L 4 radiculopathy

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  • SHuck
    Participant
    Post count: 3
    #26290 |

    Dear Dr Corenman,
    I am a British retired GP. 8 weeks ago I developed an L 4/5 disc lesion with a small sequestrated nodule impinging my left L 4 nerve root on MRI scan.I had horrible L anterior thigh and shin pain for several weeks- now settling to occasional twinges. I have had no paraesthesia or numbness. I have had fasciculations in my L quadriceps which are ongoing but less than 6 weeks ago. Last week I noticed L quadriceps wasting and on now starting to mobilise realise that I have L quadriceps weakness and mild foot slap on walking more than a few 100 yards. In addition after walking a mile or so my L leg feels a bit unstable and weak. I am a very keen mountain walker and road and mountain biker and I am now very worried.
    I suspect I need a microdiscectomy to relieve the nerve root. If my pain is so much better is it likely that I will still have nerve root pressure that might cause further nerve loss and subsequent muscle weakness? Would a conservative approach be a reasonable option at this stage? What do you feel my chances are of a good recovery here that might allow me to cycle and walk strongly again? I realise from reading your information pages that any tibialis anterior problem is likely to be permanent.
    Many thanks.

    Dr. Corenman
    Moderator
    Post count: 5383

    An L4-5 disc herniation that compresses the left L4 nerve root is a far lateral herniation. 95% are in the canal as a posterolateral hernation compressing the L5 root and only 5% are in the far-lateral position compressing the L4 root. The L4 root is more sensitive to compression than the L5 root and typically innervates the quadriceps muscle (but can innervate the tibialis anterior too). Your complaint of quad weakness with foot drop fits this nerve perfectly.

    Faciculations of the quad muscle typically occur as the first signs of denervation. The progression is fasciculation, wasting and weakness. There are times that pain is not present with compression and times that the nerve is so compressed that the nociceptors are dysfunctional and the condition is painless. There is a condition called Parsonage-Turner syndrome (that normally occurs in the shoulder but I have seen occur in the leg rarely) that could explain your weakness but if you have a documented far-lateral herniation, most likely this is the cause of weakness.

    It is my practice to decompress the nerve in the face of motor weakness within a week (or sooner)> I am completing a study on timing of weakness and decompression and it seems that the sooner surgical decompression occurs, the better the outcome. See https://neckandback.com/conditions/how-muscles-recover-from-nerve-injuries/ and https://neckandback.com/conditions/parsonage-turner-syndrome-neck/.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
    If this forum has helped you, please let Dr. Corenman know!

    SHuck
    Participant
    Post count: 3

    Dear Dr Corenman,
    Thankyou for your advice for which I am very grateful. Might I ask whether with your experience you feel it possible in my case that nerve decompression at this stage could lead to a recovery that might allow me to walk and ride strongly again. Also is it possible that my quadriceps weakness will only ever be partial because L3 might also be innervating my quads allowing some substantial function to remain. I can still climb and descend stairs etc.
    Apologies for multiple questions.
    With many thanks.

    Dr. Corenman
    Moderator
    Post count: 5383

    It has been my experience the recovery can still be possible. There are patients who do recover without surgery but I think that surgery doubles the chances of root recovery. Yes, L3 also innervates the quad so you would not have complete failure. You can test the quad by doing one-legged squats on the affected side. Crouch as far as you can and try to raise up repeatedly without help (but keep a hand on a counter surface as to prevent leg collapse). If you can raise up without help multiple times, your quad is not too bad.

    The descent of stairs requires eccentric contraction of the weakened quad and is the toughest maneuver of this muscle. If that descent onto the weak leg doesn’t require you to hold the hand rail, that is also a good sign.

    Dr. Corenman

    PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
    If this forum has helped you, please let Dr. Corenman know!

    SHuck
    Participant
    Post count: 3

    Dear Dr Corenman,
    At the risk of becoming a nuisance can I ask whether at 8 weeks any nerve injury is likely to be complete or could further damage continue if a conservative approach is taken?
    Also do you know why I have had no altered sensation or numbness. I foolishly took this as a reassuring sign and was shocked to find my quad wasted.

    PS your information pages on spinal problems are the most informative I have ever read and I wish I had known of them as a practising GP.

    With many thanks again.

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