Lumbosacral Radiculopathy
Section snippets
Epidemiology
Although precise epidemiologic data are difficult to establish, the prevalence of lumbosacral radiculopathy is approximately 3% to 5%, distributed equally in men and women [1], [2]. Men are most likely to develop symptoms in their 40s, whereas women are affected most commonly between ages 50 and 60 [1].
Anatomy
Detailed spinal anatomy is discussed elsewhere in this issue by Devereaux; however, clinically relevant points are reviewed. There are five moveable lumbar vertebrae, five fused sacral vertebrae, and four fused coccygeal vertebrae [3] with intervertebral disks sandwiched between each of the lumbar vertebrae and between the fifth lumbar vertebra and sacrum. The moveable vertebrae are connected by paired facet joints between the articular processes of the pedicles and by the anterior and
History and physical examination
Performance of a careful history and physical examination is the initial and integral step in the diagnosis and management of lumbosacral radiculopathy. Lesion localization depends on demonstration of a segmental myotomal or dermatomal distribution of abnormalities; a working knowledge of the relevant anatomy is essential. Sciatica, the classic presenting symptom of lumbosacral radiculopathy, is characterized by pain in the back radiating into the leg. Patients variably describe this pain as
L1 radiculopathy
Disk herniation at this level is rare; consequently, L1 radiculopathy is extremely uncommon. The typical presentation is one of pain, paresthesias, and sensory loss in the inguinal region, without significant weakness. Infrequently, subtle involvement of hip flexion is noted. Muscle stretch reflexes (MSRs) are normal. Differential diagnostic considerations include ilioinguinal and genitofemoral neuropathies. Physical examination may help distinguish between these conditions, but imaging of the
Lumbosacral polyradiculopathy and cauda equina syndromes
Multiple, contiguous nerve roots may be involved by compressive lesions affecting several individual nerve roots, either in the vertebral canal or the neural foramina; less frequently, infiltrating or inflammatory processes spreading along the meninges produce similar clinical syndromes. Lesions involving the cauda equina should be considered when nerve roots at more than two neighboring levels are involved, developing acutely or gradually. Acute cauda equina syndrome most often is the result
Differential diagnosis
The majority of lesions causing lumbosacral radiculopathy are compressive in nature and result from disk herniation or spondylosis with entrapment of nerve roots. It is important, however, to recognize a variety of other lesions that may produce lumbosacral radiculopathy, including several neoplastic, infectious, and inflammatory disorders (see Box 1).
Approach to initial diagnosis and management
An algorithm for the initial diagnosis and management of lumbosacral radiculopathy is shown in Fig. 1. First, whether or not patients have a disease process that could result in irreversible neurologic dysfunction must be determined. Indications for immediate neuroimaging and surgical evaluation include a cauda equina syndrome, rapidly progressive neurologic deficits, and risk factors for metastatic cancer or epidural abscess.
Provided that none of these indications for urgent evaluation is
Summary
Lumbosacral radiculopathy is a common neurologic syndrome that is an important source of disability. Although the most common causes are disk herniation and chronic spinal arthropathy, physicians should be mindful of other causes, including neoplasm and infection. Initial evaluation should focus on localization of lumbosacral radiculopathy and exclusion of disorders that may produce irreversible neurologic compromise. Treatment is aimed at providing pain relief and preventing neurologic
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