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Lumbosakralt diskbråck, ischias

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Definition:
Lumbosakralt diskbråck med rotpåverkan (rizopati). Ischias och ischialgi är utstrålande från ryggen till försörjningsområdet av nervus ischiadicus (L5- och S1-dermatom). Cauda equina-syndrom (CES) är ett diskbråck som trycker på nerver S2–S4 som kan ge irreversibla nervskador. 
Förekomst:
Akut ryggsmärta är vanlig, men lumbosakralt diskbråck är orsak till <5 % av fallen med akut ländryggssmärta.
Symtom:
Smärtor i ett dermatom och eventuellt svaghet i muskler, oftast L4, L5 eller S1. Vid CES ses ridbyxanestesi, störning av miktion/defekation, bilaterala symtom och sexuell dysfunktion.
Kliniska fynd:
Enstaka kliniska fynd har begränsad förmåga att påvisa/avfärda diskbråck i ländryggen, men flera fynd kan tala för diskbråck. Test av sensorik, motorik och reflexer ingår. 
Diagnostik:
Klinisk diagnos. I vissa fall görs MRT preoperativt, tidigast efter 4–8 veckor. Vid misstanke om cauda equina-syndrom bör akut diagnostik på akutsjukhus ske. 
Behandling:
Består av initial anpassad aktivitet, smärtlindring och i subakut skede fysioterapi. Endast vissa behöver kirurgisk åtgärd. Vid CES behövs akut kirurgisk åtgärd. 
  1. Jordan JL, Konstantinou K, O'Dowd J. Herniated lumbar disc. BMJ Clin Evid 2011. pmid:21711958 PubMed  
  2. Tarulli AW. Raynor EM. Lumbosacral radiculopathy. Neurol Clin 2007; 25(2): 387-405. pmid:17445735 PubMed  
  3. Lavy C, James A, Wilson-MacDonald J, Fairbank J. Cauda equina syndrome. BMJ 2009; 338: b936. BMJ (DOI)  
  4. Al Nezari NH, Schneiders AG, Hendrick PA. Neurological examination of the peripheral nervous system to diagnose lumbar spinal disc herniation with suspected radiculopathy: a systematic review and meta-analysis. Spine J 2013 Jun;13(6):657-74. doi: 10.1016/j.spinee.2013.02.007. DOI  
  5. van der Windt DA, Simons E, Riphagen E, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev 2010; 17(2): CD007431. doi:10.1002/14651858.CD007431.pub2 DOI  
  6. Tawa N, Rhoda A, Diener I. Accuracy of clinical neurological examination in diagnosing lumbo-sacral radiculopathy: a systematic literature review. BMC Musculoskeletal Disord 2017; 18(1): 93. pmid:28231784 PubMed  
  7. Hsu PS, Armon C, Levin K. Acute lumbosacral radiculopathy: Pathophysiology, clinical features, and diagnosis. UpToDate 2017. www.uptodate.com  
  8. Todd NV, Dickson RA. Standards of care in cauda equina syndrome. Br J Neurosurg 2016; 30(5): 518-22. pmid:27240099 PubMed  
  9. Tawa N, Rhoda A, Diener I. Accuracy of magnetic resonance imaging in detecting lumbo-sacral nerve root compromise: a systemic literature review. BMC Musculoskeletal Disord 2016; 17(1): 386. pmid:27600883 PubMed  
  10. Steffens D, Hancock MJ, Pereira LS, et al . Do MRI findings identify patients with low back pain or sciatica who respond better to particular interventions? A systematic review. Eur Spine J 2016; 25(4): 1170-87. pmid:26329648 PubMed  
  11. el Barzouhi A, Vleggeert-Lankamp CL, Lycklama à Nijeholt GJ, et al. Magnetic resonance imaging in follow-up assessment of sciatica. N Engl J Med 2013; 368(11): 999-1007. pmid:23484826 PubMed  
  12. Suri P, Hunter DJ, Jouve C, et al. Nonsurgical treatment of lumbar disk herniation: are outcomes different in older adults. J Am Geriatr Soc 2011; 59: 423-9. PubMed  
  13. Lewis RA, Williams NH, Sutton AJ et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J 2015; 15(6): 1461-77. pmid:24412033 PubMed  
  14. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews 2010; 6: CD007612. Cochrane (DOI)  
  15. Rasmussen-Barr E, Held U, Grooten WJ, et al. Non-steroidal anti-inflammatory drugs for sciatica. Cochrane Database Syst Rev. 2016 Oct 15;10:CD012382. Epub ahead of print. pmid: 27743405 PubMed  
  16. Nationellt kliniskt kunskapsstöd. Lumbago-ischias - misstänkt lumbalt diskbråck. 2015 (hämtad 2019-02-26) nationelltklinisktkunskapsstod.se  
  17. Pinto RZ, Maher CG, Ferreira M, et al . Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ 2012; 344: e497. pmid:22331277 PubMed  
  18. Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Engl J Med 2017; 376(12): 1111-1120. pmid:28328324 PubMed  
  19. Peul WC, van Houwelingen HC, van den Hout WB, et al, for the Leiden-The Hague Spine Intervention Prognostic Study Group. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007; 356: 2245-56. New England Journal of Medicine  
  20. Clark R, Weber RP, Kahwati L. Surgical Management of Lumbar Radiculopathy: a Systematic Review. J Gen Intern Med 2019. s11606-019-05476-8. pmid:31713029 PubMed  
  21. Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev, issue 2, 2007. The Cochrane Library  
  22. Bailey CS, Rasoulinejad P, Taylor D, et al. Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 Months. N Engl J Med. 2020;382(12):1093–1102. PMID:32187469. PubMed  
  23. Peul WC, van den Hout WB, Brand R et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial . BMJ 2008; 336: 1355-8. PubMed  
  24. van den Hout WB, Peul WC, Koes BW et al,. Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial . BMJ 2008; 336: 1351-4. PubMed  
  25. Strömqvist B, Hedlund R, Jönsson B, et al . Ländryggens sjukdomar. Läkartidningen 2007; 19: 1498-1502. www.lakartidningen.se  
  26. Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JTJ, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007; 356: 2245-56. New England Journal of Medicine  
  27. Pearson A, Blood E, Frymoyer J, Herkowitz H, Abdu W, Woodward R, et al. SPORT intervertebral disc herniation: does back pain improve with surgery? In: Proceedings of 34th meeting of the International Society for the Study of the Lumbar Spine, Hong Kong, 10-14 June 2007:13. www.issls.org.
  28. Ahlburg P, Duel P, Spangsberg NLH, Albeck MJ. Operation for lumbal diskusprolaps uden hospitalsindlæggelse. Ugeskr Læger 2005; 167: 1852-5. PubMed  
  29. Kehlet H, Dahl JB. Anaesthesia, surgery and challenges in postoperative recovery. Lancet 2003; 362: 1921-8. PubMed  
  30. Carragee EJ, Han MY, Yang B et al. Activity restrictions after posterior lumbar discectomy. a prospektive study of outcomes in 152 cases with no postoperative restrictions. Spine 1999; 24: 46-51. PubMed  
  31. Kjellby-Wendt G, Styf J, Carlsson SG. Early active rehabilitation after surgery for lumbar disc herniation: a prospektive, randomized study of psychometric assessment in 50 patients. Acta Orthop Scand 2001; 72: 518-24. PubMed  
  32. Singhal A, Bernstein M. Outpatient lumbar microdiscectomy: a prospective study in 122 patients. Can J Neurol Sci 2002: 29: 249-52.
  33. Ostelo RWJG, de Vet HCW, Waddell G, Kerckhoffs MR, Leffers P, van Tulder MW. Rehabilitation after lumbar disc surgery (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software. The Cochrane Library  
  34. Svensson GL. Lumbalt diskbråck. Fysioterapi 2014; 5: 32-39. www.fysioterapi.se  
  35. Fritz JM, Lane E, McFadden M, et al. Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica : A Randomized Controlled Trial published online ahead of print, 2020 Oct 6. Ann Intern Med. 2020;10.7326/M20-4187. PMID:33017565. PubMed  
  36. Wegner I, Widyahening IS, van Tulder MW, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2013 Aug 19;8:CD003010. PMID: 23959683. PubMed  
  37. Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J 2006; 6: 131-7. PubMed  
  38. Weber H, Holme I, Almlie E. The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam. Spine 1993; 18: 1433-8. PubMed  
  39. Graver V, Haaland AK, Loeb M, Magnæs B. 7-year follow-up after lumbar disc surgery. Results and predictors of outcome. Br J Neurosurg 1999; (in press).
  • Remy Waardenburg, specialist i allmänmedicin, medicinsk redaktör Medibas

Tidigare sakkunniga

  • Max Tenne, med dr och överläkare, Ortopediska kliniken, Skånes universitetssjukhus