Lumbosacral Neuritis: Causes, Symptoms, Diagnosis, Treatment, and Home Remedies
What Is Lumbosacral Neuritis?
Have you experienced lower back pains that keep coming back? Sometimes it can be accompanied by shooting pains that go down your leg. For some people, the pain that is felt in the lower back and legs is accompanied by a pronounced weakness of the muscles of the said leg or legs. These may be signs that you are experiencing what is called lumbosacral neuritis.
So, what is lumbosacral neuritis? Lumbosacral neuritis is a term that is used to describe the irritation of the several nerves that line the vertebrae or spinal column. Well, particularly in the lower back of the person being diagnosed. This part of the spine is called the lumbar region.
This particular area of the back and spine is densely packed with essential structures of the body. Now, they are housed along the spine which gives them support and protection. That means these structures that can be found on the lower back are actually really fragile.
The said structures include the joints of the spine, the soft pads that can be found in between each vertebra of the spine called discs, muscles, blood vessels, and nerves. As you can see, there are a lot of different sensitive areas that can trigger the pain felt on the lower back region.
All of these fragile essential structures can get inflamed and possibly cause lumbosacral neuritis. Whenever you feel pain in the lumbar area, know that there are several possible trouble points that your doctor will have to check. This means that your doctor will be very careful before making any critical decisions.
He or she will try to make the most accurate diagnosis. This is critical and should be made before recommending an appropriate treatment for pain in the lower back.
Note that the lumbar region includes up to 5 different vertebras – designated as L1, L2, L3, L4, and L5. Another bone – one that is particularly large – is the sacrum. That is the bone that can be found at the very base of the spinal column. This particular bone connects the spine to the pelvis.
The pain that one feels that stems from lumbosacral neuritis can be caused by the irritation of a nerve that lines any of these 5 vertebras. The irritation can be at the nerve root or at the fibers of the nerves.
Note that that is only one possible cause. Lumbosacral neuritis can also be caused when the discs on the lumbar region become bulged due to inflammation. That means inflammatory substances that are naturally produced there, such as the prostaglandin produced in the nerves, are leaking.
Sometimes the pain is more physical or mechanical than chemical. For instance, some patients may have a herniated disc which can cause a direct compression on the nerves. This continuous compression of the nerves will cause an irritation and eventually cause changes in any of the nerves that are degenerative in nature.
Ultimately, these degenerative changes in the nerves are the ones that cause the pain felt in the lumbar area. Now, these degenerative changes can also be caused by other contributing factors such as metabolic toxicity as well as metabolic disturbances.
When only one nerve is involved in a case of lumbosacral neuritis, it is called mononeuritis. On the other hand, when there are two or more nerves involved in this condition, then it is called polyneuritis.
Earlier we mentioned that there are several sensitive areas that are housed within the lumbar region. With that we also pointed out that the pain felt in that area of the spine may occur due to different possible causes. Essentially there can be an inflammation, irritation, herniated disc, compression (which can either be caused by a tumor in the spine or small bone spur, and/or endocrine condition (e.g. diabetes) that is affecting the region of the lower back.
We will look at these possible causes in detail in this chapter. Note that a doctor will try to identify the possible cause before in the process of formulating a proper and accurate diagnosis.
Possible Cause #1 - Herniated Lumbar Disc
In between each vertebra of the spinal column is a spongy disc. This small invaluable part of the spine cushions the bones that form the entire column on your back. You can think of them as a kind of shock absorber. Bones gyrating against each other given the pressure from the weight of the entire body can be quite painful.
To prevent that from happening, Mother Nature has equipped vertebral creatures, including human beings, with these discs. When these discs are healthy they are quite flexible yet durable. They can take a lot of pressure and they are usually quite tough.
However, just like any part of the human body, these discs can also become unhealthy. They can also break open due to too much pressure and they can also bulge. In which case they can rupture. This is why this condition is also called a ruptured disc or a slipped disc.
You can get a herniated disc on any part of the spine. However, the lower back is usually susceptible to this kind of injury. A lot of the weight of the human body is carried by the lumbar spine as it is. Getting a herniated disc on the thoracic spine or the upper back is considered a rare condition. However, it shouldn't surprise you that some people have experienced getting a slipped disc on the cervical spine or the neck.
Possible causes of a herniated lumbar disc:
- Spinal injury - it is possible to get the disc injured. Tiny cracks or tears in the outer layer of the disc can occur. The outer layer is usually harder compared to the rest of the parts of the disc. When these cracks or tears appear, the thick gel inside can get forced out through them. When that happens, the disc will either break open or it will tend to bulge. The effect of course is pain in the lower back or lumbar region.
- Regular wear and tear - a herniated disc can also be caused by the regular wear and tear experienced by the body. As we grow old, our organs, bones, and other parts of the body won't have the same vitality it used to have. The discs in our spinal column also experience this. When we grow older, these discs will dry out and in effect they will not be as flexible as they used to. This drying out effect increases the chances for the vertebra to grind against each other thus causing pain in the lumbar area of the back.
Symptoms of a Herniated Disc
When you have a herniated disc and it presses against one of the roots of your nerves, then it can cause a feeling of weakness, numbness, and pain in the associated area. The pain is felt wherever the nerve travels through the spine. So, for instance, you have a herniated disc in your lumbar area, you will most likely feel pain in the leg, the buttocks, and lower back with some numbness as well.
In case you feel numbness in both legs and this is coupled by the loss of bowel control or bladder control, you should seek immediate medical attention. It can be a symptom of a more serious condition known as cauda equina syndrome.
Possible Cause #2 - Compression
One of the possible causes of lumbosacral neuritis is compression. It can occur due to many different reasons. One cause is the growth of a bone spur, which, due the natural movement of the spine, presses down on the nerves. Another cause for compression is the formation of a herniated disc, which has been discussed above. Another factor that can cause compression on any of the nerves lining the lumbar region of the spine is a spinal column tumor.
What is a Spinal Column Tumor?
Tumors can also develop on the spine - well, on the spinal canal to be exact. Sometimes tumors can also grow or develop within the very bones of the spinal column. Note that these tumors aren't automatically cancerous. Some spinal column tumors are non-cancerous.
You may have heard of vertebral tumors. Those are the tumors that directly affect the bones of the spinal cord. Now, when the tumor begins within the bones of the spinal cord, then they are called spinal cord tumors. These tumors can be classified into two major types, which are the following:
- Extramedullary Tumors: Extramedullary tumors are tumors that grow or develop in the network of cells that support and are found directly surrounding the spine. They do not necessarily begin in or at the spinal cord itself. There is a chance that these tumors can affect the function of the spinal cord. The effect is either by way of compression or some other such problems. Examples of this kind of tumor include neurofibromas, meningiomas, and schwannomas.
- Intramedullary tumors: These tumors are the ones that actually begin within the cells of the spinal cord. Examples of this type of tumor include ependymomas and astrocytomas. An ependymoma is a tumor that grows in the ependymal - a body tissue that is part of the central nervous system. Astrocytomas on the other hand are the most common type of brain tumor and it is a type of glioma. An astrocytoma usually develops in the cerebrum however there are also cases where they grow on the spine.
It should also be noted here that tumors that originate from other parts of the body can actually spread (also referred to metastasized tumor) to the spinal column (cases of which are rare but they have occurred). At times tumors can also spread to the supporting cells near or around the spine.
The growth of these spinal tumors can cause a good deal of pain. They can also cause a number of neurological problems. In some cases these tumors can even cause paralysis. Some of these tumors are cancerous while others are not - however, whether they are cancerous or not these tumors are considered in the medical world as life threatening. They can also cause permanent disability.
Doctors may recommend any of these available modern treatment options: chemotherapy, radiation therapy, surgery, or medications. Your physician will determine which mode of treatment will be necessary or appropriate.
Possible Cause #3 - Infection
Serious health infections can also cause pain in the lower back area. An infection can come about due to a co-occurring condition, which includes hepatitis, diphtheria, HIV/AIDS, and others. Some infections are severe enough to cause an inflammation in the lumbar area and thus affect the nerves along the spinal cord.
Possible Cause #4 - Inflammation
There are health conditions that give rise to inflammation. These health conditions include hypothyroidism, diabetes, cancer, and other endocrine diseases. The increase in inflammation can cause an increase in pressure on the lumbar area of the spinal column, well, at the nerves lining the area in particular. The increase in pressure can lead to pain which is commonly called lumbosacral neuritis.
Possible Cause #5 - Systemic Toxin Exposure
It has been shown that exposure to a number of toxins can lead to lumbosacral neuritis. That includes environmental toxins, the interaction of different medications, drugs, exposure to different chemicals, and alcohol dependence.
An Australian Review
Some have asked if the regular consumption of alcohol can lead to pain in the lower back. There have been studies that suggested that there is such a risk. However, there is still a lack of a formal review to validate the proposed connection between alcohol consumption and lumbar pain.
A study conducted in Australia sought to change that and was published the Manual Therapy Journal. The said study was published both in print and online - the online copy was published earlier (November 2012) than the printed version.
The researchers reviewed the prior studies on lower back pain that suggested the association with alcohol intake. They pulled quantitative results from the said studies being reviewed and they conducted some statistical analysis. The goal was to determine whether there was really a connection for the risk of lower back pain with one's level of alcohol intake.
After the review, the researchers concluded that there is a risk for lumbar pain associated with alcohol intake but only for people with alcohol dependency and abuse. The association is more common with test subjects in this category than with test subjects who have no problem with alcohol abuse. But that doesn't mean you will never be susceptible to lower back pain due to alcohol intake or exposure to other systemic toxins if you don't abuse them.
Possible Cause #6 - Imbalanced Diet
Another possible cause for lumbar pain is dietary imbalance. If your diet is deficient in B vitamins like niacin and thiamin, minerals, and other vitamins, then you may be susceptible to lower back pain.
Possible Cause #7 - Scar Tissues
If you have had surgery at the lumbar area then scar tissues and the presence of adhesions can cause a form of compression in the area of the surgery. This can eventually bring about an inflammation and thus lead to pain in the lower back.
Possible Cause #8 - Chronic Acidosis
Another identified possible cause of pain in the lower back is chronic acidosis. This is a condition where the blood has become too acidic. This acidic change in the other body fluids has also been observed. Note that in normal or healthy conditions your body fluids will usually remain alkaline.
So how does the blood and other body fluids turn acidic? The acidity of body fluids can be caused by the build-up of acid waste matter in bodily tissues. This actually doesn't happen overnight. It gradually builds up over time due to an unhealthy diet. It eventually results in acidosis.
Acidosis is usually observed in people who have diabetes, who are obese, and also in those who are suffering from severe forms of diarrhea and vomiting. Another cause of acidosis is the accumulation of lactic acid both in the body as well as in the blood. The increase of lactic acid does not only contribute to the risk for acidosis but it also increases one's risk to other conditions such as heart attack and seizures.
Possible Cause #9 - Foraminal Stenosis
The nerves in the lumbar region pass through what is called the spinal foramina. From there they extend to the peripheral organs and other tissues thus forming a network of nerves outside the spine. Foraminal stenosis is referred to as the narrowing of the foramina.
This narrowing is caused by chronic ostheoarthritis. The nerves in the foramina get pinched as it were when the passageway gets tighter. Eventually this form of compression causes pain in the lumbar area.
Symptoms of Lumbosacral Neuritis
Earlier on we have touched on the symptoms that one may experience with lumbosacral neuritis. One of the most common symptoms expressed by patients is that shooting pain one feels down the legs. Of course, they also complain about the pain they experience on their lower backs. These are the most common symptoms of this condition. In this chapter we'll go over some of the details of the symptoms of this medical condition.
Pain is the number one complaint that you will get from people who suffer from lumbosacral neuritis. Some pain that is reported can be very severe while other patients who suffer from this condition report manageable pain. Most of the time they will report that the pain they feel is usually present in the dermatomal distribution of the lumbar nerves. Simply put, they are referring to that part of the skin covered by the lumbar area.
Where the nerves are located is where the pain is usually found. This type of pain is also referred to as a radicular pain. Most of the time, people who suffer from this condition will tell you that the pain they feel is continuous. In some cases, the pain is so severe that over the counter pain relief medications. The severity of the pain varies from one patient to the next.
Numbness and a Tingling Sensation
Another common symptom that is reported by people who experience this condition is either a tingling sensation in the affected areas or in some more severe cases a feeling of numbness. This is due to the fact that the blood flow to the foramina area is constricted. The nerves in that area aren't getting as much blood as they should.
This is also the first signs of nerve damage or what is known as nerve degeneration. People will feel a tingling of the nerves along the area that is affected. Since the affected area is along the lumbar, expect to feel this tingling and numbness there along with other related areas such as the hip and the legs. After a few weeks the patient will also feel a numbness along the skin that is actually being supplied by the affected nerves.
Weakness of the Muscles
As stated earlier, one of the most common symptoms of lumbosacral neuritis is the feeling of weakness in the muscles. Note that motor fibers are also located within the nerves of the affected area. Since the blood flow has gotten constricted (with the associated tingling sensation) the motor nerve that is located there will undergo ischemic changes.
That means the weakness that one feels at the time is actually a sign that the motor nerve is degenerating. That means all the muscles that are being supplied by the motor nerve will get this feeling of weakness.
When several motor nerves are affected by this condition, it is called lumbosacral polyneuritis. That means more than one motor nerve is irritated or pinched simultaneously. Note that this is a very serious condition and that lumbosacral polyneuritis can also lead to the paralysis of the leg muscles.
Other Related Symptoms
Other than the main symptoms described above there are other symptoms that can be felt or reported by people who experience this condition. They may report any or a combination (or all) of the following:
- Reduced muscle control and muscle coordination
- A reduction in muscle mass
- Poor reflexes
- Pain that is only experienced at night
- Chronic pain experienced only during the day or only at night and sometimes both
- A sharp pain
- Burning pain
- Inability to feel anything when the skin is touched or when pressure is applied
- Inability to feel any changes in the temperature
- Muscular atrophy that can affect one muscle or an entire muscle group
Getting a Diagnosis
Given all the factors that have been discussed, lumbosacral diagnosis can be a bit challenging. There are a lot of factors involved and more specifically there are several nerves to test or check. An important step is for your doctor to perform specific tests in order to identify which nerves are actually affected. Another concern that will be raised by a physician is the identification of the disc or discs that have been affected by this condition.
Now, the isolation of certain nerves can be very difficult and at times impossible to exactly pinpoint. Remember that some nerves are very small and they even have a number of parts, which contributes to the overall difficulty in isolating and identifying them.
Types of Affected Nerves
The nerves that run through the length of the spinal column can be classified into two separate groups. The first one is the sensory nerves and the other category includes the motor nerves. The sensory nerves are responsible for the transmission of messages from the brain to the different parts of the body (they are related to sensory functions). These nerves are also connected to the network of peripheral nerves (i.e. the nerves that aren't directly part of the brain and the spine). These nerves also receive signals and messages originating from other nerves of the body and send it back to the central nervous system.
The motor nerves as you may have deduced by their name is responsible for the various motor functions of the body. They are connected all the way to the extremities of your body. That means if there are messages or signals that originate from the central nervous system that need to be relayed to the body's extremities then these are the nerves that will do the job.
Which Type of Lumbosacral Neuritis?
There are actually different types of lumbosacral neuritis. A doctor will perform tests to diagnose which type is being experienced by a patient. Here are details on the three different types.
1. Lumbar Mononeuritis: analyzing this type of neuritis by name, we know that it affects the area of the lumbar region (i.e. your lower back). We can also deduce that this neuritis only affects a single nerve.
There are actually two subtypes of Lumbar Mononeuritis. The first one concerns the lumbar motor nerve and the other one affects the lumbar sensory nerve. Note that the symptoms of each subtype will differ since one affects the motor functions while the other one affects sensory. However, it is also possible that a patient will experience both of these subtypes of Lumbar Mononeuritis at the same time.
2. Lumbar Polyneuritis: Lumbar Polyneuritis also has two subtypes. Compared to the first one, this type of lumbosacral neuritis affects more than one nerve in the lumbar area or lower portion of the spine - this second type is related to inflammation. The first subtype is called lumbar sensory nerve inflammation. The second one is lumbar motor nerve inflammation. In this case, doctors will test for either motor or sensory nerve inflammation. Again, the symptoms will be different for each type but both types will still affect the lumbar region.
3. Mixed Nerve: This third type of lumbosacral neuritis affects both types of nerves - motor and sensory. This type will usually affect a few sections of the lumbar spine. If this is the case your doctor will diagnose your condition as a mixed neuritis.
There are several elements that a doctor will rely on to properly diagnose lumbosacral neuritis. The diagnostic procedure will begin as usual. The patient will come in for an examination and will report the symptoms being experienced. The doctor will then perform a thorough physical exam. Note that the physical exam will include reflex testing.
After that a set of different diagnostic tests will be conducted. The tests that a doctor will recommend will depend on the symptoms that were reported by the patient. The results of the tests will also determine whether or not other tests need to be performed.
The diagnostic tests that a doctor will recommend may include any of the following:
- Complete Blood Count (CBC) - a CBC is used to determine nutrient imbalances, particularly imbalances in vitamins and minerals. This test will also reveal the overall blood composition of the patient being examined.
- Electromyogram (EMG) - an EMG will be used to measure the level of nerve function as well as nerve conduction.
- White Blood Cell Count (WBC) - this test is used to identify a possible infection, which is one of the many possible causes for lumbosacral infection. This test will identify if there is an increase in the amount of white blood cells.
- Nerve Conduction: This test is used to identify and isolate the possibly affected sensory or motor nerves.
- Nerve Biopsy: A nerve biopsy on the other hand is used to identify possible nerve damage as well as look for neuropathy.
- X-Ray: your doctor may initially order an x-ray to check for possible structural damage on the spine. It will also be used to identify co-occurring conditions along the spinal cord. For instance, if your doctor suspects the narrowing of the area of the lumbar spine, which can possibly mean having spinal stenosis, then an x-ray will be ordered.
- Magnetic Resonance Imaging (MRI): an MRI is used by doctors to identify structural damage that cannot be completely verified using an X-Ray. If your doctor suspects cancer, aneurysm, tumors, or herniated discs but can't identify them using an X-ray then an MRI will be ordered.
In many cases a doctor can already make a diagnosis based simply on a thorough physical examination. This can be done with the help of a patient's medical history. Whenever a definitive diagnosis cannot be made this way, then will the doctor order a spinal x-ray or any of the diagnostic tests mentioned above. They will check for possible irregularities on the alignment of the bones along the spinal column.
An x-ray can already reveal possible causes such as fractures, the formation of bone spurs, tumors, osteoporosis, and the narrowing of disc spaces.
Matching the Treatment Plan with the Probable Cause
Prescribing a treatment for lumbosacral neuritis should be made after a careful and accurate diagnosis has been made. The treatment plan will be selected depending on the particular cause of the condition. For instance, if a patient's lumbosacral neuritis is due to the onset of diabetic neuropathy then the treatment should include the management of diabetic conditions.
The damage to the nerves is due to a patient's diabetic condition. Note that diabetic neuropathy is a common cause for people with lower back pain who also have diabetes. Along with good control over the diabetic condition, the treatment plans for people with this type of neuropathy will also include physical therapy as well as the intake of multivitamins.
Now, if the lumbar pain is actually caused by a tumor then an appropriate surgery will be ordered by the physician. After surgery, radiotherapy or its equivalent will be prescribed as well. As you can see, physical therapy alone will not benefit a patient with lumbosacral neuritis if the said condition is caused by a tumor.
After a definitive diagnosis, a doctor can help provide at least three different types of treatment approaches. There are conservative approaches, moderate approaches, and surgical treatment approaches.
- Conservative Approach: A conservative approach of treatment usually involves only the intake of over the counter medication. Sometimes prescriptions from your doctor may be required using this treatment type. There are also at home helps that can be prescribed by your doctor, which would include the use of lumbar cushions, assistive devices, certain types of exercise, and stretching that helps the lumbar region.
- Moderate Treatment Approach: A moderate approach to treating lumbosacral neuritis will also involve the taking of medication (over the counter and/or prescribed) as well as physical therapy. Included in this category of treatment are alternative methods of treatment which include chiropractic and acupuncture therapy. Note that both the moderate and conservative modes of treatment are non-invasive and will not have a huge impact on the quality of life of the patient.
- Surgical Treatment Approach: A doctor will only suggest and prescribe a surgical treatment approach when there is no other alternative than to use an invasive treatment. That means there are no other alternatives to relieve the pain and alleviate the other symptoms of lumbosacral neuritis. Remember that the treatment option will always be specific to the type of cause of the condition and its accompanying symptoms. If there is a co-occurring condition such as an infection, then the infection should be treated and then the other symptoms should be alleviated in time. Doctors will not focus on a symptomatic form of treatment. The strategy is to address the underlying condition for a longer lasting treatment and hopefully a complete resolution of the medical condition.
How Can You Help?
There are a few things that you can do to help your doctor arrive at a truly accurate diagnosis. You can do the following:
- Keep a daily log or diary entry of the symptoms you are experiencing. Be very specific about the details and descriptions of these symptoms. Make sure to include the time when each symptom is experienced as well as their duration.
- Make a thorough list of the medications you are currently taking. Make sure to include vitamins you take as well as other supplements that you are currently on.
- Make sure to schedule a medical exam with a trusted neurologist.
- Agree to undergo diagnostic testing in order to arrive at a truly specific diagnosis.
- Follow any treatment recommendations made by your doctor. Keep at it until all the symptom have been alleviated. Be as strict with yourself as much as possible.
Pain Management and Treatment
Pain is usually associated with this type of neuritis. Some cases can be managed with the intake of over the counter pain medications. However, some cases will require a prescription for pain medication from your doctor. In some cases, one may have to take non-steroidal anti-inflammatory drugs (NSAID).
Note that NSAIDs are used to treat cases of lumbosacral neuritis that have more severe pain. This means that over the counter medications have been tried and they aren't able to relieve the pain experienced by the patient. In other cases, a doctor may prescribe the use of opiods for pain relief. An example of which is hydrocodone.
There are physicians who will prescribe the use of injectable steroids. These steroid injections will be placed directly into a patient's spine. The effect is immediate relief from both inflammation and pain. Note that this form of pain treatment from lower back pain has been observed to be quite effective. Nevertheless, it should be noted that this mode of treatment for back pain is definitely more expensive than other options.
Apart from the spinal injection, a physician may also suggest that a patient should take vitamin supplements to help prevent the onset of pain. Vitamins supplements such as Vitamin B1, B12, B2, B6 and others may be suggested. The effects of taking these vitamins can be observed rather quickly - usually as fast as 30 minutes after intake.
As it was explained earlier, lumbosacral neuritis can be caused by acidosis. If this has been identified as the primary cause for the said condition then the patient should undergo hospitalization. Further investigations will be made by your doctor to confirm the said findings. One treatment that may be prescribed by your doctor is intravenous bicarbonate therapy.
The abnormal fluctuation of blood sugar is one of the effects of diabetes. This can be contributory to the symptoms experienced in lumbosacral neuritis. Advanced investigation and monitoring will be prescribed by a doctor in this situation. The goal is to prevent the persistent increase of the patient's blood sugar - usually making sure that it does not go over 200 mg.
Various home remedies can be prescribed to help alleviate the symptoms and pain associated with this medical condition. The following home remedies have been found to be quite beneficial:
- Hot Epsom salt baths done weekly.
- Raw spinach and carrot intake
- Barley brew
- Soya bean milk plus honey - to be taken every night
- Place a heating pad in the area that is affected
- Keep hydrated, drink lots of water
- Eat well balanced meals
I hope this hub was able to help you to understand the causes, diagnosis, and treatment of lumbosacral neurosis.
Finally, if you enjoyed this hub, then I’d like to ask you for a favor, would you be kind enough to share this hub on social media? It’d be greatly appreciated!
Do you or your relatives have lumbosacral neuritis symptoms?
Consult Your Doctor
Record of the symptoms you are experiencing and work with a qualified physician to alleviate the pain and other symptoms and to treat the condition correctly.
- "Lumbar Herniated Disc". By WebMD. Retrieved Jul. 23, 2017.
- "Spinal cord tumor". By Mayo Foundation for Medical Education and Research. Retrieved Jul. 23, 2017.
- "Astrocytomas". By Cancer Treatment Centers of America. Retrieved Jul. 23, 2017.
- "Does Drinking Alcohol Lead to Lower Back Pain?". By Spine Universe. Retrieved Jul. 23, 2017.
- "Who, what and when of surgery for the degenerative lumbar spine". By US National Library of Medicine National Institutes of Health. Retrieved Jul. 23, 2017.
This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.