Lumbar Radiculopathy

Original Editors -Clay McCollum

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Definition/Description

Lumbosacral radiculopathy is a disorder that causes pain in the lower back and hip which radiates down the back of the thigh into the leg. It is caused by compression of nerve roots exiting the spine at levels L1-S4

• Symptoms include radiating pain, tingling, numbness, paraesthesia, and occasional shooting pain
• Most common in the lower back (lumbar-sacral) and neck (cervical), less common in mid-back (thoracic)
• Prevalence estimated from 9.9% to 25% of the population

Risk factors include activities placing excessive or repetitive load on the spine.

Other key points include:

• Majority of cases are benign and resolve spontaneously
• Conservative management is typically the first approach
• Diagnostic tools include imaging studies, electromyography, and nerve conduction studies if symptoms persist
• Patients may present with radiating pain, numbness/tingling, weakness, and gait abnormalities
• Symptoms follow predictable patterns based on the affected nerve root(s)
• Most disc herniations (95%) occur at the L4/5 or L5/S1 disc spaces
• In patients under 50, herniated disc is the most frequent cause; after 50, degenerative changes are more common

Lumbosacral radiculopathy is a common complaint in clinical practice, requiring thorough assessment and appropriate management based on individual presentation....

Clinically Relevant Anatomy

Posterolateral disc herniation

The lumbar nerve roots exit beneath the corresponding vertebral pedicle through the respective foramen.

Since most disc herniations occur posterolaterally, the root that gets compressed is actually the root that exits the foramen below the herniated disc. So, a disc protrusion at L4/L5 will compress the L5 root, and a protrusion at L5/S1 will compress the S1 root.

Ninety-five percent of disc herniations occur at the L4/5 or L5/S1 disc spaces. Herniations at higher levels are uncommon.

Epidemiology

Epidemiology of lumbosacral radiculopathy:

1. Prevalence: 3-5% of the general population
2. Incidence: Overall: 1.79 per 1000 person-years, Females: 63.5 per 100,000, Males: 107.3 per 100,000
3. Age: Peak incidence between 45-64 years
4. Gender: More common in males
5. Risk factors: Smoking; Mental stress; Strenuous physical activity (frequent lifting); Driving (whole body vibration)
6. Disc-related sciatica: Annual prevalence of 2.2% in general population
7. Low back pain with radiculopathy: 5-10% of low back pain cases
8. Prognosis: Most resolve within 2 weeks; 30% have pain persisting for 1 year or longer
9. Geographic distribution (US): South most affected (39.27% of cases)
10. Insurance coverage (US): Private insurance: 41.69% of cases; Medicare: 38.81% of cases
11. Most common site: L4/5 or L5/S1 disc spaces (95% of disc herniations)

This condition is a significant cause of disability and healthcare utilization, with varying prevalence across different populations and age groups.   ..

Pathophysiology

Lumbosacral radiculopathy is the clinical term used to describe a predictable constellation of symptoms occurring secondary to mechanical and/or inflammatory cycles compromising at least one of the lumbosacral nerve roots. The noxious stimulus on a spinal nerve creates ectopic nerve signals that are perceived as pain, numbness, and tingling along the nerve distribution. 

Patients can present with radiating pain, numbness/tingling, weakness, and gait abnormalities across a spectrum of severity.  Depending on the nerve root(s) affected, patients can present with these symptoms in predictable patterns affecting the corresponding dermatome or myotome.

Clinical Presentation

osteomyelitis spine

Causes include

• Lesions of the intervertebral discs and degenerative disease of the spine, most common causes of lumbosacral radiculopathy.
• Herniated disc with nerve root compression causes 90% of radiculopathy  
• Tumors (less often)
• Lumbar Spinal Stenosis caused by congenital abnormalities or degenerative changes. Lumbar stenosis can be described as the narrowing of the spinal canal and compressing the nerve caused by the underlying causes as mentioned above.
• Scoliosis can cause the nerves on one side of the spine to become compressed by the abnormal curve of the spine.
• underlying diseases like infections such as osteomyelitis.

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 intravertebral). Risk factors for acute lumbar radiculopathy are:

• Age (peak 45-64 years)
• Smoking
• Mental stress
• Strenuous physical activity (frequent lifting)
• Driving (vibration of the whole body)

Indication for sciatica/symptoms:

• Unilateral leg pain greater than low back pain, leg pain follows a dermatomal pattern
• Pain traveling below the knee to foot or toes
• Numbness and paraesthesia in the same area
• Straight leg raise positive, induces more pain

Clinical presentation depends on the cause of the radiculopathy and which nerve roots are being affected. Also important is the nature (sharp, dull, piercing, throbbing, stabbing, shooting, burning) and localisation of the pain. Some patients report, besides radicular leg pain, also neurological signs such as paresis, sensory loss. or loss of reflexes. If not present, this is not radiculopathy.

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

cauda equina syndrome

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.

• Pseudoradicular syndrome
• Thoracic disc injuries
• Low back pain
• Cauda equina
• Inflammatory/metabolic causes: Diabetes, Ankylosing spondylitis, Paget’s disease, Arachnoiditis, Sarcoidosis
• trochanteric bursitis
• Intraspinal synovial cysts

Diagnostic Procedures 

Clinical evaluation:

• X-rays: to identify the presence of 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. 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.
• MRI: used to see if disc herniation and nerve root compression are present in patients with clinical suspicion of lumbosacral radiculopathy.

Outcome Measures

• Roland Morris Disability Questionnaire (RMDQ) - The Roland Morris Disability Questionnaire assess changes in functional status after treatment in patients with low back pain. The Questionnaire is widely used for health status.
• Back Pain Functional Scale - A scale for self-report measure that evaluates functional ability in people with back pain.
• The Maine-Seattle Back Questionnaire - A 12-item disability questionnaire for evaluating patients with lumbar sciatica or stenosis. 
• Fear Avoidance Belief Questionnaire (FABQ) - this questionnaire is developed by Waddell to investigate fear-avoidance beliefs among LBP patients in the clinical setting.
• Oswestry Low Back Pain Disability Questionnaire - considered as ‘the golden standard’ to measure the permanent functional disability of the lower back.
• The Quebec back pain disability scale (QBPDS) - used to measure the functional disability for patients with lower back pain.

Examination

The examination for lumbosacral radiculopathy typically includes:

1. Detailed medical history
2. Neurological examination (reflexes, sensation, strength)
3. Straight Leg Raise test and other neurodynamic tests
4. Range of motion assessment
5. Palpation of spine and surrounding structures
6. Special tests (e.g., Slump test, Crossed Straight Leg Raise)

For a comprehensive guide on examination techniques, please refer to our dedicated page on Lumbar Radiculopathy Assessment

Medical Management

Treatment is varied depending on the etiology and severity of symptoms.

Conservative management of symptoms is generally considered the first line.

• Medications are used to manage pain symptoms including NSAIDs, acetaminophen, and in severe cases, opiates. Radicular symptoms are often treated with neuroleptic agents. Systemic steroids are often prescribed for acute low back pain, although there is limited evidence to support its use. Nonpharmacologic interventions are often utilised as well.
• Physical therapy, acupuncture, chiropractic manipulation, and traction are all commonly used in the treatment of lumbosacral radiculopathy. Of note, the data supporting the use of these treatment modalities is equivocal.
• Interventional techniques are also commonly used and include epidural steroid injections and percutaneous disc decompression. In refractory cases, surgical decompression and spinal fusion can be performed.

The international consensus says that in the first 6-8 weeks, conservative treatment is indicated.. Surgery should be offered only if complaints remain present for at least 6 weeks after a conservative treatment. . By research the majority of radiculopathy patients respond well to this conservative treatment, and symptoms often improve within six weeks to three months.

Study results

• A 2016 study revealed that appropriate use of EI (= epidural injections) to treat sciatica could significantly improve the pain score and functional disability score leading to a decrease in surgical rate..
• A study evaluating the effect of non-steroidal anti-inflammatory drugs, or Cox-2 inhibitors reported that the drugs have a significant effect on acute radicular pain compared with placebo. But other studies say that there are no positive effects on lumbar radicular pain.
• Studies on the effect of acupuncture in people with acute lumbar radicular pain found a positive effect on the pain intensity and pain threshold.
• Among patients with acute lumbar radiculopathy, oral steroids (prednisone) will relieve them from pain and improve function.
• Another study concluded: short term there is no evidence in favor of traction when compared to sham (fake) traction or other conservative treatments; short term there is no evidence in favour of physical therapy compared to inactive treatment (bed rest), other conservative treatments or surgery.; At the short term, there is no evidence in favour of manipulation compared to other conservative treatments or chemonucleolysis. A recent systematic review concludes that vertical traction (VT) does not give additional benefits when combined with or compared with PT treatments due to insufficient data in patients with Lumbar Radiculopathy. Further research and new high-quality studies are needed to investigate VT's effectiveness, most effective delivery, treatment dosage, or the pain stage that could benefit more from this intervention. The review suggests that VT may be an effective treatment only for reducing pain for short-term and may be preferred to passive treatments as bed rest and medications; however, there was no positive effect on increasing physical activity.

Surgical

Surgical intervention for sciatica is called a discectomy and focuses on the removal of disc herniation and eventually a part of the disc.  Spinal fusion is another option. Next to simple discectomy and spinal fusion, there are 3 other surgical treatments which can be applied in patients with disc herniation: 1) chemonucleolysis 2) percutaneous discectomy 3) microdiscectomy.

• 90% of all patients who have had surgery for lumbar disc herniation underwent discectomy alone, although the number of spinal fusion procedures has greatly increased.
• The complication rate of simple discectomy is reported at less than 1%.

Physical Therapy Management

Physiotherapy treatment for lumbosacral radiculopathy typically includes:

1. Patient education
2. Exercise therapy (core strengthening, neural mobilization)
3. Manual therapy techniques
4. Postural training
5. Pain management modalities

For a detailed explanation of treatment approaches and evidence-based interventions, please refer to our comprehensive Lumbar Radiculopathy Treatment page.