Lbp with radiculopathy

1. RECENT GUIDELINE FOR RADICULOPATHY
AND BACK PAIN
DR. VINOD SINGH JATAV
SR NEUROLOGY
GMC KOTA

2. • Up to 84 percent of adults have low back pain at some
time in their lives
• >85 percent will have nonspecific low back pain.
• Acute back pain upto four weeks.
• Subacute back pain lasting between 4 and 12 weeks
• And chronic back pain lasting >12 weeks
Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012;

4. Congenital
Spinal bifida occulta
Tethered spinal cord
;

5. Causes of lower back pain without leg pain
• Ligamentous strain
• Muscle strain
• Facet pain
• Bony destruction
• Inflammation from many causes
Causes of lower back plus lower limb pain include:
• Spinal stenosis
• Radiculopathy
• Plexopathy
Leg pain without low back pain
• Peripheral mononeuropathies
• polyneuropathies
• Plexopathies
• Vascular claudication

12. Acute low back pain imaging consideration

13. Acute low back pain imaging consideration

15. Syndesmophyte
Bamboo
spine
Heel enthesitis
Dactylitis (sausage
digit)
ankylosing spondylitis imaging

16. Treatment of acute low back pain
NONPHARMACOLOGIC THERAPIES
• Heat
• Massage- no evidence that massage offers clinical benefits for acute low
back pain. increased patient satisfaction
• Spinal manipulation
• Exercise and physical therapy- in patients with acute low back pain, exercise
therapy was not more effective, patient education programs, and/or advice
to stay active evidence to support exercise therapy for patients with
subacute and chronic low back pain
• Lumbar supports No evidence to support
1.Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline
From the American College of Physicians. Ann Intern Med 2017;.

17. PHARMACOTHERAPY
• NSAIDS and acetaminophen
• Second-line therapy- Muscle relaxants
(Cyclobenzaprine, methocarbamol, carisoprodol, baclofen, chlorzoxazone, tizanidine)
• Refractory or severe pain- Opioids and tramadol
do not advise bed rest for patients with acute low back pain.
(Patients who are treated with bed rest have more pain and slower recovery
than ambulatory patients)
If activity is painful or increases pain, advise gradually increase activity as tolerated

18. Subacute and chronic low back pain:
Nonpharmacologic
• Self-care advice
• Maintain activity as tolerated
• Heat
• Exercise therapy- core strengthening, aerobic exercise, yoga and Tai Chi.
• Psychological and mind-body therapies cognitive behavioral therap,
mindfulness-based stress reduction MBSR
• Spinal manipulation
• Acupuncture
• Yoga

19. Pharmacologic treatment
• NSAIDS and acetaminophen
• second-line therapy- Muscle relaxant
• Duloxetine and tramadol
• Tricyclic antidepressants

20. Surgical Management
INDICATIONS
• severe or progressive motor weakness
• signs and symptoms of cauda equina syndrome
• persistent disabling symptoms of low back pain and significantly impaired quality
of life
• not responded to adequate trials of nonsurgical approaches
• persistent (>1 year) disabling non-radicular low back pain with discussion
of its risks and benefits

21. • Spinal fusion-(chronic nonspecific low back pain with lumbar disc degenerative
changes)
• Lumbar disc replacement.
(approved by the FDA for patients who are in good health and ≤60 years old, with
disease limited to one disc between L3 and S1 and no associated deformity,
spondylolisthesis, or neurologic deficit)

22. LUMBAR DISC PROLAPSE
• Traditional open discectomy with laminectomy
• Microdiscectomy
• Minimally invasive procedures- percutaneous manual nucleotomy, percutaneous
discectomy, laser discectomy, endoscopic discectomy, microendoscopic
discectomy, and radiofrequency nucleoplasty
(inferior due to recurrent disc herniation)
Spinal cord stimulation- in patients with persistent and disabling radicular pain
following surgery
complication,
including electrode migration, infection or wound breakdown, generator
pocket-related complications, and lead problem)

23. Approach to acute lumbosacral radiculopathy

24. Approach to acute lumbosacral radiculopathy

25. Approach to Acute lumbosacral radiculopathy
Recommend urgent imaging
• Acute radiculopathy with progressive neurologic deficits
• Radiculopathy with urinary retention, saddle anesthesia, or bilateral neurologic symptoms or signs
• Suspected neoplasm
• Suspected epidural abscess
If imaging is negative or equivocal,
• nerve conduction studies (NCS) and electromyography (EMG) identify nonstructural causes.
• A lumbar puncture and cerebrospinal fluid (CSF) analysis suspected inflammatory or infectious
cause of lumbosacral radiculopathy

26. Acute lumbosacral radiculopathy: Treatment and prognosis
• Initial conservative treatment- NSAIDs or Acetaminophen and activity
modification
• Physical therapy-in the first one to two weeks not recommended because
mild symptoms are likely to improve on their own
very severe symptoms cannot participate in exercise therapy.
delay physical therapy until symptoms have persisted for three weeks.
bed rest is ineffective for treating sciatica as well as back pain.
• Systemic glucocorticoids- who do not respond well to analgesic and activity
modification, With rapid taper over 7 to 14 days

27. • Opioids –except for severe intractable pain unresponsive to other therapies
• Benzodiazepines and antispasmodic agents
• Epidural glucocorticoids- Which not improved with conservative treatment over six
weeks
EXERCISE:
• Walking
• Aerobic exercise- bicycling, swimming, treadmill walking, and elliptical trainers
• Stretching exercises
• Yoga
• Tai Chi
• Graded activities exercise/functional restoration
• Multidisciplinary (interdisciplinary) rehabilitation

29. Surgical management
• Anterior cervical discectomy and fusion
• Posterior lamino-foraminotomy
• Artificial disc replacement
• Cervical medial branch blocks
• intermittent cervical traction
• Percutaneous radiofrequency neurotomy
Cervical collar- Routine use discouraged

32. REFERENCES
• Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay
active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010 Jun
16;(6):CD007612
• Bradely’s Neurology In Clinical Practise, 8th Edition
• Harrison’s Principle Of Internal Medicine,20th Edition
• Low back pain and sciatica © NICE 2021.
• Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint
clinical practice guideline from the American College of Physicians and the American Pain
Society. Ann Intern Med 2007; 147:478.
• Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic
review and meta-analysis. Lancet 2009; 373:463.
• Friedman BW, Irizarry E, Solorzano C, et al. A Randomized, Placebo-Controlled Trial of
Ibuprofen Plus Metaxalone, Tizanidine, or Baclofen for Acute Low Back Pain. Ann Emerg
Med 2019

33. Thank you