Lumbosacral radicular pain [Neurosurgery Wiki]

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====== Lumbosacral radicular pain ======

Lumbosacral [[radicular pain]], the most common neuropathic pain (affecting 10% to 25% of the general population), radiates along the lower extremities in the area innervated by the affected [[nerve root]] and features a sharp, stabbing, and shooting quality

====Epidemiology====
The estimated annual incidence of radicular syndrome in The Netherlands is 9 cases per 1000 adults per year
((Ter Meulen BC, van der Vegt MH, Wouda E, van Tuder MW, Ostelo R, Weinstein HC.
[Pain relief in lumbosacral radicular syndrome: the role of transforaminal
epidural injections with glucocorticoids]. Ned Tijdschr Geneeskd.
2014;158(0):A7562. Dutch. PubMed PMID: 25322354.)).
====Etiology====
[[Radicular pain]] in [[lumbar]] [[region]] is a symptom which can have many causes such as herniated [[nucleus pulposus]], migrated disc fragment, [[lumbar stenosis]], [[facet joint syndrome]], malignancy and/or infection.

The development of severe lumbar radicular pain and [[sciatica]] depends on both mechanical compression and concomitant chemical irritation of the nerve root caused by disc material 
((Nygaard OP, Mellgren SI, Osterud B. The inflammatory properties of contained and noncontained lumbar disc herniation. Spine (Phila Pa 1976) 1997;22:2484–2488.))
((Franson RC, Saal JS, Saal JA. Human disc phospholipase A2 is inflammatory. Spine (Phila Pa 1976) 1992;17(6 Suppl):S129–S132.))
((Olmarker K, Blomquist J, Stromberg J, Nannmark U, Thomsen P, Rydevik B. Inflammatogenic properties of nucleus pulposus. Spine (Phila Pa 1976) 1995;20:665–669.)).

====Pathophysiology====

The pathophysiology of lumbar radiculopathy includes both mechanical compression and biochemical irritation of apposed neural elements. Inflammatory and immune cytokines have been implicated, induced by systemic exposure of immune-privileged intervertebral disc tissue. Surgical intervention provides improved symptoms and quality of life, but persistent postoperative neuropathic pain (PPNP) afflicts a significant fraction of patients.
OBJECTIVE:

To compare the inflammatory and immune phenotypes among patients undergoing structural surgery for lumbar radiculopathy and spinal cord stimulation for neuropathic pain.
METHODS:

Consecutive patients undergoing surgical intervention for lumbar radiculopathy or neuropathic pain were studied. Demographic data included age, gender, and VAS and neuropathic pain scores. Serum was evaluated for cytokine levels (IL-6, Il-17, TNF-α) and cellular content [white blood cell (WBC)/differential, lymphocyte subtypes]. The primary analysis differentiated molecular and cellular profiles between radiculopathy and neuropathic pain patients. Subgroup analysis within the surgical radiculopathy population compared those patients achieving relief of symptoms and those with PPNP.

Heightened IL-6, Il-17, and TNF-α levels were observed for the lumbar radiculopathy group compared with the neuropathic pain group. This was complemented by higher WBC count and a greater fraction of Th17 lymphocytes among radiculopathy patients. In the lumbar discectomy subgroup, pain relief was seen among patients with preoperatively elevated IL-17 levels. Those patients with PPNP refractory to surgical discectomy exhibited normal cytokine levels.

Differences in Th17 immune activation are seen among radiculopathy and neuropathic pain patients. These cellular and molecular profiles may be translated into biomarkers to improve patient selection for structural spine surgery
((Shamji MF, Guha D, Paul D, Shcharinsky A. Systemic Inflammatory and Th17
Immune Activation among Patients Treated for Lumbar Radiculopathy Exceeds that of
Patients Treated for Persistent Postoperative Neuropathic Pain. Neurosurgery.
2017 Jun 7. doi: 10.1093/neuros/nyx052. [Epub ahead of print] PubMed PMID:
28591802.
)).
====Treatment====
Transformainal epidural steroid injections can be used
((Taskaynatan MA, Tezel K, Yavuz F, Tan AK. The effectiveness of transforaminal 
epidural steroid injection in patients with radicular low back pain due to lumbar
disc herniation two years after treatment. J Back Musculoskelet Rehabil. 2014 Oct
15. [Epub ahead of print] PubMed PMID: 25322733.
))

====Outcome====
The course of radicular syndrome is favorable, with resolution of leg pain within 3 months from onset in the majority of patients.

During the first few weeks post-onset treatment focusses on pain relief.

Besides pain medication, transforaminal, fluoroscopic injections with corticosteroids can be chosen. Transforaminal, fluoroscopic injections with glucocorticoids are safe and effective compared to placebo.- The position within the treatment protocol for radicular pain of epidural steroid injections has yet to be determined based upon further scientific knowledge.


Lumbar radiculopathy, like other forms of radiculopathy, results from nerve root impingement and/or inflammation that has progressed enough to cause neurologic symptoms in the areas that are supplied by the affected [[lumbar]] [[nerve root]](s).

see [[sciatica]].

====Treatment====
Much literature reports on selective nerve root blocks (SNRBs) in cases of lumbosacral radiculopathy. Unfortunately, authors only inconsistently reveal the exact needle tip position relative to the causative pathology at the time of injection. Different injection sites may provide different symptomatic benefits. 

A clinical scenario was devised depicting a patient with radiculopathy secondary to an L4/5 vertebral disc prolapse. Participants were questioned on their chosen management of this patient, focusing particularly on SNRB technique. Questionnaires were sent to spinal surgeons, pain management specialists and musculoskeletal radiologists.

A total of 100 responses were detailed enough for inclusion. The majority (83%) of respondents reported they would inject local anaesthetic and steroids, 4% would inject local anaesthetic alone and 13% would inject a different substance. Over half (53%) would target the L5 nerve root, 26% the L4 nerve root, 12% the prolapsed disc itself and 9% two separate vertebral levels. Variation was also noted in needle tip location relative to the neural sheath.

When treating lumbar radiculopathy, there are apparent variations in the use and positioning of SNRBs for a given level of disc pathology. Needle tip position may have a direct influence on clinical outcome following SNRBs. Caution is therefore required when considering the validity of previously published studies investigating SNRBs and different injectates
((Eastley NC, Spiteri V, Newey ML. Variations in selective nerve root block
technique. Ann R Coll Surg Engl. 2013 Oct;95(7):515-8. doi:
10.1308/003588413X13629960048073. PubMed PMID: 24112500.)).

====Case series====
Thirty-six patients, aged from 18 to 45 years, with [[lumbosacral radiculopathy]] associated with [[connective tissue dysplasia]] were examined. Detailed neurological examination, X-ray visualization and MRI of lumbosacral spine section, electromyographic assessment were performed. A five-point scale of neuro-vertebrological symptoms, the Numerical Rating Scale (NRS) and the Roland-Morris Low Back Pain and Disability Questionnaire were used.

The results contained own data on the pathogenesis, clinical manifestations and treatment of dorsopathies in connective tissue dysplasias. Inclusion of long-acting [[pentoxifylline]] (vasonite) in the combined therapy in patients with dorsopathy associated with connective tissue dysplasia had a positive effect on disease course, decreased pain intensity and improved life activities
((Chukhlovina ML, Chukhlovin AA. [Diagnosis and treatment of dorsopathy in
patients with connective tissue dysplasia]. Zh Nevrol Psikhiatr Im S S Korsakova.
2017;117(7):43-46. doi: 10.17116/jnevro20171177143-46. Russian. PubMed PMID:
28805759.
)).