Cervical and Lumbar Radiculopathy
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Direct answer
Cervical and lumbar radiculopathy are root-level syndromes of radicular pain, sensory change, weakness and reflex loss, most often caused by disc herniation or foraminal narrowing. The C7 root is the most commonly affected cervical root, while the L5 and S1 roots predominate in the lumbar spine. The root-level pattern localises the lesion on examination, and MRI then confirms it.
What you must remember
- Commonest roots: C7 is most often affected in the cervical spine, followed by C6; L5 and S1 are the most common lumbar roots.
- C6 pattern: reduced biceps and brachioradialis reflexes, wrist extension weakness and sensory loss over the thumb.
- C7 pattern: reduced triceps reflex, weakness of elbow extension and wrist flexion, and numbness over the middle finger.
- L4 pattern: reduced knee jerk, quadriceps weakness and sensory loss over the medial leg.
- L5 pattern: foot drop from weak great toe and foot dorsiflexion, with numbness over the dorsum of the foot and a preserved ankle jerk.
- S1 pattern: reduced ankle jerk, weak plantar flexion and sensory loss over the lateral foot.
- Investigations: MRI is the imaging of choice, while EMG and nerve conduction studies confirm radiculopathy and separate it from neuropathy.
- Surgical indications: progressive or severe motor deficit, intractable pain after several weeks of conservative care, and cauda equina syndrome as an emergency.
A root-by-root approach to radicular symptoms
Radiculopathy is localised clinically before imaging, because the symptom pattern and reflex loss predict the affected root. Each step narrows the diagnosis.
- Map the symptoms: record the pain, numbness and weakness, and check whether they follow a single dermatome or myotome.
- Examine reflexes: check the biceps, brachioradialis and triceps in the arms, and the knee and ankle jerks in the legs, since reflex loss localises the root.
- Test myotomes: check shoulder abduction for C5, elbow flexion for C6, elbow extension for C7, finger flexion for C8, knee extension for L4, dorsiflexion for L5 and plantar flexion for S1.
- Provoke the pain: perform the Spurling test for cervical roots and the straight-leg raise for lumbosacral roots, interpreting a positive result in context.
- Image the spine: order MRI for red flags, progressive weakness or a planned intervention, and use EMG when the diagnosis is in doubt.
- Treat conservatively first: NSAIDs, a short oral steroid course, neuropathic agents and physiotherapy usually precede any surgical opinion.
- Escalate when needed: refer for surgery when the deficit progresses, pain is intractable, or cord or cauda equina compression is present.
Where the exam tries to catch you
Radiculopathy questions usually hinge on a single reflex or on a red flag that changes management.
- Trap: localising a foot drop to S1 because the patient has a foot problem Correct: a foot drop with a preserved ankle reflex points to L5, whereas S1 causes a reduced ankle jerk.
- Trap: treating bilateral leg weakness with sphincter change as simple sciatica Correct: this is cauda equina syndrome, an emergency needing urgent MRI and neurosurgical review.
- Trap: operating on an MRI finding alone Correct: disc herniation is common in asymptomatic people, so imaging must match the clinical root syndrome.
- Trap: attributing bilateral hand clumsiness with upper motor neuron signs to a root lesion Correct: this suggests cervical myelopathy, which needs different management from radiculopathy.
Frequently asked questions
Which cervical root is most commonly affected in radiculopathy?
The C7 root is the most commonly affected cervical root, followed by C6. C7 radiculopathy typically produces a reduced triceps reflex, weak elbow extension and numbness over the middle finger.
What is the reflex pattern of L5 radiculopathy?
L5 radiculopathy produces weakness of foot dorsiflexion and great toe extension, with numbness over the dorsum of the foot. The ankle reflex is typically preserved, which helps distinguish L5 from S1 radiculopathy.
When is surgery indicated for lumbar radiculopathy?
Surgery is indicated for a progressive or severe motor deficit, for intractable pain persisting after several weeks of conservative care, and for cauda equina syndrome as an emergency. Most patients with lumbar radiculopathy improve with conservative treatment alone.
What is the Spurling test used for?
The Spurling test reproduces arm radicular pain in cervical radiculopathy by extending and rotating the neck towards the affected side while applying axial pressure. A positive result supports foraminal compression of a cervical root.
Which test supports lumbosacral radiculopathy at the bedside?
The straight-leg raise test reproduces radicular pain in lumbosacral radiculopathy by stretching the sciatic nerve roots. The crossed straight-leg raise test is more specific for disc herniation, because it reproduces pain on the opposite leg.