Lumbar Radiculopathy

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Definition/Description

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.

Lumbar radiculopathy is a disorder of the spinal nerve root from L1 to S1.

Different kinds of lumbar radiculopathy

Monoradiculopathy: one spinal nerve root is involved
Acute idiopathic polyradiculoneuropathy = Guillain-Barré Syndrome
Autoallergic reaction of the spinal nerve roots and the peripheral nerves.

Compression of the radix causes changes in the sensible (dermatome) and motorial (myotome) area of this radix. Irritation of the dorsal radix results in a sharp and burning pain with irradiation (= a higher sensation of pain that occurs in a skinarea that is bigger than the area where the stimulus is given) in the dermatome. Pressure on the ventral radix gives paresis in the muscle that belongs to that myotome.
Pay attention, there is an overlap between dermatomes and some muscles are innervated by more than one motorial radix.

Clinically Relevant Anatomy

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Epidemiology /Etiology

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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”.

Dermatomes:
- L4: medial side of the lower leg, medial side of the foot
- L5: lateral side of the lower leg, back of the foot, hallux
- S1: lateral side of the foot

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. The following chart may be useful in identifying radiculopathy clinically.

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

See test diagnostics page for explanation of statistics. 

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.

Clinical presentation for radiculopathy from each lumbar nerve root: 

File:Dermatomes.jpg

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

• 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.

Causes of lumbar radiculopathy

The most common causes of radiculopathy:
- lateral canal stenosis
- herniated disk

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

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

Differential Diagnosis

Differential diagnoses for upper lumbar radiculopathy include spondylolesthesis or an infection (diskitis, epidural abscess).

Diagnostic Procedures

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Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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