ࡱ>  8bjbjVV ><<0 8UQMMMM(((/U1U1U1U1U1U1U$WpZRUU(((((UUMMjU"#"#"#(:MM/U"#(/U"#"#MlQM@H&:b O*UU0U5OZb fZTQQZR4"#(((UUUU!Z(((U((((Z((((((((( :   References:Description Inflammation of a nerve root in the lumbar region of the spine due to compression by an extruding disk.Pathology (organ, cell, system) Grossly, cracks develop in the disc, which shrinks and buckles out. There is narrowing of the disc space. Microscopically, there are changes in disk proteoglycan composition. UpToDate Online: Lumbosacral RadiculopathyPathophysiology There are two foramina underneath an individual lumbar vertebrae. The spinal nerve roots pass through these foramina. These foramina are bordered anteriorly by the intervertebral disc, which separates the vertebral bodies. The disc consistes of an outer annulus fibrosus and an inner nucleus pulposus, which has the consistency of tooth paste and provides the disc with its shock absorbing qualities. Age-related: There are age related changes in the disk, including altered proteoglycan composition and disk space narrowing. The annulus fibrosus becomes fibrotic and develops fissures. As the disk space narrows, the inner nucleus pulposus may buckle out and compress a nerve root, leading to radiculopathy. Traumatic: herniation may occur secondary to heavy lifting while bent at the waist. Most disk herniations occur at the L4-L5 and L5-S1 levels. UpToDate Online: Lumbosacral RadiculopathyDifferential Diagnosis Spinal stenosis: Symptoms are exacerbated by standing in an erect posture (back extension). Flexion relieves symptoms. This is most commonly caused by degenerative spondylosis. Cauda equine syndrome: may present with radiculopathy, but would also expect bowell/bladder incontenance. There are multiple etiologies for nerve root compression leading to radiculopathy. These include metastases and spinal abscesses. Sacroiliitis may also cause lower back pain with radiculopathy. UpToDate Online: Lumbosacral Radiculopathy Epidemiology Prevalence is equal in men and women. Lifetime prevalence is around 3-5% in adults. Incidence increases with age. Men typically develop symptoms in their 40s, while women are typically affected between 50 and 60.UpToDate Online: Lumbosacral Radiculopathy Lumbosacral adiculopathy. Tarulli AW; Raynor EM. Neurol Clin. 2007 May;25(2):387-405. Etiology This disease is caused by the nucleus pulposis extruding through the annulus fibrosis and impinging upon nerve roots. What causes this herniation? Disk space narrowing and changes in disk structure have been noted with age. Fissures develop in the annulus fibrosus. This provides a mechanism for nucleus pulposis herniation. UpToDate Online: Lumbosacral Radiculopathy Clinical manifestations Patients present with lower back pain, stiffness, and radiculopathy due to compression of the nerve root by the herniated disk. Sciatica is a common term that refers to pain along the sciatic nerve in radiculopathy. Forward flexion (sitting, lifting, going up stairs) exacerbates pain. (This is key to differentiate from spinal stenosis). Anything that increases intraspinal pressure such as coughing will exacerbate symptoms. L5 radiculopathy is the most common, which presents with back pain radiating down the lateral side of the lower leg. There may be weakness of hip flexion, knee extension, and hip abduction. Knee reflexes may be reduced given the weakness. Sensation may be affected from the anterior thigh down to the medial lower leg. It should be noted that these findings are neither sensitive nor specific for disc herniation; many herniated disks are not symptomatic. Lower back pain and radiculopathy have a broad differential and are not specific for disk herniation. The straight leg raise test is a sensitive but not specific test to diagnose radiculopathy due to disc herniation. Raising the patients leg (symptomatic side) from the supine position will increase dural tension in the lumbar levels and may reproduce radicular pain. UpToDate Online: Lumbosacral RadiculopathyLate presentation, complications Symptoms will resolve in most instances of untreated disease. While rare, there are instances in the literature of disk herniation progressing to cord compression/cauda equine syndrome. UpToDate Online: Lumbosacral Radiculopathy  HYPERLINK "javascript:AL_get(this,%20'jour',%20'Spine%20%0d%0a(Phila%20Pa%201976).');" \o "Spine." Spine (Phila Pa 1976). 2009 Nov 15;34(24):2711-3. Cauda equina syndrome caused by a complete traumatic lumbar disc complex extrusion without alterations of facet joints.  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Gonz%C3%A1lez-Bonet%20LG%22%5BAuthor%5D" Gonzlez-Bonet LG,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Moll%C3%A1-Torr%C3%B3%20JV%22%5BAuthor%5D" Moll-Torr JV. Department of Neurosurgery, Hospital de La Ribera, Alzira, Valencia, Spain. Nutritional factorsThe main nutritional risk factor is a diet predisposing to obesity. Obesity and increased lumbar loads are key risk factors for disk herniation. Weight loss and/or a normal BMI are important to minimize risk. Spine 2009 Dec 1;34(25):E918-22. Risk factors for lumbar intervertebral disc herniation in Chinese population: a case-control study.  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Zhang%20YG%22%5BAuthor%5D" Zhang YG,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Sun%20Z%22%5BAuthor%5D" Sun Z,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Zhang%20Z%22%5BAuthor%5D" Zhang Z,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Liu%20J%22%5BAuthor%5D" Liu J,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Guo%20X%22%5BAuthor%5D" Guo X. Radiographic evidence XRAY Very insensitive for the diagnosis of disc herniation (poor soft tissue resolution), but helpful for narrowing the differential and ruling out tumors, infections, and fractures. MRI is a sensitive modality that identifies most pathology that would indicate surgical intervention. T2 MRI may show the extension of a disk (black disk separating gray vertebral bodies) protruding from the disk space. A black disk indicates a lack of water and proteoglycan, which is consistent with degenerative disk disease. CT: Better soft tissue resolution than Xray, but inferior to MRI. This can also show the shape and contents of the spinal canal as well as the surrounding soft tissue.UpToDate Online: Lumbosacral Radiculopathy Laboratory evidence EMG may be used to distinguish weakness secondary to pain-related reduced effort from neurogenic weakness, which may be observed in nerve root compression. There are no true laboratory abnormalities that aid in establishing a diagnosis of disk herniation, although normal lab values may help to rule out other possible etiologies of lower back pain.UpToDate Online: Lumbosacral Radiculopathy Psychosocial impact of disease Lower back pain is commonly associated with depression. The pain can be persistent and may generate limitations in a patients daily activities. While a causal relationship has not been established, mental side-effects of chronic pain can be substantial. While the physical limitations of chronic lower back pain and radiculopathy may be easily appreciated, the mental side-effects should not be overlooked. Risk factors Family history, lumbar load (and obesity), and patients who worked longer hours with a larger time urgency were found to be at increased risk for disk herniation. Physical exercise and sleeping on a hard bed were isolated as potential protective factors.Spine 2009 Dec 1;34(25):E918-22. Risk factors for lumbar intervertebral disc herniation in Chinese population: a case-control study.  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Zhang%20YG%22%5BAuthor%5D" Zhang YG,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Sun%20Z%22%5BAuthor%5D" Sun Z,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Zhang%20Z%22%5BAuthor%5D" Zhang Z,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Liu%20J%22%5BAuthor%5D" Liu J,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Guo%20X%22%5BAuthor%5D" Guo X. Prevention Lumbar support, hard sleeping surface, and physical activity had been shown to be protective factors. These are simple cost-effective interventions. Maintaining a normal BMI is also important for minimizing lumbar load. Spine 2009 Dec 1;34(25):E918-22. Risk factors for lumbar intervertebral disc herniation in Chinese population: a case-control study.  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Zhang%20YG%22%5BAuthor%5D" Zhang YG,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Sun%20Z%22%5BAuthor%5D" Sun Z,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Zhang%20Z%22%5BAuthor%5D" Zhang Z,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Liu%20J%22%5BAuthor%5D" Liu J,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Guo%20X%22%5BAuthor%5D" Guo X. Treatment optionsConservative management in these patients may involve NSAIDS, brief rest period following by physical therapy, oral steroids, epidural cortisone injections, lumbar back support, and weight loss. Spinal manipulation/chiropractic treatment is contraindicated. Surgery should only be considered after pain has proven refractory to conservative management. Surgery is also indicated in the event of bowell/bladder incontenance and neurological deficits. There are several surgical treatment options, including laminectomy, discectomy, and chemonucleolysis. In chemonucleolysis, the disk is chemically dissolved. In discectomy, the nucleus pulposus is removed to decompress the affected nerves. In laminectomy, the lamina of the vertebra is removed to increase the size of the spinal canal to decompress spinal nerves. This is also a common treatment for spinal stenosis. UpToDate Online: Lumbosacral Radiculopathy Vroomen PC, de Krom MC, Knottnerus JA (Feb 2002).  HYPERLINK "http://openurl.ingenta.com/content/nlm?genre=article&issn=0960-1643&volume=52&issue=475&spage=119&aulast=Vroomen" "Predicting the outcome of sciatica at short-term follow-up". Br J Gen Pract 52 (475): 11923.Outcomes of treatment Most herniated disks will heal without treatment. It has been shown in one study that 73% of patients displayed reasonable to major improvement without surgery. The Hague Spine Intervention Prognostic Study Group found that rates of pain relief and of perceived recovery were faster for patients assigned to early surgery, although 1 year outcomes were similar for conservative treatment plus eventual surgery as needed versus early surgery.Vroomen PC, de Krom MC, Knottnerus JA (Feb 2002).  HYPERLINK "http://openurl.ingenta.com/content/nlm?genre=article&issn=0960-1643&volume=52&issue=475&spage=119&aulast=Vroomen" "Predicting the outcome of sciatica at short-term follow-up". Br J Gen Pract 52 (475): 11923.Potential Complications of treatment One study of lumbar microdiscectomy found complication rates of 6.7% when the procedure was performed by surgeons who did not specialize in spinal surgery versus 7.3% in spine specialists, a statistically insignificant difference. 71% of complications were dural tear, 4% urinary retention, and 25% were transient or permanent new radiculopathy. There were no incidences of vascular injury. HYPERLINK "javascript:AL_get(this,%20'jour',%20'Can%20J%20%0d%0aNeurol%20Sci.');" \o "The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques." Can J Neurol Sci. 2010 Jan;37(1):49-53. Admission and acute complication rate for outpatient lumbar microdiscectomy.  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Fallah%20A%22%5BAuthor%5D" Fallah A,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Massicotte%20EM%22%5BAuthor%5D" Massicotte EM,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Fehlings%20MG%22%5BAuthor%5D" Fehlings MG,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Lewis%20SJ%22%5BAuthor%5D" Lewis SJ,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Rampersaud%20YR%22%5BAuthor%5D" Rampersaud YR,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Ebrahim%20S%22%5BAuthor%5D" Ebrahim S,  HYPERLINK "http://proxy.library.upenn.edu:2082/pubmed?term=%22Bernstein%20M%22%5BAuthor%5D" Bernstein M.       ^iO7/h>h4,5B*CJOJQJ\^JaJph3h>h4,0J6B*CJOJQJ]^JaJph*h>hj4F0J6CJOJQJ]^JaJ*h>h{ 0J6CJOJQJ]^JaJ,h>h4,5B*CJOJQJ^JaJph&h:2#5B*CJOJQJ^JaJph)h>h4,B*CJOJQJ^JaJph,h>h4,>*B*CJOJQJ^JaJph&h:2#>*B*CJOJQJ^JaJph t d$Ifgdhakd$$IfF0zl$J$ `'6    2d4a d$Ifgdn-o d$Ifgd4,gd> ] ^ d$Ifgdh d$Ifgd4,akd$$IfF0zl$J$ `'6    2d4a   ) \ ] ^ ˱kT</h>h4,5B*CJOJQJ\^JaJph-h>h4,0JB*CJOJQJ^JaJph-h>hv3e0JB*CJOJQJ^JaJph)h>h4,B*CJOJQJ^JaJph3h>hn-o0J6B*CJOJQJ]^JaJph3h>hE0J6B*CJOJQJ]^JaJph3h>h[Ci0J6B*CJOJQJ]^JaJph3h>hv3e0J6B*CJOJQJ]^JaJph 0 g " yym d$Ifgdh d$Ifgd* d$Ifgd d$Ifgd4,akd $$IfF0zl$J$ `'6    2d4a | / 0 = b f t f g r ˱}c}cI}/c/3h>hS0J6B*CJOJQJ]^JaJph3h>hE0J6B*CJOJQJ]^JaJph3h>h\0J6B*CJOJQJ]^JaJph3h>h*0J6B*CJOJQJ]^JaJph3h>hpI0J6B*CJOJQJ]^JaJph3h>hKBI0J6B*CJOJQJ]^JaJph3h>h0J6B*CJOJQJ]^JaJph3h>h#l0J6B*CJOJQJ]^JaJph r ! 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