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5002 Case 11 Cheat Sheet by

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
 

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