Lumbar Radiculopathy

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Definition/Description

Lumbar radiculopathy occurs in the lower back and causes pain in de lower back and hip radiating down the back of the thigh into the leg. It is caused by damage to the lower spine which causes compression of the nerve roots which exit the spine. The compression can lead to tingling, radiating pain, numbness, paraesthesia and occasional shooting pains. 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). ^{(LOE 1B)}
Radiculopathy is not the same as “radicular pain” or “nerve root pain”. Radiculopathy and radicular pain commonly occur together, but radiculopathy can occur in the absence of pain and radicular pain can occur in the absence of radiculopathy. ^{(LOE 5)}
Radiculopathy can be defined as 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 can be defined as a single symptom (pain) that can arise from one or more spinal nerve roots. ^{(LOE 3B)} Lumbar radiculopathy is a disorder of the spinal nerve roots from L1 to S1.
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.

Clinically Relevant Anatomy

The vertabral column consists of 33 vertebrae divided in five regions: a cervical, thoracic, lumbar, sacral and coccygeal region. The lumbar region counts 5 vertebrae and is located in the lower back between the thorax and sacrum. The lumbar vertebrae have massive bodies that are much larger than the other vertabrae.^{(LOE 5)} The foramina vertebralis is also bigger and the facies articularis of the processus articularis inferior are turned outwards. These structures of the lumbar vertebrae have been developed to allow forward and backward movements of the lumbar spine. ^{(LOE 5)}

The intervertebral discs provide a strong attachment between the vertebral bodies. They are important to supply movement between neighboring vertebrae but they also have a bouncy deformability that allows them to serve as shock absorbers. Each intervertebral disc consist of an anulus fibrosus, an outer fibrous part that composed of concentric lamellae and the nucleus pulposus. ^{(LOE 5)}

The lumbar plexus originates from the first four lumbar ventral rami and forms a triangular shape. The first lumbar ventral ramus is divided in the n.iliohypogastricus and the n.ilioinguinalis. They go through the anterior part of the m. quadratus lumborum. These nerves are the only elements of the lumbar plexus in contact with these muscle. The n.genitofemoralis and the n.cutaneous femoralis lateralis originates from the second lumbar ventral ramus (L2-L3). ^{(LOE 5)}

The n.genitofemoralis descended on the ventral aspect of the m. psoas major while the n.cutaneous femoralis lateralis crossed the lateral border of the m.psoas major. ^{(LOE 5)}

The large posterior divisions of the ventral rami of L2-L3-L4 unites to the n.femoralis. These nerve leaves the m.psoas major from the postero-lateral border. Then the nerve travels in the gutter between the m.psoas major and the m.iliacus. ^{(LOE 5)}

The anterior division of L2-L3-L4 are smaller and give rise to the n.obturatorius (L2-L3-L4). The n.obturatorius is the innermost nerve of the plexus lumbalis. This nerve leaves the m.psoas major on his interna land posterior side between L5 and S1.^{(LOE 5)}

The n.isciadicus originates from the L4-S3 roots in the form of two nerve trunks. These two nerves are the n.tibialis and the n.peroneus communis. ^{(LOE 3B)}

Epidemiology /Etiology

Lumbar radiculopathy is a disease that commonly arises with significant socioeconomical consequences. The discal origin of a lumbar radiculopathy incidence is around 2%. Out of a 12.9% incidence of low back complaints within working population, 11% is due to lumbar radiculopathy. ^{(LOE 5)}
The prevalence of lumbosacral radiculopathy has been situated from 9.9% to 25%. ^{(LOE 3A)}
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 with resultant pain, weakness, and/or sensor impairment in the affected nerve root, may be from direct trauma or from chemical irritation to the affected nerve root ^{(LOE 3A)}. This can be due to mechanical compression of the nerve by a disk herniation, a bone spur (osteophytes) from osteoarthritis, or from thickening of surrounding ligaments. As people age, their spines are subject to increasing degeneration which can cause herniated discs and similar problems, leading to lumbar radiculopathy.
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.

Characteristics/Clinical Presentation

Causes of lumbar radiculopathy 

In about 90% of the cases with lumbar radicular pain, the pain is caused by a herniated disc with nerve root compression, but lumbar stenoses and (less often) tumours are also possible causes. ^{(LOE 1A)}. Sometimes it may be caused by underlying disease (infections) rather than disc herniation. Imaging is indicated for this cases. ^{(LOE 1A)}. Other important causes for lumbar radiculopathy are lateral recess stenosis and radiculitis. ^{(LOE 1A)}. In patients under 50 years, a herniated disc is the most frequent cause. After the age of 50, radicular pain is often caused by degenerative changes in the spine (stenosis of the foramen intervertebrale). ^{(LOE 5)}. 

The most common causes of lumbar radiculopathy: 

• A prolapsed disk ^{(LOE 1A)}, ^{(LOE 2B)} 
• Stenosis (either of the central canal or the foramen) 
• Impinging or irritating a nerve root(s). (^{LOE 2B)}

Symptoms of lumbar radiculopathy

The most important symptoms of lumbar radiculopathy are pain in the lower back (one or more lumbar or sacral dermatomes (LOE 1A)(combined with unilateral radiating leg pain (traveling below the knee^{(LOE 1C) (LOE 2B)}) that follows a dermatomal pattern ^{(LOE 1A)} and related disabilities. It can be accompanied by objective findings of nerve root entrapment such as sensory deficits ^{(LOE 1A)}, reflex changes or muscle weakness ^{(LOE 2B)}. The clinical presentation of lumbar radiculopathy will vary depending on the cause of the radiculopathy and which nerve roots are being affected. The description of nature and localization of the pain is very important. Pain drawings are often used for this purpose. The most patients describe the lumbar pain as sharp, dull, piercing, throbbing, stabbing, shooting or burning.^{(LOE 1C)}. Patients also report radicular pain in one leg, combined with one or more positive neurological signs (paresis, sensory loss, or loss of) reflexes that indicate a nerve root irritation or neurological loss of function. Neurological signs must be present such as weakness, numbness, or reflexive changes. ^{(LOE 3B)}. Typical for sciatica are the higher levels of leg pain and more often reported below the knee pain and leg pain worse than back pain ^{(LOE 2B)}.

While it is common for patients with radiculopathy to have nerve root pain, the term "radiculopathy" refers to the whole complex of symptoms that can arise from nerve root pathology, including paresthesia, hypoesthesia, anesthesia, motor loss and pain ^{(LOE 2B)}.
Other indicators for sciatica are:

• Unilateral pain radiating to foot or toes ^{(LOE 1A)}
• Numbness and paraesthesia in the same distribution ^{(LOE: 1A)}
• Paravertebral pressure above the nerve root causes pain in the periphery.
• Failure of the sensible dermatome. Because of the overlap of the dermatomes there will never be a total loss of touch by an injury of one nerve root. (localised neurology—that is, limited to one nerve root) ^{(LOE 1A)}

Based on a Electrophysiological evaluation in lumbosacral radiculopathy ^{(LOE 3B)} , there are also some specific symptoms for.
Abnormal electrophysiological findings were recorded in 82% of the patients(n=97) showing that electrophysiologic changes. Hypoesthesia was seen mostly in L5 root distribution (21%); 22.8% of patients had paresthesia in L5, and 14% in S1 dermatome. In the population, 27% had reduced or absent Achilles reflex, and 20% and 14% had L5 and S1 myotomal weakness, respectively; 48% had positive straight leg raising test.

There is a study who claims that nerve root pain should not be expected to follow along a specific dermatome. ^{(LOE 2B)}. The purpose of this study is to describe of the distribution of pain in patients with lumbar radiculopathy. They conclude that there is a non-dermatomal pattern of pain. ^{(LOE 2B)}. The exception of this is S1 radicular pain, in which the pain does commonly follow the S1 dermatome. ^{(LOE 2B)}.

File:Dermatomes.jpg

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

Differential Diagnosis

• Radicular syndrome/ Sciatica: a disorder with radiating pain in one or more lumbar or sacral dermatomes, and can be accompanied by phenomena associated with nerve root tension or neurological deficits. ^{(LOE 1A)}
• Pseudoradicular syndrome
• Thoracic disc injuries
• Lumbosacral disc injuries
• Low back pain
• Spinal stenosis
• Cauda equina
• Inflammatory/metabolic causes ^{(LOE 1C)}: Diabetes, Ankylosing spondylitis, Paget’s disease, Arachnoiditis, Sacroidosis
  

Examination

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

Motor, sensory and reflex function should be assessed to determine the affected nerve root level. ^{(LOE 5)} 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.

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^{(LOE: 5)(LOE 4)}, Crossed Straight Leg Raise Test, Femoral Nerve Stretch Test and reflexes.

Straight Leg Raise Test (Lasègue test):
The best known clinical test is the straight-leg raising test^{(LOE 1C)}.

The supine SLR is more sensitive than the seated SLR when it comes to the diagnosis of lumbar disc herniation with radiculopathy. A pooled sensitivity for straightleg raising test was 0. 91 (95% CI 0.82-0.94), a pooled specificity 0.26 (95% CI 0.16-0.38)^{(LOE 1A)}. The test is based on stretching of the nerves in the spine^{(LOE 1A)}

The patient lies supine and raises the leg on the involved side, with an extended knee. If pain is produced at 40 degrees of hip flexion or less, 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 (Crossed Lasègue test):
A test for the containment and exclusion of lumbar radiculopathy. For the cross straight leg raising test a pooled sensitivity was 0.29 (95% CI 0.24-0.34), pooled specificity was 0.88 (95% CI 0.86-0.90)^{(LOE 1A)}. The test is based on stretching of the nerves in the spine.^{(LOE 1A)}

The 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.

Femoral Nerve Stretch Test:
For the Femoral Nerve Stretch Test, the patient lies prone with the knee passivley flexed to the thigh. The test is positive if the patient experiences anterior thigh pain. This test causes a downward and slightly lateral movement of the femoral nerve, its nerve root and the intradural rootlet. ^{(LOE 4)}

Specific vertebral level
To diagnose an L4 radiculopathy the clinician placed emphasis on the femoral nerve stretch test, the straight leg raise test, the knee reflex, sensory loss in the L4 dermatome and the muscle power for the ankle dorsiflexion.
To diagnose an L5 radiculopathy, the clinician focused on the straight leg raise test, sensory loss in the L5 dermatome, and the muscle power for the hip abduction, ankle dorsiflexion, ankle eversion, and the big toe extension.
For an S1 radiculopathy the clinician emphasized the straight leg raise test, the ankle reflex, sensory loss in the S1 dermatome, and the muscle power for hip extension, knee flexion, ankle plantarflexion, and ankle eversion.^{(LOE 1B)}

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 ^{(LOE 4)(LOE 5)}
  
  

Diagnostic Procedures 

Clinical evaluation:

• X-rays: to identify the presence of a trauma or osteoarthritis and early signs of a tumor or an infection
• EMG: useful in detecting radiculopathies but they have limited utility in the diagnosis.
• MRI: used to see if disc herniation and nerve root compression are present in patients with clinical suspicion of lumbosacral radiculopathy. ^{(LOE 3A)}

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. ^{(LOE 4)}

Outcome Measures

Roland Morris Disability Questionnaire (RMDQ):
The Roland Morris Disability Quenstionnaire assess changes in functional status after treatment in patients with low back pain. The Questionnaire is a widly used health status.^{(LOE:2B)(LOE 3B)}

Back Pain Functional Scale:
A scale for self-report measure that evaluates functional ability in people with back pain. ^{(LOE: 3A)}

The Maine-Seattle Back Questionnaire:
A 12-item disability questionnaire for evaluating patients with lumbar sciatica or stenosis. ^(LOE:2B)

Fear Avoidance Belief Questionnaire (FABQ):
this quenstionnaire is developed by Waddell to investigate fear-avoidance beliefs among LBP patients in the clinical setting. ^(LOE:2B)

Medical Management

Lumbar radicular syndrome can be treated in a conservative or a surgical way. The international consesus says that in the first 6-8 weeks, conservative treatment is indicated. ^{(LOE 2C)}. Surgery should be offered only if complaints remain present for at least 6 weeks after a conservative treatment. ^{(LOE 1B)}. A chirurgical intervention for sciatica is called a discectomy and focuses on removal of disc herniation and eventually a part of the disc. ^{(LOE 1A)}

The conservative treatment is primarily aimed at pain reduction and includes the use of analgesics, non-steroidal anti-inflammatory drugs^{(LOE 1A)}, muscle relaxants and oral steroids (prednisone) ^{(LOE 1A)}. But also other conservative treatments, such as traction, manipulation, ultrasound, hot packs, acupuncture^{(LOE 1A)}, or corsets have been widely discussed. Also the value of bed rest was examined in patients with sciatica; results suggest that advice for bed rest is not as effective as advice to stay active for people with low-back pain. ^{(LOE 1A)}. By research the majority of radiculopathy patients respond well to this conservative treatment, and symptoms often improve within six weeks to three months.

In a study with 532 patients to evaluate the effect of non-steroidal anti-inflammatory drugs, or Cox-2 inhibitors, we can conclude that the drugs have a significant effect on acute radicular pain compared with placebo. ^{(LOE 1A)}. But other studies say that there are no positive effects on lumbar radicular pain. ^{(LOE 1A)}

There are several studies that have investigated the effect of acupuncture in people with acute lumbar radicular pain. Acupuncture would have a positive effect on the pain intensity, and pain threshold.). ^{(LOE 1A)}

Among patients with acute lumbar radiculopathy, oral steroids (prednisone) will relieve them from pain and improve function. ^{(LOE 1B)}.

When we compare the surgical (50%) vs nonoperative (50%) treatment for lumbar radicular pain in a study with 501 patients, we can conclude that patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period.^{(LOE 1B)} However, in the group who received the conservative treatment (active physical therapy, education/counseling with home exercise instruction, and nonsteroidal anti-inflammatory drugs), 30% of the patients underwent the surgery at the end of the study.^{(LOE 1B)}

In an study entitled ‘Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review’^{(LOE 1A)}, 30 trials were included to evaluate the effects of injections, traction, physical therapy and manipulation as treatment for the lumbosacral radicular syndrome. They have come to the following conclusions:

• At short term there is no evidence in favour of traction when compared to sham (fake) traction or other conservative treatments. ^{(LOE 1A)}
• At short term there is no evidence in favour of physical therapy compared to inactive treatment (bedrest), other conservative treatments or surgery. ^{(LOE 1B)}
• At short term there is no evidence in favour of manipulation compared to other conservative treatments or chemonucleolysis. ^{(LOE 1B)}
  
  

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.(^{LOE 1A)}

The literature support conservative management and surgical intervention as viable options for the treatment of radiculopathy caused by lumbar disc herniation.

In the first place a conservative management is chosen. In a recent systematic review was found that a conservative treatment does not always provide for the disappearance of the symptoms of the patient. ^{(LOE 1A)}

Providing information to the patient about the causes and prognosis can be a logical step in the management of lumbosacral radiculopathy, but there are no randomized, controlled studies ^{(LOE 1A)}

Exercise therapy can have a beneficial effect. It is often a first line treatment. However, until now, evidential value for this is lacking.^{(LOE 1A)(LOE 1A)}. In a randomized study, they wanted to demonstrate what the effect was after a 52 week rehabilitation program; first exercise therapy in combination with conservative therapy and on the other hand only the conservative treatment. (79% versus 56% Global Perceived Effect, respectively). A systematic review conclude that traction and exercise therapy are effective. ^{(LOE 1A)}

Physical therapy can include mild stretching and pain relief modalities, such as ultrasound, whirlpool, ice and heat pack therapy, electrical stimulation, and/or massage ^{(LOE 1A)}, active stabilisation, lasertherapy^{(LOE 2B)}, conditioning exercise and ergonomic program. A comprehensive rehabilitation program includes postural training, muscle reactivation, correction of flexibility and strength deficits, and subsequent progression to functional exercises. ^{(LOE 3A)}

Spinal manipulation is an option for symptomatic relief in patients with lumbar disc herniation with radiculopathy. There is moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy. The quality of the evidence for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration is low.^{(LOE 1A)}

Moderate evidence favors stabilization exercises over no treatment, manipulation over sham manipulation, and the addition of mechanical traction to medication and electrotherapy. There was no difference among traction, laser, and ultrasound.^{(LOE 3A)}

When a patient complains about instability, core stability is really important.

Core stabilization exercise (CSE) with the abdominal drawing-in maneuver (ADIM) technique are commonly used. These exercices activate the deep abdominal muscles with minimal activity of the superficial muscles. ^{(LOE 2B)}

Exercise:

• Core stability and abdominal draw-in maneuver

1. Right side bridge with abdominal brace ^{(LOE 1B)}
10 reps
10 sets
3x a week

2. Birdog with abdominal brace ^{(LOE 1B)}
10 reps
10sets
3x a week

• Core stability ^{(LOE 1B)}

It is a 10 week program. The intensity of the exercise is based on your own performance.
20 min
2 x a week
Daily home exercise -> instructions of this document
In a study entitled ‘Rungthip Puntumetakul et al. Effect of 10-week core stabilization exercise training and detraining on pain-related outcomes in patients with clinical lumbar instability.‘^{(LOE 1B)}, a program is written out, you’ll find this core stabilitization exercise program under here.

Core stabilization exercise

Isolated transversus abdominis and lumbar multifidus training
1. Train transversus abdominis muscle activation in a prone lying position without spinal and pelvic movements for 10 seconds with ten repetitions. Keep respiration normal. You gently draw in the lower anterior abdominal wall below the navel level (abdominal drawing-in maneuver) with supplemented contraction of pelvic floor muscles, control your breathing normally, and have no movement of the spine and pelvis while lying prone on a couch with a small pillow placed beneath your ankles.

Train lumbar multifidus muscle activation in an upright sitting position. You raise the contralateral arm while performing the abdominal drawing-in maneuver in a sitting position on a chair.

Integrated transversus abdominis and lumbar multifidus training light activities
2. Perform cocontraction of transversus abdominis and lumbar multifidus muscles while sitting on a chair. You use the index and middle fingers to palpate contraction of transversus abdominis muscle and the opposite two fingers to palpate contraction of lumbar multifidus muscle. This exercise progresses from 10- to 60-second holds of cocontraction for ten repetitions.

Train cocontraction of these muscles with trunk forward and backward while sitting on a chair and keeping your lumbar spine and pelvis in a neutral position. The second exercise this week required 10-second holds with ten repetitions.

3. Perform cocontraction of the two muscles in a crooked lying position with both hips at 45 degrees and both knees at 90 degrees. Then you abduct one leg to 45 degrees of hip abduction and hold it for 10 seconds.
Train cocontraction of these muscles in a crooked lying position with both hips at 45 degrees and both knees at 90 degrees. Then you slide a single leg down until the knee is straight, maintain it for 10-second holds and then slide it back up to the starting position.

4. Perform cocontraction of the two muscles while sitting on a balance board. You perform cocontraction of the muscles with trunk forward, backward, and sideways while sitting on a balance board and keeping your lumbar spine and pelvis in a neutral position. You perform each pose for 10-second holds with ten repetitions.

Integrated transversus abdominis and lumbar multifidus training heavier activities
5. Perform cocontraction of the two muscles while raising the buttocks off a couch from a crooked lying position until your shoulders, hips, and knees are straight. You sustain this pose for 10 seconds and then lower the buttocks back down to the couch with ten repetitions.
Train muscle cocontraction while raising the buttocks off a couch from a crooked lying position with one leg crossed over the supporting leg. You raise the buttocks off the couch until the shoulders, hips, and knees are straight. You sustain this pose for 10 seconds and then lower the buttocks back down to the couch with ten repetitions.

6. Perform cocontraction of the two muscles while raising a single leg from a four-point kneeling position and keeping your back in a neutral position. You sustain this pose for 10 seconds and then return the leg to the starting position with ten repetitions.
Train muscle cocontraction while raising an arm and alternate leg from a four-point kneeling position and keeping your back in a neutral position. You sustain this pose for 10 seconds and then return to the starting position with ten repetitions.

7. Perform cocontraction of the two muscles in a standing position while a mini ball is behind your upper back and against the wall. You flex the hip and knee of one leg to 90 degrees. Sustain this pose for 10 seconds and then return to the starting position with ten repetitions.
Train the muscle cocontraction in a standing position with ankle movement. Perform ankle movement in the forward-backward direction while keeping your lumbar spine in a neutral position. Sustain this pose for 10 seconds and then return to the starting position with ten repetitions.

Integrated transversus abdominis and lumbar multifidus training in pain aggravating activities
8–10. Perform muscle cocontraction while walking at normal, faster and fastest speed for 5 minutes at weeks 8, 9, and 10 respectively. In addition, choose two aggravating activities or tasks that you anticipate would cause pain or instability and perform muscle cocontraction while doing these activities or tasks without having pain. Each aggravating activity or task is performed for 2.5 minutes.

Recent Related Research (from Pubmed)

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