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Lumbosacral Radiculopathy Clinical Presentation

  • Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Dec 30, 2015
 

History

The onset of symptoms in patients with lumbosacral radiculopathy is often sudden and includes LBP. Some patients state the preexisting back pain disappears when the leg pain begins.

Sitting, coughing, or sneezing may exacerbate the pain, which travels from the buttock down to the posterior or posterolateral leg to the ankle or foot.

Radiculopathy in roots L1-L3 refers pain to the anterior aspect of the thigh and typically does not radiate below the knee, but these levels are affected in only 5% of all disc herniations.

When obtaining a patient's history, be alert for any red flags (ie, indicators of medical conditions that usually do not resolve on their own without management). Such red flags may imply a more complicated condition that requires further workup (eg, tumor, infection).[6] The presence of fever, weight loss, or chills requires a thorough evaluation. Patient age is also a factor when looking for other possible causes of the patient's symptoms. Individuals younger than 20 years and those older than 50 years are at increased risk for more malignant causes of pain (eg, tumor, infection).

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Physical

A comprehensive physical examination of a patient with acute LBP should include an in-depth evaluation of the neurologic and musculoskeletal systems.

The neurologic examination should always include an evaluation of sensation, strength, and reflexes in the lower extremities. This portion of the examination allows the examiner to detect sensory or motor deficits that may be consistent with an associated radiculopathy or cauda equina syndrome. Often, an assessment of the L5 reflex (medial hamstrings) is helpful. Also, in L5 radiculopathy, the presence of weakness in foot invertors should raise the additional suspicion of a peroneal nerve palsy.

When differentiating between an L3 radiculopathy versus a femoral neuropathy, weakness in the hip adductors in addition to the quadriceps group would indicate an L3 radiculopathy. In an isolated femoral neuropathy, only the quadriceps group would show weakness.

Provocative maneuvers, such as the straight-leg raising test or the slump test, may provide evidence of increased dural tension, indicating underlying nerve root pathology. Attempts at pain centralization through postural changes (ie, lumbar extension) may suggest a discogenic etiology for pain and may also assist in determining the success of future treatment strategies.

The musculoskeletal evaluation should include an assessment of the lower extremity joints, as pain referral patterns may be confused with focal peripheral involvement. For example, a patient with anterior thigh and knee pain may actually have a degenerative hip condition rather than an upper lumbar radiculopathy. By assessing lower extremity flexibility, hip rotation, muscular balance, and ligamentous stability, the evaluating physician might be alerted to the patient's predisposition toward an acute LBP episode.

Combining the findings of the patient's history and physical examination increases the overall predictive value of the clinical evaluation process. Further diagnostic studies are indicated only upon the completion of a thorough history and physical examination and the establishment of a differential diagnosis.

A study by Zheng et al found that tarsal tunnel syndrome coexisted in 27 (4.8%) of the study's 561 patients with lumbosacral radiculopathy.[7]

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Contributor Information and Disclosures
Author

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

Coauthor(s)

Mariam Rubbani, MD Staff Physician, Department of Medicine--Physical Medicine and Rehabilitation Division, Trinitas Regional Medical Center

Mariam Rubbani, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Charles J Buttaci, DO, PT Pain Management, Northeast Orthopedics

Charles J Buttaci, DO, PT is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic College of Physical Medicine and Rehabilitation, International Spine Intervention Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Andrew D Perron, MD Residency Director, Department of Emergency Medicine, Maine Medical Center

Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Sagittal magnetic resonance image showing loss of intervertebral disc height at L5/S1. Herniations of the nucleus pulposus are noted at L4/5 and L5/S1. Courtesy of Barton Branstetter, MD.
Discogram showing examples of an intact disc and a disrupted disc at the lumbar level.
Magnetic resonance image demonstrating extension of the nucleus pulposus to the right paracentral region of the spinal cord. The disc is adjacent to the inflamed right L5 nerve root. Courtesy of Barton Branstetter, MD.
 
 
 
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