Radiculopathy is a symptom complex formed as a result of lesions of the spinal root of various etiologies and manifested by symptoms of irritation (pain, muscle tension, antalgic posture, paresthesia) and prolapse (paresis, decreased sensitivity, muscular hypotrophy, hyporeflexia, trophic disorders). Disease is diagnosed clinically, its cause is determined by the results of radiography, CT or MRI of the spine. Treatment is more often conservative, according to indications, surgical removal of the root compression factor is performed.
ICD 10
G54 Lesions of nerve roots and plexuses
General information
Radiculopathy is a common vertebrogenic symptom complex with variable etiology. Previously, the term “radiculitis” was used in relation to the root syndrome — inflammation of the root. However, it does not quite correspond to reality. Recent studies have shown that the inflammatory process in the root is often absent, there are reflex and compression mechanisms of its lesion. In this regard, the term “radiculopathy” — a lesion of the root began to be used in clinical practice. The root syndrome is most often observed in the lumbosacral spine and is associated with damage to the 5th lumbar (L5) and 1st sacral (S1) vertebrae. Cervical radiculopathy is less common, and thoracic is even rarer. The peak incidence is in the middle age category — from 40 to 60 years. The tasks of modern neurology and vertebrology are the timely identification and elimination of the factor causing root compression, since prolonged compression entails degenerative processes in the root with the development of persistent disabling neurological dysfunction.
Causes
On both sides of the human spinal column, 31 pairs of spinal nerves depart, which originate in the spinal roots. Each spinal root is formed by the posterior (sensory) and anterior (motor) branches coming out of the spinal cord. From the spinal canal, it exits through the intervertebral foramen. This is the narrowest place where compression of the root most often occurs. Radiculopathy can be caused by both primary mechanical compression of the root itself and its secondary compression due to edema developing as a result of compression of the radicular veins. Compression of the root vessels and microcirculation disorder that occurs with edema, in turn, become additional factors of damage to the root.
The most common cause provoking radiculopathy is osteochondrosis of the spine. A decrease in the height of the intervertebral disc entails a decrease in the diameter of the intervertebral openings and creates prerequisites for infringement of the roots passing through them. In addition, the compression factor may be formed as a complication of osteochondrosis intervertebral hernia. Radiculopathy is possible when the root is compressed by osteophytes formed during spondylosis or parts of the arched joint changed due to spondyloarthrosis.
Traumatic damage to the spinal root can be observed with spondylolisthesis, spinal injuries, subluxation of the vertebra. Inflammatory damage to the root is possible with syphilis, tuberculosis, spinal meningitis, osteomyelitis of the spine. Radiculopathy of neoplastic genesis occurs in spinal cord tumors, spinal root neurinoma, vertebral tumors. Instability of the spine, which entails displacement of the vertebrae, can also cause radiculopathy. Contributing factors to the development of radiculopathy are:
- excessive loads on the spine,
- hormonal failures,
- obesity,
- physical inactivity,
- spinal abnormalities,
- hypothermia.
Symptoms
The clinic of radiculopathy consists of various combinations of symptoms of irritation of the spinal root and loss of its functions. The severity of signs of irritation and prolapse is determined by the degree of compression of the spine, individual features of the location, shape and thickness of the spinal roots, inter-root connections.
Symptoms of irritation include pain syndrome, motor disorders such as crampy or fascicular muscle twitching, sensory disorders in the form of tingling or crawling goosebumps (paresthesia), local feelings of heat / cold (dysesthesia). The distinctive features of root pain are its burning, baking and shooting nature; appearance only in the area innervated by the corresponding root; spread from the center to the periphery (from the spine to the distal parts of the arm or leg); amplification with overstrain, sudden movement, laughter, coughing, sneezing. Pain syndrome causes reflex tonic tension of muscles and ligaments in the affected area, which contributes to increased pain. To reduce the latter, patients take a gentle position, restrict movement in the affected spine. Musculotonic changes are more pronounced on the side of the affected root, which can lead to a misalignment of the trunk, in the cervical region – to the formation of a torticollis, followed by curvature of the spine.
Symptoms of prolapse appear with a far-reaching lesion of the root. They are manifested by weakness of the muscles innervated by the root (paresis), a decrease in the corresponding tendon reflexes (hyporeflexia), a decrease in sensitivity in the area of innervation of the root (hypesthesia). The area of the skin, for the sensitivity of which one root is responsible, is called a dermat. He receives innervation not only from the main root, but also partially from the above- and below- lying. Therefore, even with significant compression of one root, only hypesthesia is observed, whereas with polyradiculopathy with pathology of several adjacent roots, complete anesthesia is noted. Over time, trophic disorders develop in the area innervated by the affected root, leading to muscular hypotrophy, thinning, increased vulnerability and poor healing of the skin.
Symptoms of damage to individual roots
Root C1. The pain is localized in the back of the head, often dizziness appears against the background of pain, nausea is possible. The head is in the tilt position in the affected direction. There is tension of the occipital muscles and their palpatory soreness.
Root C2. Pain in the occipital and parietal areas on the side of the lesion. Turns and tilts of the head are limited. Hypesthesia of the occipital skin is observed.
Root C3. The pain covers the back of the head, the lateral surface of the neck, the area of the mastoid process, radiates into the tongue, orbit, forehead. Paresthesia is localized in the same zones and hypesthesia is observed. Radiculopathy includes difficulties in bending and extending the head, soreness of paravertebral points and points above the spinous process C3.
Spine C4. Pain in the upper arm with a transition to the front surface of the chest, reaching the 4th rib. It spreads along the posterolateral surface of the neck to its middle 1/3. Reflex transmission of pathological impulses to the diaphragmatic nerve can lead to hiccups, phonation disorder.
Spine C5. The radiculopathy of this localization is manifested by pain in the upper arm and on the lateral surface of the shoulder, where sensory disorders are also observed. Shoulder abduction is impaired, deltoid muscle hypotrophy is noted, the reflex from the biceps is lowered.
Spine C6. Pain from the neck spreads through the biceps area to the outer surface of the forearm and reaches the thumb. Hypesthesia of the latter and the outer surface of the lower 1/3 of the forearm is revealed. There is paresis of the biceps, shoulder muscle, supinators and pronators of the forearm. Reduced reflex from the wrist.
Spine C7. The pain goes from the neck along the back of the shoulder and forearm, reaches the middle finger of the hand. Due to the fact that the root C7 innervates the periosteum, this root syndrome differs in the deep nature of pain. A decrease in muscle strength is noted in the triceps, pectoralis major and latissimus muscles, flexors and extensors of the wrist. The triceps reflex is lowered.
Root C8. Root syndrome at this level is quite rare. Pain, hypesthesia and paresthesia spread to the inner surface of the forearm, ring finger and little finger. The weakness of flexors and extensors of the wrist, extensor muscles of the fingers is characteristic.
Roots T1-T2. The pain is limited to the shoulder joint and the armpit area, it can spread under the collarbone and to the medial surface of the shoulder. Accompanied by weakness and hypotrophy of the muscles of the hand, its numbness. Gorner’s syndrome is typical, homolateral to the affected root. Dysphagia, peristaltic dysfunction of the esophagus is possible.
Roots T3-T6. The pain has a shingling character and goes along the corresponding intercostal space. It can be the cause of painful sensations in the mammary gland, when localized on the left, it can simulate an attack of angina pectoris.
Roots T7-T8. The pain starts from the spine below the shoulder blade and reaches the epigastrium along the intercostal space. Radiculopathy can cause dyspepsia, gastralgia, enzyme insufficiency of the pancreas. There may be a decrease in the upper abdominal reflex.
Roots T9-T10. Pain from the intercostal space spreads to the upper abdomen. Sometimes the radiculopathy has to be differentiated from the acute abdomen. There is a weakening of the mid-abdominal reflex.
The roots are T11-T12. Pain can radiate into the suprapubic and inguinal zones. The lower abdominal reflex is reduced. Radiculopathy of this level can cause intestinal dyskinesia.
Root L1. Pain and hypesthesia in the groin area. The pain spreads to the upper-outer quadrant of the buttock.
The spine is L2. The pain covers the front and inner surface of the thigh. There is weakness when bending the hip.
Root L3. The pain goes through the iliac spine and the large trochanter to the anterior surface of the thigh and reaches the lower 1/3 of the medial part of the thigh. Hypesthesia is limited to the area of the inner thigh located above the knee. The paresis accompanying this radiculopathy is localized in the quadriceps muscle and adductors of the thigh.
Root L4. The pain spreads along the anterior surface of the thigh, knee joint, medial surface of the lower leg to the medial ankle. Hypotrophy of the quadriceps muscle. Paresis of the tibial muscles leads to external rotation of the foot and its “slapping” when walking. The knee reflex is reduced.
Spine L5. Pain radiates from the lower back through the buttock along the lateral surface of the thigh and lower leg in the first 2 toes. The pain zone coincides with the area of sensory disorders. Hypotrophy of the tibial muscle. Paresis of the extensors of the thumb, and sometimes the entire foot.
Root S1. Pain in the lower back and sacrum, radiating along the posterolateral sections of the thigh and lower leg to the foot and the 3rd-5th fingers. Hypo- and paresthesia are localized in the area of the lateral edge of the foot. Radiculopathy is accompanied by hypotension and hypotrophy of the calf muscle. Rotation and plantar flexion of the foot are weakened. The Achilles reflex is lowered.
Spine S2. Pain and paresthesia begin in the sacrum, covers the back of the thigh and lower leg, sole and thumb. Convulsions in the adductors of the thigh are often noted. The reflex from the achilles is usually not changed.
S3-S5 roots. Sacred caudopathy. As a rule, there is a polyradicular syndrome with the defeat of 3 roots at once. Pain and anesthesia in the sacrum and perineum. Radiculopathy occurs with dysfunction of the sphincters of the pelvic organs.
Diagnostics
In the neurological status, attention is drawn to the presence of trigger points above the spinous processes and paravertebral, muscular-tonic changes at the level of the affected segment of the spine. Symptoms of tension of the roots are revealed. In the cervical region, they are provoked by a rapid tilt of the head opposite to the affected side, in the lumbar region by lifting the leg in a horizontal position on the back (Lasega’s symptom) and on the stomach (Mackiewicz and Wasserman’s symptoms). According to the localization of pain syndrome, areas of hypesthesia, paresis and muscle hypotrophy, a neurologist can determine which root is affected. Electroneuromyography allows to confirm the radicular nature of the lesion and its level.
The most important diagnostic task is to identify the cause that provoked the radiculopathy. For this purpose, radiography of the spine is performed in 2 projections. It allows you to diagnose osteochondrosis, spondyloarthrosis, spondylolisthesis, ankylosing spondylitis, curvature and abnormalities of the spinal column. A more informative diagnostic method is CT of the spine. MRI of the spine is used to visualize soft tissue structures and formations. MRI makes it possible to diagnose intervertebral hernia, extra- and intramedullary spinal cord tumors, hematoma, meningoradiculitis. Thoracic radiculopathy with somatic symptoms requires additional examination of the relevant internal organs to exclude their pathology.
Treatment
In cases where the radiculopathy is caused by degenerative-dystrophic diseases of the spine, conservative therapy is mainly used. With intense pain syndrome, rest, analgesic therapy (diclofenac, meloxicam, ibuprofen, ketorolac, lidocaine-hydrocortisone paravertebral blockades), relief of muscle-tonic syndrome (methyllicaconitin, tolperizone, baclofen, diazepam), decongestant treatment (furosemide, ethacric acid), neurometabolic agents (vitamins g. B) are indicated . In order to improve blood circulation and venous outflow, euphyllin, xanthinol nicotinate, pentoxifylline, troxerutin, horse chestnut extract are prescribed. According to the indications, chondroprotectors are additionally used (cartilage and calf brain extract with vitamin C, chondroitin sulfate), resorption treatment (hyaluronidase), drugs to facilitate neuronal transmission (neostigmine).
A long-term radiculopathy with chronic pain is an indication for the appointment of antidepressants (duloxetine, amitriptyline, desipramine), and when pain is combined with neurotrophic disorders – for the use of ganglioblockers (benzohexonium, ganglefen). For muscular atrophy, nandrolone decanoate with vitamin E is used. Traction therapy has a good effect (in the absence of contraindications), which increases intervertebral distances and thereby reduces the negative impact on the spinal root. In the acute period, reflexotherapy, UHF, hydrocortisone ultraphonophoresis can act as an additional means of relieving pain. In the early stages, they begin to use physical therapy, during the rehabilitation period — massage, paraffin therapy, ozokeritotherapy, therapeutic sulfide and radon baths, mud therapy.
The question of surgical treatment arises with the ineffectiveness of conservative therapy, the progression of symptoms of prolapse, the presence of a spinal tumor. The operation is performed by a neurosurgeon and aims to eliminate the compression of the root, as well as to remove its cause. With herniated intervertebral discs, discectomy, microdiscectomy is possible, with tumors — their removal. If the root syndrome is caused by instability, then the spine is fixed.
Forecast
The prognosis of radiculopathy depends on the underlying disease, the degree of compression of the root, the timeliness of therapeutic measures. Long-term symptoms of irritation can lead to the formation of a difficult to stop chronic pain syndrome. Timely compression of the spine, accompanied by symptoms of prolapse, eventually causes the development of degenerative processes in the tissues of the spinal root, leading to a persistent violation of its functions. The result is irreversible paresis disabling the patient, pelvic disorders (with sacral caudopathy), sensitivity disorders.
