Lumbar Radiculopathy

115 Lumbar Radiculopathy

Daniel G. Tobert MD1 and James D. Kang MD2

1 Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

2 Brigham and Women’s Hospital, Boston, MA, USA

Clinical scenario

  • A 48‐year‐old woman is referred to clinic with pain on the outside of her thigh radiating down her leg for the past nine weeks.
  • The symptoms began atraumatically and has been steady in its intensity and location since its onset.
  • She reports no problems with leg strength, or bowel or bladder control.

Top three questions

  1. In adult patients with lumbar radiculopathy, what work‐up is needed to establish a diagnosis?
  2. In adult patients with lumbar radiculopathy, do injections alter the natural history of the symptoms compared to noninvasive or surgical treatments?
  3. In adult patients with lumbar radiculopathy, does surgical treatment result in superior sustained symptom relief compared to nonsurgical treatment?

Question 1: In adult patients with lumbar radiculopathy, what work‐up is needed to establish a diagnosis?


A patient’s complaint of sciatica can originate from myriad pathologies in the lumbar spine and distal to the spine. The clinician must understand the common and rare etiologies of lumbar radiculopathy and the appropriate work‐up.

Clinical comment

Radiating leg pain is a common complaint in the outpatient and Emergency Department setting. It is important to understand which exam maneuvers are more sensitive than others in narrowing the differential diagnosis. Additionally, an awareness of the role of advanced imaging avoids unnecessary tests.

Available literature and quality of the evidence

There is level III evidence available regarding the ability of history‐taking to establish a diagnosis in patients with lumbar radiculopathy. Level I evidence from multiple prospective studies and subsequent meta‐analyses has been published to better understand the diagnostic role of physical exam maneuvers in lumbar radiculopathy. There is level I evidence supporting the use of MRI (magnetic resonance imaging), CT (computed tomography) and CT‐myelogram in the work‐up of lumbar radiculopathy.


The history and physical exam steer the clinician toward a diagnosis of lumbosacral pathology if radiculopathy is present, and primary clinicians are trained to search for red flag symptoms that would prompt a referral to a specialist. However, the diagnostic accuracy of history‐taking is low. Verwoerd et al. performed a cross‐sectional study investigating the ability of individual questions and a six‐question model to predict lumbosacral nerve root compression confirmed by MRI.1 Questions pertaining to sensory loss were effective, with odds ratios of 2.31 (95% confidence interval [CI]: 1.10–4.85) for nerve root compression and 3.54 (1.64–7.64) for disc herniation. However, the six‐question model as a whole was poorly predictive of lumbosacral nerve root compression with an area under the receiver operator characteristic curve (AUC) of 0.65 (0.58–0.71) and 0.66 (0.58–0.74).

Earlier prospective studies argued that physical exam maneuvers and testing could sufficiently diagnose lumbar radiculopathy and even localize the vertebral level of pathology.2 However, a subsequent Cochrane review concluded the role of diagnostic physical exam tests in lumbosacral radiculopathy was poorly substantiated after reviewing 18 studies on the subject.3 Iversen et al. performed a prospective study on the accuracy of the physical exam maneuvers recommended by the American Spinal Injury Association (ASIA) to predict nerve root impingement.4 They reported that no individual test was reliable at predicting the laterality or level of impingement, with low sensitivities and specificities and wide confidence intervals.

A systematic review by Wassenaar provided level I evidence on the role of MRI in diagnosing lumbosacral pathology.5 The pooled data calculated a sensitivity of 75% (95% CI: 65–83%) and specificity of 77% (95% CI: 61–88%) for diagnosing herniated nucleus pulposus (HNP). Likewise, for nerve root compression, two studies showed sensitivities of 81 and 92% with specificities of 52 and 100%. Importantly, clinicians must be aware that there is poor interrater agreement on MRI findings in degenerative lumbar conditions.6 A systematic review of the use of CT for diagnosing lumbosacral pathology concluded CT was useful for HNP but not other causes of lumbosacral radiculopathy.7

Resolution of clinical scenario

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Lumbar Radiculopathy

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