Lumbosacral Radiculopathy Clinical Presentation

  • Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD   more...
 
Updated: Feb 1, 2012
 

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).

Next

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.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Gerard A Malanga, MD  Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine

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

Disclosure: Cephalon Honoraria Speaking and teaching; Endo Honoraria Speaking and teaching; Genzyme Honoraria Speaking and teaching; Prostakan Honoraria Speaking and teaching; Pfizer Consulting fee Speaking and teaching

Coauthor(s)

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, and International Spine Intervention Society

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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 and American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

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, Director of Primary Care Sports Medicine Fellowship, 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, and Phi Beta Kappa

Disclosure: Nothing to disclose.

References

  1. Bull RC, ed. Dance injuries. Bull's Handbook of Sports Injuries. Baltimore, Md: McGraw-Hill; 1999:627-8.

  2. Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:844-6.

  3. Birnbaum JS. The Musculoskeletal Manual. 2nd ed. Orlando, Fla: Greene & Stratton; 1986:135.

  4. Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. May 2007;25(2):387-405. [Medline].

  5. Bono CM. Low-back pain in athletes. J Bone Joint Surg Am. Feb 2004;86-A(2):382-96. [Medline]. [Full Text].

  6. Padua L, Commodari I, Zappia M, Pazzaglia C, Tonali PA. Misdiagnosis of lumbar-sacral radiculopathy: usefulness of combination of EMG and ultrasound. Neurol Sci. Jun 2007;28(3):154-5. [Medline].

  7. Cohen SP, Gupta A, Strassels SA, et al. Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial. Arch Intern Med. Jan 23 2012;172(2):134-42. [Medline].

  8. Tsao B. The electrodiagnosis of cervical and lumbosacral radiculopathy. Neurol Clin. May 2007;25(2):473-94. [Medline].

  9. Barr KP, Griggs M, Cadby T. Lumbar stabilization: a review of core concepts and current literature, part 2. Am J Phys Med Rehabil. Jan 2007;86(1):72-80. [Medline].

  10. Willardson JM. Core stability training: applications to sports conditioning programs. J Strength Cond Res. Aug 2007;21(3):979-85. [Medline].

  11. Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil. Mar 2004;85(3 suppl 1):S86-92. [Medline].

  12. Memmo PA, Nadler SF, Malanga GA. Lumbar disc herniation: a review of surgical and non-surgical indications and outcomes. J Back Musculoskelet Rehabil. 2000;14(3):79-88.

  13. Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine. Jul 15 2007;32(16):1754-60. [Medline].

  14. Abram SE. Treatment of lumbosacral radiculopathy with epidural steroids. Anesthesiology. Dec 1999;91(6):1937-41. [Medline].

  15. Iversen T, Solberg TK, Romner B, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ. Sep 13 2011;343:d5278. [Medline].

  16. Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Arch Phys Med Rehabil. Nov 1998;79(11):1362-6. [Medline].

  17. Cyteval C, Fescquet N, Thomas E, et al. Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy. AJNR Am J Neuroradiol. May 2006;27(5):978-82. [Medline]. [Full Text].

  18. DePalma MJ, Bhargava A, Slipman CW. A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy. Arch Phys Med Rehabil. Jul 2005;86(7):1477-83. [Medline].

  19. Borg-Stein J, Wilkins A. Soft tissue determinants of low back pain. Curr Pain Headache Rep. Oct 2006;10(5):339-44. [Medline].

  20. Brown FW. Management of diskogenic pain using epidural and intrathecal steroids. Clin Orthop Relat Res. Nov-Dec 1977;129:72-8. [Medline].

  21. Burnett C, Day M. Recent advancements in the treatment of lumbar radicular pain. Curr Opin Anaesthesiol. Aug 2008;21(4):452-6. [Medline].

  22. Cohen SP, Wenzell D, Hurley RW, et al. A double-blind, placebo-controlled, dose-response pilot study evaluating intradiscal etanercept in patients with chronic discogenic low back pain or lumbosacral radiculopathy. Anesthesiology. Jul 2007;107(1):99-105. [Medline].

  23. Dimar JR 2nd, Glassman SD, Carreon LY. Juvenile degenerative disc disease: a report of 76 cases identified by magnetic resonance imaging. Spine J. May-Jun 2007;7(3):332-7. [Medline].

  24. [Best Evidence] Dworkin RH, O'Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. Dec 5 2007;132(3):237-51. [Medline].

  25. Fisher MA, Bajwa R, Somashekar KN. Routine electrodiagnosis and a multiparameter technique in lumbosacral radiculopathies. Acta Neurol Scand. Aug 2008;118(2):99-105. [Medline].

  26. Gordon SL, Weinstein JN. A review of basic science issues in low back pain. Phys Med Rehabil Clin N Am. May 1998;9(2):323-42, vii. [Medline].

  27. Hyun JK, Lee JY, Lee SJ, Jeon JY. Asymmetric atrophy of multifidus muscle in patients with unilateral lumbosacral radiculopathy. Spine. Oct 1 2007;32(21):E598-602. [Medline].

  28. Katayama Y, Matsuyama Y, Yoshihara H, et al. Comparison of surgical outcomes between macro discectomy and micro discectomy for lumbar disc herniation: a prospective randomized study with surgery performed by the same spine surgeon. J Spinal Disord Tech. Jul 2006;19(5):344-7. [Medline].

  29. Kirita T, Takebayashi T, Mizuno S, et al. Electrophysiologic changes in dorsal root ganglion neurons and behavioral changes in a lumbar radiculopathy model. Spine. Jan 15 2007;32(2):E65-72. [Medline].

  30. Malanga GA, Nadler SF. Nonoperative treatment of low back pain. Mayo Clin Proc. Nov 1999;74(11):1135-48. [Medline].

  31. Morsø L, Hartvigsen J, Puggaard L, Manniche C. Nordic walking and chronic low back pain: design of a randomized clinical trial. BMC Musculoskelet Disord. Oct 2 2006;7:77. [Medline]. [Full Text].

  32. Smeets RJ, Wade D, Hidding A, et al. The association of physical deconditioning and chronic low back pain: a hypothesis-oriented systematic review. Disabil Rehabil. Jun 15 2006;28(11):673-93. [Medline].

  33. van Rijn JC, Klemetso N, Reitsma JB, et al. Symptomatic and asymptomatic abnormalities in patients with lumbosacral radicular syndrome: Clinical examination compared with MRI. Clin Neurol Neurosurg. Sep 2006;108(6):553-7. [Medline].

  34. Yeung AT, Yeung CA. Minimally invasive techniques for the management of lumbar disc herniation. Orthop Clin North Am. Jul 2007;38(3):363-72; abstract vi. [Medline].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.