Lumbar Radiculopathy/Radicular Pain/Sciatica/Stenosis

While you will see words like “radiculopathy,” “radicular pain” and “sciatica” used interchangeably, they have different meanings. Radiculopathy implies “true” neurological findings. This may include a loss of strength, reflexes and/or sensation. If present, you may be referred to a neurologist depending on the severity of findings. If we decide to continue physical therapy, these neurological findings (such as loss of strength, sensation and/or reflexes) will be closely monitored to assure they are not worsening. Radicular pain is the less severe cousin of radiculopathy, as it implies leg pain without true neurological findings. Radicular pain is far more common than radiculopathy, though it can be more painful than radiculopathy. This reason for this is sensation is fully intact. ‘Sciatica” is a broad-umbrella term that refers to “irritation” of the sciatica nerve. The sciatic nerve is the main nerve that comes off the lumbar nerve roots, that travels down each leg. The sciatic nerve splits close to the level of the knee and forms nerves that travel all the way to the foot. It was once a healthcare “fad” to blame peripheral causes of “sciatica,” such as the piriformis muscle. We now know piriformis entrapment of the nerve is rare, though possible.

Treatments for back and leg pain depend on the unique clinical presentation of a patient and may include joint mobilizations, specific exercises (i.e., moving in a specific direct repeatedly), “neuro-dynamic” exercises (i.e., flossing or stretching), amongst others. To track progress, we look for the leg pain to travel back towards the spine. For example, when a patient has back pain that travels all the way to his foot, the first sign of success is  the pain not traveling south of his knee. This person may experience a worsening of his back/thigh symptoms, however since the pain is no longer traveling past the knee, we can say this person is moving in the right direction. Why the body recovers this way is beyond the scope of this report.

Lumbar stenosis is characterized by a narrowing of the lumbar spine canal resulting in leg pain. This maybe with or without neurological findings. Patients with lumbar spinal stenosis are generally older and have pain that is worse with standing/walking that improves when bending forward/sitting. Lumbar spinal stenosis is the most common reason for spinal surgery in older adults, despite surgery not showing superior results to physical therapy.

Since lumbar spinal stenosis is typically a limitation in being in a fully erect position clinically (i.e., difficulty with standing and walking), treatments are intended to restore full extension. This maybe include treatments designed to increase the mobility at neighboring joints (such as the hips) to offload the spine or treating to increase the mobility directly at the lumbar spine. This choice depends on the severity of a person’s symptoms. Since walking/standing tolerance are the most likely reported limitations with spinal stenosis, we track progress with each to determine if we are on the right track with our treatments and make adjustments if need be.

References:

1. Backstrom, K., Whitman, J. and Flynn, T., 2011. Lumbar spinal stenosis-diagnosis and management of the aging spine. Manual Therapy, 16(4), pp.308-317.
2. Bogduk, N., 2009. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain, 147(1), pp.17-19.
3. Cook, C., Brown, C., Michael, K., Isaacs, R., Howes, C., Richardson, W., Roman, M. and Hegedus, E., 2010. The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis. Physiotherapy Research International, 16(3), pp.170-178.
4. Delitto, A., George, S., Van Dillen, L., Whitman, J., Sowa, G., Shekelle, P., Denninger, T. and Godges, J., 2012. Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy, 42(4), pp. A1-A57.
5. Furman, M. and Johnson, S., 2019. Induced lumbosacral radicular symptom referral patterns: a descriptive study. The Spine Journal, 19(1), pp.163-170.
6. Peterson, S., Mesa, A., Halpert, B. and Bordenave, L., 2021. How people with lumbar spinal stenosis make decisions about treatment: A qualitative study using the Health Belief Model. Musculoskeletal Science and Practice, 54, p.102383.

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