As with any disease process, a thorough history and physical exam are crucial in diagnosing lumbosacral radiculopathy. Pain is the most commonly reported symptom. However, numbness or weakness along the distribution supplied by the respective nerve root(s) is often appreciated. Radicular pain is typically characterized by patients as "electrical shocks" or "shooting pains" that radiate from the buttock to the foot.  While gathering the history, it is important to screen for any red-flag symptoms, which could indicate an urgent/emergent clinical condition.  Evaluating clinicians must first rule out associated "red flag" symptoms including:

• Thoracic pain
• Fever/unexplained weight loss
• Night sweats
• Bowel or bladder dysfunction
• Malignancy (document/record any previous surgeries, chemo/radiation, recent scans and bloodwork, and history of metastatic disease)
  • Can be seen in association with pain at night, pain at rest, unexplained weight loss, or night sweats
• Significant medical comorbidities
• Neurologic deficit or serial exam deterioration
• Gait ataxia
• Saddle anesthesia
• Age of onset (bimodal -- Age < 20 years or Age > 55 years)

A full neurologic exam shoulder is performed, including an assessment for upper motor neuron findings (Babinski sign, clonus, spasticity). On physical exam, several maneuvers can assist the clinician in making a diagnosis. Lasègue test, or straight leg test, is performed by passively raising one leg into the air. This creates increased tension on the sciatic nerve between 30 degrees to 60 degrees from the exam table. A reproduction of the patient's symptoms during passive movement between 30 degrees to 60 degrees is considered a positive sign and is suggestive of lower lumbar nerve root involvement (L4 to S1). Of note, a similar stretch can be created on the femoral nerve using a reverse straight leg, or Ely test. With this test, the patient's symptoms are reproduced by extending the hip and flexing the knee with the patient in the prone position. This will stretch the femoral nerve and the L2 to L4 nerve roots. Reproduction of radicular symptoms can also be produced by placing the patient in a seated position with the neck in full flexion and knees in full extension (slump test). [5][6]

Given the favorable outcome, and often spontaneous resolution of the vast majority of low back pain symptoms, extensive imaging is usually not necessary in patients with low back pain of less than four to six weeks duration. As stated above, work-up begins with a thorough physical exam. Neurologic deficits in a focal distribution warrant further workup. In cases of low back pain that fails to resolve within one to two months, MRI is considered the gold standard in evaluating radicular low back pain. Of note, MRI with contrast is recommended in patients with previous spinal surgeries. For patients unable to undergo MRI, CT scan is an alternative option. However, CT is not as sensitive in visualizing soft tissue or tumors and is not recommended for routine use. X-rays are simple, readily available in most developed countries, and can reveal gross bony abnormalities such as fractures, disc space narrowing, and other osteodegenerative changes. Often, it is not clinically possible to distinguish lumbosacral radiculopathy from peripheral neuropathy or plexopathy. In these instances, electromyography and nerve conduction study can be utilized to localize a lesion with relatively high diagnostic specificity. [7]

Treatment is varied depending on the etiology and severity of symptoms. However, conservative management of symptoms is generally considered first line. Medications are used to manage pain symptoms including NSAIDS, acetaminophen, and in severe cases, opiates. Radicular symptoms are often treated with neuroleptic agents. Systemic steroids are often prescribed for acute low back pain, although there is limited evidence to support its use. Nonpharmacologic interventions are often utilized as well. Physical therapy, acupuncture, chiropractic manipulation, and traction are all commonly used in the treatment of lumbosacral radiculopathy. Of note, the data supporting the use of these treatment modalities is equivocal. Interventional techniques are also commonly used and include epidural steroid injections and percutaneous disc decompression. In refractory cases, surgical decompression and spinal fusion can be performed. [8][9][10]

• Ankylosing spondylitis

• Epidural abscess

• Inflammatory arthritis

• Inflammatory bowel disease

• Leukaemia

• Lumbosacral disc injuries

• Lymphoma

• Metastatic carcinoma

• Multiple myeloma

Overall, lumbosacral radiculopathy is an extraordinarily common complaint seen in clinical practice and comprises a large proportion of annual doctor visits. The vast majority of cases are benign and will resolve spontaneously, and thus, conservative management is the most appropriate first step in the absence of clinical red flag symptoms. In cases where symptoms fail to resolve, imaging studies, electromyography, and nerve conduction studies can assist in making a diagnosis. [2][4][10]

Lumbosacral radiculopathy is a common problem and nurse practitioners, physician assistants, and physicians working as a team should be aware of the red flag symptoms that require emergent intervention and reporting to the physician providing team management.