29/07/2021
LUMBAR RADICULOPATHY
/ Diagnosis, Rehabilitation /
• Most common causes:
° Nerve root impingement
° Disc herniation
° Facet arthropathy
Symptoms :
• Pain at lumbar region and area of affected nerve root
° Varies in severity and location
° Severe, exacerbated by standing, sitting, coughing, sneezing
° Location depends on nerve root affected
° Starts in back, radiates down lower extremity
▪ Can have both or just in buttocks or lower extremity
• Paresthesias
° Dermatomal distribution of affected nerve root
• Weakness
° Part of the limb
Physical Exam :
• Inspection: possible asymmetry in standing position, weight may
be shifted over one side of pelvis to avoid pain
• Palpation: may have tenderness/spasm at lumbar region
• ROM: may have limited range or increased pain mostly with
flexion
• Reflex: may be decreased at regions innervated by affected roots
° Patellar reflex—L2, L3, L4
° Adductor reflex—L2, L3, L4
° Medial hamstring reflex—L4, L5, S1, S2
• Strength:
° Weakness in distribution of affected disc
° Proximal weakness in nerve root distribution can differ between
bilateral vs. peripheral neuropathy
• Sensation: may have decreased sensation at regions of affected
roots
° L1—oblique band on upper anterior portion of thigh (inferior
to inguinal ligament)
° L2—inferior to L1, superior to L3 (see below)
° L3—oblique band on anterior thigh, superior to knee cap
° L4—medial aspect of leg
° L5—lateral aspect of leg and dorsum of foot
° S1—lateral malleolus and lateral aspect and plantar surface of
foot
• Provocative Maneuvers:
° Straight leg raise—Patient sitting or supine, Leg raised straight
up by examiner maintaining extension of the knee, Positive if
pain is reproduced in lower extremity at 80–90°
° Slump test—patient is seated, patient flexes neck to increase
dural tension, Positive if pain s reproduced in lower extremity
° Seated root test—patient seated on exam table, examiner lifts
the affected leg into hip flexion and knee extension, positive if
pain is reproduced at the affected lower extremity
Imaging :
• X-ray
° Typically unremarkable in radiculopathy secondary to herniated nucleus pulposus
° Used to rule out serious structural pathologic conditions
• MRI
° Study of choice for nerve root impingement
° Immediately ordered for progressive neurological deficits; suspected malignancy, inflammatory disease, infection
• EMG
° Used when diagnosis unclear (localization of pain to specific
nerve root level)
° Excludes other causes of sensory/motor impairments
° Quantifies degree of axonal involvement
Rehabilitation Program :
• Goal: Alleviate pain; increase back/core stability
• Modalities: ice, heat, massage, TENS, electrical stimulation
• “Back school”
° Proper lifting, posture awareness
• Lumbar stabilization program
° Flexion/extension exercises (see below for biases)
• Strengthening
° Core strengthening (abdominals, paraspinals, gluteal)
Flexion Bias
• Commonly used with facet pathology
• Decreases facet joint compression
° Stretch lumbar muscles, ligaments
• Cardiovascular fitness program (exercises in slight lumbar
flexion)
° Stationary bike
° Aquatic stabilization exercises [10]
Extension Bias
• Commonly used with discogenic pathology
• Decreases intradiscal pressure
° Anterior migration of nucleus pulposus away from compression site
• May increase symptoms with large central disc herniation
• Concomitant cardiovascular fitness program to avoid exacerbation
of symptoms during exercise
