28/5/2021 Lumbosacral Radiculopathy - StatPearls - NCBI Bookshelf

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Lumbosacral Radiculopathy
Christopher E. Alexander; Matthew Varacallo.

Author Information
Last Update: May 4, 2021.

Continuing Education Activity

Low back pain is one of the most common musculoskeletal complaints encountered in clinical practice.
It is the leading cause of disability in the developed world and accounts for billions of dollars in
healthcare costs annually. Although epidemiological studies vary, the incidence of low back pain is
estimated to be anywhere between 5% to more than 30% with a lifetime prevalence of 60% to 90%.
However, radicular symptoms can be a harbinger of more serious conditions, including discopathy or
acute disc herniation. Lumbosacral radiculopathy can also appear in the absence of actual lumbar pain.
This activity reviews the pathophysiology and presentation of lumbosacral radiculopathy and highlights
the role of the interprofessional team in its management

Objectives:

Review the potential etiologies of lumbar radiculopathy.

Describe the evaluation of a patient with lumbosacral radiculopathy, includng imaging studies as
may be appropriate.

Summarize the treatment options for lumbosacral radiculopathy.

Explain the importance of improving care coordination among interprofessional team members to
improve outcomes for patients affected by lumbosacral radiculopathy.

Earn continuing education credits (CME/CE) on this topic.

Introduction
Low back pain is one of the most common musculoskeletal complaints encountered in clinical practice.
It is the leading cause of disability in the developed world and accounts for billions of dollars in
healthcare costs annually. Although epidemiological studies vary, the incidence of low back pain is
estimated to be anywhere between 5% to more than 30% with a lifetime prevalence of 60% to 90%.
Most occurrences of low back pain are self-limited and resolve without intervention. Approximately
50% of cases will resolve within one to two weeks. 90% of cases will resolve in six to 12 weeks. The
differential for low back pain is broad, and amongst other diagnoses, should include lumbosacral
radiculopathy. Lumbosacral radiculopathy is a term used to describe a pain syndrome caused by
compression or irritation of nerve roots in the lower back. It can be caused by lumbar disc herniation,
degeneration of the spinal vertebra, and narrowing of the foramen from which the nerves exit the spinal
canal. Symptoms include low back pain that radiates into the lower extremities in a dermatomal pattern.
Other accompanying symptoms can include numbness, weakness, and loss of reflexes, although the
absence of these symptoms does not exclude a diagnosis of lumbosacral radiculopathy. [1]

Etiology
The noxious stimulus of a spinal nerve creates ectopic nerve signals that are perceived as pain,
numbness, and tingling along the nerve distribution. Lesions of the intervertebral discs and degenerative
disease of the spine are the most common causes of lumbosacral radiculopathy. However, any process
that causes irritation of the spinal nerves can cause radicular symptoms. The differential diagnosis for
lumbosacral radiculopathy should include (but is not limited to) the following:

Degenerative conditions of the spine (most common causes)

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Spondylolisthesis: in the degenerative setting, this occurs as a result of a pathologic

cascade including intervertebral disc degeneration, ensuing intersegmental instability, and
facet joint arthropathy

Spinal stenosis

Adult isthmic spondylolisthesis is typically caused by an acquired defect in the par

interarticularis

Pars defects (i.e. spondylolisis) in adults are most often secondary to repetitive
microtrauma

Trauma (e.g. burst fractures with bony fragment retropulsion)

Clinicians should recognize spinal fractures can occur in younger, healthy patient
populations secondary to high-energy injuries (e.g. MVA, fall from height) or secondary
low energy injuries and spontaneous fractures in the elderly populations, including any
patient with osteoporosis

Associated hemorrhage from the injury can result in a deteriorating clinical and neurologic
exam

Benign or malignant tumors

Metastatic tumors (most common)

Primary tumors

Ependymoma

Schwannoma

Neurofibroma

Lymphoma

Lipomas

Paraganglioma

Ganglioneuroma

Osteoblastoma

Infection

Osteodiscitis

Osteomyelitis

Epidural abscess

Fungal infections (e.g. Tuberculosis)

Other infections: lyme disease, HIV/AIDS-defining ilnesses, Herpes zoster (HZ)

Vascular conditions

Hemangioblastoma, aterior-venous malformations (AVM)[2]

Epidemiology
While the literature lacks concise epidemiologic data, most reports estimate about a 3% to 5%
prevalence rate of lumbosacral radiculopathy in patient populations. Moreover, the condition constitutes
a significant reason for patient referral to either neurologists, neurosurgeons, or orthopedic spine
surgeons.

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While the incidence of low back pain is estimated to be between 13% and 31%, the incidence of
radicular symptoms in patients presenting with low back pain ranges from 12% to 40%. In the
workforce, low back pain is the second greatest cause of absenteeism behind upper respiratory tract
infections. About 25 million people miss one or more days of work due to low back pain, and more
than five million are disabled from it. Patients with chronic back pain account for 80% to 90% of all
health care expenditures. [1][3]

Pathophysiology
Lumbosacral radiculopathy is the clinical term used to describe a predictable constellation of symptoms
occurring secondary to mechanical and/or inflammatory cycles compromising at least one of the
lumbosacral nerve roots. Patients can present with radiating pain, numbness/tingling, weakness, and gait
abnormalities across a spectrum of severity. Depending on the nerve root(s) affected, patients can
present with these symptoms in predictable patterns affecting the corresponding dermatome or
myotome. [4]

History and Physical

As with any disease process, a thorough history and physical exam are crucial in diagnosing lumbosacral
radiculopathy. Pain is the most commonly reported symptom. However, numbness or weakness along
the distribution supplied by the respective nerve root(s) is often appreciated. Radicular pain is typically
characterized by patients as "electrical shocks" or "shooting pains" that radiate from the buttock to the
foot. While gathering the history, it is important to screen for any red-flag symptoms, which could
indicate an urgent/emergent clinical condition. Evaluating clinicians must first rule out associated "red
flag" symptoms including:

Thoracic pain

Fever/unexplained weight loss

Night sweats

Bowel or bladder dysfunction

Malignancy (document/record any previous surgeries, chemo/radiation, recent scans and

bloodwork, and history of metastatic disease)

Can be seen in association with pain at night, pain at rest, unexplained weight loss, or night
sweats

Significant medical comorbidities

Neurologic deficit or serial exam deterioration

Gait ataxia

Saddle anesthesia

Age of onset (bimodal -- Age < 20 years or Age > 55 years)

A full neurologic exam shoulder is performed, including an assessment for upper motor neuron findings
(Babinski sign, clonus, spasticity). On physical exam, several maneuvers can assist the clinician in
making a diagnosis. Lasègue test, or straight leg test, is performed by passively raising one leg into the
air. This creates increased tension on the sciatic nerve between 30 degrees to 60 degrees from the exam
table. A reproduction of the patient's symptoms during passive movement between 30 degrees to 60
degrees is considered a positive sign and is suggestive of lower lumbar nerve root involvement (L4 to
S1). Of note, a similar stretch can be created on the femoral nerve using a reverse straight leg, or Ely
test. With this test, the patient's symptoms are reproduced by extending the hip and flexing the knee with
the patient in the prone position. This will stretch the femoral nerve and the L2 to L4 nerve roots.
Reproduction of radicular symptoms can also be produced by placing the patient in a seated position
with the neck in full flexion and knees in full extension (slump test). [5][6]

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Evaluation
Given the favorable outcome, and often spontaneous resolution of the vast majority of low back pain
symptoms, extensive imaging is usually not necessary in patients with low back pain of less than four to
six weeks duration. As stated above, work-up begins with a thorough physical exam. Neurologic
deficits in a focal distribution warrant further workup. In cases of low back pain that fails to resolve
within one to two months, MRI is considered the gold standard in evaluating radicular low back pain.
Of note, MRI with contrast is recommended in patients with previous spinal surgeries. For patients
unable to undergo MRI, CT scan is an alternative option. However, CT is not as sensitive in visualizing
soft tissue or tumors and is not recommended for routine use. X-rays are simple, readily available in
most developed countries, and can reveal gross bony abnormalities such as fractures, disc space
narrowing, and other osteodegenerative changes. Often, it is not clinically possible to distinguish
lumbosacral radiculopathy from peripheral neuropathy or plexopathy. In these instances,
electromyography and nerve conduction study can be utilized to localize a lesion with relatively high
diagnostic specificity. [7]

Treatment / Management
Treatment is varied depending on the etiology and severity of symptoms. However, conservative
management of symptoms is generally considered first line. Medications are used to manage pain
symptoms including NSAIDS, acetaminophen, and in severe cases, opiates. Radicular symptoms are
often treated with neuroleptic agents. Systemic steroids are often prescribed for acute low back pain,
although there is limited evidence to support its use. Nonpharmacologic interventions are often
utilized as well. Physical therapy, acupuncture, chiropractic manipulation, and traction are all commonly
used in the treatment of lumbosacral radiculopathy. Of note, the data supporting the use of these
treatment modalities is equivocal. Interventional techniques are also commonly used and include epidural
steroid injections and percutaneous disc decompression. In refractory cases, surgical decompression
and spinal fusion can be performed. [8][9][10]

Differential Diagnosis

Ankylosing spondylitis

Epidural abscess

Inflammatory arthritis

Inflammatory bowel disease

Leukaemia

Lumbosacral disc injuries

Lymphoma

Metastatic carcinoma

Multiple myeloma

Pearls and Other Issues

Overall, lumbosacral radiculopathy is an extraordinarily common complaint seen in clinical practice and
comprises a large proportion of annual doctor visits. The vast majority of cases are benign and will
resolve spontaneously, and thus, conservative management is the most appropriate first step in the
absence of clinical red flag symptoms. In cases where symptoms fail to resolve, imaging studies,
electromyography, and nerve conduction studies can assist in making a diagnosis. [2][4][10]

Enhancing Healthcare Team Outcomes

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28/5/2021 Lumbosacral Radiculopathy - StatPearls - NCBI Bookshelf

Lumbosacral radiculopathy is a common problem and nurse practitioners, physician assistants, and
physicians working as a team should be aware of the red flag symptoms that require emergent
intervention and reporting to the physician providing team management.

Continuing Education / Review Questions

Access free multiple choice questions on this topic.

Earn continuing education credits (CME/CE) on this topic.

Comment on this article.

Figure

Lumbar MRI T2 sagital and axial slice. Contributed by S.

Dulebohn, M.D.

References
1. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin
Rheumatol. 2010 Dec;24(6):769-81. [PubMed: 21665125]
2. Urits I, Burshtein A, Sharma M, Testa L, Gold PA, Orhurhu V, Viswanath O, Jones MR, Sidransky
MA, Spektor B, Kaye AD. Low Back Pain, a Comprehensive Review: Pathophysiology,
Diagnosis, and Treatment. Curr Pain Headache Rep. 2019 Mar 11;23(3):23. [PubMed:
30854609]
3. Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. 2007 May;25(2):387-405.
[PubMed: 17445735]
4. van der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W,
Deyo RA, Bouter LM, de Vet HC, Aertgeerts B. Physical examination for lumbar radiculopathy
due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010 Feb 17;
(2):CD007431. [PubMed: 20166095]
5. Al Nezari NH, Schneiders AG, Hendrick PA. Neurological examination of the peripheral nervous
system to diagnose lumbar spinal disc herniation with suspected radiculopathy: a systematic review
and meta-analysis. Spine J. 2013 Jun;13(6):657-74. [PubMed: 23499340]
6. Nguyen HS, Doan N, Shabani S, Baisden J, Wolfla C, Paskoff G, Shender B, Stemper B. Upright
magnetic resonance imaging of the lumbar spine: Back pain and radiculopathy. J Craniovertebr
Junction Spine. 2016 Jan-Mar;7(1):31-7. [PMC free article: PMC4790145] [PubMed:
27041883]
7. Kennedy DJ, Noh MY. The role of core stabilization in lumbosacral radiculopathy. Phys Med
Rehabil Clin N Am. 2011 Feb;22(1):91-103. [PubMed: 21292147]
8. Tang S, Mo Z, Zhang R. Acupuncture for lumbar disc herniation: a systematic review and meta-
analysis. Acupunct Med. 2018 Apr;36(2):62-70. [PubMed: 29496679]
9. Wenger HC, Cifu AS. Treatment of Low Back Pain. JAMA. 2017 Aug 22;318(8):743-744.
[PubMed: 28829855]

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