Lumbar / Pelvis

Lumbar Radiculopathy

Definition

If radicular pain persists after surgery for disc prolapse, this is known as lumbar radiculopathy. Lumbar radiculopathy is also given the sometimes-confusing title 'Failed Back Surgery Syndrome'.

According the classification of the International Association for the Study of Pain (IASP), lumbar radicular pain is defined as pain observed to originate in the lower extremities, and is caused by ectopic activation of nociceptive afferent fibres in a spinal nerve or root, or other neuropathic mechanisms. This definition is problematic since ectopic activation of nociceptive afferent fibres has seldom or never been proved in a clinical setting.

Lumbar radicular pain must be distinguished from lumbar radiculopathy. In the case of lumbar radiculopathy, there is an objective sensory and/or motor deficit. Although these terms are used interchangeably in the literature, radicular pain and radiculopathy are not synonymous.

Radicular pain is a symptom that is caused by ectopic impulses, while radiculopathy comprises neurological signs such as sensory and motor changes.  Radicular pain and radiculopathy can occur simultaneously.

Aetiology

Narrowing of the intervertebral foramen, intervertebral disc prolapse, and radiculitis due to arteritis, infection, or inflammatory exudates.

Signs and symptoms

Lumbar radiculopathy pain is characterised by pain starting in the back, and radiating via the dorsal side of the upper leg to the calf and foot. The irradiating pain has a typical segmental pattern.

Pain of different dermatomes can overlap, and there is no specific region of the leg that is characteristic of a certain root segment. Radicular pain is not restricted to a particular dermatome, and can be observed in all structures innervated by the affected nerve root, such as muscles, joints, ligaments and the skin.

Diagnostics

Physical Examination

As in most pain syndromes, there is no gold standard available for making the diagnosis of lumbar radiculopathy. For that reason, the diagnosis is made based on a combination of medical history, neurological examination and additional diagnostics. The neurological examination consists of testing sensibility, strength and tendon reflexes.

Lumbar radiculopathy provocation tests comprise: Lasègue combined with passive cervical forward flexion, lumbar forward flexion combined with passive cervical forward flexion, and the Bragard test.

Additional Somatic Diagnostics

  • Imaging techniques (MRI scan, CT scan)
  • Neurophysiological tests (electromyography)
  • Segmental diagnostic test blocks.
  • RAND-36 (quality of life)
  • VAS Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Additional Psycho-cognitive Diagnostics

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment consisting of various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

  • Tricyclic antidepressants
  • Anticonvulsives: carbamazepine, oxcarbazepine, gabapentine and pregabaline.

Interventional Pain Treatment