Diagnosing Radiculopathies Through History & Observation

MRI is currently the gold standard for identifying radicular pathology in the upper and lower extremities. Unfortunately, MR imaging requires preauthorization, which isn’t easy to obtain.

As a result, diagnosis of radiculopathies is initially based on case history, observation, physical examination findings, and indirect information from routine radiographs. (Describing information from routine radiographs as “indirect” relates to the technology’s worth in identifying chronic issues over acute issues.)

Among the three most readily available methods, physical tests are what most practitioners depend on – despite the marginal reliability of the tests. “Marginal reliability” questions the emphasis on physical tests and stresses the need to increase reliance upon other diagnostic methods, case history and observation.

The information below addresses this need. It brings history and observation to the forefront of radicular diagnostics. Each factor listed can significantly increase the clinician’s ability to diagnose radiculopathies.

• When neck and arm pain are equally severe or neck pain is worse than arm pain, the extremity pain is more likely to be referred.
• When back and leg pain are equally severe or back pain is worse than leg pain, the extremity pain is more likely to be referred.
• Radiculopathy is most likely when extremity pain is more severe than spinal pain or extremity pain is present without spinal pain.
• Patient facial expressions during acute radiculopathy move beyond general expressions of pain to an expression of panic. Patients with radiculopathy to the point of panic have difficulty understanding explanations of their condition, paying attention to instructions, and being patient with less-than-instantaneous results.
• These patients also have a tendency to “doctor-hop.” The patient is impatient and does not allow time for individual methods of care to take effect before moving on to another provider.
• Significant extremity pain is present throughout the night in radiculopathy. Significant extremity pain throughout the night prevents sleep, and the unrelenting pain and lack of sleep have detrimental effects on the patient’s mood and affect.
• Patients with radiculopathy have difficulty staying still. They writhe, shift their weight and change positions continuously.
• Patients with upper-extremity radiculopathy may exhibit Bakody’s or the abducted arm sign; antalgic positions that provide a degree of relief by holding the involved arm above shoulder height / above their head. Holding the arm across the body with the elbow flexed, as though the arm is in a sling, is another antalgic posture frequently seen in upper-extremity radiculopathy.
• Patients with lower-extremity radiculopathy will exhibit a list or shift of the lumbar spine. Unlike scoliosis, compensations placing the head over the pelvis may be absent. The list often reduces when the patient is non-weight-bearing.
• Patients with lower-extremity radiculopathy may suspend themselves while sitting by pressing down on the arms of the chair to take the weight / pressure off their lower spine.

If any of the above is noted, be diligent about documenting the information. It will prove essential if preauthorization is initiated.