This is an excellent article which will change your practice for the best when you are seeing patients with suspected lumbar rediculopathy. Read on for the essentials you should include in your clinical practice.
Low back related leg pain can be radicular pain, this is described as radiating pain where the nerve root is involved causing leg pain along the spinal nerve. It is often accompanied by numbness, tingling, weakness and loss of reflex subsequently it is one of the reasons why low back pain is one of the most debilitating musculoskeletal conditions world wide.
The majority of patients with lumbar radiculopathy have a good outcome and chances are boosted with early diagnosis and management, this is why guidelines exist of which there are many. Most though focus on treatment rather than diagnosis which means the consistency of diagnostic recommendations is very variable.
A new systematic review aimed to retrieve all existing guidelines which include diagnosis and mangement of lumbar radiculopathy and summarise 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 adhering to their protocol which improved replicability of the study outcome furthermore it was reported using PRISMA.
MEDLINE, PEDro, National Guidance Clearninghouse, NICE, NZGG, International Guideline Library, Google Scholar and Guideline Central were the databases searched with the full search strategy available and with the exploded terms removed it was basically:
“Guideline” OR “practice guideline” AND “low back pain” OR “sciatic*” OR “radicul*”
No language or date restrictions applied however a pragmatic approach was applied to databases such as google scholar with screening limited to the first 10 pages because it retrieves the most relevant search results. Backward citation tracking of references was also applied. Overall this was a sound search strategy considering the specific interest in guidelines.
The quality of the included articles was assessed using AGREE II, a 26-item tool for appraising guidelines which has good inter-rater reliability. Two authors review and apply the AGREE II tool which provides each guideline with a score of high-quality, average-quality or low-quality. In this study if a consensus wasn’t reaching with the two authors a third was consulted.
Recommendations regarding diagnosis and treatment were extracted from the studies and if this included surgery only recommendations for discectomy were extracted. This is because it is the most common procedure applied for herniation. Radicular pain is often covered by generic LBP guidelines, therefore data was only extracted if it was explicitly for radicular pain.
In total 23 guidelines from ten countries were included within this review, the most coming from the United States (n=12) and 14 coming from specific professional associations. Overall quality of the guidelines included varied considerably ranging from 17% to 92% or poor to high. NICE Guidance had the highest score whereas DLW-DWC had the lowest.
Overall ten of the guidelines were rated as high quality, seven as average and siz a low-quality. The best quality guidelines were:
The article goes into a great level fo detail about why these guidelines are excellent, in summary what makes them great is their ability to consistently and clearly summarise the available evidence in an unbiased and rigourous manner. Definitely check them out if you work with people living with low back pain.
Physical Examination & Diagnostics
6 guidelines made recommendations about physical examination with the consistent ‘should do’ tests being; SLR, crossed SLR, mapping pain distribution, steppage gait and clarification of pain distribution. Femoral stretch test, reflex tests and slump tests were inconsistently recommended.
A consistent ‘should do’ is to perform a CT or MRI when history and physical examination are consistent with disc herniation, after 4-6 weeks of pain, if surgery is considered or severe or progressive neurologic signs and
symptoms are present. Routine imaging should not be offered in primary care unless there is a red flag present.
16 of the guidelines recommend education and physical activity being ‘should do’ treatment options. TENS, PENS, acupuncture, traction and other manual therapies are ‘do not do’ recommendations.
Pharmacological interventions are inconsistently recommended across all guidance to the point at which no conclusions can be made. Even paracetamol is recommended in some guidelines and not in others.
The surgical recommendation is a ‘could do’ and is a discectomy when conservative therapy fails or when progressive / persistent disability is present.
These recommendations should be adopted by clinicians to provide the best care possible for patients with suspected radiculopathy. Overall this study is of high quality and there is so much more we could discuss. So head over to the full text link to read more or why not cement this new knowledge by taking part in the BRAND NEW course below.