This is an excellent article that will change your practice for the best when you see patients with suspected lumbar rediculopathy. Read on for what you should definitely pay attention to in your clinical practice.
Pain in the lower back can be radicular pain, this is described as radiating pain involving the nerve root which causes leg pain along the spinal nerve. It is often accompanied by numbness, tingling, weakness and loss of reflexes and is one of the reasons why lower back pain is one of the most debilitating diseases of the musculoskeletal system worldwide.
Quickly include or exclude lumbar pathology
The majority of patients with lumbar radiculopathy have a good outcome and the chances are increased by early diagnosis and treatment, which is why there are many guidelines. Most, however, focus on treatment rather than diagnosis, which means that the consistency of diagnostic recommendations varies widely.
A new systematic review article aimed to call up all existing guidelines for the diagnosis and treatment of lumbar radiculopathy and to summarize their diagnostic and therapeutic recommendations.
Methods – The search strategy
This systematic review was pre-registered on PROSPERO and appears to have done a good job in sticking to their protocol, which improved the replicability of the study results, and PRISMA was also reported.
MEDLINE, PEDro, National Guidance Clearninghouse, NICE, NZGG, International Guideline Library, Google Scholar, and Guideline Central were the databases that were searched with the full search strategy available, and with the terms exploded it was essentially:
"Guideline" OR "Practice Guideline" AND "Lower Back Pain" OR "Sciatica *" OR "Radical *"
No language or date restrictions were applied, however a pragmatic approach was applied to databases such as Google Scholar, with screening limited to the first 10 pages as it retrieves the most relevant search results. Backward citation tracking of references was also used. Overall, given the specific interest in guidelines, this was a solid search strategy.
The quality of the articles included was rated with AGREE II, a 26-item tool for the assessment of guidelines that has good interrater reliability. Two authors review and apply the AGREE II tool, which gives each guideline a high quality, average quality, or low quality rating. If no consensus was reached with the two authors in this study, a third was called in.
Methods
Recommendations for diagnosis and therapy were extracted from the studies and if these included an operation, only recommendations for discectomy were extracted. This is because it is the most common procedure used for hernias. Radicular pain is often covered by generic LBP guidelines, so data were only extracted if it was explicitly about radicular pain.
A total of 23 guidelines from ten countries were included in this review, most of them from the USA (n = 12) and 14 from certain professional associations. The overall quality of the included guidelines varied considerably between 17% and 92% or ranged from poor to high. NICE Guidance had the highest score, while DLW-DWC had the lowest.
A total of ten of the guidelines were classified as high quality, seven as average and as inferior. The best quality guidelines were:
The article goes into great detail why these guidelines are so excellent. In summary, what makes them great is their ability to consistently and clearly summarize the available evidence in an unbiased and rigorous manner. Be sure to check it out when you work with people who live with low back pain.
Brief summary of the recommendations for the diagnosis and treatment of lumbosacral radicular pain
The NICE Guidance was the highest quality guideline included.
SLR, gait analysis and clarification should be essential components of your physical examination
CT or MRI is recommended if the anamnesis shows a herniation after 4-6 weeks of pain with red flags.
Education and physical activity are essential treatments
No recommendations for the use of medication can be given
A discectomy is a " could" when conservative treatment has failed or there is progressive disability
Physical examination & diagnostics
6 guidelines gave recommendations for a physical examination with the consequent “should” tests: SLR, crossed SLR, mapping of pain distribution, steppage walk and clarification of pain distribution. Femoral stretch tests, reflex tests and slump tests were recommended contradictingly.
A consistent & # 39; should & # 39; CT or MRI should be performed if the history and physical examination agree with a herniated disc, pain after 4-6 weeks if surgery is considered or severe or progressive neurological signs and
symptoms are present. Routine imaging should not be offered in primary care unless there is a warning signal.
Treatment instructions
16 of the guidelines recommend education and physical activity as “should” treatment options. TENS, PENS, acupuncture, traction and other manual therapies are “do not do” recommendations.
Pharmacological interventions are recommended inconsistently across all guidelines to the point where no conclusions can be drawn. Paracetamol is also recommended in some guidelines, but not in others.
The surgical recommendation is a "could" and is a discectomy if conservative therapy fails or a progressive / persistent disability is present.
These recommendations should be adopted by clinicians in order to offer patients with suspected radiculopathy the best possible care. Overall, this study is of high quality and there is so much more we could discuss. So go to the full text link to read more or why not consolidate this new knowledge by taking the BRAND NEW course below.
