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Sciatica/Herniated Disc, Emergency Medicine

Basics

Description

- Pain that radiates from the back into buttocks and lower extremity distal to knee, with or without sensory or motor deficits: - 95% sensitive, 88% specific for herniated disc (HD) - 3 " 5% lifetime prevalence - Peaks 4th to 5th decade - 2 " 10% of low back pain - 95% L5 or S1 nerve root - 90% improve with conservative management - Radicular symptoms usually resolve within 6 wk - 5 " 10% require surgery

- Low back pain precedes onset of leg pain - Leg pain predominates with time - Sharp, well localized, radiates distal to knee - Exacerbated by activities that increase intradiscal pressure: - Valsalva maneuver - Cough - Nerve-root tension (sitting, straight leg raise)

- Neurologic exam (motor, sensory, deep tendon reflexes) - L4 root/L3 " L4 disc: - Knee extension/hip adduction - Anteromedial leg/knee/medial malleolus - Patellar reflex

- L5 root/L4 " L5 disc: - Great toe and foot dorsiflexion - Dorsomedial foot/1st web space - No reflex

- S1 root/L5 " S1 disc: - Foot plantarflexion - Posterior leg/lateral malleolus/dorsolateral foot - Achilles reflex - Rectal exam (tone, sensation)

- Helps to rule out some DDX - Indications: - Extremes of age (<20, >55 yr) - Unresolved back pain (>4 " 6 wk) despite conservative treatment - Red flags on history and physical exam: - Trauma - Constitutional symptoms (fever, unexplained weight loss, malaise) - History of cancer - Immunocompromised - IV drug abuse - Recent bacterial infection - Worse at night/wakes patient from sleep - Fever - Midline point tenderness - Neurologic deficits

- Muscle relaxants (short term): - Cyclobenzaprine (Flexeril): 5 " 10 mg TID - Diazepam (Valium): 2 " 10 mg (peds: 0.1 mg/kg/dose) PO TID " QID - Methocarbamol (Robaxin): 1,000 " 1,500 mg PO QID

- Opioids (short term): - Hydromorphone (Dilaudid): 2 " 4 mg PO/0.5 " 2 mg IM/IV q4 " 6h PRN - Morphine sulfate: 2 " 10 mg (peds: 0.1 mg/kg/dose) IM/IV q2 " 4h PRN - Codeine 30 mg + acetaminophen 300 mg; do not exceed acetaminophen4 g/24 h - Hydrocodone 5 mg + acetaminophen 300 mg; do not exceedacetaminophen 4 g/24 h

- Consultant (orthopedic spine surgeon or neurosurgeon) or PCP within 1 wk - Conservative treatment (4 " 6 wk): - Medication as noted - Avoid complete bed rest, 2 days at most - Limited activity in acute phase but gradually increase activity/exercise as tolerated - Avoid movements that load lower back or exacerbate pain: - Heavy lifting, twisting, bending, stooping, bodily vibration

  • Pain that radiates from the back into buttocks and lower extremity distal to knee, with or without sensory or motor deficits:95% sensitive, 88% specific for herniated disc (HD)3 " 5% lifetime prevalencePeaks 4th to 5th decade2 " 10% of low back pain95% L5 or S1 nerve root90% improve with conservative managementRadicular symptoms usually resolve within 6 wk5 " 10% require surgery

Etiology

  • Protrusion of colloidal gel (nucleus pulposus) through weakened surrounding fibrous capsule (annulus fibrosis)
  • Risk factors:SmokingRepetitive lifting/twistingVehicular/machinery vibrationObesitySedentary lifestyle

Diagnosis

Signs and Symptoms

History

  • Low back pain precedes onset of leg pain
  • Leg pain predominates with time
  • Sharp, well localized, radiates distal to knee
  • Exacerbated by activities that increase intradiscal pressure:Valsalva maneuverCoughNerve-root tension (sitting, straight leg raise)
  • Relieved by decreasing pressure/tension:
  • Paresthesia is the most common sensory symptom

Physical Exam

  • Neurologic exam (motor, sensory, deep tendon reflexes)
  • L4 root/L3 " L4 disc:Knee extension/hip adductionAnteromedial leg/knee/medial malleolusPatellar reflex
  • L5 root/L4 " L5 disc:Great toe and foot dorsiflexionDorsomedial foot/1st web spaceNo reflex
  • S1 root/L5 " S1 disc:Foot plantarflexionPosterior leg/lateral malleolus/dorsolateral footAchilles reflexRectal exam (tone, sensation)
  • Straight leg raise:Elevate ipsilateral leg by heel 30 " 60 ° with or without dorsiflexing footReproduces radicular pain past knee80% sensitive for HD
  • Crossed straight leg raise test (pathognomonic):Elevate contralateral legPain in involved legLess sensitive but very specific for HD

Essential Workup

  • Complete history and physical exam
  • See below for test indications

Diagnosis Tests & Interpretation

Lab

  • Indicated if clinical suspicion for differential diagnoses (DDX), not limited to:

Imaging

PA/Lateral of LS spine

  • Helps to rule out some DDX
  • Indications:Extremes of age (<20, >55 yr)Unresolved back pain (>4 " 6 wk) despite conservative treatmentRed flags on history and physical exam:TraumaConstitutional symptoms (fever, unexplained weight loss, malaise)History of cancerImmunocompromisedIV drug abuseRecent bacterial infectionWorse at night/wakes patient from sleepFeverMidline point tendernessNeurologic deficits

MRI (Criterion Standard)

  • Indications:Acute, severe neurologic deficits (order from ED)Suspicion of infectious etiology of back pain:Epidural abscessOsteomyelitisDiscitis6 wk failed conservative therapy (order on outpatient basis)Disc disease (>25%):Incidental finding on MRI in asymptomatic patientsNo relationship between extent of protrusion and degree of symptoms

CT Myelogram

  • Rarely used alternative for MRI
  • CT better at bone details

Diagnostic Procedures/Surgery

  • Postvoid residual (PVR):Overflow incontinence = PVR >100 mL, suspect cauda equina syndrome

Differential Diagnosis

  • Lumbosacral strain
  • Degenerative joint disease
  • Spondylolisthesis
  • Hip/sacroiliac joint (infection, fracture, bursitis)
  • Pneumonia, pulmonary embolus
  • Pyelonephritis, renal calculi
  • Ectopic pregnancy, pelvic inflammatory disease
  • Abdominal aortic aneurysm (AAA)
  • Peripheral vascular disease (claudication)
  • Herpes zoster
  • Psychological: Functional or secondary gain (drug seeking, disability)
  • Irritating lesion affecting a lumbosacral nerve anywhere along its route:Brain:Thalamic or spinothalamic tumor, hemorrhageSpinal cord (myelopathy):Spinal stenosis, tumor, hematoma, infection (epidural abscess, discitis, osteomyelitis)Root (radiculopathy):Intradural: Tumor, infectionExtradural: HD, lumbar spine/foraminal stenosis (pseudoclaudication), spondylolisthesis, cyst, tumor, infectionPlexus (plexopathy):Tumor, AAA, infection (iliopsoas abscess), hematoma (retroperitoneal)Peripheral nerve (neuropathy):Toxic/metabolic/nutritional, infection, trauma, ischemia, infiltration, compression, entrapment
  • Usually secondary to trauma or serious underlying medical disease (e.g., leukemia); consider complete workup
  • <10 yr:InfectionTumorArteriovenous malformation
  • ≥10 yr:Traumatic HDSpondylolisthesisScheuermann diseaseTumor
  • Ectopic pregnancy
  • Labor
  • Pyelonephritis
  • Musculoskeletal

Treatment

Pre-Hospital

Full spine precautions for trauma victims

Initial Stabilization/Therapy

Evaluate for neurosurgical emergency

Ed Treatment/Procedures

Pain relief:

  • NSAIDs 1st line
  • Muscle relaxants, opioids as needed in acute phase

Medication

  • NSAIDs:Ibuprofen (Motrin, Advil): 600 " 800 mg (peds: 5 " 10 mg/kg/dose) PO TID " QIDNaproxen (Naprosyn, Aleve): 500 mg PO BID
  • Muscle relaxants (short term):Cyclobenzaprine (Flexeril): 5 " 10 mg TIDDiazepam (Valium): 2 " 10 mg (peds: 0.1 mg/kg/dose) PO TID " QIDMethocarbamol (Robaxin): 1,000 " 1,500 mg PO QID
  • Opioids (short term):Hydromorphone (Dilaudid): 2 " 4 mg PO/0.5 " 2 mg IM/IV q4 " 6h PRNMorphine sulfate: 2 " 10 mg (peds: 0.1 mg/kg/dose) IM/IV q2 " 4h PRNCodeine 30 mg + acetaminophen 300 mg; do not exceed acetaminophen4 g/24 hHydrocodone 5 mg + acetaminophen 300 mg; do not exceedacetaminophen 4 g/24 h

Follow-Up

Disposition

Admission Criteria

  • Severe neurologic deficit (cauda equina syndrome, inability to walk)
  • Progressive neurologic deficit
  • Multiple root involvement
  • Unstable fracture, infection, neoplasm
  • Inability to manage as outpatient (social situation/pain)

Discharge Criteria

Patient able to ambulate, follow instructions, has reliable home situation and planned follow-up

Issues for Referral

Abnormal workup that does not warrant immediate admission. Where and when depend on results (large DDX)

Follow-Up Recommendations

  • Consultant (orthopedic spine surgeon or neurosurgeon) or PCP within 1 wk
  • Conservative treatment (4 " 6 wk):Medication as notedAvoid complete bed rest, 2 days at mostLimited activity in acute phase but gradually increase activity/exercise as toleratedAvoid movements that load lower back or exacerbate pain:Heavy lifting, twisting, bending, stooping, bodily vibration
  • Therapies of unproven benefit:Chiropractic careTranscutaneous electrical nerve stimulationTractionBack brace/corsetUltrasoundDiathermyAcupuncture, acupressureMassageSystemic glucocorticoids

Additional Reading

  • Haas M, Sharma R, Stano M. Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain. J Manipulative Physiol Ther. 2005;28(8):555 " 563.
  • Jegede KA, Ndu A, Grauer JN. Contemporary management of symptomatic lumbar disc herniations. Orthop Clin North Am. 2010;41(2):217 " 224.
  • Schoenfeld AJ, Weiner BK. Treatment of lumbar disc herniation: Evidence-based practice. Int J Gen Med. 2010;3:209 " 214.
  • Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. 2007;25:387 " 405.
  • van der Windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010;(2):CD007431.

Codes

ICD9

  • 722.10 Displacement of lumbar intervertebral disc without myelopathy
  • 724.3 Sciatica
  • 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified

ICD10

  • G57.00 Lesion of sciatic nerve, unspecified lower limb
  • M51.16 Intervertebral disc disorders w radiculopathy, lumbar region
  • M54.30 Sciatica, unspecified side

SNOMED

  • 23056005 Sciatica (disorder)
  • 311804006 Prolapsed lumbar intervertebral disc with sciatica (disorder)
  • 299967007 Compression of sacral nerve root (disorder)