Radicular Pain

Radicular pain can be created by compression or irritation of the nerve root in the lateral recess or from zygapophysial joint hypertrophy. Extruded disc material within the neural foramen compresses the ipsilateral exiting nerve root and is most often seen at the C4-5 and C5-6 levels in the cervical region and at the L3-4 and L4-5 levels in the lumbar region. The disc can bulge initially, and later the disc can herniate through the fibers of the annulus centrally or laterally. Radicular lesions commonly present as focal pain, and the natural course is to progress. In the cervical spine, spondylosis can present as focal acute pain and can become chronic.

Radicular Movement Hip

Fig. 3. (A) Test of hip flexion: L2. (B) Test of knee extension: L3. (C) Test of foot dorsiflexion: L4. (D) Test of great toe extension: L5. (E) Test of foot eversion: S1. (F) Test of buttock contraction: S2.

Over Spondylolisthesis

Fig. 3. (A) Test of hip flexion: L2. (B) Test of knee extension: L3. (C) Test of foot dorsiflexion: L4. (D) Test of great toe extension: L5. (E) Test of foot eversion: S1. (F) Test of buttock contraction: S2.

Great Toe Extension Test
Fig. 3. (G) Test of knee flexion: S1 and S2. (H) Test of toe standing: S2.

In the neck, pain can radiate to the occiput or upper extremities. Patients may experience numbness in the upper extremities and episodic spastic paresthesias. Over time there may be loss of position and vibration sense.

In the lumbar spine, patients complain of persistent low back pain. There can be weakness, paresthesias, and bilateral or unilateral lower extremity pain that are exacerbated by prolonged standing and walking. The patient may find that squatting or sitting often relieves the pain. Radicular pain suggests tension on, or compression of, the nerve root, which can be caused by a herniated disc. Radicular pain from a herniated lumbar disc may be replicated by dorsiflexion of the foot.

Physical Examination A straight leg raise test can confirm radicular pain. Lay the patient supine, raise the leg slightly bent, and then straighten the leg or dorsiflex the foot to re-create the pain. Radicular pain may also be re-created in the affected side by raising the opposite leg. Test the legs and feet for loss of sensation or for vibration and for weakness with resistance. The range of motion and reflexes may be normal.

Diagnostic Imaging Several common disease entities may present with radicular pain, including lesions causing compromise of the spinal canal and neural foramen (such as diffuse idiopathic skeletal hyperostosis [DISH], hypertrophy of the posterior longitudinal ligament, spondylolisthesis, facet arthropathy, and disc her-niation). The plain film and CT image findings can optimize a diagnosis. Although plain film radiographs can be diagnostic for evaluation of the spinal column,

Spinal Column Rheumatoid Arthritis

axial or three-dimensional imaging with CT produces a more detailed analysis of the central canal.

With spondylolisthesis and spondylolysis, plain films are observed for a step off or break in the pars interar-ticularis, and these fractures are best viewed on an oblique projection. In cases of facet arthropathy, observe for overgrowth of the facet and cartilage erosion leading to joint space narrowing. Ankylosis, erosions in ankylosing spondylitis, cranial settling, and atlantoaxial subluxation in rheumatoid arthritis are signs that are readily observed on plain film radiography. Skeletal hyperostosis in DISH, ossification of the posterior longitudinal ligament, and ossification of the ligamentum flavum are better observed with CT imaging.

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