Herniated Lumbar Disc with Sciatica: Evaluation Summary

PHYSICAL EXAMINATION Major Criteria for Diagnosis (Pp. 11-12)

 Thoracolumbar AROM
 Mannequin sign RADICULAR CLUES
 SLR (seated and lying)  Presence of leg pain (especially if dermatomal)
 Maximum SLR (e.g., Slump) or confirmation Often dominates, may be sharp, burning, electrical
tension tests (e.g., Bragard, Bowstring) and superficial, worse than the back pain
 Valsalva maneuver or cough test  Presence of dermatomal paresthesia
 Sensory testing (in most cases, L4, L5, S1  Positive SLR and other tension tests: pain past
dermatomes) the knee between 35-70 degrees of elevation
(especially if < 45°); confirm with other tension
 Achilles and patellar reflexes (consider
tests; XSLR uncommon but very specific
hamstring reflex)
 Neurologic deficits 20% of cases will have no
 Muscle tests (especially ankle eversion, great deficits
toe extension and flexion, ankle plantar and
dorsiflexion) NOTE: Three of the above criteria—or two, with a
 Girth measurement of thigh and calf positive imaging test—support a clinical diagnosis.
 Palpation of lumbar spine and pelvis for painful
restrictions, joint challenge, peripheralization or DISCOGENIC CLUES (as cause of radiculopathy)
centralization  Decreased sagittal thoracolumbar ROM
 Palpation of lumbar and pelvic soft tissue  Mannequin sign
 Consider McKenzie protocol to identify  Pain which centralizes with repetitive or sustained
centralization maneuvers. end range loading
 If there are signs of a neurological disease not  Positive Valsalva
explained by the low back diagnosis, consider  Sitting may be poorly tolerated.
testing cranial nerves, cerebellum and upper  DeJeurine’s triad
extremity sensation, muscle strength, and  Flexion load sensitivity
stretch and pathological reflexes.

NOTE: Other orthopedic maneuvers or biomechanical EVALUATION STEPS (Pp. 19-35)

procedures can be done as needed to explore other
diagnoses, but may not be necessary initially when a 1. Rule out causes for emergency or urgent referral.
herniated intervertebral disc diagnosis is made. In 2. Rule out organic disease, fracture.
female patients, determine whether a pelvic 3. Rule in the presence of a radicular syndrome.
examination is indicated. 4. Rule in herniated disc diagnosis. Rule out other
potential diagnoses.
5. Determine type of herniation, probability of
contained vs. uncontained (on clinical grounds).
Red Flags for Cauda Equina (Pp. 19-20) 6. Determine likely level of herniation and which
nerve roots are involved (on clinical grounds).
This demands emergency referral, especially if
7. Determine direction of herniation: medial, midline,
symptoms have come on rapidly.
lateral or far lateral herniation (on clinical
 Urinary retention (90% sensitivity) grounds).
 Incontinence 8. Estimate the severity of the condition.
 Saddle anesthesia (80% sensitivity) 9. Determine need for imaging.
 Sexual dysfunction 10. Empirically determine if patient is a candidate for
 Common additional findings: some combination manipulation, flexion-distraction, McKenzie
of unilateral/bilateral sciatica, altered SLR, protocol.
sensory or motor deficits 11. Set outcome measurements.
12. Determine if there are significant psychosocial
factors. This can be done on subsequent visits.
13. Determine if there are other weak links in the
kinetic chain (e.g., overpronation). This can be
done on subsequent visits.

Revised 10/07 Copyright © 2007 Western States Chiropractic College

RULE IN A RADICULAR SYNDROME (Pp. 21-24) syndrome, or in the subacute or chronic
presentation.
1) Is there nerve damage vs. a deep referred pain
syndrome? Advanced imaging should not be ordered routinely
2) If there is suspected nerve damage, is the if a herniation diagnosis can be made based on
lesion in the nerve root, plexus or a peripheral clinical grounds alone and is sufficient to begin a
entrapment/neuropathy? therapeutic trial of conservative care.
 Diab etic amyotrophy/neuropathy
 Herpes zoster
When to order an MRI (preferably) or CT
 Signs of cauda equina syndrome
 HIV/AIDS
 Progress ive muscle weakness
 L yme disease
 Herniated disc diagnosis in doubt
 Entrapment Syndromes: piriformis
syndrome and peroneal nerve injury vs.  Profound muscle weakness at first visit (relative
common peroneal nerve injury indicator)
 Pre-surgic al assessment
3) If a nerve root is involved, which one?
4) What is the nature and degree of the nerve root
injury (irritated, soft neurological signs, hard IDENTIFY YELLOW FLAGS (Pp. 32-35)
signs)?  Psychol ogical factors
o Catastrop hizing
RULE OUT OTHER POTENTIAL DIAGNOSES (Pp. 24-26) o Fear avoidance behaviors
o Depression and anxiety
 Stenosis (central and lateral recess) o Self-perception of poor health
 Space occupying lesions such as tumors, cysts and o Sexua l abuse
hematomas Other factors: complete work loss (because of LBP)
 Spinal Infection in prior 12 months, substance abuse, perceived
 Spon dylolisthesis stress, heavy smoking and poor coping resources,
 Fra cture and lack of social support.
 Adhes ions  Worker’s compensation issues
 Instabil ity  Litigation
 Chemical irritation from disc degeneration, inflamed  Job environment: job control, work under time
facet, etc.
pressure, monotonous work, perceived
workload, poor satisfaction with social
SIGNS OF UNCONTAINED/SEQUESTERED relationships at work, and “mental overstrain.”
HERNIATION (Pp. 26-27)  Educatio n
 Lumbar flexion-extension excursion < 25 degrees
 Positive XSLR Presence of Waddell’s Signs
 A positive SLR below 30 degrees o Widespread (nonanatomic) tenderness to light touch
 Perip heralization with lumbar extension o Significant LBP with axial loading (light pressure to
 Leg pain precedes back pain or without back pain skull) or with full trunk rotation in a standing position
 Neurological deficits migrate (rotating hips and shoulders together so that there is
no true twisting of the trunk)
DETERMINE LEVEL OF HERNIATION (Pp. 27-28) o Lack of pain on sitting SLR when supine SLR was
positive or a difference of 40 or 45 degrees between
the two tests
DETERMINE DIRECTION OF HERNIATION (Pp. 28-30) o Unexplained weakness (e.g., giving way) and/or
sensory testing that is not neurologically correlated
 Midline o A pattern of exaggeration (e.g., overreaction,
 Medi al grimacing, bracing, etc.)
 Latera l
 Far lateral
WEAK LINK IN THE KINETIC CHAIN (P. 35)
DETERMINE SEVERITY (Pp. 31-32)
Chart properly (see Appendix V).
 N eurological deficits
 Effect on ADL
 Pain severity

DETERMINE NEED FOR IMAGING (P. 32)

Radiographs are not necessary in the absence of
red flags in the acute presentation (less than 7
weeks), but should be considered if there are
significant neurologic deficits, cauda equina

Revised 10/07 Copyright © 2007 Western States Chiropractic College

Herniated Lumbar Disc with Sciatica: Management Summary

Acute/Initial Phase (Pp. 40-43) PAIN CONTROL STRATEGY (choose as needed) (P. 40)
 Physical medicine (manual therapy/passive PT
modality)
Objectives  OTC or botanical
 Centralize pain and decrease inflammation;  Referral for medical treatment
prevent further neurologic loss.
 Attempt to reduce herniation. HOME CARE (P. 42)
 Teach the patient how to protect and stabilize  Give specific exercises.
the low back.  Encourage mild activity.
 Prevent further deconditioning.  Address home and work ergonomics.
 Address/prevent illness behavior.  Modify activities (sitting, side lying, aggravating
loads).
 Increase water and fiber intake to soften stool
SUMMARY – Initial Treatment Options and reduce the chance for constipation.
Not all of these options need be utilized.  Use pain relief postures (e.g., 90/90) and other
pain relief aids as necessary.
 Palpate the spine with patient seated, supine  Limit bed rest.
and prone (assess centralization,
 Consider home traction (if necessary)
peripheralization and local response).
 Prescribe OTC sleep aids (if necessary)
 Consider HVLA manipulation and/or
 Short-term use of back belt (optional)
mobilization.
 Crut ches (optional)
 Con sider flexion-distraction.
 Utilize soft tissue manipulation to treat
associated myofascial dysfunctions (MFTP’s, CLINICAL TIPS
spasm, adhesions).
 In view of the relatively serious nature of disc
 Consider therapeutic modalities to control
herniations, take special care in conducting and
pain and inflammation.
documenting PARQ conference.
 Consider home exercise for pain control (e.g.,
 If prone extension exercises are prescribed, it is
directional preference assessment and
critical to teach the patient how to transition down
prescription).
to the floor and back again without flexing the
 Teach the patient to protect the spine (e.g., lumbar spine (e.g., use hip hinging and modified
abdominal brace, neutral pelvis, hip hinge). kneeling or squat).
PATIENT EDUCATION (P. 41)  Extension may peripheralize symptoms with far
lateral disc herniations.
 Set expectations.
 Bed rest should be short term only. Active rest is
 Progress into early phase of lumbar
preferable (i.e., bouts of activity which still
stabilization program.
manage to protect the back and may be
 Address any significant current or potential punctuated with periods of rest).
psychosocial components.  Normal activities should resume ASAP.
 Give emergency instructions (e.g., signs of  A common relief position is to lie with knees bent
cauda equine syndrome). and a pillow between the legs.

Evidence of Effectiveness of Common Medications

TABLE: The fractions listed in this table represent the number of studies cited over the number that were judged to be of higher quality by at
least one systematic review (e.g., 3/2). Drugs with evidence of positive benefits are in bold.
SCIATICA ACUTE LBP CHRONIC LBP
Anti-epileptics Small benefit, consistent Unknown Small to moderate benefit, poor
evidence of fair quality (3/2) quality evidence (1/1)
NSAIDs No benefit, consistent Moderate benefit, consistent evidence of Moderate benefit, consistent
(e.g., Motrin) evidence of fair quality (4/2) good quality (31/10) evidence of good quality (6/3)
Acetaminophen Unknown Moderate benefit, fair quality, some incon- Moderate benefit, consistent
(e.g., Tylenol) sistency when compared to NSAIDs (3/0) evidence of good quality (2/1)
Skeletal No benefit based on one higher Moderate benefit, consistent evidence of Benefit unclear, poor quality
muscle relaxants quality study (1/1) good quality (31/21) (6/2)
systemic corticosteroid No benefit, consistent evidence No benefit, fair quality evidence (1/1) Unknown
(oral, IM) good quality (3/3)
Opioids (e.g., Tylenol 3, Unknown Moderate benefit, fair quality (1/1) Moderate benefit, evidence of
Vicodin) fair quality (7/1)
tricyclic anti-depressants Unknown U nknown Small to moderate effects, good
(e.g., amitriptyline) quality (10/5)

Revised 4/08 Copyright © 2008 Western States Chiropractic College

Acetaminophen doses  If manual therapy or distraction worsens leg
 Ages 0-12 yrs: 15 mg/kg every 4 hrs (not to symptoms anytime during therapy, stop and
exceed adult dose) with a max of 5 doses. re-evaluate.
 Ages 12 yrs and older: 325-650 mg every 4  Clinical Warning for flexion-distraction! It is
hrs with a max dose of 4000mg. safer if the practitioner under treats rather than
over treats during a visit, especially when starting
Ibuprofen (Motrin, Advil) doses with a new patient. The most common reason for
 Ages 6 mos-12 yrs: 10 mg/kg every 6 hrs (not causing a flare-up is dropping the table into too
to exceed adult dose) with a max of 4 doses. much flexion.
 Ages 12 yrs and older: 200-400 mg every 6
hrs with a max dose of 1200mg.
Passive PT Modalities (Pp. 55-59)
OTC/MEDS – NOTES & WARNINGS! (P. 61)
 It is WSCC Clinic policy to screen all For specific parameters, see CSPE protocol,
patients taking OTC NSAIDs and to Physical Therapy Modalities.
provide them with an educational sheet on
side effects. (Consult the CSPE protocol on NSAIDs PT MODALITIES TIPS
for side effects and screening at-risk patients.) US & EMS: Ultrasound may be used in combination
 Acetaminophen is a reasonable first choice of with EMS therapy. The dispersive pad is placed
OTCs. If prescribed, analgesics should be adjacent and, where appropriate, proximal to the
taken at regular intervals, not on an “as treatment area.
needed” basis.
 Acetaminophen is an ingredient in many other “Active” Contrast Therapy: While patients are
OTC medications. It is important to survey the receiving contrast therapy, they can actively contract
patient’s total intake so as not to exceed their muscles. This muscle pumping has a greater
recommended doses. effect on edema, venous return and lymphatic fluid.
 Warning! Patients who have been on
systemic corticosteroids for weeks, months or
years are susceptible to osteoporosis, Initial Operational End-Point/Outcome
attenuation of the transverse ligament of Measures
Atlas, and increased risk for spinal/peripheral
joint infections, avascular necrosis and CLINICAL WARNING! Progressive motor loss at
infections in general. any time during the treatment program should trigger
 In select cases, referral for corticosteroid a neurological/surgical consult.
injection may provide enough temporary relief
to allow a patient to remain more active and to
more fully participate in a physical In most acute cases expect approximately 50%
rehabilitation program. improvement within the first three weeks of care.
Outcome measurements include the following:
 Pain centralization
 Stabilization or improvement of motor signs
Choose Mode of Manual Therapy  Pain improvement at rest (e.g., mVAS)
(Pp. 48-55)
 Decrease use of analgesics
 Mobilization & HVLA (P. 48; Appendices VIIIa-d)  Improvement in the SLR and thoracolumbar
AROM
 Flexion-Di straction (P. 51; Appendix IX)
 Improved ADLs (e.g., Oswestry, Roland Morris or
 Other Treatments: muscle energy technique
the PSFS can be used).
(MET), blocking, long-axis traction, soft tissue
manual therapy, neuromobilization of the NOTE: In cases that present with severe motor loss
sciatic nerve (“flossing”) (Pp. 52-55) at the initial visit, either immediately seek
medical/surgical consult or treat for 3-6 weeks while
MANUAL THERAPY – CLINICAL TIPS & carefully monitoring motor status. If there is still no
WARNINGS! improvement at that time, a surgical consult should
be considered.
 Palpation loads when used as therapy may
need to be sustained from 30 seconds up to
several minutes.
 Tolerance to side-posture palpation/treatment
may be influenced by whether the affected leg
is side up or side down. In difficult cases,
explore both positions.

Revised 4/08 Copyright © 2008 Western States Chiropractic College

Subacute Phase (Pp. 43-45) PATIENT EDUCATION (P. 45)
 Periodically check in on the quality of home
exercise programs.
Objectives  Continue to give postural and ergonomic advice
 Continue to control pain. as needed.
 Return to work with modified duties.
 Restore biomechanical function as it applies HOME CARE (P. 46)
to joint function, flexibility, endurance,  Continue directional preference protocols as
proprioceptive integrity, and aerobic needed to manage flare-ups.
conditioning.  Continue lumbar stabilization and proprioceptive
activities.
 Do muscle endurance exercises.
OFFICE TREATMENT (P. 44)  Follow prescribed aerobic conditioning program.
 Continue soft tissue therapy
 Continue taking the patient through lumbar
stabilization protocols and progress into Overall WSCC Rehabilitation “Menu”
proprioceptive training.  Neutral pelvis, hip hinge, abdominal bracing
 Restore good biomechanics.  Directional preference exercises
 Posture and breath training
PATIENT EDUCATION (P. 44)
 Return to activity
 Teach the patient how to protect the low back.
 Floor exercises to re-program stability
HOME CARE (P. 44) (quadruped, dead bug, side-bridge)
 Emphasize progression through the  Weight-bearing exercises (lunge, squat)
stabilization program.  Muscle balance exercises (stretches & activation)
 Continue aerobic activities.  Propri oceptive training
 If doing directional preference protocol,
continue as needed. See CSPE protocol, Low Back Rehabilitation
Program, for specific details.
NOTE: In the subacute phase, the patient should
be weaned from any of these passive physical
NOTES & CLINICAL TIPS
therapy modalities if they have been used at all.
 Many of the steps of a rehabilitation program can
be introduced during mid- to late-subacute
phase, based on patient tolerance and response.
Rehabilitation Phase (Pp. 45-46)  If patients improve early in the course of
treatment but then plateau, up to 2-3 months of
Objectives additional conservative care is indicated. (See
Surgical Referral section.)
 Address any flare-ups of back/leg pain.  If curl-ups are prescribed, a posterior pelvic tilt
 Improve low back and pelvic stabilizer should not be held because of the possible
strength to normative values. injurious load it places on the disc fibers.
 Continue to improve proprioceptive integrity
and aerobic conditioning.
 Return to full work duties and ADLs with
minimal residuals.

OFFICE TREATMENT (P. 45)

 Treat acute flare-ups as necessary (see acute
intervention).
 Evaluate muscle endurance.
 Take patients through advanced steps of
appropriate stabilization tracks.

Revised 4/08 Copyright © 2008 Western States Chiropractic College

Clinical Outcome Measures (Pp. 64-65) Surgical Referral (Pp. 65-70)
SUMMARY Cauda Equina WARNING! In cauda equina cases,
If possible, consider all of the following: surgical intervention should be within 48 hours of the
 Neu rological deficits onset of urinary symptoms.
 Centralization/peripheralization
 Oswestry, Roland Morris or SF-36 Absolute/Strong Indicators
 PSFS or any specific activity (e.g., sitting time)  Cauda equina syndrome
 mVAS or VAS  Progressive deficits (especially motor)
 SLR  Myelopathy
 Thoracolumb ar AROM
 Analge sic use Relative Indicators
 Functional Capacity Exam (FCE)  Severe radicular pain
(See Appendix X)  Und erlying stenosis
 Acute onset of severe muscle weakness/atrophy
NOTES & CLINICAL TIPS Disputed Indicators
 Motor deficits should be checked every visit,  Uncontained disc (extrusion or sequestration)
especially during the acute phase.
Non Indicators
 The minimally clinically important difference  Size of herniation
(MCID) for Oswestry is 4-6 points and for
 Stable neurological deficits
Roland Morris is 3-5 points.
 In Worker’s Compensation cases, an Negative Predictors for Surgical Outcomes
inclinometer must be used to measure spinal  Midline disc herniations
ROM for medically stationary workers.  Radiculopathy > 1 year
 Far lateral disc herniations
 No pain with sitting
Management Timeline/Milestones  Bulging or protruding disc
 Ongoi ng litigation
First three days: Centralization of leg pain  Low education level
 Heavy manual labor
End of first week: In the rare cases that patients  Low work satisfaction
are on bed rest, they are beginning to ambulate.  Longer duration of sick leave
 Anxiety, somatisation and passive avoidance
First 3 weeks: 50% improvement based on coping
flexion-distraction treatment (usually extrapolated  D epression
to various forms of manual therapy)

First 6 weeks: 50% improvement based on

functional rehabilitation evaluation

At week 6: Refer for surgical consult if treating a

profound muscle weakness that has not
responded.

At 8-12 weeks: Refer for surgical consult patients

that have had poor response to care and who
have relative indication for surgery.

NOTE: Opinions of how long surgery can be

delayed range from 6-8 weeks to 3-6 months.

Revised 4/08 Copyright © 2008 Western States Chiropractic College