LUMBAR RADICULOPATHY

I. Anatomical Background and Kinesiological Background

A typical lumbar vertebra has the following characteristics:

 The body is large, and kidney shaped.
 The pedicles are strong and directed backward.
 The laminae are short in a vertical dimension.
 The vertebral foramina are triangular.
 The transverse processes are long and slender.
 The spinous processes are short, flat, and quadrangular and project posteriorly.
 The articular surfaces of the superior articular processes face medially, and
those of the inferior articular processes face laterally.
Reference: Seeley’s 10th Ed.
 Snell 9th Ed.
Magee Orthopedic Physical Assessment 6th Ed.

II. Medical background

A. Definition
 A pain syndrome caused by compression or irritation of nerve roots in the lower
back
Reference: https://www.ncbi.nlm.nih.gov/books/NBK430837/

B. Etiology
 Lumbar disc herniation, degeneration of the spinal vertebra, and narrowing of the
foramen from which the nerves exit the spinal canal
 Lesions of the intervertebral discs and degenerative disease of the spine are the
most common causes
 However, any process that causes irritation of the spinal nerves can cause it
 Structural lesions such as disk protrusions and bony lesions that can press upon
the root
 The most common underlying cause of radiculopathy is irritation of a particular
nerve, which can occur at any point along the nerve itself and is most often a
result of a compressive force
Reference: https://www.ncbi.nlm.nih.gov/books/NBK430837/
De Lisa 5th Ed.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858271/

C. Pathophysiology
 Secondary to mechanical and/or inflammatory cycles compromising at least one
of the lumbosacral nerve roots
Reference: https://www.ncbi.nlm.nih.gov/books/NBK430837/

D. Epidemiology
 The literature lacks concise epidemiologic data
 Most reports estimate about a 3% to 5% prevalence rate
 Its prevalence has been estimated to be 3%-5% of the population, affecting both
men and women.
 Age is a primary risk factor, as it occurs secondary to the degenerative process
within the spinal column. Symptoms typically begin in midlife, with men often
affected in the 40s while women are affected in the 50s and 60s.
Reference: https://www.ncbi.nlm.nih.gov/books/NBK430837/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858271/
 E. Clinical manifestations
 Low back pain that radiates into the lower extremities in a dermatomal pattern
 Can include numbness/tingling, weakness, loss of reflexes and gait abnormalities

Reference: https://www.ncbi.nlm.nih.gov/books/NBK430837/
Magee 6th Ed.

F. Sequelae

NA

G. Prognosis
 The clinical course of acute sciatica is favorable and most pain and related
disability resolves within few weeks. Therefore, in most cases the prognosis is
good, but at the same time up to 30% of patients continue to have pain for at
least a year
Reference: De Lisa 5th Ed.

H. Medical Assessment
 Electrodiagnostic evaluation
 Most useful electrodiagnostic assessment in radiculopathy is needle EMG
 Fibrillation potentials, positive sharp waves, CRD, fasciculation potentials
 In cases where MRI is not available or possible, a CT myelogram is a reasonable
alternative
Reference: De Lisa 5th Ed.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858271/

I. Medical Treatment
  ESI is most effective for lumbosacral radiculopathy associated with intervertebral
disc herniation, bulging, or degeneration
 Treatment is the same as treatment of acute mechanical low back pain, although
prescription pain medicines (including narcotics) may also be indicated. Muscle
relaxants may also be helpful.
 Patients need to be educated that this condition takes time to resolve. Over 90%
of radiculopathies heal as well without, as with surgery.
 These patients are generally in a lot of pain. If the patient does not obtain
significant relief within a reasonable amount of time a referral to physical therapy
or a specialist may be indicated.
 Oral steroids can be given to patients who do not have contraindications.
Reference: De Lisa 5th Ed.
https://www.mahealthcare.com/pdf/practice_guidelines/Low_Back_Pain.pdf

J. PT Assessment

 The initial exam should include a complete history and physical exam, including
manual muscle testing, sensory testing, deep tendon reflexes, and Lasegue’s
sign
Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858271/
Seeley’s 10th Ed.

K. PT Treatment
 Practitioners referring patients to physical therapy should instruct the patient that
appointments for physical therapy are to be viewed as a learning opportunity.
The long-term goal is to learn home exercises.
 When ordering physical therapy, modalities may be used judiciously (i.e. hot
packs, e-stim, ultrasound) but similar effects can be obtained by modalities at
home. The most valuable service the therapist has to offer is an extensive
knowledge of exercise programs, positioning, and education about spine care.
Whether a spine extension or flexion program is ordered depends on what the
patient finds comfortable. If spine extension hurts more, then an extension
program should not be done. Usually, disc herniation in younger people responds
best to a spine extension program (McKenzie) but in older people with spinal
 stenosis, extension worsens their symptoms and flexion programs (Williams)
should be utilized.
 If physical therapy provides no relief in 4-6 sessions, the treatment plan should
be changed, or the treatment should be discontinued. Once a patient is
recovering, the therapist’s main job is to advance the exercise program. This can
be accomplished by seeing the patient once or twice a week, or even less
frequently.
 The best positions/activities for patients with acute radiculopathies are those
which are comfortable. Patients should gradually return to activities as their
condition improves.
 Chiropractic treatment would be reasonable to consider. If the patient does not
notice relief within 3 visits, discontinue.

 Chronic back pain or radicular pain is highly situational. Some patients have lived
with the problem for a long time and are content to do so. If their pain changes,
they may need to start at the beginning of the attached algorithm, or they may
need a new workup. A referral may be appropriate.

Reference:
https://www.mahealthcare.com/pdf/practice_guidelines/Low_Back_Pain.pdf

HERNIATED NUCLEUS PULPOSUS

Medical Background
 Lumbar disc herniation is defined as a prolapse of the annulus fibrosis of the lumbar disc
into the spinal canal causing compression of the neural elements or frank rupture of the
annulus fibrosis with extrusion of nucleus pulposus material into the spinal canal causing
compression of the neural elements.
Paul A. Lotke, Joseph A. Abbud, Jack Ende, Lippincott’s Primary Care Orthopaedics
  Occurs when all or part of the nucleus pulposus (the soft, gelatinous, central portion of
an intervertebral disk) is forced through the disk’s weakened or torn outer ring (annulus
fibrosus)
 20-25% IVD
Straight A’s in Pathophysiology

Etiology
 Prolonged flexion posture
 Repetitive flexion microtrauma
 If the annulus fibers have started to degenerate
 Traumatic flexion injuries
 Occurs from stress, such as lifting, twisting, continuous flexion with lifting, or fall on
buttocks.
Kisner’s Therapeutic Exercise 6th edition
The Physiology of the Joints, A.I. Kapandji
Epidemiology
 The typical patient with a lumbar disc herniation presents in the third to sixth decade of
life.
 The most common disc in the lumbar spine to herniate is L4-5.
Paul A. Lotke, Joseph A. Abbud, Jack Ende, Lippincott’s Primary Care Orthopaedics
 Lumbar disc syndrome is a common cause of acute, chronic or recurrent low back pain,
particularly in young to middle-aged men, but it also occurs in women, older persons and
even adolescents, especially if they are involved in strenuous physical activity. Overall,
the mean age of the patient with lumbar disc herniation is the early 40s.
 Disc herniation may occur in the midline, but it often occurs to one side. Pain may be
unilateral, bilateral, or bilateral but more prominent on one side.
 The cause is usually a flexion injury. Repetitive injury results in degeneration of the
posterior longitudinal ligaments and annulus fibrosus.
Braddom’s Physical Medicine and Rehabilitation
Pathophysiology
 Physical stress, usually a twisting motion, can tear a rupture the annulus fibrosus so that
the nucleus pulposus herniates into the spinal canal.
 Vertebrae move closer together and the ruptured disk material exerts pressure on the
nerve roots, causing pain, and possibly, sensory and motor loss.
 Minor trauma may lead to herniation if the patient has intervertebral joint degeneration.

Straight A’s in Pathophysiology
Clinical Manifestations
 Paraspinal muscle spasm
 Loss of lumbar lordosis
 Listing of the spine away from the side of root pain
 Limitation of motions of the lumbar spine with “corkscrew phenomenon” on flexion and
straightening
 (+) SLR test
 Different degrees and types of disc herniation may occur. Macnab’s classification is
useful, and it indeed correlates well with MRI findings
- Bulging Disc – a bulge and convexity of disc beyond the adjacent vertebral disc
margins, but with intact annulus fibrosus and Sharpey’s fibers
- Prolapsed Disc – the disc herniates posteriorly and through an incomplete defect
in the annulus fibrosus
- Extruded Disc – the disc herniates posteriorly through a complete defect in the
annulus fibrosus
- Sequestered Disc – part of the nucleus pulposus is extruded through a complete
defect in the annulus fibrosus and has lost continuity with the present nucleus
pulposus
- Schmorl nodes, also referred as intravertebral disc herniations, refer to protrusions of
the cartilage of the intervertebral disc through the vertebral body endplate and into the
adjacent vertebra. The protrusions may contact the marrow of the vertebra, leading to
inflammation.

Braddom’s Physical Medicine and Rehabilitation

  Pain in the lower back may not be severe and often is not associated with trauma.
 Pain tends to last 7 to 14 days and often is not precipitated by any kind of specific
trauma.
 Over the course of several days, the back pain tends to dissipate and the patient begins
to experience increasing buttock and, thereafter, increasing radicular leg pain, more
commonly in pone leg than the other
 Numbness, pins and needles, and tingling accompanying the pain are common.
 Weakness in a particular muscle group may occur, but it is rare for multiple muscle
groups to be affected.
 Physical examination of the patient with a lumbar disc herniation will typically reveal
minimal, if any, low back tenderness.
 Range of motion of the lower back will usually be restricted secondary to pain.
 Some patients have pain with deep palpation in their buttock (in the area of the “sciatic
notch”)
Paul A. Lotke, Joseph A. Abbud, Jack Ende, Lippincott’s Primary Care Orthopaedics
Sequelae
 Bowel and bladder problems
 Neurologic deficits
Straight A’s in Pathophysiology
Prognosis
 Healing is attempted, but there is poor circulation in the disc. There may be self-sealing
of a defect with nuclear gel or proliferation of cells of the annulus. Any fibrous repair is
weaker than normal and takes a long time because of the relative avascular status of the
disc.
Braddom’s Physical Medicine and Rehabilitation

SPONDYLOSIS

 Spondylosis (also called spondylosis deformans) a degeneration of the intervertebral

disc, is often seen in persons 25 years of age or older, and it is present in 60% of those
older than 45 years and 85% of those older than 65 years of age. It is a generalized
disease of aging initiated by intervertebral disc degeneration.

SPONDYLOLYSIS

 Sometimes referred to as a “Scottie dog with a collar;”, a defect in the pars

interarticularis or the arch of the vertebra

SPONDYLOLISTHESIS
Sometimes referred to as a “Scottie dog decapitated”;

 Degenerative spondylolisthesis as a result of disk degeneration and degenerative

changes of the posterior facet joint is marked by anterior slippage of one vertebra over
another with an intact posterior neural arch. The L4-L5 spinal segment is the most
common site for this to occur.
 Lytic or isthmic spondylolisthesis (a separate etiology from degenerative
spondylolisthesis and more common in younger groups) is marked by anterior slippage
of one vertebra over another with a defective posterior neural arch. The L5-S1 spinal
segment is the most common site for lytic spondylolisthesis to occur. The loss of disk
height associated with degeneration allows for a buckling of the annulus and ligamentum
flavum, slackening them somewhat. This allows the vertebrae to migrate anteriorly in
response to the shear forces inherent to the lumbar lordosis.

SPONDYLODISKITIS

 Spondylodiskitis is a range of conditions from a self-limiting inflammatory process to a

pyogenic infection. The intervertebral disk is the most common site for spinal infection,
with the infection affecting the annulus, nucleus, or the vertebral endplates.

References:
https://www.ncbi.nlm.nih.gov/books/NBK430837/
Goodman’s Pathology Implications for the Physical Therapist
Magee’s Orthopedic Physical Assessment, 6th Ed

Prepared by:
Castillo, Arren Fria
LPU-B PT Intern Batch 2020

Mendez, Julia Sacha Marie M.

LPU-B PT Intern Batch 2020