NEUROSURGERY

The management of communicate with other roots to form plexi and thereon pe-
ripheral nerves. The root traverses four zones: (1) the central

radiculopathy, neurogenic canal (intrathecal); (2) the lateral recess (within the root sleeve);
(3) the foramen; and (4) the extraforaminal space (Figure 2).

claudication and cauda The nomenclature of the root is related to the spinal region. In
the thoracic and lumbar spine the nerve is named by the pedicle

equina syndrome underneath from which it exits; at the L4/5 segment the L4 nerve
exits (underneath the L4 vertebra’s pedicle.)
In the cervical spine there is an additional root that exits
Nick Carleton-Bland above the atlas that is confusingly named the C1 root. Therefore,
Martin Wilby all cervical nerve roots are named by the pedicle above which
they exit; at the C5/6 segment the C6 nerve exits (above the C6
pedicle.) Furthermore, this nomenclature anomaly leads to the
nerve exiting at the cervico-thoracic junction (C7/T1) being
Abstract
referred to as the C8 root.
Radiculopathy is a commonly encountered symptom in neurosurgical
practice. This article discusses the clinical presentation, anatomy,
pathophysiology and treatment of radiculopathy, neurogenic claudica- Pathology
tion and cauda equina syndrome. Radiculopathy is a multifactorial pathology involving both a
Keywords Acute foot drop; cauda equina syndrome; lumbar canal mechanic compression and an inflammatory component leading
stenosis to a ‘chemical neuroradicululitis’.1 Indeed in human and animal
models, compression to nerve roots alone, with the absence of
inflammatory mediators, causes only mild discomfort.2 A com-
Introduction mon source of both compression and inflammation and ac-
counting for 90% of radiculopathy is nucleus pulposis
Radiculopathy is a symptom generated by pathology affecting the
herniation, a ‘slipped disc’. Most intervertebral disc prolapses are
most proximal part of the peripheral nerve system (PNS) e the
paracentral and cause inflammation and compression in zones 1
nerve roots. Radiculopathy manifests in all modalities subsumed
and 2. Irritation here can cause symptoms in the transiting root
by the root, commonly pain, paraesthesia and motor weakness.
(e.g. a L4/5 disc prolapse irritating the L5 transiting root, mani-
In addition, some patients report joint proprioceptive alteration
festing as a foot drop and pain to the great toe.)
and skin perfusion changes (Table 1).
Less common is foraminal and extra-foraminal compression
Peripheral neuropathy is differentiated from radiculopathy by
in zones 3 and 4, which cause an exiting nerve issue (e.g. a far
the distribution of the symptoms. Root symptoms are ‘referred’
lateral disc at L3/4 compressing the exiting L3 nerve manifesting
to the limb in the corresponding dermatome and myotomal dis-
as quadriceps weakness and pain and paraesthesia to the knee).
tribution (Figure 1). The nature of the pain is often described as
The acute inflammatory response leads to phagocytosis of the
an ‘electric shock’. It is severe, often associated with axial spinal
disc material. This often leads to resorption and resolution of the
pain, exacerbated by limb extension and is recalcitrant to opioid
radiculopathy; however, in a significant minority there is a
pharmacotherapy.
failure of disc resorption and a chronic, fibrotic reaction occurs.
Radiculopathy is a common condition with a 3% prevalence
The failure of resorption leads to continuing compression and
in the UK population. The disability radicular symptoms cause
inflammatory cytokine production and thence continuing
has significant impact to the patient’s quality of life, social and
radiculopathy.
economic function.

Anatomy Nerve fibre types

The nerve roots ‘radiate’ from the spinal cord, hence radiculop- Nerve fibre Modality Conduction Diameter
athy. The root comprises a condensation of both efferent ventral types speed
roots containing lower motor neurons and afferent dorsal first
order sensory neurons. Type A
The root navigates a short distance from within the spinal a Motor, proprioception 80e120 m/s 13e20 mm
canal to exit the spinal column and commonly then goes on to b Pressure
g Muscle spindle
d Pain/temperature
Nick Carleton-Bland BSc(Hons) MSc PGCert MBBS(Lond) MRCS(Eng) Type B Autonomic
is a Consultant Neurosurgeon at the Walton Centre,
FRCS(Neuro. Surg) (preganglionic)
Liverpool and Honorary Lecturer at the University of Liverpool, UK. Type C Pain 0.5e2 m/s 0.1e1.5 mm
Conflicts of interest: none declared. (unmyelinated) Autonomic
Martin Wilby MB BChir MA FRCS (SN) PhD is a Consultant Neurosurgeon (Post-ganglionic)
at the Walton Centre, Liverpool, UK and Director of Research.
Conflicts of interest: none declared. Table 1

SURGERY 36:11 664 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
 NEUROSURGERY

Myotomal distribution of root symptoms

Trigeminal nerve branches

C2 T2
C3 T3
C4 T4
C5 T5
C6 T6
C7 T7
C8 T8
T9
T10
T11
T12
T1

S2–S4

L1 Level Myotome
L2
L3 C6 Wrist extension
L4 C7 Elbow extension
L5 C8 Finger extension
T1 Finger abduction

S1 L3 Knee extension

L5 Great toe extension

Figure 1

Assessment  screen for upper motor neuron pathology

 examine for important time-critical deficits (acute painful
The goals of the patient’s history are to:
foot drop and CES)
 assess if the symptoms are likely neurological in origin
 fitness for surgery.
 to localize the level of the lesion
Clinical examination should include root tension manoeuvres
 consider the nature of the lesion
(Lasegue and Braggard’s) and neurological testing-tone; power;
 screen for emergency conditions (see Box 1)
reflexes and sensation. Tone and reflexes should be normal or
 screen for anaesthetic risk factors.
reduced. If hyperreflexia and hypertonia are found, assessment
In the history it is mandatory to enquire about perianal
must be made of the cervicothorcaic spine. Motor and sensory
sensation and urogenital symptoms. The specific urinary
deficits often help corroborate the history and aid localization.
dysfunction of neurological aetiology is insensate urinary in-
Perianal sensory loss is a statistically significant predictor of
continence, i.e. the patient has no desire to void, is in retention
cauda equina compression.4
and has overflow leakage. This so called ‘autonomic dysfunction’
is vital to recognize and act upon in a time critical manner (see
Cauda Equina syndrome below). Imaging
Goals of clinical examination: The core radiological assessment is a sagittal and paired axial
 confirm localization as suggested by history T2 MRI imaging performed within 6 months of onset of

SURGERY 36:11 665 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
 NEUROSURGERY

Nerve root anatomy

Dura

L4 pedicle

‘Exiting’
L4 root and
dural sleeve
‘Transiting’ L5 root
L4/5 disc
L5 pedicle
‘Exiting’L5 root
and dural sleeve

Zone 1 2 3 4

Figure 2

symptoms and assessment. In this sequence CSF appears as

white hyperintensity, in stark contrast to the isointense neural
structures and the dark discs (Figure 3). The CSF surrounding
the neural structures is used as a proxy for compression;
absence of CSF represents neural compression. Patients with
older implantable ferromagnetic devices such as pacemakers
will require a CT myelogram.
Goals of imaging:
 confirm the clinical localization and the nature of the
compression
 screen for other levels of potential concern
 allow review of bone marrow suggestive of bony benign
and malignant pathology
 assess for conus and lower spinal cord
 review the root through all four zones.

Red flags that suggest cauda equina syndrome include3

C Severe or progressive bilateral neurological deficit of the legs,
such as major motor weakness with knee extension, ankle ever-
sion, or foot dorsiflexion
C Recent-onset urinary retention (caused by bladder distension
because the sensation of fullness is lost) and/or urinary inconti-
nence (caused by loss of sensation when passing urine)
C Recent-onset faecal incontinence (due to loss of sensation of
rectal fullness)
C Perianal or perineal sensory loss (saddle anaesthesia or
paraesthesia)
C Unexpected laxity of the anal sphincter

Box 1 Figure 3

SURGERY 36:11 666 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
 NEUROSURGERY

Treatments Controversies
The natural history of radiculopathy has been characterized by a
The majority (90%) of patients with radiculopathy are treated
number of observational studies. The outcome is that 75% of pa-
non-surgically.1 Antineuropathics such as pregabalin, gabapentin
tients at three months and 95% of patients at one year will have
and amitriptyline are effective and are first-line treatment in
recovered with conservative management.6,7 Surgical interventions
radiculopathy without motor symptoms as per NICE guidelines.
such as injection therapy or surgery are known to be effective and
The mechanism of action of the GABAergics works at the root
provide faster pain relief with associated improvement in patient
and spinal cord level reduce ascending pain fibre neuronal
experience. However, there is associated risk with operation
discharge. The tricyclics function by reducing reuptake of 5-HT
including the potential for nerve damage and paralysis. Therefore,
and NA thus augmenting the paraaqueductal grey descending
the timing of the intervention is controversial, as many patients will
inhibition system.
improve without intervention. Therefore, most UK surgeons offer
the patient surgery or injection therapy after 3e6 months of failed
Intervention
conservative management. Another controversy is the choice of
Peri-root steroid injection is an effective treatment. This inter- intervention as both root injection and microdiscectomy have good
vention does not remove compression of the disc but reduces the efficacy; this is question is currently the subject of a randomized
production of inflammatory mediators. The procedure is usually controlled trial.8
performed as a day case. The patient is position prone on an
x-ray table and the needle is introduced percutanously from a
Specific conditions
paramedial entry point to the foramen. Often the patient will
have an exacerbation of symptoms when the needle abuts the Cauda equina syndrome
root. Contrast is instilled to confirm the needle within the root Cauda equina syndrome (CESR) is a defined as a triad of symp-
sleeve and then a steroid and local anaesthetic is injected. Effi- toms including:
cacy rates are high, with 66% of patients with good relief at a  bilateral lower limb radicular pain
year.  perianal sensory loss
Surgery is an effective and very commonly performed treat-  insensate urinary retention and subsequent incontinence.
ment. Between 80% and 90% of patients treated with micro- Often the first symptom is the radiculopathy, followed later by
discectomy have relief of the radicular pain in the immediate the addition of perianal sensory loss and then finally the triad
postoperative period, often motor and sensory symptoms completed by episodes of incontinence. A patient progressing
respond less reliably and less immediately. The principle of the through these symptoms is termed a cauda equina in evolution
operation is to remove the compressive disc extrusion, but in (CESE). A clinical picture with the absence of the urinary
addition, decompression of the lateral recess and foramen are dysfunction is termed impending cauda equina syndrome
achieved with osteo-ligamentous resection. The procedure is (CESI9). CESI, CESE and CESR represent a neurosurgical emer-
performed under general anaesthetics and can be as a day case. gency and when seen mandates an urgent MRI scan (Figure 3). If
The patient is placed prone and x-ray is used to localize the level. there is radiological evidence of compression to the cauda equina
A midline incision of the skin and lumbar fascia is performed and that correlate with the clinical findings then surgical decom-
then the multifidus muscle is stripped from the spinous process pression should occur within 24e48 hours. Delays in recogni-
to expose the lamina. A small laminotomy allows for fenestration tion, investigation or treatment can leave the patient with
of the ligamentum flavum. Beneath this layer is the thecal sac devastating urogenital dysfunction that is a source of distress and
medially and exiting root laterally, often the root obscured by the morbidity for the patient and a source of great cost to the NHS;
overhanging facet joint. Medial facetectomy allows lateral recess between 2010 and 15 CES claims have cost the NHS £25m in
and proximal foraminal decompression of the nerve root. The compensation and legal fees.10
root is medialised to allow access to the disc. The disc annulus is
incised and the fragment is removed. Acute foot drop
The Pan-European SPINE TANGO registry shows the inci- Ankle dorsiflexion is vital to locomotion. It is an action generated
dence of common complications: by tibialis anterior, extensor halluces longus and extensor dig-
 infection 3% itorum longus. The supply to these muscles is mostly L5, with a
 recurrent disc prolapse 5% less contribution from L4. The peripheral nerve that delivers the
 inadvertent durotomy (‘CSF leak’) 7% L5 outflow is the common peroneal nerve.
 continuing radicular symptoms 10%. An acute painful foot drop suggests compression and is a
Material but rare complications that are mandatory to discuss potential surgical treatment maybe indicated. Painless foot drop
with the patient include: is likely a ‘medical’ aetiology such as diabetes.
 1% nerve injury resulting in urogenital, motor or sensory A favourite question for examiners is how one can differen-
deficits tiate between a foot drop of L5 root aetiology and a foot drop
 1:4000 of iliac vessel injury during discectomy from a common peroneal nerve aetiology:
 very rare risk of visual deficit from prone positioning.  The L5 root aetiology will present with a weakness asso-
Wrong-level surgery is not a risk of surgery, it is a ‘never ciated with back pain, gluteal weakness, radicular pain and
event’ that intraoperative x-ray level checks should abolish. paraesthesia in a dermatomal distribution, and relative
Despite this, in 2017 in the UK wrong-level or wrong-side spine preservation of the broadly innervated peroneus muscle
surgery occurred 13 times.5 group (L4-S1) leading to normal foot eversion.

SURGERY 36:11 667 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.
 NEUROSURGERY

decompression can improve the claudicant symptoms greatly;

however, caution must be exercised as this patient group has
potentially multiple co-morbidity and anaesthetic input is vital to
fully assess the risks of surgery.

Conclusion
Spine surgery for relief of radiculopathy makes a clinically and
statistically significant improvement in health-related quality
of life. The cost per quality adjusted life year is half that of a
hip replacement surgery or even coronary stenting, and so
represent a cost-effective intervention.11 Injection therapy may
prove to be equally effective to surgery for isolated radicul-
opathy management, but for CES, acute foot drop and neuro-
genic claudication surgical decompression remains the
standard. A

REFERENCES
Figure 4 1 Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural
steroid injections in lumbosacral radiculopathy: a prospective
randomized study. Spine 2002; 27: 11e6.
 The common peroneal nerve aetiology will have no gluteal 2 Kulisch SD, Ulstrom CL, Michael CJ. The tissue origin of low-back
weakness, no back pain, pain and paraesthesia limited to pain and sciatica: a report of pain response to tissue stimulation
the first webspace and impaired foot eversion. during operations on the lumbar spine using local anesthesia.
Many neurosurgeons are moving to early decompression of a Orthop Clin N Am 1991; 22: 181e7.
MRC grade <3/5 in a patient with <48 hours history and an 3 Red flag signs e National Institute for Health and Care Excellence.
appropriate sided disc prolapse. After this window functional Accessed at URL: https://cks.nice.org.uk/sciatica-lumbar-
stimulation and foot drop splints have similar efficacy and radiculopathy#!diagnosissub:1.
overall many root aetiology foot drops slowly improve. 4 Balasubramanian K, Kalsi P, Greenough C, Seetharam M. Reli-
ability of clinical assessment in diagnosing cauda equina syn-
Lumbar canal stenosis
drome. BJNS 2010; V24.
Neurogenic claudication is placing an increasing burden on spi-
5 NHS improvement never events. Accessed at URL: https://
nal services due to improvements in longevity and increased
improvement.nhs.uk/resources/never-events-data/.
patient expectation.
6 Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery
Clinical presentation:
versus prolonged conservative treatment for sciatica. N Engl J
 older patients
Med 2007; 356: 2245e56.
 classically pain/numbness/pins and needles down one or
7 Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoper-
both legs when they walk or stand (worse with spine
ative treatment for lumbar disk herniation: the Spine Patient
extended)
Outcomes Research Trial (SPORT): a randomized trial. JAMA
 flexion improves symptoms ‘shopping trolley sign’
2006 Nov 22; 296: 2441e50.
 often vague symptoms (legs feel dead, start dragging legs)
8 Wilby M, NERVES Study Group. Multi-centre randomised control
 symptoms usually alleviated with rest, but slowly and
trial comparing the clinical and cost effectiveness of trans-
often incompletely
foraminal epidural steroid injection to surgical microdisectomy for
 significant limitation to walking distance
the treatment of chronic radicular pain secondary to prolapsed
 neurological/autonomic signs uncommon
intervertebral disc herniation: NErve Root Block VErsus Surgery
 major differential diagnosis is vascular claudication.
(NERVES): trial protocol. In: National Institute for Health Research
The compressive pathology is often asymptomatic and insid-
Evaluation, Trials and Studies (NETS) Project Portfolio. NIHR
iously progresses to lead to significant neural compression before
NETS, 2015.
symptoms. The compression is mainly from facet joint hyper-
9 Srikandarajah N, Boissaud-Cooke MA, Clark S, Wilby MJ. Does
trophy and liagmentum flavum degeneration posteriorly, with
early surgical decompression in cauda equina syndrome improve
some contribution from disc degeneration anteriorly to narrow
bladder outcome? Spine 2015 Apr 15; 40: 580e3.
the neural canal and lateral recess (Figure 4). The compression is
10 http://www.nhsla.com/Safety/Documents/DYK_Cauda_Equina_
likely symptomatic when walking due to relative ischaemia of
Syndrome_Web.pdf.
the roots. Due to the intermittent nature and likely ischaemia
11 Rasanen P, Ohman J, Sintonen H, et al. Cost-utility analysis of
basis for the pain, antineuropathics are unhelpful. Due to the
routine neurosurgical spinal surgery. J Neurosurg Spine 2006; 5:
non-inflammatory nature of the pathology, steroid injections
204e9.
have been shown not to be an efficacious treatment. Posterior

SURGERY 36:11 668 Crown Copyright Ó 2018 Published by Elsevier Ltd. All rights reserved.