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leg dominant pain

An Approach to the Differential Diagnosis of Sciatica in the Primary Care Setting

Teaser: 

Taryn Walker B.Kin, MM, 1 Vahagn Karapetyan MD PhD FRCSC,2 Greg McIntosh MSc,3 Christopher S Bailey MD FRCSC,4

1Department of Surgery, Schulich School of Medicine, Western University
2Department of Surgery, Schulich School of Medicine, Western University
3Director of Research Operations, Canadian Spine Outcomes and Research Network
4Department of Surgery, Schulich School of Medicine, Western University

CLINICAL TOOLS

Abstract: Sciatica is a well-recognized complaint, with the hallmark presenting symptom of lancinating pain running down the back of the leg, along the path of the sciatic nerve. While it is typically caused by a herniated lumbar disc within the spinal canal, an understanding of the course of the sciatic nerve and associated regional anatomy is useful in forming a broader differential diagnosis. In rare cases, sciatica, usually bilateral, is associated with a loss of bowel or bladder function, indicating cauda equina syndrome, a medical emergency. Other degenerative conditions of the lumbar spine such as spondylolisthesis and spinal stenosis can occasionally produce sciatica while deep gluteal pain is often used to describe the muscular causes. Malignancy, trauma, vascular causes and ectopic endometrial tissue can cause compression of the lumbosacral plexus within the pelvis and produce similar symptoms. In this review, we highlight the common clinical presentations, physical examination and relevant diagnostic investigations for a broad differential diagnosis of sciatica.
Key Words: Sciatica, leg dominant pain, nerve compression, straight leg raise.

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1. Herniated intervertebral disc accounts for up to 90% of sciatica cases 
2. An understanding of the course of the sciatic nerve and associated regional anatomy can be useful in forming a differential diagnosis; one should consider gluteal region sciatic compression disorders, pelvic pathology involving the lumbosacral plexus, malignancy, infection, trauma and conditions that mimic sciatica.
3. Patients usually have low back pain associated with their leg complaints, but genuine sciatica from a herniated lumbar disc produces leg pain that is the dominant symptom. Back dominant pain, with any direct nerve involvement, can extend into the leg, occasionally all the way to the foot, but unless the leg pain is more intense than the back pain, it is not sciatica. 
4. The physical examination should include checking lower limb reflexes, dermatome and myotome assessment, upper motor neuron tests such as the plantar response and specialized neural tension tests such as the passive straight leg raise (SLR) and slump tests.
5. A positive crossover sign occurs when raising the straight leg on the affected side reproduces not only the typical pain in the affected leg but causes pain to radiate down the seemingly unaffected leg as well. This finding of bilateral sciatica suggests pathology located in the midline, a central disc herniation.
True sciatica from a herniated lumbar disc is when the leg pain is the dominant symptom over back pain. Lancinating, constant, radicular pain down the posterior leg along the path of the sciatic nerve is the hallmark symptom. Activity, prolonged sitting or Valsalva maneuvers such as coughing or bearing down aggravate sciatic pain. A patient may prefer to stand because sitting is intolerable.
Neurogenic Claudication from spinal stenosis is distinctive from herniated lumbar disc sciatica. Unlike classic sciatica, lumbar spinal stenosis neural tension tests are often negative and the neurological assessment may be normal; however, the more classic sciatic presentation, may be present in spinal stenosis if a focal nerve root is also compressed.
To distinguish piriformis syndrome from sciatica, muscle tenderness with deep gluteal palpation and specialized piriformis stretch tests such as the FAIR, Pace and Beatty maneuvers may be helpful.
Greater trochanteric bursitis, meralgia paresthetica, and cluneal nerve entrapment are conditions that can cause pain in a distribution that is similar to the sciatic nerve, but without involving the nerve directly.
Identifying any posterior thigh pain when the leg is elevated above 60 or 70 degrees as sciatica is a common diagnostic error. Unless the leg pain produced is identical to the patient’s chief complaint on history, the test is negative.
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Related Terms: Back Health, sciatica, leg dominant pain, nerve compression, straight leg raise

Managing Leg Dominant Pain

Managing Leg Dominant Pain

Teaser: 

Yoga Raja Rampersaud, MD, FRCSC,1 Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,2 Hamilton Hall, MD, FRCSC,3

1Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Immediate Past President Canadian Spine Society, Toronto, ON.
2Associate Professor, Department of Family and Community Medicine, University of Toronto, Medical Director, Sport CARE, Women’s College Hospital, Toronto, ON.
3Professor, Department of Surgery, University of Toronto; Medical Director, Canadian Back Institute; Executive Director, Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: Leg dominant pain suggests direct nerve root involvement: radicular, not referred symptoms. Constant pain associated with positive neurological findings usually results from an acute disc herniation. Symptoms are the result of mechanical compression but principally reflect an inflammatory response, properly designated sciatica. Intermittent leg dominant pain triggered by activity in extension and relieved by rest in flexion probably represents neurogenic claudication: nerve root ischemia secondary to spinal stenosis. Except for acute cauda equina syndrome, acute sciatica is initially managed with scheduled rest, adequate medication, and time. Non-responsive cases may require surgery. Surgery also shows superior outcomes for disabling neurogenic claudication.
Key Words:leg dominant pain, sciatica, neurogenic claudication, cauda equina syndrome, surgery.

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True spine-generated, leg dominant pain is consistently reproduced by particular spinal movements or positions.
No imaging investigation is required for a patient presenting an unequivocal clinical picture and exhibiting steady predictable improvement.
Of the four back pain syndromes, only neurogenic claudication is consistently best treated by surgery.
In contrast to the back dominant cases, in sciatica there is a definite role for short-acting narcotics or psychotropic drugs for uncontrolled pain.
Criteria for Surgical Referral
Emergency Referral The symptoms of Cauda Equina Syndrome are: - Urinary retention followed by insensible urinary overflow. - Unrecognized fecal incontinence. - Loss or decrease in saddle/perineal sensation. Acute Cauda Equina Syndrome is a surgical emergency.
Consider Elective Referral Failure to respond to a trial of conservative care: - Unbearable constant leg dominant pain. - Worsening nerve irritation tests (SLR or femoral nerve stretch). - Expanding motor, sensory or reflex deficits. - Recurrent disabling sciatica. - Disabling neurogenic claudication.
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Related Terms: Arthritis, Back Health, Musculoskeletal Disease, Osteoporosis, Pain, neurogenic claudication, surgery, leg dominant pain, sciatica, cauda equina syndrome