How many times have we seen this scenario? The Injured employee reports low back pain secondary to a modest lifting type of event, and the symptoms radiate into one or both lower extremities. A diagnosis of radiculopathy is assigned.
One of the most common diagnostic mistakes in workers’ compensation occurs when radiating leg pain is automatically labeled as radiculopathy.
The two are not the same thing.
Reviewing the Clinical Picture
Before accepting the diagnosis, claims professionals should determine whether the mechanism of injury, examination findings, and diagnostic testing actually support nerve root involvement.
The next question is what does a documented diagnosis of radiculopathy mean? Simply put, radiculopathy refers to a specific dysfunction of a spinal nerve root. However, this diagnosis is more than just simple pain traveling into an upper or lower extremity. Objective findings to support this diagnosis may include sensory loss, motor weakness, diminished reflexes, or electrodiagnostic abnormalities. A positive straight leg raise may support the clinical picture but is not, by itself, evidence of neurologic deficit. A compressed or irritated nerve needs to produce a predictable pattern of findings based specifically on the nerve root compromised.
Does the Medical Record Support the Diagnosis?
An all-too-common problem is that many files contain this diagnosis without documenting the specific clinical findings that objectively support this determination. You, as the claim file professional handling this claim, need to carefully review the clinical records provided and ensure the clinical history identified a mechanism of injury that supports this diagnosis, the symptomology presented is contained within a specific radicular pattern, what makes the symptoms better, conversely what makes these symptoms worse, are there any specific physical examination findings or motor complaints or prior history of similar findings.
Understanding Radiculopathy Symptomology
Radicular pain is strictly a phenomenon (symptom) specifically, a type of neuropathic pain. It occurs when a spinal nerve root is irritated, inflamed, or compressed, causing ectopic electrical discharges to fire along the nerve. Patients experience this as a sharp, shooting, burning, or electric-shock-like sensation that travels along a specific dermatomal path (such as down the leg in sciatica or down the arm from the neck). Crucially, radicular pain is merely an expression of distress; a person can experience this distinct pain while their nerve is still fundamentally conducting signals normally.
A huge red flag would be changes in bowel or bladder habits, saddle anesthesia, progressive weakness, gait deterioration, fever, weight loss, or history of cancer. A thorough, comprehensive physical examination needs to be provided. Without a thorough examination, it may be difficult to determine whether the diagnosis is adequately supported.
Next, the effort put forth by the individual needs to be assessed, and this would include a noted “give-way” weakness. These findings should be present on repeat examinations and in the same severity. Again, the finding should be in a specific dermatomal distribution and the presence of symptoms in a non-dermatomal distribution argues against a diagnosis of radiculopathy.
Evaluating Imaging and Electrodiagnostic in the Claim File
If after completing appropriate diagnostic imaging studies, such as MRI, a detailed neurologic examination should be obtained in order to differentiate between the reported symptoms and actual diagnosis. Beyond that, electrodiagnostic testing continues to be an alternative. With respect to electrodiagnostic testing, timing matters. Electrodiagnostic testing has limitations early after injury. Objective changes may not appear for several weeks, which makes test timing an important consideration when evaluating the results. This piece adds to the determination of connection to the noted event. MRI findings should distinguish acute pathology from age-related degenerative change whenever possible. The imaging findings should also correlate with the patient’s symptoms and examination findings.
The needle electromyography is the diagnostic component. Nerve conduction studies do not diagnose radiculopathy. What these nerve conduction studies do is exclude a peripheral nerve entrapment or polyneuropathy, which is significantly different than a diagnosis of radiculopathy.
The Mechanism of Injury Must Support the Diagnosis
At this point, the single most important aspect is that there needs to be a marriage between the noted symptomology, the reported mechanism of injury, and the physical examination that encompasses each of specific details as outlined above. An individual with numbness in the L5 distribution, a weakness to great toe extension, and an MRI documenting nerve root compression at the L4/L5 level makes a very credible case for a true, verifiable radiculopathy. This scenario is far beyond the simple complaints of leg pain. Objective findings are significant, as they can be verified.
Avoiding Common Pitfalls
The more common pitfalls for accepting a diagnosis of radiculopathy, is that when the assessment is made based on:
- Radiating pain alone
- Numbness without specific sensory loss in a dermatomal fashion
- A reported “positive” straight leg raise without any neurologic deficits.
- MRI findings do not correlate with the symptoms presented.
It is well documented that many adults have disc bulges and multiple level degenerative changes noted on diagnostic imaging studies. However, this pathology does not always correlate with the clinical presentation made. To be clear, the straight leg raise test is a provocative maneuver of neural tension but is not a specific identifier of neurologic deficit. A crossed straight leg raise is more specific and would add to the diagnostic rationale.
How Objective Medical Findings Prevent Claim Creep
A common pattern in workers’ compensation is diagnostic drift (aka claim creep). A lumbar strain becomes lumbar strain with radiculopathy. Several visits later it becomes a disc herniation with radiculopathy. Each change in diagnosis should be supported by new objective findings. When the diagnosis changes but the examination does not, the claim professional should ask what new evidence supports the upgrade.
As such, adding this diagnosis to the problem list can significantly impact claims. This diagnosis can become expensive, particularly in terms of excessive treatment, surgical interventions addressing unrelated comorbidities, elevating impairment ratings, and the overall compensability debate. Any diagnosis that can significantly alter the claim should be supported by objective medical evidence that is independently confirmable by all parties.
Objective Findings Strengthen Claim Determination
To be clear, radiculopathy is a valid diagnosis when based on objective neurologic clinical findings. This is not a description of pain. Only when you have a mechanism of injury that supports this type of injury, tempered by presenting complaints consistent with a diagnosis of radiculopathy, and there are specific physical examination findings as well as changes on diagnostic testing all align; only then is the diagnosis of radiculopathy well supported and based on objective medical evidence.
Four Questions to Ask Before Accepting the Diagnosis
The four questions that need to be resolved prior to accepting this diagnosis would include:
- Does the mechanism support a nerve root injury?
- Is the symptom distribution anatomically consistent?
- Are objective neurologic deficits documented?
- Do the MRI findings match the examination findings?
If any of the answers are no, more investigation is warranted. A diagnosis of radiculopathy should never be accepted simply because pain radiates into an extremity. The diagnosis becomes credible when the mechanism of injury, symptom pattern, objective neurologic findings, and diagnostic testing all point to the same nerve root.
Closing the Claim File: Separating Symptom from Diagnosis
Consequently, prior to accepting a diagnosis of radiculopathy claims professionals should ensure that all relevant clinical information has been obtained and carefully reviewed. Having all the pertinent information for this diagnosis is key to successfully handling this claim file. Radiating pain is a symptom. Radiculopathy is a diagnosis. The diagnosis should be supported by a mechanism capable of producing nerve root injury, objective neurologic findings, and diagnostic studies that point to the same nerve root.
