Radiculopathy

Radiculopathy is a syndrome of symptoms caused by the compression/irritation of a nerve root.

Background and Epidemiology

  • Commonly occurs at the cervical spine (85/100,000) and lumbar spine (3-5% of the population)
    • Lifetime prevalence is thought to be as high as 12-43%

Aetiology

  • The most common cause is a herniated (‘slipped’) spinal disc (90%)- acute presentation
  • Spondylolisthesis can also cause lumbar radicular pain
  • Other causes include other degenerative ‘wear & tear’ conditions e.g. ligamentous hypertrophy and osteophyte formation (chronic presentation)
    • Disc herniation and degenerative changes are more commonly seen in patients with a history of injury/disease or physical stress to these areas
      • Ask about occupational history; injuries; triggers etc
  • Rarer causes include injury (rarely will cause an isolated radiculopathy although may include radiculopathy); infections; growths (e.g. tumours- more likely to cause a spinal cord compression but have the possibility of causing a radiculopathy)

Risk factors

  • Age
  • Strenuous physical activity (occupational or otherwise)
  • Driving for prolonged durations (e.g. lorry-drivers)
  • Smoking
  • Stress (?reduced tolerance)

Presentation

  • In general, the patient may present with an abnormal gait (lumbar) or with their head tilted to one side (cervical)- mechanisms of reducing nerve root irritation
    • neck is often held in a rigid position
  • Radicular pain is the most common presenting complaint
    • Note that this pain IS NOT perceived in a dermatomal distribution but in a more general anatomical distribution (the myotomal distribution, can therefore often be more accurate).
      • This is because sensation is not just perceived by the skin- muscles also have sensory innervation (e.g. pain felt when pulled a muscle)
      • I.e. the pain is usually felt in a narrow band down the limb
    • It is typically sharp, shooting, ‘lancinating’ (piercing) and can be felt superficially or deeply
    • Back/neck pain may or may not be present (if it is, it shouldn’t be worse than the limb pain)
    • Nerve stretching manoeuvres can bring on/worsen the pain
      • e.g. straight leg raise
  • The patient will rarely complain of numbness in the lower limbs, but if present, this is found in the dermatomal distribution.  In the upper limbs, numbness/paraesthesia is more common.
  • Weakness of the myotomal region may be present.  This is usually detected after the onset of pain and is usually a marker of worse nerve root compression/irritation.

vfdvfd

x0y0

3484418034844180

Grant_1962_663

Dermatomes_and_cutaneous_nerves_-_anterior

 

Features of common radiculopathies

  • C5/6- Sensory changes (anaesthesia/paraesthesia) down the lateral arm, thumb and index finger; pain in the shoulder and biceps; weakness of shoulder abduction and elbow flexion
  • L4/5 or L5/S1- Sensory changes may affect the foot; pain runs from the buttock down the back of the leg and calf; weakness most commonly presents as weakness of plantar flexion of the foot (foot ‘slap’- problems walking on tip toes e.g. walking up stairs).  Foot drop (weakness of dorsiflexion) is less common (although more commonly quoted) but can be a sign of L4/5 compression (or alternative diagnosis).
  • Radiculopathies at other spinal levels are possible but are rarer.

Investigations

  • MRI imaging is the investigation of choice as it can diagnose herniated discs (most common cause) and neoplastic causes
  • Other imaging techniques may be useful e.g. CT, for identifying bone problems e.g. fractures, trauma, osteophytes
  • In the investigation of cervical radiculopathy- nerve conduction tests can be useful where there are contraindications to MRI.  They may also be useful if the diagnosis is uncertain e.g. differentiating entrapment syndromes.

Management

  • Analgesia (using the analgesic ladder) is the mainstay of treatment
  • Physiotherapy is also often beneficial
  • If pain persists and is troublesome, epidural corticosteroid may be an option
  • Transforaminal steroid injection is rarely used but can be considered
  • Surgery
    • Considered where
      • severe, unrelenting and disabling pain remains refractory to conservative management for >6 weeks
    • Refer if there are any red flag symptoms

Major dermatomal landmarks

  • C2 (posterior half of skull)
  • C3 (high turtle neck shirt)
  • C4 (low-collar shirt)
  • C5/6 (Thumb and index finger- make a 6 with thumb and index finger)
  • C7 (Middle finger and palm)
  • C8 (Ring and little finger)
  • T4 (Nipples- T4 at Teat Pore)
  • T5 (Inframammory fold)
  • T7 (Xiphoid process)
  • T10 (Umbilicus- Belly but-TEN)
  • L1 (Inguinal ligament- L-ligament; 1-Inguinal)
  • L4 (Knee caps- down on all fours)
  • S1 (Lateral foot, small toe- S1- smallest one)
  • S2,3 (Genitalia)

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: