This is a common spinal complaint in clinical practice. Most cases are benign. Often the pain will resolve itself and non-operative management is the recommended first step.
As patients get older it becomes more likely that the pain is caused by progressive degenerative stenosis. In which case the pain may persist instead of resolving.
The classic symptom is a recurrent stabbing pain down their leg.
It originates in their buttock and runs down the sciatic nerve to the calf. There may be associated numbness and weakness. Often sitting down will provide relief when the cause is stenosis. Whereas pain from a disc protrusion is usually worse in the sitting position.
Causes
The most common cause is degeneration of the spine at L4 /5, which bears the brunt of wear and tear in the back. Over time it degenerates.
Bony spurs develop and encroach into the spinal canal which can pinch the L5 nerve, giving rise to pain that is felt on the lateral side of the calf, ankle, and foot.
Lumbar disc herniation is another cause, and although most frequently seen in the 4th and 5th decades of life, is not infrequently seen in the middle aged to elderly patient.
A common clinical confounder is hip arthritis. It can present as lower limb pain; causing difficulty walking and relieved by rest (sitting). Of course, that has a vastly different treatment to spine problems. Every month I send a couple of patients to my hip colleagues.
The other important cause of limb pain brought on by walking is peripheral vascular disease. Doppler studies are useful in discriminating this condition.
Sometimes patients have combined problems with their back and hip or vascular status.
Diagnosis
On examination, hip arthritis is identified as pain caused by internal rotation of the hip in the flexed position. If you can feel the foot pulses then there is no clinically important vascular disease.
If the pain is typically radicular – buttock to calf – with stabbing and tingling, then nerve root compression is likely. It may also be accompanied by altered sensation and weakness.
A spinal scan, preferably an MRI is the best way to confirm lumbar nerve root compression.
Management
A cortisone injection usually only provides temporary pain relief.
With advanced degeneration and persistent pain, surgery is the best course of action.
If there is spinal slippage or deformity like scoliosis then fusion surgery is recommended.
If it is simple nerve compression such as stenosis, then decompression surgery is sufficient.
In either case the long-term prognosis is excellent, with restored mobility and increased quality of life.
I performed a recent operation a 77-year-old woman with lumbar radiculopathy and scoliosis. The operation was on a Monday afternoon. On Wednesday she was up walking around unaided.
As always if you have any questions about a patient, please feel free to call me on 02 9650 4893.
I will return your call and discuss how we can help.
You can also reach me via ralphstanford@powspine.com.au.
Resources for Referrers
Further Resources available include:
- Why I only operate when it makes a difference to my patient's quality of life
- Back pain and how to manage it
- Management Regime for Lumbar Disc Herniation & Sciatica
- Why your patients might be struggling to walk (Lumbar Canal Stenosis)
- Cervical Radiculopathy – shooting pains from the neck
- Cervical myelopathy – a disease of the spinal cord that may pass unnoticed
- Adult Spinal Deformities: Symptoms & Treatments
- Vertebroplasty – worth a rethink
Dr Ralph Stanford is a spinal surgeon with over 20 years’ experience. He is adept in all surgical approaches to successfully treat his patients.
Dedicated to lifelong learning and sharing his expertise with others, Ralph attends spinal conferences worldwide and regularly consults with colleagues about successful treatments.
As a teacher Dr Ralph Stanford is Conjoint Senior Lecturer at the University of New South Wales; Supervisor of Training for Orthopaedic Trainees, Prince of Wales Hospital; and Education Secretary for the Spine Society of Australia.
As a researcher and scientist, he is a well-published author and Honorary Senior Scientist at Neuroscience Research Australia (NeuRA). He is also a current member of Spinal PFET.
Posted 22 January 2021
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