Radiculopathies

Question 1

What is radiculopathy ?

Answer 1

• commonly called ‘a pinched nerve’
• injury or damage causing conduction block in the axons of a spinal nerve or its roots where they leave the spine
• Impacts on motor axons causing weakness and sensory axons causing paraesthesia and/or anaesthesia.

Question 2

What is the difference between

1. Radiculopathy
2. Radicular pain

Answer 2

1. Radiculopathy: state of neurological loss and may or may not be associated with radicular pain.
2. Radicular pain: pain deriving from damage or irritation of the spinal nerve tissue, particularly the dorsal root ganglion.

Question 3

Describe the anatomy of how nerves exit the spinal cord

Answer 3

The anterior and posterior roots of the spinal nerves unite within the intervertebral foramina.

Both roots originate from the cord and pass to their appropriate intervertebral foramina, where each evaginates the dura mater separately before uniting to form the mixed spinal nerve.

Question 4

What are the most common causes of radiculopathy?

Answer 4

due to NERVE COMPRESSION

• Intervertebral disc prolapse
• Degenerative diseases of the spine - leading to neuroforaminal or spinal canal stenosis
• Fracture - trauma / pathological
• Malignancy - often mets
• Infection

Question 5

Which part of the spine is most likely to get intervertebral disc prolapse?

Answer 5

The lumbar spine

Predominantly affected - repeated minor stresses that predispose to rupture of the annulus fibrosus and sequestration of disc material (the nucleus pulposus)

Question 6

Which part of the spine is likely to see degenerative disease and at what age?

Answer 6

Cervical spine

normal part of ageing process; 80% of the population over 55 years old have degenerative changes between C5/6 and C6/7

Question 7

What are some examples of an infection that could lead to radiculopathy?

Answer 7

extradural abscesses

osteomyelitis (most commonly tuberculosis (‘Pott’s disease’)

Herpes Zoster

Question 8

What are some clinical features of radiculopathy?

Answer 8

sensory features (paraesthesia and numbness)

motor features (weakness)

Question 9

How do pts often describe radicular pain?

Answer 9

‘burning’, ‘deep’, ‘strap-like’, or ‘narrow pain’.

Radicular pain can be intermittent

Question 10

What is it important to do when examining a pt with radiculopathy?

Answer 10

• Identify dermatomal + myotmal involvement
• Assess for CES (e.g anal tone, rectal pressure sensation, anocutaeneous reflex)

Question 11

In a pt presenting with clinical features of radiculopathy what are the red flag symptoms you must ask about in association with:

Cauda equina (CES)

Answer 11

Faecal incontinence

Urinary retention (painless, with secondary overflow incontinence)

Saddle anaesthesia

Question 12

In a pt presenting with clinical features of radiculopathy what are the red flag symptoms you must ask about in association with:

Infection

Answer 12

Immunosuppression

Intravenous drug abuse

Unexplained fever

Question 13

In a pt presenting with clinical features of radiculopathy what are the red flag symptoms you must ask about in association with:

Fracture or infection

Answer 13

Chronic steroid use

Question 14

In a pt presenting with clinical features of radiculopathy what are the red flag symptoms you must ask about in association with:

Fracture

Answer 14

Significant trauma

Osteoporosis or metabolic bone disease

Question 15

In a pt presenting with clinical features of radiculopathy what are the red flag symptoms you must ask about in association with:

Malignancy

Answer 15

New onset after 50 years old

Question 16

In a pt presenting with clinical features of radiculopathy what are the red flag symptoms you must ask about in association with:

metastatic disease

Answer 16

History of malignancy

Question 17

What are some DD for radiculopathy?

(Pseudoradicular pain syndromes not due to nerve root dysfunction but cause radiating limb pain in an approximate radicular pattern)

LONG ANSWER BUT EXPLAINS WHY

Answer 17

1. Referred pain – e.g. arm from myocardial ischaemia, R shoulder from hepatobiliary disease, or flank/ groin/ thigh from urinary tract
2. Myofascial pain – hip muscles can mimic pain from lumbar radiculopathy; shoulder girdle muscles can produce pain radiating into the upper extremity. Examine for tenderness at specific muscle sites which when palpated produce radiating pain
3. Thoracic outlet syndrome – compression or irritation of the structures between the base of the neck and axilla due to anatomical variations
4. Greater trochanteric bursitis – palpation will reveal the area of inflammation, typically over the superolateral aspect of the trochanter
   Iliotibial band syndrome – excessive friction (long distance runners, cyclists) between the iliotibial band and underlying bursa; often associated with tightness of the iliotibial tract; pain felt laterally, 2-3cm proximal to the knee joint
5. Meralgia paraesthetica – compression of the lateral cutaneous nerve of the thigh as it passes under the inguinal ligament. It presents with clearly demarcated area of paraesthesia and/or numbness in the anterolateral aspect of the thigh
6. Piriformis syndrome – anatomic variations in either the muscle or the sciatic nerve that can cause pain in the region of the sacroiliac joint or the sciatic notch.

Question 18

What is the management of radiculopathy?

Answer 18

Depends on underlying cause

Emergency surgical treatments = cauda equina
Most IV disc prolapse = non operatively

Question 19

Although most IV disc prolapses are managed non-operatively, what are indications for surgical treatment?

Answer 19

unremitting pain despite non-surgical management

progressive weakness

new or progressive myelopathy (compression of the spinal cord).

Question 20

What are some treatments for symptomatic management of radiculopathy ?

Answer 20

• Analgesia
  e.g. Amitriptyline (usually 1st line), pregabalin and gabapentin
• Muscle spasm
  e.g. benzodiazepines (often diazepam) or baclofen.

Physiotherapy

Question 21

What physical findings might you get with a pt with L5 radiculopathy?

Answer 21

• Foot drop (weakness of dorsiflexors)
• Weakness in hip abduction
• Loss of inversion
• Sensory loss over L5 dermatome
• Sciatic type shooting leg pain

common cause: Lumbosacral disc herniation

Question 22

In a pt with foot drop, how could you tell if it was due to a radiculopathy (L5 root lesion) or due to a common peroneal nerve lesion?

Answer 22

radiculopathy - loss of inversion (tibial nerve function)

Peroneal nerve lesion - invers
ion present as tibial nerve not affected