Acute lumbosacral radiculopathy: Pathophysiology, clinical features, and diagnosis
- Philip S Hsu, MD
Philip S Hsu, MD
- Assistant Professor
- Tufts University School of Medicine
- Carmel Armon, MD, MHS
Carmel Armon, MD, MHS
- Chairman, Department of Neurology
- Assaf Harofeh Medical Center
- Associate Clinical Professor of Neurology
- Tel Aviv University Sackler School of Medicine
- Kerry Levin, MD
Kerry Levin, MD
- Chairman, Department of Neurology
- Cleveland Clinic
- Cleveland Clinic Lerner College of Medicine
- Section Editor
- Jeremy M Shefner, MD, PhD
Jeremy M Shefner, MD, PhD
- Section Editor — Neuromuscular Disease
- Professor and Chair of Neurology, Barrow Neurological Institute
- Professor of Neurology, University of Arizona, Phoenix
- Clinical Professor of Neurology, Creighton University
Lumbosacral radiculopathy is a condition in which a disease process affects the function of one or more lumbosacral nerve roots . The clinical aspects of lumbosacral radiculopathy will be reviewed here.
The treatment of lumbosacral radiculopathy and other disorders of the lower spine are discussed separately. (See "Acute lumbosacral radiculopathy: Treatment and prognosis" and "Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis" and "Evaluation of low back pain in adults" and "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment" and "Subacute and chronic low back pain: Nonsurgical interventional treatment" and "Subacute and chronic low back pain: Surgical treatment".)
The lumbar spine consists of five movable lumbar vertebral bodies, numbered L1 to L5 (figure 1). The sacrum is made up of five developmentally fused vertebral levels (S1 to S5), followed by a terminal bony prominence, the coccyx. The entire region is commonly described as the lumbosacral spine.
Directly beneath each lumbar and sacral vertebra, there is a pair of neural foramina with the same number designation, such that the L1 neural foramina are located just below the L1 vertebral body. Neural foramina are bounded superiorly and inferiorly by pedicles, anteriorly by the intervertebral disc and vertebral body, and posteriorly by facet joints (figure 1).
Through each neural foramen passes the same numbered spinal nerve root, recurrent meningeal nerves, and radicular blood vessels. On each side there are five lumbar, five sacral, and one coccygeal spinal nerve roots.
- Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin 2007; 25:387.
- Ranson SW. The structure of the spinal ganglia and of the spinal nerves. J Comp Neurol 1912; 22:159.
- Hay MC. Anatomy of the lumbar spine. Med J Aust 1976; 1:874.
- Hamanishi C, Tanaka S. Dorsal root ganglia in the lumbosacral region observed from the axial views of MRI. Spine (Phila Pa 1976) 1993; 18:1753.
- Kikuchi S, Sato K, Konno S, Hasue M. Anatomic and radiographic study of dorsal root ganglia. Spine (Phila Pa 1976) 1994; 19:6.
- Levin KH. Electrodiagnostic approach to the patient with suspected radiculopathy. Neurol Clin 2002; 20:397.
- Lee MW, McPhee RW, Stringer MD. An evidence-based approach to human dermatomes. Clin Anat 2008; 21:363.
- Tsao BE, Levin KH, Bodner RA. Comparison of surgical and electrodiagnostic findings in single root lumbosacral radiculopathies. Muscle Nerve 2003; 27:60.
- Foerster O. The dermatomes in man. Brain 1933; 56:1.
- Bogduk N. The anatomy of the lumbar intervertebral disc syndrome. Med J Aust 1976; 1:878.
- Groen GJ, Baljet B, Drukker J. Nerves and nerve plexuses of the human vertebral column. Am J Anat 1990; 188:282.
- Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal cord. N Engl J Med 1934; 211:210.
- Weinstein PR. Anatomy of the lumbar spine. In: Lumbar Disc Disease, 2nd ed, Hardy RW (Ed), Raven Press, New York 1993. p.5.
- Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363.
- Ljunggren AE. Natural history and clinical role of the herniated disc. In: The Lumbar Spine, 2nd ed, Wiesel SW, Weinstein JN, Herkowitz H, et al (Eds), WB Saunders, Philadelphia 1996. Vol 1, p.473.
- Maroon JC, Kopitnik TA, Schulhof LA, et al. Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg 1990; 72:378.
- Keim HA, Kirkaldy-Willis WH. Low back pain. Clin Symp 1980; 32:1.
- Chin CH, Chew KC. Lumbosacral nerve root avulsion. Injury 1997; 28:674.
- Love JG. The differential diagnosis of intraspinal tumors and protruded intervertebral disks in their surgical treatment. J Neurosurg 1944; 1:275.
- Anders HJ, Goebel FD. Cytomegalovirus polyradiculopathy in patients with AIDS. Clin Infect Dis 1998; 27:345.
- Viali S, Hutchinson DO, Hawkins TE, et al. Presentation of intravascular lymphomatosis as lumbosacral polyradiculopathy. Muscle Nerve 2000; 23:1295.
- Grossman SA, Krabak MJ. Leptomeningeal carcinomatosis. Cancer Treat Rev 1999; 25:103.
- Paulsen RD, Call GA, Murtagh FR. Prevalence and percutaneous drainage of cysts of the sacral nerve root sheath (Tarlov cysts). AJNR Am J Neuroradiol 1994; 15:293.
- Lucantoni C, Than KD, Wang AC, et al. Tarlov cysts: a controversial lesion of the sacral spine. Neurosurg Focus 2011; 31:E14.
- Acosta FL Jr, Quinones-Hinojosa A, Schmidt MH, Weinstein PR. Diagnosis and management of sacral Tarlov cysts. Case report and review of the literature. Neurosurg Focus 2003; 15:E15.
- Oaklander AL, Long DM, Larvie M, Davidson CJ. Case records of the Massachusetts General Hospital. Case 7-2013. A 77-year-old woman with long-standing unilateral thoracic pain and incontinence. N Engl J Med 2013; 368:853.
- Chad DA. Disorders of nerve roots and plexuses. In: Neurology in Clinical Practice, 4th ed, Bradley WG, Daroff RB, Fenichel GM, et al (Eds), Elsevier, Philadelphia 2004. p.2267.
- Dyck PJ, Norell JE, Dyck PJ. Microvasculitis and ischemia in diabetic lumbosacral radiculoplexus neuropathy. Neurology 1999; 53:2113.
- Holmes JM, Sworn BR. Lumbo-sacral Root Pain. Br Med J 1946; 1:946.
- Marshall LL, Trethewie ER, Curtain CC. Chemical radiculitis. A clinical, physiological and immunological study. Clin Orthop Relat Res 1977; :61.
- Slipman CW, Isaac Z, Lenrow DA, et al. Clinical evidence of chemical radiculopathy. Pain Physician 2002; 5:260.
- Zwart JA, Sand T, Unsgaard G. Warm and cold sensory thresholds in patients with unilateral sciatica: C fibers are more severely affected than A-delta fibers. Acta Neurol Scand 1998; 97:41.
- Strian F, Lautenbacher S, Karlbauer G, Galfe G. Disturbances of C-fibre-mediated sensibility in lumbosacral disc disease. J Neurol Neurosurg Psychiatry 1991; 54:1013.
- Bischoff RJ, Rodriguez RP, Gupta K, et al. A comparison of computed tomography-myelography, magnetic resonance imaging, and myelography in the diagnosis of herniated nucleus pulposus and spinal stenosis. J Spinal Disord 1993; 6:289.
- Norlen G. On the value of neurological symptoms in sciatica for localization of a lumbar disc herniation. Acta Chir Sand 1944; 95:7.
- BROWN HA, PONT ME. DISEASE OF LUMBAR DISCS. TEN YEARS OF SURGICAL TREATMENT. J Neurosurg 1963; 20:410.
- Esene IN, Meher A, Elzoghby MA, et al. Diagnostic performance of the medial hamstring reflex in L5 radiculopathy. Surg Neurol Int 2012; 3:104.
- van der Windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev 2010; :CD007431.
- Weir BK. Prospective study of 100 lumbosacral discectomies. J Neurosurg 1979; 50:283.
- Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992; 268:760.
- Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol 1999; 246:899.
- Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990; 72:403.
- Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 1994; 331:69.
- Borenstein DG, O'Mara JW Jr, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. J Bone Joint Surg Am 2001; 83-A:1306.
- Cho SC, Ferrante MA, Levin KH, et al. Utility of electrodiagnostic testing in evaluating patients with lumbosacral radiculopathy: An evidence-based review. Muscle Nerve 2010; 42:276.
- Levin KH. Radiculopathy. In: Comprehensive Clinical Neurophysiology, Levin KH, Lüders HO (Eds), WB Saunders, New York 2000. p.627.
- Nardin RA, Patel MR, Gudas TF, et al. Electromyography and magnetic resonance imaging in the evaluation of radiculopathy. Muscle Nerve 1999; 22:151.
- Kuruoglu R, Oh SJ, Thompson B. Clinical and electromyographic correlations of lumbosacral radiculopathy. Muscle Nerve 1994; 17:250.
- Wilbourn AJ, Aminoff MJ. AAEM minimonograph 32: the electrodiagnostic examination in patients with radiculopathies. American Association of Electrodiagnostic Medicine. Muscle Nerve 1998; 21:1612.
- Albeck MJ, Taher G, Lauritzen M, Trojaborg W. Diagnostic value of electrophysiological tests in patients with sciatica. Acta Neurol Scand 2000; 101:249.
- Katifi HA, Sedgwick EM. Evaluation of the dermatomal somatosensory evoked potential in the diagnosis of lumbo-sacral root compression. J Neurol Neurosurg Psychiatry 1987; 50:1204.
- Aminoff MJ, Goodin DS, Barbaro NM, et al. Dermatomal somatosensory evoked potentials in unilateral lumbosacral radiculopathy. Ann Neurol 1985; 17:171.
- Dumitru D, Dreyfuss P. Dermatomal/segmental somatosensory evoked potential evaluation of L5/S1 unilateral/unilevel radiculopathies. Muscle Nerve 1996; 19:442.
- Bogduk N. The lumbar disc and low back pain. Neurosurg Clin N Am 1991; 2:791.
- Myotomes and dermatomes
- Sinuvertebral nerves
- PATHOPHYSIOLOGY AND ETIOLOGY
- Pain generators in the lumbosacral spine
- Degenerative changes
- Disc protrusion and level of injury
- Other skeletal causes
- Nonskeletal causes
- Fiber size
- CLINICAL PRESENTATIONS
- L1 radiculopathy
- L2/L3/L4 radiculopathy
- L5 radiculopathy
- S1 radiculopathy
- S2/S3/S4 radiculopathy
- EVALUATION AND DIAGNOSIS
- Physical examination
- - Maneuvers
- - Nerve conduction studies and electromyography
- - Somatosensory evoked potentials
- Cerebrospinal fluid analysis
- DIFFERENTIAL DIAGNOSIS
- Low back pain
- Spinal stenosis
- Cauda equina syndrome
- Diabetic amyotrophy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS