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Back and Neck Pain part-2      Table 16 1: Lumbosacral Radiculopathy>Neurologic Features

Examination Findings

Lumbosacral Nerve Roots

Reflex

Sensory

Motor

Pain Distribution

Lumbar-2 or L2 Psoas (hip flexion)

Upper anterior thigh

Psoas (hip flexion)

Anterior thigh

L3-

Psoas (hip flexion)
Quadriceps (knee extension)
Thigh adduction

Lower anterior thigh
Anterior knee

Psoas (hip flexion)
Quadriceps (knee extension)
Thigh adduction

Anterior thigh, knee

L4-Quadriceps (knee)

Quadriceps (knee extension)
Thigh adduction
Tibialis anterior (foot dorsiflexion

Quadriceps (knee)

Medial calf

Quadriceps (knee extension)
Thigh adduction
Tibialis anterior (foot dorsiflexion)

Knee, medial calf

L5^b
Tibialis anterior (foot dorsiflexion)
Gluteus medius (hip abduction)
Toe dorsiflexors

Lateral calf, dorsal foot, posterolateral thigh, buttocks

S1^c

Gastrocnemius/soleus (ankle)Plantar surface foot
Lateral aspect foot

Gastrocnemius/soleus (foot plantar flexion) b
Abductor hallucis (toe flexors)sup>b
Gluteus maximus (hip extension)

Bottom foot, posterior calf, posterior thigh, buttocks

^aReverse straight leg raising sign present see 'Examination of the Back.'
^bThese muscles receive the majority of innervation from this root.
^cStraight leg>raising sign present see 'Examination of the Back.'

Laboratory Studies

Routine laboratory studies such as a complete blood count, erythrocyte sedimentation rate, chemistry panel, and urinalysis are rarely needed for the initial evaluation of acute (<3 months), nonspecific, low back pain. If risk factors for a serious underlying disease are present, then laboratory studies (guided by the history and examination) are indicated (Fig. 16 6B).

Plain films of the lumbar or cervical spine are helpful when risk factors for vertebral fracture (trauma, chronic steroid use) are present. In the absence of risk factors, routine x>rays of the lumbar spine in the setting of acute, nonspecific, low back pain are expensive and rarely helpful. In general, the definition of soft tissue structures by MRI is superior, whereas CT>myelography provides optimal imaging of bony lesions in the region of the lateral recess and intervertebral foramen and is tolerated by claustrophobic patients.

Electromyography (EMG) can be used to assess the functional integrity of the peripheral nervous system (Chap. 357) in the setting of back pain. Sensory nerve conduction studies are normal when focal sensory loss is due to nerve root damage because the nerve roots are proximal to the nerve cell bodies in the dorsal root ganglia. The diagnostic yield of needle EMG is higher than that of nerve conduction studies for radiculopathy. Denervation changes in a myotomal (segmental) distribution are detected by sampling multiple muscles supplied by different nerve roots and nerves; the pattern of muscle involvement indicates the nerve root(s) responsible for the injury. Needle EMG provides objective information about motor nerve fiber injury when the clinical evaluation of weakness is limited by pain or poor effort. EMG and nerve conduction studies will be normal when only limb pain or sensory nerve root injury or irritation is present. Mixed nerve somatosensory evoked potentials and F>wave studies are of uncertain value in the evaluation of radiculopathy.

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