Edit concept Question Editor Create issue ticket

Radiculopathy

Radiculopathy is a term derived from radicular nerves or nerve roots which exit the foramina of the vertebral bones. When these nerve roots are compressed by a herniated disc or prolapsed disc, there is a resultant sensation of discomfort, burning and pain felt in the distribution of the nerve giving rise to the term radiculopathy. The nerve roots are classified as cervical, thoracic, lumbar and sacral, according to the region in which they leave the spinal cord


Presentation

Patients tend to complain of severe neck and arm pain in the case of cervical radiculopathy; there are also symptoms of burning and tingling. The distribution of these symptoms however, follows a myotomal pattern rather than a dermatomal pattern [7]. There is concomitant loss of motor function and altered reflexes in the nerves affected [5]. The pain felt in cervical radiculopathy manifests through the shoulder girdle, arm and forearm, the paresthesias and numbness is mostly felt in the central portion of the hand and muscular weakness is felt in the arm and forearm [9]. In one study, symptoms were preceded by some sort of physical exertion or trauma in 15% cases [8]. Although there are no criteria for the confirmed diagnosis of cervical radiculopathy, the history and examination of the patient usually give evidence enough to make the diagnosis [17] [18]. On examination, certain maneuvers further confirm the diagnosis of cervical radiculopathy, these include holding up the affected arm on top of the head [19] or moving the head to look down and away from the side of pain tends to improve the pain; whereas rotation of or bending of the head towards the side of symptoms tends to increase the pain [20].

Thoracic radiculopathy is characterized by sharp, burning pain felt in chest, arm or abdomen. The symptoms worsen with coughing, straining or sneezingLumbar radiculopathy, commonly known as sciatica, presents as numbness, tingling and muscle weakness in the lower back radiating all the way down to one or both the legs and feet.

Infertility
  • Endometriosis is characterized by ectopic endometrial tissue, typically located in the female pelvic cavity, that causes a cyclical pain syndrome, bleeding, and infertility.[ncbi.nlm.nih.gov]
Pharyngitis
  • Further evaluation revealed the cause to be a moderately differentiated squamous cell carcinoma of the posterior pharyngeal wall.[ncbi.nlm.nih.gov]
  • Tumors stemming from thyroid, esophageal, pharyngeal, and lung tissue have been reported to compress individual cervical nerves distal to the neural foramen, as have sarcoidosis and arteriovenous malformations. 3 Enlarge Print Table 3.[aafp.org]
Restless Legs Syndrome
  • "RLS mimics"), proper diagnosis of Restless Legs Syndrome usually fails.[ncbi.nlm.nih.gov]
  • Walters and Paisit Paueksakon , Restless legs syndrome – Theoretical roles of inflammatory and immune mechanisms , Sleep Medicine Reviews , 10.1016/j.smrv.2011.09.003 , 16 , 4 , (341-354) , (2012) . Thiru M. Annaswamy, Samuel M.[dx.doi.org]

Workup

Laboratory studies are often not necessary to diagnose radiculopathy. Although the erythrocyte sedimentation rate and C-reactive protein levels may be increased in many patients with spinal infection or cancer, these tests are not specific [9].

Radiographs of the affected region of the spine are usually obtained; lateral, anteroposterior, and oblique views are helpful [21]. However, radiographs have a low sensitivity for the detection of tumors or infections; they are also insufficient to detect disk herniation and the intervertebral narrowing [22]. Magnetic resonance imaging (MRI) is the modality of choice when a detailed workup is required in patients with radiculopathy [23]. MRI is indicated if substantial pain is still present four to six weeks after the initiation of treatment or if there are progressive neurologic deficits [9]. Computed tomography (CT) is of limited value in assessing radiculopathy, due to the lack of soft tissue visualization, but it is useful in assessing the extent of bony spurs, narrowing of foramina, or the extent of ossification of the posterior longitudinal ligament [9] [24].

Hypertriglyceridemia
  • CASE REPORT: 56-year old male patient, with history of arterial hypertension, hypertriglyceridemia, obesity, glucose intolerance and alcohol abuse, diagnosed with gout in his fifth decade of life.[ncbi.nlm.nih.gov]
Hepatocellular Carcinoma
  • After a systemic diagnostic work-up, he was finally diagnosed with primary hepatocellular carcinoma. INTERVENTIONS: He received transarterial chemoembolization in the liver and radiotherapy to the T1 spine.[ncbi.nlm.nih.gov]

Treatment

The main objectives of treatment are to provide symptomatic relief from pain and improve function [25]. Analgesics, including opioids and non-steroidal antiinflammatory drugs (NSAIDs), are usually used as first-line therapy [9]. Patients suffering from acute pain have been given a short course of prednisone, starting with a dose of 70 mg per day and decreasing by 10 mg every day [25]. Some studies have reported favorable results with epidural injections of corticosteroids. These show that up to 60 % of patients were relieved of their symptoms and were able to return to their routine activities [9]. Epidural injections, however, come with several rare and serious complications including neurologic sequelae from infarction of the spinal cord or brainstem [26]. 

Short-term immobilization (less than two weeks) with a hard or a soft collar (either continuously or every at night) also aids in pain control in cervical radiculopathy, according to some researches [25]. Rarely, surgery is recommended in cases where there is compression of the spinal cord and substantial evidence of moderate to severe myelopathy [9]. It is also recommended for those who have persistent and debilitating pain after a minimum of 6 to 12 weeks of nonsurgical management [9]. It is recommended to join a progressive exercise program once the pain is under control [9].

Prognosis

Most cases of radiculopathy improve with a few days or weeks of treatment and rest. Radiculopathy caused by a herniated disc usually improves without surgery. However, recurrence of radiculopathy is possible. It can happen whether or not surgery was used for treatment.

Etiology

Cervical radiculopathy is due to the narrowing of the foramina in the vertebrae in 70% of the cases [9]. This occurs because of changes taking place in these bones due to old age and osteoporosis. In many cases, there is no actual pathology and the symptoms are due to excessive tension and stretching in neck and shoulder muscles due to prolonged periods of poor posture and muscle use [4].

Lumbar radiculopathy, on the other hand, is mostly caused by degenerative conditions such as lumbar spinal stenosis or herniated disc. Studies have identified extradural masses such as synovial cysts and gas-containing ganglion cysts as less common causes [2]. Other occasional causes of lumbar radicular syndromes include obstruction of venous outflow, venous congestion and lumbar epidural varix [1].

Certain symptoms, when present, signal toward a more serious, albeit unusual [10] etiology like cancer or infection. These symptoms include history of cancer itself, fever, chills, unremitting night time pain and unexplained weight loss [9]. An important differential diagnosis to keep in mind when a patient complains of radiculopathy is signs and symptoms of myelopathy. These may be mild such as diffuse numbness and clumsiness, urinary urgency and frequency, or advanced like urinary retention and incontinence [9].

Epidemiology

The most common causes of radiculopathy include compression of nerve roots, osteoarthrosis of joints, disk degeneration and prolapsed intervertebral disks [9]. Prolapsed lumbar disk is seen mostly in the age group of 20-39 years of age and is mostly due to sitting for prolonged periods of time such as when driving motor vehicles or in sedentary occupations; pregnant women at full term are also at risk for prolapsed disk [9].

The likelihood of osteoarthrosis of the cervical and lumbar spine increases with age [9]. Disk degeneration is also related to age where the initial stages occur from the ages of 20 to 29 years and osteophyte formation occurs from the age of 50 years onwards [3]. According to research conducted in Rochester, Minnesota of the United States of America, the annual incidence of cervical radiculopathy for men is 107.3 per 100,000 and for women are 63.5 per 100,000 [6]. Lumbosacral radiculopathy is estimated to affect around 3 to 5% of the population in the US.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology behind radiculopathy is still undetermined. However, studies have shown that symptoms tend to arise when the dorsal-root ganglion is also involved [11] [12]. Once there is superimposed hypoxia, the symptoms are further aggravated [13]. It has been documented through several studies that a number of inflammatory mediators are released by herniated intervertebral disks including prostaglandin E2, matrix metalloproteinases, interleukin-6 and nitric oxide causing the symptoms of radiculopathy [14] [15] [16].

Prevention

While some causes of radiculopathy are not avoidable, there are certain ways to reduce the risk of developing a radiculopathy. These include maintaining good posture and a healthy weight. In order to avoid complications, one must use safe techniques when lifting heavy objects and take frequent breaks when performing repetitive tasks. A regular exercise regime not only helps with physical fitness but also improves strength and flexibility of muscles, this hinders the chances of developing a radiculopathy.

Summary

Radiculopathy is the discomfort or pain which is perceived when there is nerve root damage due to pathology in the surrounding tissues such as muscles, tendons, cartilage or bone [5]. When the nerve roots are compressed, there is inflammation [5] resulting in numbness, weakness, and pain. Cervical radiculopathy most commonly occurs due to disc herniation or degenerative changes, or as in most cases, both [5]. Thoracic radiculopathy is a less common condition. Lumbar radiculopathy occurs mostly due to a structural problem like a herniated disc. Treatment varies according to the type of pathology and the severity of the disease.

Patient Information

Radiculopathy is usually due to nerve root compression which may occur due to a number of reasons. While mostly the reasons are disc compression and herniation, certain morbid conditions may also be the cause of discomfort. Hence a follow up with your physician is advised. Radiculopathy most often results in pain, weakness and numbness. The modes of treatment usually involve pain medication and physiotherapy. Surgery is indicated only in advanced cases when the spinal cord itself is being compressed. The best way to prevent any sort of radiculopathy is to exercise regularly and maintain the strength of ones muscles and bones by taking a balanced diet.

References

Article

  1. Hanley, Edward N. Jr. MD; Howard, Brian H. MD; Brigham, Craig D. MD et.al; Lumbar Epidural Varix as a Cause of Radiculopathy. The Spine Journal September 15, 1994 - Volume 19 - Issue 18
  2. Gerard K Jeong, MD, John A Bendo, MD. Lumbar intervertebral disc cyst as a cause of radiculopathy. The Spine Journal. May - June 2003, Vol 3. Issue 3
  3. Kelsey JL.Epidemiology of radiculopathies. Advances in Neurology 1978, 19:385-398
  4. Raj Rao, MD. Neck Pain, Cervical Radiculopathy, and Cervical Myelopathy. J Bone Joint Surg Am, 2002 Oct; 84 (10): 1872 -1881 
  5. Bogduk N. The anatomy and pathophysiology of neck pain. Phys Med Rehabil Clin N Am2003;14:455-472
  6. Radhakrishan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990. Brain1994;117:325-335
  7. Slipman CW, Plastaras CT, Palmitier RA,Huston CW, Sterenfeld EB. Symptom provocation of fluoroscopically guided cervical nerve root stimulation: are dynatomal maps identical to dermatomal maps? Spine 1998;23:2235-2242
  8. Salemi G, Savettieri G, Meneghini F, et al. Prevalence of cervical spondylotic radiculopathy: a door-to-door survey in a Sicilian municipality. Acta Neurol Scand 1996;93:184-188
  9. Simon Carette, M.D., M.Phil., and Michael G. Fehlings, M.D., Ph.D. Cervical Radiculopathy. N Engl J Med 2005; 353:392-399July 28, 2005
  10. Shelerud RA, Paynter KS. Rarer causes of radiculopathy: spinal tumors, infections, an other unusual causes. Phys Med Rehabil Clin N Am 2002;13:645-696
  11. Howe JF, Loeser JD, Calvin WH. Mechanosensitivity of dorsal root ganglia and chronically injured axons: a physiological basis for the radicular pain of nerve root compression. Pain 1977;3:25-41
  12. Song XJ, Hu SJ, Greenquist KW, Zhang JM, LaMotte RH. Mechanical and thermal hyperalgesia and ectopic neuronal discharge after chronic compression of dorsal root ganglia. J Neurophysiol 1999;82:3347-3358
  13. Sugawara O, Atsuta Y, Iwahara T, Muramoto T, Watakabe M, Takemitsu Y. The effects of mechanical compression and hypoxia on nerve root and dorsal root ganglia: an analysis of ectopic firing using an in vitro model. Spine 1996;21:2089-2094
  14. Kang JD, Georgescu HI, McIntyre-Larkin L, Stefanovic-Racic M, Evans CH. Herniated cervical intervertebral discs spontaneously produce matrix metalloproteinases, nitric oxide, interleukin-6 and prostaglandin E2. Spine 1995;20:2373-2378
  15. Kang JD, Stefanovic-Racic M, McIntyre LA, Georgescu HI, Evans CH. Toward a biochemical understanding of human intervertebral disc degeneration and herniation: contributions of nitric oxide, interleukins, prostaglandin E2, and matrix metalloproteinases. Spine 1997;22:1065-1073
  16. Furusawa N, Baba H, Miyoshi N, et al. Herniation of cervical intervertebral disc: immunohistochemical examination and measurement of nitric oxide production. Spine2001;26:1110-1116
  17. Wainner RS, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther 2000;30:728-744
  18. Honet JC, Ellenberg MR. What you always wanted to know about the history and physical examination of neck pain but were afraid to ask.Phys Med Rehabil Clin N Am 2003;14:473-491
  19. Davidson RI, Dunn EJ, Metzmaker JN. The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies. Spine 1981;6:441-446
  20. Spurling RG, Scoville WB. Lateral rupture of the cervical intervertebral discs: a common cause of shoulder and arm pain. Surg Gynecol Obstet 1944;78:350-358
  21. Mink JH, Gordon RE, Deutsch AL. The cervical spine: radiologist's perspective. Phys Med Rehabil Clin N Am 2003;14:493-548
  22. Pyhtinen J, Laitinen J. Cervical intervertebral foramen narrowing and myelographic nerve root sleeve deformities. Neuroradiology 1993;35:596-597
  23. Brown BM, Schwartz RH, Frank E, Blank NK. Preoperative evaluation of cervical radiculopathy and myelopathy by surface-coil MR imaging. AJR Am J Roentgenol 1988;151:1205-1212
  24. Scotti G, Scialfa G, Pieralli S, Boccardi E,Valsecchi F, Tonon C. Myelopathy and radiculopathy due to cervical spondylosis: myelographic-CT correlations. AJNR Am J Neuroradiol 1983;4:601-603
  25. Wolff MW, Levine LA. Cervical radiculopathies: conservative approaches to management. Phys Med Rehabil Clin N Am 2002;13:589-608
  26. Rathmell JP, Aprill C, Bogduk N. Cervical transforaminal injection of steroids. Anesthesiology 2004;100:1595-1600

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-22 11:43