S1 nerve root compression

Hi Friends,

I would like to get your ideas on a patient of mine whom I saw today.

He played golf on a weekend and then presented with symptoms of an S1 nerve root compression with numbness on the S1 area with a decreased ankle jerk. I am giving him grade II/III PA on L5, which I am not sure would help him or not. However, when I give him these mobs he presents with a tingling sensation in his non-symptomatic limb.

I am not sure where I would go from here with him. Can anyone give me some ideas?

Nit

This guy needs an xray. He may have a spondylolisthesis or stenosis, aggravated by his recent golf episode. Bilateral symptoms and loss of reflex are warning signs!

hello Nit, Is there pain ?, would be usefull to know if there is compromise to SIJ function, is he tight in the sciatic dura?, does he complain of pain as you mobilise L5/S1?, does this pain decrease with mobs?. Also what is the distribution of the S1 altered sensation pattern in this guy. These details would be of some help in an evaluation, though on the details so far he appears to have a disc bulge, in which case traction might decrease his symptoms, this might lend credence to the disc being involved. Not an absolute of course but probably worth a try manually.
Cheers

Thanks for replying friends.

Pain is not a problem for him and his major concern is his numbness in the sole of his foot (lateral aspect). Initially he had numbness in the back of his leg and thigh above his knee which has resolved now. He does not feel any pain in his leg during the application of mobs, however he feels the tingling sensations on his other leg.

I have checked his stork's test which is negative for any spondylolysis.

Thanks again for your replies.

If you think of the golfing action, and the twist of the lower leg, you could also check the distal neural structures. Perhaps mobilise the superior tib/fib joint and release the peroneals with some deep tissue massage, especially at the distal third where peroneal structures resurface. Let us know if this reduces any of the lateral foot numbness 8o

Considering the tingling is more of a concern than the pain in his back I guess I would test his neural tension in slump and SLR. If positive, neural mobilisation ex's might be beneficial. Depending on how irritable he is it may aggravate symptoms though. You can compensate by neural slide techniques which will allow the nerve to glide more freely (i.e. like a flossing technique). Hydrotherapy may be beneficial in maintaining ROM and retraining core stability may help with prevention.

For S1 root compression wheteher it is due to spinal stenosis caused by facet joint problems or due to the prolapse of intervertebral discs, try to remember these things. Flexion exercises of spine causes the unloading of the facet joints so relieve the spine from problems caused due to facet joint problems. On the other hand spinal extension exercises causes the unloading of the intervertebral discs, and so relieve the problems caused by intervertebral disc prolapse or degeneration,etc. So both spinal flexion and extension exercises will help to relieve the compression of S1 root caused by both facet and/or disc problems depending upon the nature of the cause. Try ultrasound therapy with continous mode paraspinal region to relieve the inflammation or oedema around the affected nerve sheath or nerve root to relieve the nerve ischemia caused by compression due to inflammation.

Williams flexion type of exercises will help best in stenosis of spine and of course of the nerve root compression. Advise the patient to do the bicycling and walking on a sloped treadmill to produce the flexion of the spine. In my opinion it will help you in clearing the problem of S1 root compression.

What about the results of continuous or sustained mode of lumbar traction? I have successfully treated the patient having nerve root compression symptoms due to prolapse of discs in the L/s region. The patients received these treatment sessions for several days with sustained traction for 24 hours after admitting in the indoor section of our hospital and were managed successfully regarding that. As they improved, they were discharged with a routine scheme of spinal flexion/extension exercises prophylactically to do at home.

Have any body out there also tested the results of these treatments?

Thanks everybody for the replies.

I have tried traction on a traction unit on this guy as well as tib-fib mobs along with deep tissue release on the peroneals. But unfortunately, he is still the same and I am not sure what can I do further for him.

He is waiting for an MRI scan for the problem.

As I mentined earlier his only problem is the numbness in his foot rather than pain.

Recently, I saw a patient with numbness in the lower limb that presented similarly to sciatica. After doing a neural length test this was ruled out. However, palpating the piriformis muscle caused pain and reproduction of his symptoms. Piriformis causes symptoms exactly that of sciatica eg: numbness in the foot. By using trigger point release over the piriformis muscle, the patient's symptoms dissipated. So maybe palpate this muscle checking for tightness or pain and go from there.

Best of luck

After over 25 years of practicing Physio, I have not found any techniques to remove numbness. When you give traction to relieve pressure on nerve root the numbness should also recover. You don't need 24 hours traction either, 15 minutes with continuous pull of 45 kgs will do the job.

Dear jowales

Kindly have a look over that whole discussion on S1 root compression to get a bird's eye view to get a better idea. I'm scared of your idea of giving 45KG traction if applied to a 50KG weight individual. Generaly when you are giving traction in sustained mode for longer duration, you have to use low weight.

Have a look on the over view upon the spinal traction procedures.
Spinal traction has effects of mechanical elongation of spine, facet joint mobilization, promoting muscle relaxation, reduction of pain. Spinal traction is indicated for spinal nerve root impingement, hypomobility of joints from dysfunction or degenerative changes, joint pain from symptomatic facet joints, muscle spasm or guarding, meniscoid blocking, discogenic pain, post compression fracture.
Continuous or prolonged traction is an effective mode of therapy. In it a static traction force is applied for several hours to several days usually in bed. Only small amount of weight is tolerable.
The effective force is influenced by the body position, weight of the part, friction of the treatment table, method of traction used and the equipment itself. Generally for vertebral separation:
1-In cervical spine, under friction free circumstances a force of approximately 7 percent of the total body weight separates the vertebrae. A minimum force of 11.25 to 13.5KG (25 to 30 l) is necessary to lift the weight of head when sitting and to counteract the resistance of muscle tension. The greatest amount of separation occurs during the first few minutes of treatment at a given force. To avoid treatment soreness, the first treatment should not exceed 10 to 15 lb. Muscle relaxation can be achieved at levels less than those needed for mechanical separation (4.5 to 6.75KG, or 10 to 15 lb) in the cervical spine. Progression of dosage at succeeding treatment will depend upon the goals and patient reactions.
2-In lumbar spine a minimum friction free force of half the body weight is necessary for mechanical separation. Some authorities suggest that 1/3 of the body weight should be used for lumbar traction. While some suggests that 60 percent of the body weight should be used for lumbar traction. Generally lumbar traction should be applied in range of 18 to 45KG. To avoid treatment soreness, the first treatment should not exceed half the patient weight. Progression of dosage at succeeding treatment will depend upon the goals and patient’s reaction.

There are controversies that exist between different literatures regarding the dosage applied for the spinal traction. Opinions vary among different authorities.
Have a look over a very useful article on Lumbar Traction.

www.thesaundersgroup.com/lumbar.pdf

I think that it will be of help to you. Please feel free to discuss more ideas or views in this regard.