Spine: Radiculopathy

Question 1

Define radiculopathy.

Answer 1

Disease affecting the nerve roots. Most commonly affects the lumbar spine (150/100,000/yr) and cervical spine (20/100,000/yr)

Question 2

What are the most common locations for radiculopathy?

Answer 2

C5/C6- cervical

L5/S1 - lumbosacral

Question 3

What is the aetiolgy of radiculopathy?

Answer 3

Compression by displaced intervertebral discs of degenerative spine disease. Disc protrusions are most common at C5,6 in neck and L5 S1 in lower back, but occurs at other levels too.

Several causes:

Acute disc - young in absence of degenerative changes. Hx of recent injury/straining. Herniation through nucleus pulposis through rupture of annulus fibrosis - “soft disc”

Spondylosis - discs dehydrate, losing height so annulus prolapses –> osetophytic outgrowths on vertebral bodies and instability of apophyseal joints which hypertroophy. This may compress nerve roots –> radiculopathy OR compress spinal cord –> myelopathy.

Other causes: tumours (e.g. neurofibroma, meningioma), inflammatory conditions (e.g. shingles or meningitis rarely)

Question 4

List 4 possible causes of radiculopathy.

Answer 4

1. Acute disc
2. Spondylosis
3. Tumours e.g. neurofibroma, meningioma
4. Inflammation e.g. shingles, meningitis

Question 5

What are the symptoms of radiculopathy?

Answer 5

1. Pain which radiates from spine - may be made worse by coughing, sneezing, straining in mechanical aetiology. Spinal tenderness and restriction of movement may be present. Onset depends on aetiology.
2. Weakness - loss of function in distribution of the nerve
3. Sensory loss

Question 6

What are the signs of radiculopathy on examination?

Answer 6

1. Pain - in distribution of affected nerve root. Maneouvres may make pain worse. Spinal tenderness/restriction of movement.
   
   • Sciatic stretch - straight leg rasing makes pain radiate to leg in sciatic distribution in L5/S1 lesion.
2. Weakness - loss of function, wasting/fasciculations of muscles innervated by root
3. Reflex changes - loss of reflexes
4. Sensory loss/alteration in distribution and UMN signs if spinal cord compression is also present

Question 7

How do you test for L5/S1 radiculopathy?

Answer 7

Sciatic stretch

Question 8

Describe the pattern of loss of sensation and pain in the most commonly affected nerve roots in radiculopathy.

Answer 8

Question 9

What is polyradiculopathy? What does it suggest?

Answer 9

Involvement of more than one nerve root

Implies an inflammatory process or neoplastic process within spinal fluid

Question 10

Give 3 examples of polyradiculopathy.

Answer 10

Inflammatory:

• Guillain-Barre syndrome
• Inflammatory meningitis e.g. sarcoidosis

Neoplastic process in spinal fluid:

• Malignant meningitis infiltrating nerve roots at multiple levels

Question 11

What investigations would you do for radiculopathy?

Answer 11

Depends on clinical presentation:

• MRI - investigation of choice for single-level radiculopathy
• EMG - may show radicular pattern of denervation
• Nerve conduction studies - excludes neuropathy but is unhelpful in identifying cause of radiculopathy

Other:

• Lumbar puncture - in multiple radiculopathy, might be useful to examine CSF for systemic illness

Question 12

What is the time of onset of lumbosacral radiculopathy?

Answer 12

Sudden

Patients often report that back pain goes away when leg pain begins.

Question 13

List 6 differences between UMN and LMN lesions.

Answer 13

UMN

• spastic paralysis
• hypertonic
  
  • decorticate rigidity = lesion bove midbrain
  • decerebrate rigidity = below midbrain
• atrophy - DISUSE atrophy
• decreased speed of voluntary movement
• large area of body involved

LMN

• flaccid paralysis
• hypotonic
• atrophy - WASTING atrophy
• no movement
• small area of body involved