11/14/24, 10\:57 AM Lumbar Radiculopathy

Lumbar Radiculopathy

Table of contents
Key points ⚡
Succinct notes to superpower your revision
Radiculopathy\: nerve root compression/irritation causing pain, sensory changes (numbness, paraesthesia), and/or motor
changes (weakness, diminished re
Common cause\: herniated disc (90% cases), spinal stenosis, trauma, or degenerative processes; commonly a
nerve roots (sciatica).
Risk factors\: smoking, obesity, heavy lifting, whole-body vibration, age 40-70, history of low back pain.
Symptoms\: unilateral or bilateral radiating pain (sharp, dull, throbbing), sensory de
motor weakness (e.g. foot drop), worsened by movement, coughing, or sneezing.
Investigations\: MRI (gold standard), X-ray (for spinal injury/degeneration), electromyography (nerve conduction tests),
lumbar puncture if indicated.
Red
symptoms).
Conservative management\: lifestyle modi
psychological support; 70% of cases resolve within 12 months.
Surgical management\: discectomy, spinal decompression, or microendoscopic discectomy for intractable symptoms,
failed conservative treatment, or neurological de
Complications\: chronic pain, central sensitisation, muscle atrophy, progressive weakness, cauda equina syndrome.
Article 🔍
A comprehensive topic overview

Introduction

Radiculopathy refers to the compression or irritation of a spinal nerve root, causing pain with sensory changes (e.g.
numbness,
‘pins and needles’) and/or motor changes (e.g. weakness, diminished deep tendon re
Unlike radicular pain, which refers only to pain, radiculopathy encompasses any combined symptoms that stem from the
a
While any area of the spine can be a
women in the 4 th th 1
to 6 decades of life, with an estimated prevalence of 3-5% within the general adult population.
The most common cause is a herniated disc, which occurs secondary to degenerative changes and is responsible for
approximately 90% of cases.
1
Since the L4-S1 nerve roots are most commonly a
diagnosed as sciatica.

Aetiology

Each spinal nerve contains a ventral (anterior) and dorsal (posterior) nerve root, which pass through the intervertebral
foramina. The ventral root contains motor
https\://app.geekymedics.com/notebook/2845/ 1/811/14/24, 10\:57 AM Lumbar Radiculopathy
Due to their anatomical position, either or both may become compressed or irritated due to trauma (e.g. herniation or
prolapse) or a degenerative process (e.g. spinal stenosis), which can result in oedema, ischemia, and in
2
These changes can give rise to radicular pain (which spreads distally via the a
also spreads distally via the a
whether the dorsal
Figure 1. A transverse section of the spinal cord,
showing the major anatomical landmarks used to
identify the ventral and dorsal surfaces

Causes of lumbar radiculopathy

Although a herniated disc is the most common cause, any condition that compresses or irritates a nerve root can lead to
radiculopathy.
Spinal stenosis and spondylolisthesis are known causes, and pelvic or lumbar fractures can lead to nerve root avulsions
or ruptures via traction, although these cases are very rare. 3,4
When a nerve root becomes compromised due to peripheral
nervous system syndromes (e.g. Guillain-Barré syndrome), this is known as polyradiculopathy.
5
Lumbar radiculopathy can also be caused by a serious pathology, such as cancer, infection, or a spinal fracture.
6
Therefore, a thorough examination and history are essential.
All patients with low back pain should be assessed for cauda equina syndrome, and any thoracic symptoms (e.g. a ‘band-
like’ pain that radiates into the chest and ribs) should be treated as unusual and warrant immediate investigation.

Risk factors

The following are associated with an increased incidence of lumbar radiculopathy or sciatica\:
2,7
Modiobesity, strenuous physical activity (e.g. heavy lifting involving bending and twisting of the spine),
and whole-body vibration (e.g. operating machinery)
Non-modith th
to 6 decades), a history of low back pain, and some genetic factors,
such as variations in the intragenic vitamin D receptor gene (believed to increase predisposition to degenerative disc
disease)

Clinical features

History

The most common symptom is radiating pain (e.g.
‘sharp’
,
‘stabbing’
,
‘shooting’
,
'dull'
,
distally from the lumbar spine and can often be easily localised by the patient (e.g. right hamstring).
‘throbbing’
, or ‘aching’) that spreads
Pain is usually unilateral but can also be bilateral (here, it is important to assess for malignant spinal cord compression) and
is accompanied by sensory changes and/or motor changes – these tend to follow the course of the a
impacting the pelvic and buttock region, as well as the legs and feet\:
Sensory changes\: numbness, paraesthesia
Motor changes\: paresis (weakness), loss of strength/power (e.g. foot dragging due to loss of dorsi
giving way)
https\://app.geekymedics.com/notebook/2845/ 2/811/14/24, 10\:57 AM Lumbar Radiculopathy
Pain often worsens during movement especially after long periods of inactivity (e.g. standing up after sitting or lying down
for a while). It can also worsen while coughing or sneezing due to increased lumbar compression and subsequent irritation
of the a
Symptoms can develop suddenly (acute onset due to injury or trauma) or insidiously (which may also be due to injury or
trauma or a progressive condition) and can be consistent, worsening, or relapsing-remitting.
Past medical history may include\:
Low back pain
Degenerative disc disease
Previous disc herniation or prolapse
Previous exacerbations or
Social history\:
Smoking
Occupation (exposure to vibrating machinery)
Strenuous physical activity (e.g. bending and twisting of the spine under heavy loads)
Recent falls or any indicators of potential injury to the lumbar spine
Medications\:
Some medications (e.g. amiodarone, docetaxel, carbamazepine) can cause side-e
symptoms to radiculopathy
Table 1. Questions to ask when taking the history of a patient with suspected lumbar radiculopathy and reasons for asking
them.
Example questions Why?
" W h a t a r e y o u r s y m p t o m s ?"
" H a v e y o u e x p e r i e n c e d a n y n u m b n e s s d o w n o n e o r b o t h
l e g s ?''
'' H a v e y o u e x p e r i e n c e d a n y c h a n g e o f s e n s a t i o n , s u c h a s
p i n s a n d n e e d l e s ? ( i n c l u d i n g w i t h i n t h e p e l v i c a n d gr o i n
a r e a w h i c h c o u l d b e i n d i c a t i v e o f s a d d l e a n a e s t h e s i a a n d
c a u d a e q u i n a s y n d r o m e
)''
" H a v e y o u e x p e r i e n c e d a n y w e a k n e s s / l o s s o f s t r e n gt h ?"
" D o e s y o u r f o o t d r o p / d r a g ? ( D o y o u h a v e a n y d i
l i f t i n g y o u r f o o t / t o e s o
" D o y o u r k n e e s e v e r g i v e w a y ? ( I f y e s , d o t h e y p a r t i a l l y gi v e
w a y s o t h a t t h e p a t i e n t i s a b l e t o p r e v e n t a f a l l o r gi v e w a y
c o m p l e t e l y ? )"
" D o y o u t e n d t o s t u m b l e , t r i p , o r f a l l ?"
" W h e n d i d y o u r s y m p t o m s b e g i n ?"
" D o y o u k n o w w h a t m i g h t h a v e c a u s e d y o u r s y m p t o m s t o
h a p p e n ? ( e .g . f a l l s , s t r e n u o u s l i f t i n g )"
" D i d y o u r s y m p t o m s b e g i n s u d d e n l y o r d e v e l o p g r a d u a l l y ?"
To ascertain what the patient’s clinical features are, and
whether pain is accompanied by sensory and/or motor
changes, to aid diagnosis
To establish if there is a mechanism of injury and the
likely duration of symptoms
https\://app.geekymedics.com/notebook/2845/ 3/811/14/24, 10\:57 AM Lumbar Radiculopathy
" C a n y o u t e l l m e w h e r e y o u r s y m p t o m s a r e ? ( i n c l u d i n g
w h e t h e r t h e y a r e u n i l a t e r a l , b i l a t e r a l , o r a l t e r n a t i n g)"
" W h a t t y p e o f p a i n i s i t ? ( e .g . a d u l l a c h e o r a s h a r p ,
s h o o t i n g-t y p e p a i n )"
" D o y o u r s y m p t o m s f o l l o w a c o n s i s t e n t p a t t e r n ? ( e .g. p a i n
t h a t s p r e a d s i n t o t h e h a m s t r i n g a n d c a l f ? )"
" H a s t h i s p a t t e r n c h a n g e d o v e r t i m e ? ( h a s i t s p r e a d t o m o r e
t h a n o n e a r e a ? )''
" H o w i n t e n s e i s y o u r p a i n o n a s c a l e o f 1-1 0 ?"
" H a s i t g o t b e t t e r o r w o r s e o v e r t i m e , o r h a s i t s t a y e d t h e
s a m e ?"
" W h a t a g g r a v a t e s y o u r p a i n ?"
" W h a t e a s e s y o u r p a i n ?"
" D o e s i t e a s e / w o r s e n a t a c e r t a i n t i m e o f d a y , r e s p o n s e t o a c e r t a i n a c t i v i t y ?"
o r i n
To ascertain the type, location, and pattern of symptoms
To establish the patient's baseline and monitor changes
in response to treatment - document using a 1-10 visual
analogue scale (VAS) or numerical pain rating scale
(NPRS)
To establish what makes the pain better or worse to aid
diagnosis and management (e.g. lifestyle changes to
avoid pain triggers)
For more information, see the Geeky Medics OSCE guide to back pain history taking.

Clinical examination

All patients with low back pain should undergo a spine examination.
If radiculopathy is suspected, a lower limb neurological examination, including an assessment of dermatomes,
myotomes, and reslump test and straight leg raise test (with a positive Lasègue’s Sign) can aid
in diagnosis, and clinical signs (e.g. muscle atrophy, gait disturbances) can also indicate radiculopathy.
Clinical signs can include muscle atrophy, diminished deep tendon re
depending on which nerve
muscle atrophy is indicative of chronic impairment).
Targeted clinical examination for suspected lumbar radiculopathy
Dermatomes\: L1-S2
Myotomes\: L1-S2 (grade using MRC scale)
Re
Special tests\: slump test, straight leg test
However, be aware that dermatome and myotome maps are poor predictors of nerve root involvement (they do not
indicate precisely which nerve root is a
clinical presentations are highly variable between individuals.
8-10
https\://app.geekymedics.com/notebook/2845/ 4/811/14/24, 10\:57 AM Lumbar Radiculopathy
Figure 2. Whole body dermatome map

Di

These include neurological disorders (e.g. myelopathy, peroneal palsy), systemic disorders (e.g. sacroiliitis, vascular
claudication), and various other conditions (e.g. abdominal aortic aneurysm, greater trochanteric pain syndrome) that can
mimic symptoms of lumbar radiculopathy.
3
Important di
Spinal tumour\: associated pain is typically described as a constant, dull ache not necessarily related to activity. Other
symptoms such as loss of appetite and weight loss may be present.
Spinal infection (e.g. osteomyelitis)\: pain may be aggravated by bending and twisting, systemic symptoms such as fever
may be present and an acute onset would be expected.
Postural/mechanical back pain\: lower back pain without any associated neurological symptoms, red
malignancy should not be present.
Sacroiliac joint pathology (e.g. ankylosing spondylitis)\: pain from the sacroiliac joint in in
radiate to the lower back. Pain would typically have a gradual onset with the symptoms being worst in the morning and
improving with exercise. Further investigations like blood tests and imaging may be needed to di
radiculopathy.
Mechanical low back pain that spreads into the hip, buttock, or thigh does not necessarily indicate radiculopathy, as pain
can radiate without nerve root compression or irritation.

Investigations

The majority of cases are managed conservatively and do not need investigations. Further investigations are implied if likely
to change management (e.g. to determine the need for surgery), when a serious pathology is suspected (e.g. malignancy,
cauda equina syndrome), or if symptoms persist/worsen beyond the normal trajectory (symptoms normally self-resolve
within 12 months), especially if conservative management fails.

Imaging

In most cases, imaging may identify an aetiology and the level of nerve compression\:
Magnetic resonance imaging (MRI)\: the gold-standard investigation to identify a disc herniation, prolapse, or
degenerative process.
X-Ray imaging\: appropriate if a spinal injury is suspected (e.g. fracture, spondylolisthesis), or to assess for degenerative
joint changes (e.g. spinal stenosis, facet joint deterioration, bone spur formation).
Pain intensity corresponds poorly with imaging 11,12
and the
stage/magnitude of degenerative changes. 13
It is also a poor predictor of long-term outcomes such as the need for
surgery. 14 15 16
Pain is complex and in

Other investigations

Other relevant investigations may include\:
https\://app.geekymedics.com/notebook/2845/ 5/811/14/24, 10\:57 AM Lumbar Radiculopathy
Electromyography (EMG) and nerve conduction tests\: to identify which nerve roots are a
and to detect other neurological abnormalities (in cases of lumbar radiculopathy, however, they are not routinely used to
aid diagnosis).

Management

Patients with lumbar radiculopathy usually have a good prognosis. In cases of sciatica, symptoms usually self-resolve
1 17
within 12 months in about 70% of cases , and disc herniations can regress in size over time with no intervention. conservative management is the preferred
Therefore,

Conservative management

Conservative management of lumbar radiculopathy may consist of\:
Patient education\: advice about how to avoid pain triggers (such as prolonged sitting), information lea
supported self-management, and reassurance (e.g.
‘‘
…most uncomplicated cases of sciatica self-resolve within 12
months…
’’)
Lifestyle modi
reasonable adjustments (e.g. warehouse workers may need modi
Medication\: over-the-counter analgesia such as paracetamol and NSAIDs (with gastroprotection), unless
contraindicated. Also consider prescription oral analgesics (e.g. codeine)
Referral to musculoskeletal physiotherapy for exercise guidance and lifestyle modi
Referral to psychological services (e.g. behavioural therapies) as part of a multi-disciplinary approach if indicated (e.g. if
radiculopathy is causing problems with mental health, impacting the ability to work or ful
Safety netting
Always ensure that the patient knows what to do if they develop any red
equina syndrome, malignancy, and infection.

Surgical management

Surgical management may be indicated in some cases, for example\:
When conservative management fails beyond the normal trajectory
When symptoms are intractable
When radiculopathy is caused by a serious pathology
When the patient has severe neurological de
However, each case is reviewed individually and involves shared decision-making. Outcomes for both surgical and non-
surgical interventions are similar after 2 years.
18
Common procedures include\:
Discectomy
Spinal decompression
Open laminectomy with discectomy
Microendoscopic discectomy (MED)

Complications

People with lumbar radiculopathy may develop the following complications\:
3,19
Pain\: causes reduced functional mobility, loss of independence, the inability to ful
decreased health-related quality of life
Central sensitisation or nociplastic pain if clinical features persist
https\://app.geekymedics.com/notebook/2845/ 6/811/14/24, 10\:57 AM Lumbar Radiculopathy
Muscle atrophy and deconditioning, exacerbating loss of function
Progressive limb weakness and major motor radiculopathy
Cauda equina syndrome\: which can develop secondary to lumbar radiculopathy, and must be investigated immediately

References

Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of sciatica. B M J . 2007;334(7607)\:1313-1317.
Fairag M, Kurdi R, ALkathiry A, et al. Risk Factors, Prevention, and Primary and Secondary Management of Sciatica\: An
Updated Overview. C u r e u s J o u r n a l o f M e d i c a l S c i e n c e . 2022;14(11).
Sciatica (lumbar radiculopathy). NICE. Published February 2022. Available from\: [LINK]
Sasaka KK, Phisitkul P, Boyd JL, Marsh JL, El-Khoury GY. Lumbosacral Nerve Root Avulsions\: MR Imaging Demonstration of
Acute Abnormalities. A J N R \: A m e r i c a n J o u r n a l o f N e u r o r a d i o l o gy . 2006;27(9)\:1944-1946. Available from\: [LINK]
Rubin DI. Acute and Chronic Polyradiculopathies. C O N T I N U U M \: L i f e l o n g L e a r n i n g i n N e u r o l o g y . 2011;17\:831-854.
Finucane LM, Downie A, Mercer C, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies.
J o u r n a l o f O r t h o p a e d i c & S p o r t s P h y s i c a l T h e r a p y . 2020;50(7)\:1-23.
Doraiswamy R, Pillai J, Krishnamurthy K. Genetics of intervertebral disc disease\: a review. C l i n i c a l A n a t o m y . Published online
October 24, 2021.
Zale C, Mitsunaga K. Accuracy of dermatomes in the localization of lumbar disc herniations for pre-operative planning\: A
systematic review. I n t e r d i s c i p l i n a r y N e u r o s u r g e r y . 2023;32\:101728.
Schirmer CM, Shils JL, Arle JE, et al. Heuristic map of myotomal innervation in humans using direct intraoperative nerve root
stimulation. J o u r n a l o f N e u r o s u r g e r y \: S p i n e . 2011;15(1)\:64-70.
London D, Birkenfeld B, Thomas J, et al. A broad and variable lumbosacral myotome map uncovered by foraminal nerve
root stimulation. J o u r n a l o f N e u r o s u r g e r y S p i n e . Published online May 13, 2022\:1-7.
Dunsmuir RA, Nisar S, Cruickshank JA, Loughenbury PR. No correlation identi
prolapsed intravertebral disc with disability or leg pain. T h e b o n e & j o i n t j o u r n a l . 2022;104-B(6)\:715-720.
Kilic RT, Yildirimalp S, Sayaca C. The impact of protrusion size on pain, range of motion, functional capacity, and multi
muscle cross-sectional area in lumbar disc herniation. M e d i c i n e . 2023;102(46)\:e35367.
Rahyussalim AJ, Zufar MLL, Kurniawati T. Signi
and Low Back Pain\: A Review Article. A s i a n S p i n e J o u r n a l . 2020;14(2)\:245-257.
Gupta A, Upadhyaya S, Yeung CM, et al. Does Size Matter? An Analysis of the E
Success of Nonoperative Treatment. G l o b a l S p i n e J o u r n a l . 2019;10(7)\:881-887.
Yang H, Liu H, Li Z, et al. Low back pain associated with lumbar disc herniation\: role of moderately degenerative disc and
annulus
[LINK]
Picavet HSJ. Pain Catastrophizing and Kinesiophobia\: Predictors of Chronic Low Back Pain. A m e r i c a n J o u r n a l o f
E p i d e m i o l o g y . 2002;156(11)\:1028-1034.
Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc
herniation with radiculopathy. T h e s p i n e j o u r n a l \: o
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation. J A M A .
2006;296(20)\:2441.
Dydyk AM, Khan MZ, Singh P. Radicular back pain. In\: StatPearls. Treasure Island, FL\: StatPearls Publishing; 2024. Available
from\: [LINK]

Image references

Figure 1\: BruceBlaus. License\: [CC BY-SA]

Reviewer

Dr Rich Armitage
https\://app.geekymedics.com/notebook/2845/ 7/811/14/24, 10\:57 AM Lumbar Radiculopathy

Aphasia
Benign Paroxysmal Positional Vertigo (BPPV)
Cervical Radiculopathy
Chiari Malformations
Down's Syndrome
Source\: geekymedics.com
https\://app.geekymedics.com/notebook/2845/ 8/8