Confrontation radio-clinique: Lombocruralgie

Confrontation Radio-Clinique :

Lombo-cruralgie

Benmouna Karim Novembre 2014

1/ Cas clinique n°1

- Anamnèse & Examen clinique - Examens Complémentaires - Diagnostic

2/ Cas clinique n°2

- Anamnèse & Examen clinique - Examens Complémentaires - Diagnostic

1/ Cas clinique n°1 :

- Anamnèse :

- _{♀ 51 ans.}

- Lombalgie aiguë.

- Irradiation inguino-crurale droite. - Boiterie à la marche.

- Impotence fonctionnelle à la mobilisation du tronc. - Pas d’amélioration malgré repos et AINS per os.

1/ Cas clinique n°1 :

- Antécédents :

- Diabète de type 2, non insulinorequérant (avril 2013) - AVC ischémique en 2005

- Mutation hétérozygote pour le facteur V de Leyden avec antécédents de TVP en 1987

- Traitement en cours :

1/ Cas clinique n°1 :

- Examen clinique :

- Boiterie droite à la marche plantigrade. - Marche talons/pointes ok, boiterie droite. - Attitude antalgique pseudo-psoïtisme.

- Propédeutique lombaire : pas de limitation majeure, flexion antérieure à –10cm ; Schober 10/14.5 ; rotation G enraidie.

- Examen neurologique :

- Hyporéflexie L4 droit

- Hypoesthésie à la piqûre territoire L3L4 droit.

- Testing analytique déficitaire psoas et quadriceps à Lovett 4-/5 - Lasègue inversé vivement douloureux

1/ Cas clinique n°1 :

- Examens complémentaires : CT-Scanner Lombaire 23/07

- Discarthrose L1L2 avec protrusion postérieure et hernie discale postéro-latérale gauche + conflit radiculaire L2 gauche.

- Discarthrose L2L3 avec bombement discal circonférentiel postéro-latérale gauche.

- Discret bombement discal circonférentiel en L3L4 & L4L5 - Minime débord discal postérieur L5S1.

1/ Cas clinique n°1 :

- Examens complémentaires sollicités :

- ENMG membres inférieurs - RMN colonne lombaire

1/ Cas clinique n°1 :

1/ Cas clinique n°1 :

- RMN Colonne Lombaire :

- Hernie discale pré-foraminale L3L4 ascendante comprimant la racine L3 droite.

1/ Cas clinique n°1 :

- RMN Colonne Lombaire :

- Hernie discale pré-foraminale L3L4 ascendante comprimant la racine L3 droite.

2/ Cas clinique N°2 :

- Anamnèse :

- Femme 31 ans G1P1.

- AVB le 22/11/12 sans complication.

- Vive douleur paralombaire droite et fessière droite dans le post partum.

- Douleur constante, sans irradiation type cruro-sciatalgique. - Pas de notion de fièvre.

2/ Cas clinique N°2 :

- Antécédents :

- 1 accouchement PVB sans complication - HDL5-S1 gauche

- Allergies :

- Aucune

- Facteur de risque :

2/ Cas clinique N°2 :

- Examen clinique :

- Attitude antalgie - Marche 3 modes - PCM

-/-- Flexion antérieure du tronc doigts/sol

- Vive douleur paralombaire droite à l’extension du rachis lomb - Examen neurologique

- Douleur extension passive hanche droite - Douleur inguinale et SI droite

2/ Cas clinique N°2 :

- Examens complémentaires :

- Scanner lombaire :

2/ Cas clinique N°2 :

- Examens complémentaires :

- Scanner lombaire

- Biologie sanguine :

Syndrome inflammatoire avec 22,7 de CRP

- Examens complémentaires :

- Scanner lombaire - Biologie sanguine

- Examen gynécologique

2/ Cas clinique N°2 :

- Examens complémentaires :

2/ Cas clinique N°2 :

- Examens complémentaires :

Abcès du muscle iliaque droit de 59x31x93mm associé à de nombreuses adénopathies iliaques droites

2/ Cas clinique N°2 :

3/ Revue Littérature

- _{The lumbosacral spine is susceptible to disc herniations because of its mobility} from flexion, extension, and torsion.

- _{75% of flexion and extension occurs at the lumbosacral joint. This level, on the} other hand, has limited torsion.

- _{20% of flexion and extension occurs at L4-L5.} - _{5% occurs between L1 and L3.}

> As the L4-L5 and L5-S1 levels are most susceptible to injuries from routine

movements of the spine, about 90 to 95 percent of compressive radiculopathies occur at these levels.

3/ Revue Littérature

- Reverse Straight Leg Raise (= femoral stretch)

The reverse straight leg raise (femoral stretch) test is accomplished by placing the patient prone on the table and passively extending the hip and leg straight up off the plane of the table. This maneuver is most useful for evaluating the L2, L3, and L4 roots. However, the value of this test is limited by inadequate information on its

sensitivity and specificity.

3/ Revue Littérature

IMAGING

- _{« Approximately one-quarter of patients 18 to 50 years of age with acute} low back pain who received imaging tests had no identifiable indication for imaging. An approach to determining when it is appropriate to order radiographic studies in patients with low back pain is outlined in an

algorithm »

- _{« There is a high prevalence of abnormal neuroimaging findings in}

asymptomatic individuals, including some who have what appears to be frank nerve root compression by MRI. As an example, one study of 98 people without back pain found MRI evidence of disc herniation in 27 percent. Furthermore, lumbar spine abnormalities on MRI in

3/ Revue Littérature

IMAGING

- _{A comparison of computed tomography-myelography, magnetic resonance imaging, and}

myelography in the diagnosis of herniated nucleus pulposus and spinal stenosis. J Spinal Disord. 1993;6(4):289.

- _{« According to the results obtained from this series of patients, myelo-CT seems to be the most sensitive and} accurate test in diagnosing HNP and spinal stenosis, whereas myelography is the most specific, although no

statistical significance was noted in this study. However, because MRI did compare favorably with myelo-CT in most instances, particularly in revision surgery; it may be the procedure of choice due to its noninvasiveness and relative lack of side effects. »

- _{Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Intern Med.}

2002;137(7):586-597.

- _{« Nonetheless, this review suggests that imaging may not be needed for patients with acute back pain of less than} 6 weeks' duration unless findings suggest systemic disease or progressive neurologic deficit. The reasons for this conclusion are that imaging is unlikely to reveal a specific cause and irrelevant findings are common. Choice of imaging tests after acute pain has persisted for 6 weeks depends on clinical findings. However, for patients with systemic diseases, MRI probably offers the greatest sensitivity and specificity; for patients with degenerative conditions that produce neurologic compromise, MRI offers results comparable to those obtained with CT. The frequent finding of abnormalities in normal adults limits the specificity of all these tests. »

3/ Revue Littérature

ELECTRODIAGNOSTIC

- _{The primary electrodiagnostic procedures for lumbosacral radiculopathy} are electromyography (EMG) and nerve conduction studies (NCS). In

combination, the information provided gives insights into the integrity of spinal nerve roots and their connection with the muscles they innervate. These tests are most commonly considered in patients with persistent disabling symptoms of radiculopathy in whom neuroimaging findings are not consistent with the clinical presentation.

3/ Revue Littérature

IMAGING & ELECTRODIAGNOSTIC

- _{EMG and imaging studies have a comparable diagnostic sensitivity,}

varying between 50 to 85 percent, depending on the patient population. In a retrospective comparison of 47 patients who had a clinical history suggestive of either cervical or lumbosacral radiculopathy, there was congruence between EMG and MRI findings in 60 percent of patients. Agreement between EMG and MRI was highest for patients with clearly abnormal examination findings consistent with radiculopathy.

- _{MRI and EMG provide unique anatomic and physiologic information,} respectively

3/ Revue Littérature

EXPLORATION

- _{Advanced imaging is infrequently indicated early in the course of}

patients with low back pain. However, the clinician must be vigilant to identify patients requiring specialized testing. An MRI or CT scan should be performed for the following patients :

- Clinical exam findings or other tests suggesting possible emergent conditions affecting the spine : cauda equina syndrome, infection, tumor, fracture with neurologic impingement, or other mass lesions or defects.

- Radicular symptoms consistent with a disc herniation and symptoms lasting > 4 to 6 weeks that are severe enough to consider surgical intervention.

3/ Revue Littérature

EXPLORATION

- _{The diagnosis of a lumbosacral radiculopathy is clinical, and can usually be made based} upon compatible symptoms and examination findings. Evaluation requires a careful neurologic examination. Immediate diagnostic testing is not necessary for patients with suspected radiculopathy who are neurologically intact and not suspected of having underlying neoplasm, infection, or inflammation. Nevertheless, testing is suggested to confirm the diagnosis and etiology for patients who have persistent

symptoms that are not adequately controlled with conservative therapy and for whom invasive treatment options are an option. We recommend neuroimaging as part of the initial evaluation for patients with any of the following conditions :

- _{Acute radiculopathy with rapidly progressive neurologic deficits}

- _{Radiculopathy with urinary retention, saddle anesthesia, or bilateral neurologic symptoms or} signs

- _{High suspicion for neoplasm or epidural abscess}

- _{For patients with persistent or severe findings in whom the etiology is not confirmed} on neuroimaging, we suggest electromyography and nerve conduction studies

3/ Revue Littérature

EXPLORATION

- _{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. Epub 2013 Mar 15.

- « This systematic review and meta-analysis demonstrate that neurological testing procedures have limited overall diagnostic accuracy in detecting disc herniation with suspected radiculopathy. Pooled diagnostic accuracy values of the tests were poor, whereby all tests demonstrated low sensitivity, moderate specificity, and limited diagnostic accuracy independent of the disc herniation reference standard or the specific level of herniation. The lack of a standardized classification

3/ Revue Littérature

EVOLUTION

- _{While acute lumbosacral radiculopathy is often extremely painful, the} likelihood of spontaneous improvement is thought to be high when the cause is disc herniation or lumbar spinal stenosis due to degenerative arthritis. However, natural history data for lumbosacral radiculopathy are limited.

- _{Some insight can be gained from placebo arms of randomized trials. In} this regard, a trial of 208 patients with acute L5 and/or S1 radiculopathy found no significant difference in outcome for those assigned to

nonsteroidal antiinflammatory treatment or to placebo at four weeks, and most patients had a satisfactory recovery . At three months,

approximately 30 percent of patients in both groups still had complaints of back pain.