What is the next step for a patient presenting with acute radiculopathy and foot drop?

From the Guidelines

The next step for a patient presenting with acute radicular pain and foot drop is to obtain an urgent MRI of the lumbar spine. This imaging is essential to identify the likely cause, which is often a herniated disc compressing the L4-L5 or L5-S1 nerve roots, as suggested by the guidelines from the American College of Physicians and the American Pain Society 1. While arranging the MRI, provide appropriate pain management with NSAIDs such as ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily, and consider a short course of oral steroids like prednisone 20mg daily for 5-7 days to reduce inflammation.

Key Considerations

• Physical examination should include assessment of muscle strength, reflexes, and sensation in the affected leg to document the neurological deficit.
• The foot drop (inability to dorsiflex the foot) represents a significant motor deficit that may require urgent neurosurgical consultation depending on the MRI findings, as prolonged compression can lead to permanent nerve damage, as highlighted in the British Pain Society's pathway for care 1.
• If the MRI confirms significant disc herniation with nerve compression, referral to neurosurgery or spine surgery for possible surgical decompression is warranted, especially with this progressive neurological deficit.
• The urgency of this workup is justified by the need to prevent permanent neurological damage, as foot drop that persists beyond 48-72 hours has a poorer prognosis for complete recovery.

Management Approach

• A stepped care approach has been recommended for radicular pain, based upon a logical progression of ease of administration, severity of symptoms, and known risks and benefits 1.
• Image-guided steroid injections or surgery can be considered, depending on patient choice and clinical appropriateness.
• Patients with less severe radicular pain should be referred to specialist services for assessment and management not later than 3 months (earlier if the pain is severe).

From the Research

Diagnosis and Treatment of Radicular Pain and Foot Drop

• The patient presents with acute radicular pain and foot drop, which can be caused by various factors such as herniation of the nucleus pulposus, spinal stenosis, or degenerative changes to the vertebrae 2.
• Foot drop can be a symptom of many diseases, including injury to the common peroneal nerve, sciatic nerve injury, lumbar plexopathies, L4/L5 radiculopathy, and central nervous system related neuropathies 3, 4.
• A meticulous neurological evaluation is essential to ascertain the site of the lesion, and nerve conduction and electromyographic studies can be useful adjuncts in localising the site of injury 4.
• Imaging studies such as ultrasonography, CT, and MR imaging can help establish the cause of foot drop, whether it be at the level of the spine, along the course of the sciatic nerve, or in the popliteal fossa 4.

Treatment Options

• Treatment options for radicular pain and foot drop can include rest, physical therapy, medications, epidurals, and surgery 2, 5.
• Ankle-foot orthoses (AFO) can be helpful in the treatment of paralyzed extensor muscles of the foot, enabling patients to walk better and more safely 3, 4.
• Surgical treatment should be connected with the etiology of the foot drop and can include neurolysis of the nerve, "end to end" repair, autogenous nerve graft procedures, nerve transfers, direct neuromuscular neurotization, and tendon transfers 3.
• Conservative management, including pharmacologic management, physical and rehabilitation measures, and interventional techniques, can be effective in managing radicular pain, despite surgical management being the gold standard 5, 6.