What is a radiculopathy?
Lower back pain is a common condition and has many differential diagnoses. One of these is radiculopathy. Radiculopathy comprises of neurological deficits and, occasionally, pain radiating from the buttocks down the leg below the knee. Symptoms are one sided (1).
Your health professional will listen to your symptoms, screen for red flags/sinister
conditions and start differentially diagnosing/ruling out other causes. These may be the following:
- Hip joint referral.
- Sacro-iliac joint referral.
- Vascular causes.
- Sciatic nerve compression.
- Other causes such as inflammatory or metabolic disorder or
tumour.
The nature of the symptoms will also then be further defined whether it is “true radiculopathy” or “radicular pain”.
Radiculopathy vs Radicular pain.
This can be generalised to the whole spine, but today we’re focussing on the lumbar spine. Radiculopathy is defined as a whole complex of symptoms that can occur from nerve root
irritation or pathology. This can include the following symptoms:
- Pins and needles.
- Numbness.
- Reduced sensation.
- Loss of muscle strength.
- Pain (2).
Radicular is defined as a single symptom, pain. It can arise from one or more spinal nerve roots (2).
What causes a radiculopathy?
A radiculopathy is caused when the nerve root is irritated/inflamed or compressed where it exits the spine. This hole where the nerve exits is called the foramen. Most commonly it is somewhere between the levels of L4-S1 and very rarely higher up in the spine. For reference when looking at the spine, your lower back levels are numbered from 1 to 5, therefore L1-5. This is followed by your tailbone (named the sacrum) where levels are listed from 1 to 5, therefore S1-5.
The space around the nerve can be reduced due to inflammatory chemicals, disc position (i.e. a herniated disc), canal narrowing known as stenosis and other variants of the spine. Other factors which can add to the risk/exacerbate this condition include (but are not limited to) include the following:
- Smoking.
- Obesity.
- Manual work.
- Work involving bending down.
- Driving a lot.
- Moderate walking.
- Mental stress.
- Poor job satisfaction (2).
What does it look and feel like?
As the nerve root is affected, symptoms are often in what we call a dermatome pattern or myotome distribution (see image 1). Symptoms will be one sided. The leg pain will be more dominant than the back. You might not have leg pain but only have altered sensation instead. Reflexes will be altered. You would’ve noticed these symptoms gradually arising.
A dermatome is a specific area of the skin that is innervated by a particular level of the spine. Changes to that area can include altered sensation such as pins and needles/prickling
feeling, numbness/less sensation, burning/stabbing or aching pain. A myotome is a group of muscles innervated by a certain spinal level. So we test certain movements looking for loss of strength and power to indicate a radiculopathy and at what level of the spine.
We will test the tension of sciatic nerve by doing a straight leg raise. We will then assess the severity by seeing if the other leg raise brings on your symptoms. If suspecting higher in the spine/femoral nerve we will raise your leg lying on the tummy.
What does treatment look like and prognosis?
Conservative management is the first line of treatment for the first 6-12 weeks. Our beliefs of conditions are so powerful in impacting outcomes. In short, the more positive, the better the outcome. Understanding the condition as the nerve root is becoming “crowded out”, inflamed and sensitive and know that disc bulges can resorb are important for the healing journey (3).
Your health professional can provide individualised treatment and education. This can help to minimise pain, optimise function, set goals, provide a diagnosis and improve your understanding of your condition. Aligning your beliefs and anxieties, prognosis and natural healing time frames can all help you to feel more empowered and supported.
Advice might include:
- Nerve pain often doesn’t like to be still for a long time. Try to move every 30 minutes or so during the day to help reduce the level or pain.
- You may have certain positions of ease or movement directions which you can bias to get relief.
- Pillow propping at night may optimise comfort and minimise pain.
- Heat/ice, muscle activation, stretches, nerve mobilisation, and hands-on treatment (including massage, needling, spinal mobilisation, taping and bracing) may all make a difference for you.
- Sometimes a short period of bed rest may also be suitable but, overall, trying to keep active is important.
Pharmaceutical options:
Medications including NSAIDs and paracetamol are used to manage the pain. If these are ineffective, anti-depressant medication may be the next appropriate option. Oral steroids
(i.e prednisolone), neuroleptics and others can really help with symptoms (3).
We often refer to a Sports Doctor/Physician to aid in medication, injections, education and
management. They can administer epidural corticosteroid injections/anaesthetic which can be very effective for symptom relief.
Research has shown that majority of radiculopathy patients respond well to this
conservative management and symptoms often improve within 6 to 12 weeks (3). For a minority, when symptoms are non-responsive, progressively worsening neurological
symptoms and the patient chooses so after exhausting all conservative management,
referral for surgical opinion may be suitable (3).
References:
- Berry, J.A. et al. (2019) “A review of lumbar radiculopathy, diagnosis, and
treatment,” Cureus [Preprint]. Available at: https://doi.org/10.7759/cureus.5934. - Murray, L. (no date) “Management of Radicular Pain – The Clinician’s Guide, Differential Diagnosis of Radicular Pain. Physio Network. Available at: https://www.physio-network.com/blog/managing-radicular-pain/ Accessed: December 30, 2022).
- Murray, L. (no date) Management of Radicular Pain – The Clinician’s Guide. Physio Network. Available at: https://www.physio-network.com/blog/managing-radicular- pain/Accessed: December 30, 2022).
Lucy Bowden
Physiotherapist
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