Lumbar pain and driving, and non-traumatic medullary compression and its interference with driving

Lumbar pain and driving, and non-traumatic medullary compression and its interference with driving Lumbar pain and driving, and non-traumatic medullary compression and its interference with driving

Lumbar or low back pain is a common condition arising in the lumbar spine and spinal nerve roots.

Its estimated incidence rate ranges from 65%-80%, and is the leading cause of work disability in people under 45 years of age.

Acute lumbar pain

This is related to multiple causes, including:

  • Strong effort causing localised pain with non-irradiated spinal muscle contracture.
  • Vertebral fracture occurring after falling on the legs or in forced flexion; patients with osteoporosis, Cushing disease, bone disease, hyperparathyroidism, bone metastasis, multiple myeloma, and Paget disease are most vulnerable.
  • Protrusion of lumbar intervertebral disks, particularly at L5-S1 and L4-L5 levels, causing back pain, abnormal posture, and restricted motion.
  • Nerve root involvement causes pain, that is usually unilateral and associated to sensitivity disorders.
  • Facet joint syndrome, resulting from nerve root compression with no disk disease.
  • Hip diseases, that may cause pain irradiating to the buttocks and knees.

Chronic lumbar pain

Commonly associated to:

  • Lumbar spondylarthrosis, due to a degenerative process in lumbar vertebras causing exostosis, spinal canal stenosis, and nerve root compression.
  • Ankylosing spondylitis, with lumbar pain irradiating to the thighs, restricted motion and stiffness, evolving until decreased chest mobility and thoracic spine flexion occur.
  • Psoriatic arthritis, Reiter’s syndrome, and inflammatory bowel disease cause a similar motion restriction pattern.
  • Spondylolisthesis induces relapsing lumbar pain that may often be irradiated to the lower limbs.
  • Inadequate posture may cause lumbar pain due to muscle and ligament overload, but may be secondary to disk changes.
  • Lumbar hyperlordosis caused by standing for too long, a forced back and neck inclined position before computers and with no footrest, or a bad seating posture may cause lumbar pain.
  • Static changes in the lower limbs due to flat or cavus foot, forcing the spine to compensate posture, result in lumbar pain.
  • Scoliosis and uncompensated lower limb asymmetry cause pain.

The underlying cause should be treated, as well as symptoms using analgesic, muscle relaxant, and anti-inflammatory drugs.

Tips

  • Rehabilitation and recommendations to prevent exacerbations include driving advice.
  • Patients cannot drive while they are experiencing symptoms such as pain, loss of strength, and sensitivity changes.
  • Rest and physical therapy with massage are advised, and recommendations should be given to prevent exacerbation, including advice on driving.
  • A driver who sits inadequately at the driving wheel may promote the occurrence or worsening of lumbar pain.
  • Patients should therefore avoid low, soft chairs, and cushions under the knees. The vehicle should have a high, comfortable seat, with a straight back and a good neck rest.
  • Pain and neurological or motion restrictions may lead the physician to advise against driving.
  • If the patient is experiencing a period of anxiety or stress, all symptoms are exacerbated, thus decreasing vehicle control.
  • Drugs used for symptomatic treatment of these clinical conditions often have a sedative effect, e.g. benzodiazepines and major tranquillisers.
  • Physicians should warn patients that even if symptoms have improved and they already able to drive, maintenance treatment may cause them significant and dangerous side effects that may delay driving resumption until doses are decreased or treatment is discontinued.
  • Patients must not drive while they have symptoms.

Non-traumatic spinal cord compression

An extradural compression, due to vertebral metastases, or an intradural compression caused by extramedullary benign tumours, neurinoma, and meningioma may occur.

  • The lesional syndrome is characterised by involvement of one or several roots at compression level resulting in radicular pain that is usually severe, fixed, refractory to treatment, and exacerbated by Valsalva manoeuvres.
    Pain may be associated to a band of hypoesthesia, amyotrophic paralysis, and an abolished or inverted tendon reflex, a characteristic sign in cervical cord compressions.
  • The sublesional syndrome causes motor disorders initially causing intermittent gait impairment, with an unsteady limb and leg fatigue following motion, first unilateral and then bilateral.Changes subsequently become permanent, and gait is rigid, spastic, and finally impossible.
    Sensitive signs include tenderness and multiple paraesthesias, distal to lesion level, and are usually delayed as compared to motor signs. Thermal and pain sensitivity is impaired to a greater extent than position sensitivity.
    Sensitive symptoms slowly worsen until complete anaesthesia of the sublesional area eventually occurs.
    Sphincter disorders occur relatively late and cause a frequent urinary urgency that will limit driving.
  • The spinal syndrome is characterised by segmental spinal stiffness, mainly at cervical and lumbar level, painful deformity, and tenderness in spinous processes.

Tips

  • Loss of strength, pain, and sensitive and motor changes prevent movements for adequate use of vehicle controls, and driving is therefore not possible.
  • Pain and neurological or motion restrictions may lead the physician to advise against driving.
  • Patients cannot drive while they are experiencing symptoms such as pain, loss of strength, and sensitive changes interfering with driving safety.
  • Surgical spinal cord decompression requires a more or less prolonged subsequent functional recovery and safety period in which driving will not be allowed until a favourable report is issued by the specialist.
  • Depending on the required treatment for each condition, the specialist will determine in each case the ability to drive of the patient and will report it at each revision.
  • Eventual sequelae must be assessed for its potential interference with driving and reported. The possibility of recovering from sequelae over time should also be evaluated.
  • After surgery, the convalescence period before unrestricted driving is permitted is left to the discretion of each physician.
  • Permanent disabilities may be evaluated based on the specialist report to try and adapt the vehicle to the driver and permit driving with the restrictions imposed by law for each case.