
Discussion
Working diagnosis
- L5 radiculopathy
- Most likely 2° to progressive degenerative change occurring in the lower Lx & mechanical dysfunction, resulting in DNE (dynamic nerve entrapment) |
- 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 |
- Increased pain on Pheasant's test likely due to extension intolerance &/or facet pain associated with degenerative change |
→ 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) |
→ 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 |
→ Radicular pain 2° to disc herniation
- Aggravated: prolonged sitting |
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) |
Learning Outcomes
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 |
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 |
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 |
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 |
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 |
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 |
|
Created By
Metadata
Comments
No comments yet. Add yours below!
Add a Comment
Related Cheat Sheets
More Cheat Sheets by bee.f