Lumbar Radiculopathy

Contents

Definition/Description

Radiculopathy is a condition due to a compressed nerve in the spine that can cause pain, numbness, tingling, or weakness along the course of the nerve. Radiculopathy is not a synonym for “radicular pain” or “nerve root pain”, but patients with radiculopathy common have nerve root pain.

Radiculopathy = the whole complex of symptoms that can rise from nerve root pathology, including anaesthesia, paresthesia, hypoesthesia, motor loss and pain.

Radicular pain and nerve root pain = specifically apply of a single symptom (pain) that can arise from one or more spinal nerve roots.[1] Lumbar radiculopathy is a disorder of the spinal nerve root from L1 to S1.Radiculopathy can occur in any part of the spine, but it is most common in the lower back (lumbar radiculopathy) and in the neck (cervical radiculopathy). It is less commonly found in the middle portion of the spine (thoracic radiculopathy).[2]

Lumbar radiculopathy is a chronic pain which occurs in the lower back and legs. It is caused by damage to the lower spine which causes compression of the nerve roots which exit the spine. The compression leads to tingling, numbness, and occasional shooting pains. A variety of conditions can lead to compression of the nerve roots, which means that there are several different approaches to the treatment and management of lumbar radiculopathy. Radiculopathy can occur in any part of the spine, but it is most common in the lower back (lumbar radiculopathy) and in the neck (cervical radiculopathy). It is less commonly found in the middle portion of the spine (thoracic radiculopathy).

Epidemiology /Etiology

Risk factors for radiculopathy are activities that place an excessive or repetitive load on the spine. Patients involved in heavy labour or contact sports are more prone to develop radiculopathy than those with a more sedentary lifestyle.
Radiculopathy is caused by compression or irritation of the nerves as they exit the spine. This can be due to mechanical compression of the nerve by a disk hernia ion, a bone spur (osteophytes) from osteoarthritis, or from thickening of surrounding ligaments.
Other less common causes of mechanical compression of the nerves is from a tumour or infection. Either of these can reduce the amount of space in the spinal canal and compress the exiting nerve. Scoliosis can cause the nerves on one side of the spine to become compressed by the abnormal curve of the spine. Another causes is degeneration. As people age, their spines are subject to increasing degeneration which can cause herniated discs and similar problems, leading to lumbar radiculopathy. There is no specific prevention for radiculopathy. Maintaining a reasonable weight, good muscle conditioning, and avoiding excessive exercises.

Characteristics/Clinical Presentation

Symptoms of lumbar radiculopathy

General symptoms of a spinal nerve root injury:

  • - Failure of the sensible dermatome. Because of the overlap of the dermatomes there will be never be a total loss of touch by an injury of one nerve root.
  • - Radiating electric pain, coupled with irritation in the periphery. The pain arises or decreases by pressure increment, stretch (Lasègue) and certain positions. Paravertebral pressure above the nerve root causes pain in the periphery.
  • - Tendonreflexes are reduced or fall out
  • - Sometimes there is a motorial loss, where the pain often disappears abruptly

Pain: the description of nature and localisation of the pain is important. Pain drawings are often used for this purpose.
The most patients describe their pain as “aching” or “sharp”.

Nerve root pain should not be expected to follow along a specific dermatome. Dermatomal maps and a dermatomal distribution of pain is not a useful historical factor in the diagnosis of radiculopathy. The exception of this is S1 radicular pain, in which the pain does commonly follow the S1 dermatome.

The clinical presentation of lumbar radiculopathy will vary depending on the cause of the radiculopathy and which nerve roots are being affected. Patients will often present with pain in the lumbar region that radiates through one or both legs. This pain is often described as burning, stabbing, or shooting. For this pain to be considered radiculopathy, however, neurological signs must be present such as weakness, numbness, or reflexive changes.[3] The following chart may be useful in identifying radiculopathy clinically.

Question +LR (yes) -LR(no)
Weakness? 1.2 .73
Numbness? 1.0 .94 [4]

See test diagnostics page for explanation of statistics. 

Clinical presentation for radiculopathy from each lumbar nerve root: 


Nerve Root Dermatomal area Myotomal area Reflexive changes
L1 Inguinal region Hip flexors
L2 Anterior mid-thigh Hip flexors
L3 Distal anterior thigh Hip flexors and knee extensors Diminished or absent patellar reflex
L4 Medial lower leg/foot Knee extensors and ankle dorsiflexors Diminished or absent patellar reflex
L5 Lateral leg/foot Hallux extension and ankle plantar flexors Diminished or absent achilles reflex 
S1 Lateral side of foot Ankle plantar flexors and evertors Diminished or absent achilles reflex [4]
  • Dermatomes and myotomes aren't intended as an all-inclusive list, but rather a clinically relevant system to assist in neurological screening. See dermatomal map to the left for further clarification.


Cauda Equina Syndrome:

Although relatively rare, cauda equina syndrome is a serious condition resulting from a central prolapse of a nucleus pulposus in the lumbar region. Cauda equina syndrome will present as bowel and bladder impairments, saddle area paresthesia (S4), and possible gross limitation of all lumbar movement. This condition constitutes an immediate referral to a physician.[5]

Causes of lumbar radiculopathy

The most common causes of radiculopathy:
- lateral canal stenosis
- herniated disk [6][7]

The leading causes of monoradiculopathy:
- Compression: prolapse of the discus intervertebralis, arthrosis deformans with narrowing of the foramen intervertebrale, metastasis at the vertebral column
- Infections: Herpes zoster [2]

Spinal cord disorders with a back strand disorder:
- Myelitis transversa (radicular irritation often preceding)
- Myelopathy because of B12- deficiency (arise gradual with gnostic sensibilisation disorders and paresthetics in the legs)
- Multiple sclerosis
- Spinocerebellum degeneration [8]

Differential Diagnosis

Clinical evaluation of lumbosacral radiculopathy begins with:

  • - Medical history (type, location and duration of symptoms, presence of subjective weakness and dysesthesia, current therapy, dermatomal radiation, absence of work)
  • and physical examination: dermatomal sensory loss, myotomal weakness, straight leg raise[9][10]  and reflexes
  • - X-rays(identify the precence of trauma or osteoarthritis and early signs of tumor or infection)
  • - EMG: useful in detecting radiculopathies
  • - MRI: used to see if disc herniation and nerve root compression are present in patients with clinical suspicion of lumbosacral radiculopathy.[11]
  • Nerve root compression is present  discectomy will be considered.[12][13]
  • In patients with clinical suspicion of lumbosacral radiculopathy and normal MRI findings, EMG may help in diagnosing nerve root involvement in patients with otherwise unexplained leg pain.[12]
  • Significant predictors of radiological nerve root compression (one of the most common causes of radiculopathy) are:
  • - dermatomal radiation
  • - more pain on coughing, sneezing or straining
  • - positive straight leg raise (SLR) and finger-floor distance
  • - ongoing denervation on EMG [12][13]

Diagnostic Procedures

Special Tests:

Straight Leg Raise Test: 

Patient lies supine and raises the leg on the involved side with the knee extended. If pain is produced at 40 degrees or less of hip flexion, the test is positive. Symptoms can be sharpened by adding ankle dorsiflexion to the straight-leg raise. Even if the test is negative, useful information can be gained if symptoms are produced past 40 degrees of hip flexion, assuming that hamstring length is equal. 

Crossed Straight Leg Raise Test:

Patient lies supine and raises the leg on the uninvolved side with the knee extended. If pain is provoked down the involved leg, the test is positive for radiculopathy, and indicates that there is likely a large space-occupying lesion (herniated nucleus pulposus). This test is useful for ruling in radiculopathy, as it is highly specific for it. 


Examination

A complete physical and neurologic examination can reveal defects at specific levels.

Physical examination[14]

  • Search for external manifestations of pain, including an abnormal stance.
  • Examination of the patiënt’s posture and gait. (Sciatic list = indicator)
  • Palpation of the spinous processus and the interspinous ligaments.
  • Evaluation Range of Motion.

Motor, sensory and reflex function should be assessed to determine the affected nerve root level.[15] Specific movements and positions that reproduce the symptoms should be investigated during the examination to help determine the source of the pain and the affected nerve root level.

More information about the neurologic examination: See 'Characteristics/Clinical Presentation'

Medical Management

Medical management includes patient education, medications to relieve pain and muscles spasm, cortisone injection around the spinal cord (epidural injection), physical therapy (heat, massage, ultrasound, electrical stimulation), anti-inflammatory medications, or chiropractic treatment, and avoiding activity that strains the neck or back. By research the majority of radiculopathy patients respond well to this conservative treatment, and symptoms often improve within six weeks to three months. 

Physical Therapy Management

The more treatable condition of lumbar radiculopathy, however, arises when extruded disc material contacts, or exerts pressure, on the thecal sac or lumbar nerve roots.[16]

The literature support both conservative management and surgical intervention as viable options for the treatment of radiculopathy caused by lumbar disc herniation. Surgical intervention may result in faster relief of symptoms and earlier return to function, although long-term results appear to be similar regardless of type of management. The ultimate decision regarding type of treatment should be bases on a surgeon-patient discussion, in light of proper surgical indications, duration of symptoms, and patient wishes.[16]

Physical therapy can include mild stretching and pain relief modalities, such as ultrasound, whirlpool, ice and heat pack therapy, electrical stimulation, and/or massage [16] ,active stabilisation, lasertherapy[17], conditioning exercise and ergonomic program [18],
Positional distraction: It can isolate the spinal level to maximally open the effected neuroforamen. The combination of lateral flexion (away from the targeted neuroforamen), lumbar flexion (flexed hips to induce forward bending at targeted segment) and lumbar rotation (patient’s bottom arm is pulled upward) can maximally open a targeted neuroforamen. The intervention is effective when the patient report relief of leg pain shortly after placement in the position. It can be performed in the clinic and at home.[18]

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References

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  1. Pain patterns and descriptions in patients with radicular pain: Does the pain necessarily follow a specific dermatome?;Donald R Murphy*1,2,3, Eric L Hurwitz4, Jonathan K Gerrard5 and Ronald Clary6
  2. 2.0 2.1 Klinische neurologie; dr. H.J.G.H. Oosterhuis
  3. Svetlana Tomic et al. (2009). Lumbosacral Radiculopathy - Factors Effects on It's Severity. Coll. Antropol. (33)1: 175-178.
  4. 4.0 4.1 Flynn, T., Cleland, J., Whitman, J. (2008). User's Guide to Musculoskeletal Examination. Buckner, Kentucky. Evidence in Motion.
  5. Dutton, M. (2008). Orthopaedic Examination, Evaluation, and Intervention, 2nd edition. McGraw Medical, New York.
  6. Movement, stability & lumbopelvic pain; A. Vleeming,V. Mooney, R. Stoeckart
  7. Donald R Murphy, Eric L Hurwitz, Jonathan K Gerrard, Ronald Clary. Pain patterns and descriptions in patients with radicular pain: Does the pain necessarily follow a specific dermatome?. BioMed Central (2009).
  8. Klinische neurologie; dr. H.J.G.H. Oosterhuis
  9. Manual physical therapy of the spine; Kenneth A. Olson
  10. Diagnostic value of history, physical examination and needle electromyography in diagnosing lumbosacral radiculopathy;Suzan Coster Æ Sebastiaan F. T. M. de Bruijn Æ De´nes L. J. Tavy
  11. ALLEN R. LAST, MD, MPH, and KAREN HULBERT; Chronic Low Back Pain: Evaluation and Management;Am Fam Physician. 2009;79(12):1067-1074(Level B)
  12. 12.0 12.1 12.2 Diagnostic value of history, physical examination and needle electromyography in diagnosing lumbosacral radiculopathy;Suzan Coster Æ Sebastiaan F. T. M. de Bruijn Æ De´nes L. J. Tavy
  13. 13.0 13.1 Plastaras CT, Joshi AB.; The electrodiagnostic evaluation of radiculopathy; Phys Med Rehabil Clin N Am., 2011, 22, 59-74.(level B)
  14. Humphreys SC, Eck JC. Clinical evaluation and treatment options for herniated fckLRlumbar disc. Am Fam Physician. 1999 Feb 1;59(3):575-82, 587-8. (Level of evidence: 2B)
  15. Klein JD, Garfin SR. Clinical evaluation of patients with suspected spine problems. In: Frymoyer JW, ed. The adult spine. 2d ed. Philadelphia: Lippincott-Raven, 1997:319–40.(Level of evidence: 5)
  16. 16.0 16.1 16.2 Andrew J. Schoenfeld, Bardley K. Weiner. Treatment of lumbar disc herniation: Evidence-based practice. International Journal of General Medicine (2010).
  17. Ksenija Bošković, Snežana Todorović-Tomašević, Nada Naumović, Mirko Grajić, Aleksandar Knežević; The quality of life of lumbar radiculopathy patients under conservative treatment; Vojnosanit Pregl 2009; 66(10): 807–812 (level B)
  18. 18.0 18.1 Manual physical therapy of the spine; Kenneth A. Olson

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