Author: Andrea Cheung
Cauda equina is the collection of nerves at the very end of the spinal cord. When the cauda equina was damaged and compressed causing pain and numbness sensation, we call it “Cauda Equina Syndrome” (CES).
CES is very rare which only account for 1 in 2000 of lower back pain patients. However, if health practitioners failed to diagnosis CES, this will cause serious consequence to patient’s bladder, bowel, and sexual function.
The major cause of CES is a large lumbar disc herniation at immediate vicinity of L2 or below, which compresses the cauda equina. Infections such as meningitis can also lead to CES. Moreover, sacral fracture can also cause CES when it compresses the cauda equina.
The signs and symptoms of CES can be universal to other chronic disease. Common signs reported from patients are low back pain, unilateral or bilateral sciatica, motor weakness in lower extremities, and/or numbness around the buttock area. With regards to bladder and bowel dysfunction, it may not present in the early stage.
CES can be present acutely or chronically. With acute CES, patient may present sudden back pain with dramatic sensory changes around the buttock area, and possible weakness in urination. During chronic CES, previous symptoms mentioned will build up gradually or may fluctuate over weeks, months or even years. If the patient had slow onset of bladder and bowel dysfunction, it will present with increase severity and less responsive to management.
Health practitioners and patients should monitor the red flag to CES such as bladder dysfunction and numbness tingling between legs and around the anus if the patient have continuous back pain, sciatica, and increase urinary frequency and urgency.
When patient has diagnosis with CES, surgery is the first option to prevent further neurological damage. Study had found significantly improvement in neurological outcome if patient had surgical operation within 24 hours of onset compare to 48 hours. Some patient may also be able to regain bladder continence if they have surgery within the 24 hours to 48 hours timeframe. Therefore, surgery should be done as soon as CES was diagnosed.
The goal of the surgery is to decompress any compressed lesions to improve sensory and motor deficits. However, some patient may still experience some degrees of neurological deficit.
What is Whiplash Associated Disorder?
Whiplash is a general termed injury that usually take place in a motor vehicle crash where the head is subject to sudden acceleration and deceleration, causing forceful bending in neck region. Since the movement is unlikely to occur in normal human range of motion, the muscles that control your neck movement do not have time to respond to the force, causing damage to the neck region.
The Quebec Task Force classifies Whiplash into five gradings, based on severity:
- Grade 0: No complaint about pain, tenderness, or stiffness of the neck. No physical signs.
- Grade I: Complaint of pain, tenderness, or stiffness of the neck without physical signs.
- Grade II: Complaint of pain, tenderness, or stiffness of the neck with musculoskeletal signs such as decrease range of motion and point tenderness.
- Grade III: Complaint of pain, tenderness, or stiffness of the neck with neurological signs such as sensory deficits.
- Grade IV: Complaint of pain, tenderness, or stiffness of the neck with signs of fracture and dislocation.
During a rear-end crush, the torso the carried forward, forcing the cervical spine, located in our neck, into an abnormal “S-shaped” position. Then, the head and neck were forced backwards since the torso was pulled forward during the collision. This may cause injuries to anterior cervical ligaments. The head and neck will swing forward as the driver stop the vehicle immediately.
Signs and symptoms
Whiplash Associated Disorder comprised range of symptoms including neck pain and stiffness, headache, memory loss, dizziness, dysphagia, and temporomandibular joint pain.
Patients with history of sudden or excessive neck extension, flexion, or rotation are in the risk of whiplash injury. During initial assessment, patient may report having reduced cervical spine range of motion, loss of muscle control in both cervical spine and shoulder gridle, loss or decrease in balance and deficits in neck-influenced eye movement control. For more serious cases, some patient may experience muscle degeneration in the cervical extensor muscles, lead to long lasting pain and disability.
In the first 96 hours after injured, mobilization such as active and passive range of motion exercises can result in reduced pain levels and improve function. Active rest, such as continue daily activity with brief rest period, can help blood flowing and muscle recover. Immobilization of long period of time can delay recovery time as muscle and ligament fibers are not aligned properly which can reduce strength and energy absorption capacity. Moreover, some patients will take NSAIDs to reduce inflammation, and neck rang of motion had reported improved after two weeks with medicine. Other physical treatments that practitioners will used are heat and cold packs, ultrasound therapy, and head traction. Theses can reduce pain and enhance recovery during the acute phase of whiplash injury.
During subacute phase, the goal for the patient is to return cervical muscle function as normal as possible. Light isometric and isotonic strengthening exercises that target the neck and scapular can help restore neck active range of motion. Light stretching also play a crucial role to improve tissue healing by increasing blood flow to the injured area. Vestibular and motor control exercises can improve neuro deficits and retraining muscle activation. Manual joint manipulation provided by chiropractors can reduce pain and initiate body’s natural healing processes. For ongoing management, continue with all the treatments stated above as well as increase the intensity of strengthen exercises.
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Barnsley, L., Lord, S., & Bogduk, N. (1994). Whiplash injury. Pain, 58(3), 283–307. https://doi.org/10.1016/0304-3959(94)90123-6
Elliott, J. M., Noteboom, J. T., Flynn, T. W., & Sterling, M. (2009). Characterization of Acute and Chronic Whiplash-Associated Disorders. Journal of Orthopaedic & Sports Physical Therapy, 39(5), 312–323. https://doi.org/10.2519/jospt.2009.2826
Pastakia, & Kumar, S. (2011). Acute whiplash associated disorders (WAD). Open Access Emergency Medicine, 29. https://doi.org/10.2147/oaem.s17853
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Posted on by Andrea Cheung
What is sciatica?
Sciatica is the symptom of an underlying medical condition, not a medical diagnosis. However, this term has been incorrectly used to describe pain in back and leg symptoms by the general population. This is a term to describe a pain symptom that radiates from the middle or lower buttock down to the back and the side of the leg along the sciatic nerve, sometime it could radiate below the knees into the foot and toes. Sensory symptoms may also be reported by the patient. Usually, the pain only affects either left or right rather than both sides. Other thing to note is that Low back pain is not a consistent feature seen in sciatica but may also present in patient.
Symptoms and examination
Research has found that 90% of the cases are due to herniated disc that compress the nerve root from L4 to S1. Different levels of compression will present slightly different clinical features. With L4 compression, the pain is front and to the side of the thigh, which may sometimes mistake as a hip disease. Vis versa, L5 compression show pain at the back and the sides. Some other causes of sciatica might be lumbar canal or foraminal stenosis and tumors or cysts.
To examine whether a patient have sciatica, Straight Leg Raising Test have shown high sensitivity of 91%. When the patient is lying down and facing up, raising the whole leg straight can stretch the nerve root of the protruding disc. This will reproduce the pain and discomfort that the patient complains. If the leg is angled between 30 to 70 degrees with pain from buttock to below knee, disc compression of nerve root might be the cause of radiated pain.
Sometimes, sciatica might be mixed up with non-specific low back pain. Some major signs to justify sciatica are radiated pain towards foot or toes, numbness and paranesthesia.
Conservative non-surgical treatments are recommended for patient. Most common initial treatment will be pain control by medication prescribed by family doctor, which could provide relief to patient’s discomfort. The most common medication is naproxen, used to relieve pain for various conditions. Other conservative treatment such as acupuncture, steroid injections, etc. might be beneficial but studies has been inconsistent with pain relief of sciatica. However, rest and bed rest are not recommended to reduce pain as it might lead to acute low back pain although it might provide instant relief. Staying active likely to be more beneficial in improving sciatica and aid in faster recovery.
Another conservative treatment is spinal manipulation. It is widely used to provide a short-term benefit in relief pain symptoms in addition to exercise program targeting the low back and hip. Study had found that patient who has sciatica of at least six weeks, both conservative and disc surgery might improve patient’s pain and function. But we must aware of possible confounding in the study due to self reported data and patients’ preference for treatment may also affect treatment outcome.
If pain does not diminish in six to eight weeks, patient should meet a neurologist, neurosurgeon, or orthopedic surgeon to discuss other treatment methods such as surgery. It is always the last resource to treat sciatica when practitioner suspect a disc herniation or disc rupture. However, evidence has shown controversial outcomes with surgery. Studies has shown patient who did surgery has faster relief of pain compare to conservative treatment.
Exercise is always the best prevention protocols that a patient could do during their free time. Specific strengthening exercise that targets the core and the lower back can help protect the spine and maintain good posture. Patient can also stay active by jogging around the neighborhood or swimming and the pool.
Maintaining a good sitting posture is also important to prevent disc compression. Prevent bending the lower back which could reduce pressure on the discs and ligaments. Moreover, take a small break every 30 minutes of sitting can relief the pressure in the disc.
Harvard Health Publishing. (2020, September 24). 5 tips with coping sciatica. https://www.health.harvard.edu/pain/5-tips-for-coping-with-sciatica
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Ropper, A. H., & Zafonte, R. D. (2015). Sciatica. New England Journal of Medicine, 372(13), 1240–1248. https://doi.org/10.1056/nejmra1410151
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What is ultrasound?
Ultrasound has been wildly accepted as a therapeutic modality among the medical field by delivering noninvasive soundwaves causing the molecules in our body to vibrate. Depends on the frequency that practitioner prescribed, it has slightly different positive effects to the patient. However, the main goal for ultrasound therapy is to decrease plain, enhance tissue repair, and aid in muscle relaxation.
What are the theories behind it?
The theory behind ultrasound therapy is the soundwaves transmitted by the machine will cause vibrations in deep tissues, thus heat production. Heat can enhance blood flow and reduce pain symptoms.
Usually, frequency range from 0.8MHz to 3MHz are used during the therapy session. Higher frequency will be used in deep tissues treatment since ultrasound energy will be absorbed by superficial tissues.
How does the treatment looks like?
Transducer can be applied directly to patient’s skin with a layer of gel moving in a circular motion or under water. However, direct application is more common in clinical settings. For acute injury, application will be around 3-5 minutes. For chronic injury, the treatment will take 5-10 minutes. Excessive exposure to ultrasound will cause burning to the skin and damage to cell tissues.
Is it safe? What are some contraindications?
Ultrasound therapy is generally safe for most people. However, certain conditions may prohibit patients from receiving ultrasound therapy. People who are pregnant and in the presence of a pacemaker should avoid direct application over the affected area. Moreover, application will not be placed in areas with cancer, fractures, or directly over spinal cord, and epiphyseal growth center.
Ultrasound therapy is very useful to treat pain symptoms and enhance tissue healing. In addition, incorporating exercise therapy such as active rehabilitation can enhance one’s physical function and recover quicker than only with electrical therapy.