Radiculopathy

Question 1

What is radiculopathy?

Answer 1

A radiculopathy is a conduction block in the axons of a spinal nerve or its roots, with impact on motor axons causing weakness and on sensory axons causing paraesthesia and/or anaesthesia.

Question 2

Briefly differentiate between radiculopathy and radicular pain

Answer 2

There is a distinction between radiculopathy versus radicular pain:

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

Question 3

Briefly describe the anatomy of the spinal nerves

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 can cause radiculopathy?

Answer 4

Radiculopathy is most commonly a result of nerve compression, which can be caused by:

1. Intervertebral disc collapse
2. Degenerative disease of the spine
3. Fracture
4. Malignancy
5. Infection

Question 5

Which part of the spine is most susceptible to intervertebral disc collapse?

Answer 5

The lumbar spine is predominantly affected by repeated minor stresses that predispose to rupture of the annulus fibrosus and sequestration of disc material (the nucleus pulposus).

Question 6

What is the eventual outcome of degenerative diseases of the spine?

Answer 6

Leading to neuroforaminal or spinal canal stenosis.

Question 7

Which part of the spine is most susceptible to degenerative disease?

Answer 7

The cervical spine is the most mobile segment of the spine and degenerative change is a normal part of ageing process; 80% of the population over 55 years old have degenerative changes between C5/6 and C6/7.

Question 8

What are the clinical features of radiculopathy?

Note: signs and symptoms

Answer 8

Clinical features of radiculopathy include sensory features (paraesthesia and numbness) and motor features (weakness).

Radicular pain is often also present, typically described as a burning, deep, strap-like, or narrow pain. It is not uncommon for radicular pain to be intermittent.

Question 9

What are the clincal features of radiculopathy?

Note: on examination

Answer 9

On examination, it is important to identify dermatomal and myotomal involvement.

Ensure to evaluate for cauda equina syndrome, by assessing for pinprick sensation in the perianal dermatomes (reduced in CES), anocutaneous reflex (diminished or absent in CES), anal tone (reduced in CES), and rectal pressure sensation (reduced in CES).

Question 10

What “red flag” symptoms should be asked about?

Answer 10

• Faecal incontinence
• Urinary retention (painless, with secondary overflow incontinence)
• Saddle anaesthesia
• Immunosuppression
• Intravenous drug abuse
• Unexplained fever
• Chronic steroid use
• Significant trauma
• Osteoporosis or metabolic bone disease
• New onset after 50 years
• History of malignancy
  *

Question 11

What disorder is associated with faecal incontinence, urinary retention (painless, with secondary overflow incontinence) and saddle anaesthesia?

Answer 11

Cauda Equina Syndrome (CES).

Question 12

What disorder is associated with immunosuppression, intravenous drug abuse and unexplained fever?

Answer 12

Infection.

Question 13

What disorder is associated with chronic steroid use?

Answer 13

Fracture or infection.

Question 14

What disorder is associated with significant trauma, osteoporosis or metabolic bone disease?

Answer 14

Fracture.

Question 15

What disorder is associated with new onset after 50 years?

Answer 15

Malignancy.

Question 16

What disorder is associated with history of malignancy?

Answer 16

Metastatic disease.

Question 17

Briefly describe the management of radiculopathy

Answer 17

Definitive long-term management depends on the underlying cause. In general, the only condition that requires emergency surgical treatment is cauda equina syndrome.

Question 18

Briefly describe the symptomatic management of radiculopathy

Answer 18

Analgesia is an important aspect of management in these patients. The WHO analgesic ladder can be utilised in the first instance, however neuropathic pain medications are frequently utilised.

Amitriptyline is usually first line, or pregabalin and gabapentin as alternatives. The patients may also suffer from muscle spasms and these can be managed with benzodiazepines (often diazepam) or baclofen.

Physiotherapy remains an important part of management in this patient group.

Question 19

How are most disc prolapses managed? When may surgery be indicated?

Answer 19

Most IV disc prolapses can be managed non-operatively, but indications for surgical treatment include unremitting pain despite comprehensive non-surgical management, progressive weakness and new or progressive myelopathy (compression of the spinal cord).

Question 20

What differentials should be considered for radiculopathy?

Answer 20

The differential diagnosis for radicular pain should include pseudoradicular pain syndromes: these are conditions that do not arise directly from nerve root dysfunction, but cause radiating limb pain in an approximate radicular pattern.

These include:

• Referred pain
• Myofascial pain
• Thoracic outlet syndrome
• Greater trochanteric bursitis
• Iliotibial band syndrome
• Meralgia paraesthetica
• Piriformis syndrome