Discs and Sciatica: When to Treat and When to Refer
Lumbar disc herniations frequently trigger radiculopathy. But not all sciatica is created equal. A chemical inflammatory reaction in response to herniated nuclear material can trigger radicular sensory symptoms. However, signs of reflex or motor loss suggest a more threatening compressive neuropathy. Differentiation is essential since one of the two can quickly lead to permanent deficits.
Regrettably, the clinical picture is not always definitive. But fortunately, a new study (1) has identified four additional diagnostic clues that can help differentiate chemical/ inflammatory vs. mechanical/compressive pain for disc herniation and radiculopathy patients.
BMC Musculoskeletal Disorders will soon publish a study that “evaluated the diagnostic accuracy of clinical features to predict the presence/absence of histologically confirmed inflammation in herniated disc specimens removed at surgery in patients with lumbar disc herniation and associated radiculopathy.” (1)
The following clinical features predicted the presence or absence of
histologically confirmed inflammation:
Back pain < 5/10
Symptoms worse the next day after injury
Lumbar flexion range between 0 and 30°
Positive clinical inflammation score- i.e., at least 3 of the following:
constant symptoms
morning pain/stiffness greater than 60-min
short walking not easing symptoms
significant night symptoms
The model achieved a sensitivity of 90.9%, a specificity of 92.9%, and a predictive accuracy of 92.3% for histologically confirmed inflammation. (1)
Check out this short new clinical pearls video to learn several additional tips (from the NSM diplomate program) about assessing lumbar disc herniations and radiculopathy.
View a dissected disc & nucleus
Clinical assessment of mechanical vs. chemical radiculopathy
When to treat and when to incorporate co-management or referral
Your ChiroUp lumbar disc lesion protocol has already been updated with this information. Plus, we’ve updated more than 50 other ChiroUp protocols within the past month! Subscribers can rest assured that your care is supported by the most up-to-date research.
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1. Ford JJ, Kaddour O, Gonzales M, Page P, Hahne AJ. Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy. BMC Musculoskeletal Disorders. 2020 Dec;21(1):1-9. Link
