Radiculopathy (sciatica, cervical radiculopathy)

Question 1

Which investigation is most useful for radiculopathy?

Answer 1

MRI

Question 2

A 42 year old man complains of low back pain dating back 2-3 years. Symptoms have become more severe and he is now experiencing pain radiating down the back of the right leg to the ankle, with numbness of the lateral side of his foot. Which nerve root is likely affected?

Answer 2

L5

Question 3

Where does the spinal cord end?

Answer 3

L1

Question 4

What are the signs and symptoms of cauda equina syndrome?

Answer 4

Severe narrowing of the spinal canal compressing the nerves –>

• Sciatic symptoms
• Leg weakness
• Leg numbness
• Perianal./perineal numbness
• Weakness of the anal sphincter
• Bowel/bladder disturbance

Question 5

Define radiculopathy.

Answer 5

Radiculopathy is a neurological state in which conduction is limited or blocked along a spinal nerve or its roots — it is differentiated from radicular pain*, although they commonly occur together

*Radicular pain is usually caused by compression of the nerve root due to cervical disc herniation or degenerative spondylotic changes, but radicular symptoms can also occur without evident compression (for example, due to inflammation of the nerve).

Question 6

What are the general clinical features of radiculopathy?

Answer 6

• Pain/’electrical’ sensations at the level of the compression
• Numbness
• Dull reflexes
• LMN weakness
• Eventual wasting of muscles innervated by that nerve roots

Question 7

What do UMN signs below the level of root compression suggest?

Answer 7

UMN signs below the level of affected root suggest cord compression

Question 8

What is polyradiculopathy?

Answer 8

When more than one nerve root is compressed

Question 9

Define sciatica.

Answer 9

Sciatica describes radiating leg pain caused by inflammation or compression of the lumbosacral nerve roots (L4–S1) forming the sciatic nerve.

Question 10

What are the clinical features of sciatica?

Answer 10

• Sudden/slow onset
• Unilateral leg pain radiating below the knee to the foot or toes.
• Low back pain — if present, which is less severe than any leg pain.
• Numbness, tingling (paraesthesia) in the distribution of a nerve root.
• Weakness or reflex changes, or both in a myotomal distribution.
• A positive result in a straight leg raise test

Question 11

What are the causes of nerve root compression in sciatica?

Answer 11

• A herniated intervertebral disc — in about 90% of cases; usually due to age-related degenerative changes, but rarely it can be caused by trauma
• Spondylolisthesis
• Spinal stenosis.
• Infection e.g. discitis, vertebral osteomyelitis, spinal epidural abscess
• Cancer - usually due to metastatic disease of the spine rather than primary tumour

Question 12

What are the risk factors for sciatica?

Answer 12

• Old age
• Genetic influlence- these are a more important cause of disc degeneration than mechanical causes
• Smoking
• Obesity
• Occupational factors — for example, whole body vibration, strenuous physical activity
• General health and comorbidities

Question 13

What is the prognosis with sciatica?

Answer 13

Half of people recover spontaneously within 6 weeks

A quarted experience transient episodes with recurrence

Worse prognosis if workplace contributing factors persist or if there are psychosocial factors like low mood.

Question 14

What are the red flags for patients with sciatica?

Answer 14

• Bowel/bladder dysfunction (most commonly urinary retention).
• Progressive neurological weakness.
• Saddle anaesthesia.
• Bilateral radiculopathy.
• Incapacitating pain.
• Unrelenting night pain.
• Use of steroids or intravenous drugs.

Question 15

What are some differential diagnoses for sciatica?

Answer 15

• Cauda equina syndrome
• Spinal fracture
• Cancer
• Infection

Question 16

What is the management of sciatica?

Answer 16

• Admit or refer urgently to spinal surgery service if red flag symptoms present +/- MRI

Conservative:

• Physiotherapist for manual therapy e.g. massage
• Psychological therapies e.g. CBT
• Group exercise programme

Medical:

• Simple analgesia
  
  • Do not offer gabapentinoids, other antiepileptics, oral corticosteroids, or benzodiazepines for managing sciatica as there is no overall evidence of benefit and there is evidence of harm. Do not offer opioids.

Safety net: seek follow up if symptoms worsen, persist for over 2 weeks, severe pain has not subsided within 1 week, if new symptoms develop, or if symptoms recur

Question 17

What general advice should be given about sciatica?

Answer 17

• Stay active - bed rest not recommended
• Resume normal activities
• Return to work ASAP - work adjustments may help
• A modest increase in pain on resuming activities does not indicate that damage has occurred.
• Application of heat may relieve pain

Question 18

Define spondylolisthesis.

Answer 18

Spondylolisthesis — when a proximal vertebra moves forward relative to a distal vertebra.

Question 19

What are the complications of sciatica?

Answer 19

• Chronicity
• Diability, poor quality or life, increased use of healthcare resources
• Time off work, reduced productivity, and loss of employment

Question 20

Which cancers are responsible for more than 80% of cases of metastatic bone disease?

Answer 20

Spine is the most common site for these metastases.

Breast, prostate, lung

Question 21

How is a straight leg raise test for sciatica done?

Answer 21

With the person lying supine, the hip is flexed gradually with the knee extended. Pain reproduced below 60 degrees of hip flexion on the ipsilateral side indicates a positive test.

Question 22

What investigations are used to diagnose sciatica?

Answer 22

• Examination - a positive result in a straight leg raise test
• STarT Back Screening Tool is a nine item questionnaire - used in GP to assess risk of chronicity so that appropriate level of support can be given
• Routine imaging is not required but consider if infection, malignany or inflammation suspeced. Then do FBC, ESR, CRP, blood cultures, urinalysis.

Question 23

Should you offer traction, TENS or PENS for sciatica?

Answer 23

Do not offer:

• foot orthotics,
• belts or corsets,
• rocker sole shoes,
• traction,
• acupuncture,
• ultrasound,
• transcutaneous electrical nerve simulation (TENS),
• or percutaneous electrical nerve simulation (PENS),

…for people with sciatica

Question 24

In what instances should you refer sciatica to a specialist?

Answer 24

1. Pain at 2-6 weeks
2. Non-tolerable pain at 6 weeks
3. Acute and severe sciatica - for consideration of epidural corticosteroid/local anaesthetic injection
4. When non-surgical treatment has not worked —> consider spinal decompression

Question 25

Define cervical radiculopathy.

Answer 25

Pain and weakness and/or numbness in one or both of the upper extremities which corresponds to the dermatome of the involved cervical nerve root.

Often occurs alongside neck pain which is secondary to compression.

Question 26

What are the causes of cervical radiculopathy?

Answer 26

• Degenerative changes incl. disc herniation and spondylosis
• OA may cause bone hypertrophy ususally at facet joints
• Trauma

Question 27

When is cervical radiculopathy most common?

Answer 27

Age 5-54yrs

Question 28

What is the prognosis with cervical radiculopathy?

Answer 28

88% improve within 4 weeks regardless of treatment

Question 29

What are the clinical features of cervical radiculopathy?

Answer 29

• Positive Spurling’s test
• Positive arm squeeze test
• Pain in the neck/shoulder/arm that corresponds to dermatome
  
  • usually unilateral
  • may be worse at night
• Absent/altered sensation
  
  • shooting pain
  • numbness
  • hyperaesthesia
• Muscle weakness
• Postural asymmetry to decompress nerve root
• Restricted neck movement

Question 30

What is the function of the individual C5-T1 nerve roots?

Answer 30

Question 31

List 5 differentials for cervical radiculopathy.

Answer 31

Question 32

What is Lhermitte’s sign?

Answer 32

Lhermitte’s sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs - suggests cervical myelopathy (not cervical radiculopathy)

Question 33

What is the management of cervical radiculopathy?

Answer 33

• Conservative management - if <6 weeks duration and no neurological signs. Encourage activity and home exercises/
  
  • Advise not to drive if reduced neck motion
  • Discourage neck collars
  • Firm pillow at night for lateral support
  • Simple analgesi
• Consider amitriptyline, duloxetine, pregabalin or gabapentin.
• If >6 weeks OR objective neurological signs:
  
  • MRI to confirm diagnosis
• If >6-12 weeks or progressive symptoms:
  
  • Surgery

Question 34

What is the Spurling test?

Answer 34

The Spurling test — flex the neck laterally, rotate and then press on top of the person’s head. The test is positive if this pressure causes the typical radicular arm pain.

Question 35

What is the arm squeeze test?

Answer 35

Squeeze the middle third of the upper arm with simultaneous thumb and fingers compression (the thumb from posterior on the triceps muscle and the fingers from anterior on the biceps muscle).

The test is positive when the pain score (on a 0-10 visual analogue scale) is 3 points or higher during pressure on the middle third of the upper arm compared with two other areas.