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Adam Dobson Profile picture
@adamdobson123
Feb 26, 2023 • 7 tweets • 3 min read • Read on X
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Radicular pain and/or radiculopathy. A thread on decision making.

1⃣ Setting the scene

3Ps/serious pathology (red lines) aside. What does the evidence tells us?

✳️Wait & see
✳️Physiotherapy interventions
✳️Nerve root block
✳️Microdiscectomy
👇👇👇 Image
2⃣ A stepped care approach

So, who will get better anyway? What about relieving suffering? We only have early work into trajectories and prognostics.

Current guidelines and national pathways recommend a stepped approach. One that is 'least intrusive'.
👇👇👇 Image
3⃣ Management variables

What characteristics should we consider? To map onto the stepped care approach.

✳️Confidence in dx
✳️Prognostics
✳️Additional factors
4⃣ Confidence in dx

Does the story fit?
Is symptomology consistent?

Does the pt have clear muscle power loss? Any objective numbness with clear borders?
👇👇👇 Image
5⃣ Prognostics

Green: Positive prognostically
Red: Negative prognostically

Use these to plan care and have sensible conversations with pts.
👇👇👇 Image
6⃣Additional variables

Does your pt even want to consider interventional procedures ? Do they understand their options.

Gone are the days that pt MUST have interventions done to them.

What about surgical fitness?
#SharedDecisionMaking
👇👇👇 Image
7⃣
So remember, a stepped approach with least level of intrusiveness. Remember your redlines.

For further CPD come attend our annual @NatSpineNetwork event
mailchi.mp/boa/nsn-17-apr…

Also check out our NHS booklets
southtees.nhs.uk/services/back-…

@AnninaBSchmid @SiobhanStynes

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More from @adamdobson123

Adam Dobson Profile picture
May 27, 2024
Get ‘unstuck’ on neurodynamics for lumbar radicular pain.
A brief thread. 🧵

We’ve recently had some content on nerve mechanosensitivity and lumbar radicular pain. I thought it’d be a good opportunity to share some work, and my thoughts on neurodynamics as a treatment.
1⃣ Can lumbar nerve roots get stuck?
It seems so, or indeed it is possible. Those with painful lumbar radiculopathy associated with disc-related nerve compression have been shown to have reduced lumbar nerve root excursion compared to contralateral limb and controls.





Common mechanosensitivity tests include the passive the Straight Leg Raise (pSLR) test, slump test, and femoral nerve stretch test. The pSLR has been shown to be moderately reliable if structural differentiation is used. Range of motion continues to be unreliable.
journals.lww.com/spinejournal/f…
onlinelibrary.wiley.com/doi/10.1002/jo…
journals.lww.com/spinejournal/a…
sciencedirect.com/science/articl…
2⃣ Neurodynamics
Neurodynamics is a term used to describe a series of novel, low-load stretches claimed to preferentially move, glide, and ‘floss’ tethered nerves and through soft tissue structures (interfaces). This approach is proposed to improve the health of these tissues, thereby aiding in pain relief and healing. It was made popular by Michael Shacklock, David Butler, and their colleagues.

In cases of lumbar radicular pain, these tissues include the spinal cord via the conus, lumbosacral nerve roots, associated peripheral nerves, and somatic structures. Its not just the sciatica nerve!!!

Here is a video by the @Physiotutors on sliders and tensioners.
Read 6 tweets
Adam Dobson Profile picture
Dec 28, 2023
Lumbar spine modic changes. A🧶

1⃣ What are modic changes
2⃣ LBP associations
3⃣ Management with antibiotics
4⃣ Closing thoughts

Disclaimer: While I am not an interventionalist, it does not preclude me from being critical of the care my patients may otherwise receive🫡
1⃣What are modic changes.

Modic changes refer to observations on lumbar MRI at the vertebral endplate, most commonly seen at the bottom two lumbar levels. They are thought to be related to previous disc herniations and were first described by Modic and colleagues in 1988.

Modic changes are categorized based on visual characteristics and proposed composition.

They are classified into Type 1, 2, and 3. Modic 1 changes correspond to oedema (fluid) at the endplate, appearing hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI with fat suppression (see images below).

Images courtesy of @RadiopaediaImage
Image
Modic 2 changes correspond to fat replacement. Hyperintense on both T1w and T2w MRI (see below)

Modic 3 changes correspond to sclerotic or fibrotic changes and are hypointense on both T1w and T2w MRI.

Images courtesy of @Radiopaedia
Image
Image
Read 17 tweets
Adam Dobson Profile picture
Dec 1, 2023
Do you know the differences between your disc bulges & your herniations? How they classified?

I've been playing about with some illustrations for my 'Navigating Painful Radiculopathy course in 2024. So here we go.
First of all, it's important to know that there are different schemas.

The following is based on a consensus paper here:


These are used by my radiology department. If you review imaging, check what they use. If it's not standard? Should it be?pubmed.ncbi.nlm.nih.gov/24768732/
1️⃣ THE NORMAL DISC

Here is the 'normal disc'.
No dessications (dehydration) AKA loss of disc height, annular fissures, schmorl nodes or end plate changes, e.g. modics (oedema).

No bulging/herniation. The annular tissue does not project beyond the vertebral bodies - pink line Image
Read 11 tweets
Adam Dobson Profile picture
Mar 25, 2023
Below is a tweetorial on Diagnostics Labels in Low Back Pain.

1⃣ Labels. An easy fit, A societal expectation!
2⃣ The opposition
3⃣ Non-specific LBP
4⃣ Evidence to support Non-specific LBP

Its a bit of long one but i hope its helpful.
Diagnostic Labels (DLs) in Low Back Pain (LBP).
Any good?

1⃣ An easy fit, A societal expectation!

Clinicians like DLs
We pride ourselves on them.
They imply a degree of mastery and skill
They offer a vocabulary
They set boundaries and bundle up info – a bit like jargon.
People can also like DLs
They can validate & legitimise problems
They can lessen stigma and trivialisation – at home, at work and play.
There is also an expectation that they will lead to a cure or tailored treatments
Read 22 tweets
Adam Dobson Profile picture
Mar 6, 2023
Adding to my radicular pain and/or radiculopathy decision making tweetorial, here is deep dive into muscle power and decision making.

1⃣/9⃣ Recap.
👇👇👇
2⃣/9⃣ RED-LINES.
Important to know when to hold and when to immediately refer on.
👇👇👇
3⃣/9⃣Confidence in dx
What can we learn from power testing ?
Reports are helpful but we should screen all patients with suspected LBRLP.
👇👇👇
Read 9 tweets
Adam Dobson Profile picture
Feb 26, 2023
Radicular pain and/or radiculopathy. A thread on decision making.

1️⃣ setting the scene

3Ps or serious suspicion aside. What does the evidence tell us

❇️ Wait and see
❇️ Physiotherapy
❇️ Nerve root blocks
❇️ Microdiscectomy
👇👇👇 Image
2️⃣ A stepped care approach.

So, who will get better anyway? What about relieving suffering? We only have early work into trajectories and prognostics.

Current guidelines recommend a stepped care approach. One that is 'least intrusive'.
👇👇👇 Image
3️⃣ Management variables

So what pt charactistics should we consider? To map on the stepped care approach.

❇️ Confidence in dx
❇️ Prognostics
❇️ Additional factors
Read 8 tweets

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