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

The estimated annual incidence of radicular syndrome in The Netherlands is 9 cases per 1000 adults per year ¹⁾.

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 ^{2) 3) 4)}.

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 ⁵⁾.

Transformainal epidural steroid injections can be used ⁶⁾

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.

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 ⁷⁾.

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 ⁸⁾.