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…

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 @Radiopaedia

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/

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.

Adding to my radicular pain and/or radiculopathy decision making tweetorial, here is deep dive into muscle power and decision making.

1⃣/9⃣ Recap.
👇👇👇

https://twitter.com/adamdobson123/status/1629903709982318593?s=20

2⃣/9⃣ RED-LINES.
Important to know when to hold and when to immediately refer on.
👇👇👇

v2.0 with adjustments
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
👇👇👇 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'.
👇👇👇

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
👇👇👇 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'.
👇👇👇

1️⃣
A tweetorial on navigating the role of imaging in spinal care.
* Comms
* Triage
* Consequences
* CPD for upskilling/interpretation 2️⃣
THE PROBLEM.

1-4 patients with LBP are referred for imaging
pubmed.ncbi.nlm.nih.gov/30760458/

Of 306 MSK-MRI requests only 4.9% were indicated and only 1.3% lead to change in management
pubmed.ncbi.nlm.nih.gov/34215659/

Here is a tweetorial on bending and low back pain.
Bit of a longer one but a number of juicy papers included.
1/9 There is a long held belief that bending, particularly with a flexed spine is harmful and more likely to lead to low back pain compared to a more sparing type strategies.
ncbi.nlm.nih.gov/pmc/articles/P…

Here is a thread on FMS. If you’re a generalist or a specialist you see pts with FMS (dx or not) and it matters. Here is some needs to knows. 1/8 FMS is a syndrome. Pts suffer with more than pain. Intrusive fatigue and a number of somatic problems have a big a impact on health related quality of life.

Here are the presentating features in a little more detail 2/8