Differential Diagnosis in Neurology

6.7. Differential Diagnosis of Radiculopathy

Cervical Roots

• Congenital Defects:
  • Abnormalities of odontoid ossification centers (C1–C2)
  • Failure of odontoid tip fusion (C1–C2)
  • Platybasia (C1–C2)
  • Basilar impression (C1–C4)
  • Klippel-Feil Syndrome (C4–C7)
  • Sprengel's deformity with Klippel-Feil (C4–C7)
  • Arnold Chiari Malformation (C1–C3)
  • Roos' cervical bands (C4–T1)
  • Cervical ribs (C8–T1)
  • Perineural cyst (C1–T1; L1–S1)
  • Thoracic outlet syndrome (C4–T1)
  • Branchial cleft cyst (C1–T1)
  • Spinal stenosis (lumbar > cervical > thoracic); L4–L5; C4–C5 often primary level
  • Achondroplasia (all roots); particularly severe C1–C3
  • Free fragment disc (lumbar > cervical; migrates up and down the cord)
• Lax ligament (hypermobility of odontoid process C1–C2 and concomitant cord compression)
  • Rheumatoid arthritis
  • Mongolism
  • Marfan's syndrome
  • Ehlers–Danlos syndrome
  • Type VI collagen defects
  • Trauma (flexion–extension)
• Ligament hypertrophy (of all cervical roots)
  • Acromegaly
  • Mucopolysaccharidoses
  • Posterior ligament ossification syndrome
• Pachymeningitis
  • Syphilis (cervical > lumbar > thoracic)
  • Lymphoma (all roots)
  • Sarcoid (cervical > lumbar > thoracic)
  • Idiopathic pachymeningitis (cervical > lumbar > thoracic)
  • Tuberculosis (cervical > lumbar > thoracic)
  • Subarachnoid hemorrhage (lumbar > cervical > thoracic)
  • Arachnoiditis (lumbar > cervical)
• Degenerative disease
  • Cervical spondylosis (C5–C6; L5–S1 primary levels)
  • Spondylolisthesis
  • Spinal stenosis (L4–L5; L5–S1, primary levels)
  • Disc disease (hard desiccated disc; C5–C6; C6–C7; L4–S1 primary levels)
  • Foraminal exit osteophytes
  • Uncovertebral joint hypertrophy
• Tumor
  • Schwannoma
  • Neurofibroma
  • Meningioma
  • Pancoast (lung apex tumors) (C8–T1 primary level)
  • Lymphoma; lymphomatous B-cell
  • Leukemia
  • Salivary gland (adenocarcinoma)
  • Metastatic (carcinomatosis)
  • Post X-RT of breast (late onset) (C5–C6)
  • Chordoma (cervical C1–C4)
  • Osteogenic sarcoma
  • Ewing's sarcoma
  • Chondrosarcoma
  • Hodgkin's disease (neuromyotonia)
  • Lymphomatous B-cell radiculopathy
• Infection
  • HIV
  • HTLVI
    • mixed HTVI and concomitant HIV infection
  • Herpes zoster
  • Herpes simplex
  • Brucella
  • Lyme's disease
  • Bacterial infection
    • Staphylococcus aureus (IV drug)
    • Gram negative ( post-surgery )
  • Parsonage–Turner syndrome (C5–C6); viral
  • Polio
  • Hepatitis C
  • EBV
  • Adenovirus
• Immune mediated cervical radiculopathy
  • AIDP
  • CIDP
  • Post vaccination
  • Demyelinating (dorsal root entry zone; DREZ)
  • ADEM (Acute Disseminated Encephalomyelitis; overwhelmingly CNS demyelinating rare DREZ)
  • Specific Epitopes:
    • GM1
    • GAL-NAc-GDT1a
    • GQ1b
    • Gd1b
    • SGPG
• Trauma
  • Jumped facet joints
  • Rotary subluxation of facet
  • Disc Disease
  • Burst fracture
  • Anterior compression fraction
  • Spondylolisthesis
  • Plate fixation screw displacement
  • Epidural catheter trauma
  • Avulsion of the nerve root (C5–C6; C8–T1)
• Systemic disease
  • Diabetes
  • Acute intermittent porphyria
  • Variegate porphyria
  • Coproporphyrinuria
  • X-RT (myokymia, atrophy, sensory loss)
  • Idiopathic pachymeningitis
  • Sicca complex
  • Wegener's disease
  • SLE
  • PAN
  • Amyloidosis: FOLMA/FAP-1
  • Necrotizing angiitis
  • Mixed connective tissue disease
  • Severe dying back neuropathies
    • Diabetes mellitus
    • Toxin
    • AIP
    • Severe B vitamin deficiencies
  • Ankylosing spondylitis
  • Hyperparathyroidism

• Vascular disease:
  • AVM of the root
  • Dural AVM
  • Dilated vein compression of the root
  • Klippel–Weber–Trenaunay
• Plasmacytoma
• Paget's Syndrome (sarcoma)
• Immune mediated (similar to cervical root)

Thoracic Roots

• Differential Diagnosis of Thoracic Root Disease
  • Disc disease (nerve root involvement by compression)
  • Trauma (direct nerve injury)
  • Amyloid (Charcot joint; loss of innervation)
  • Diabetes (Charcot joint)
  • Syphilis (Charcot joint)
  • Ochronosis (homogentisic aciduria); multiple levels of degeneration
  • Spondylosis (dissection of disc; nerve root exit foramina compression)
• Infection
  • HZ
  • HIV
  • Bacterial infection (staff aureus)
  • TbC (T12) L1–L2
  • Nocardia
  • Actinomycosis
  • Herpes simplex
  • Surgical disc space infection
  • Epidural abscess
• Trauma
  • Compression fracture
  • Chest surgery (heart, lung)
  • Intercostal neuralgia
  • Jumped facet
  • Rotary subluxation of facet joint
  • Reflex sympathetic dystrophy (CRPS I and II)
    • T1–T4 recurrent nerve of Kuntz
    • Intercostobrachial nerve (derived from the medial cord of brachial plexus)

• Systemic Disease
  • Diabetes
  • Amyloid
  • Sicca complex
  • Epidural hematoma (coagulopathy; anticoagulation)
  • Homogentisic aciduria (ochronosis)
• Tumor
  • Anhidrosis/hyperhidrosis
    • Cancer of the lung
  • Meningioma
  • Neurofibrosis
  • Metastatic
  • Leukemia
  • Carcinomatosis of the meninges
  • Lymphoma
• Immune Mediated
  • CIDP
  • AIDP
  • Radiculopathy with increased sed rate
  • Autoimmune epitopes
    • MAG
    • SGPG
    • Gd1b
    • GQ1b
    • GM
    • Asialo GM1

Lumbosacral Roots

Differential Diagnosis of Lumbosacral Root Disease

• L1–S1 congenital defect
  • Conjoined nerve roots
  • Scoliosis (T12–L1–L3)
  • Block vertebrae (achondroplasia (T12–L1–L2)
  • HSMN-I, II, V (compression of roots)
  • Perineural cysts (all lumbar and sacral roots)
  • Congenital spinal stenosis; short pedicles; trefoil canal
  • Congenital midline/paravertebral dermal sinus (L4–S1)
  • Deep lordotic curve (L4–L5)
  • Meningomyelocele (L5–S1)
  • Diastematomyelia (T10–T12–L1–L2)
  • Reduplicated cord (L1–S5 roots)
  • Achondroplasia (L1–S5)
  • Spondylosis (pars interarticularis defect)
  • Sacral agenesis; caudal regression syndrome (L4–S5)

Degenerative Disease of Lumbar and Sacral Roots

• Disc disease: L4–L5; L5–S1 primarily
  • Free fragment (penetrates posterior longitudinal ligament)
  • Schmorl's nodes (vertebral midline herniation)
  • Far lateral disc (L1–S1)
• Lateral recess syndrome (L5; S1)
• Spinal stenosis (spondylosis, ligament, facet hypertrophy)
• Facet hypertrophy (trophism)
• Synovial cyst of the facet joint
• Osteophyte formation in the foraminal exit canal
• Spondylolisthesis

Bone Tumors of the Lumbosacral Area

• Dermoid
• Lipoma
• Liposarcoma
• Chordoma
• Osteoblastoma
• Giant cell tumor of bone
• Osteosarcoma
• Chondrosarcoma
• Hemangioblastoma
• Hemangioma
• Aneurysmal bone cysts
• Metastatic disease
  • Lung
  • Breast
  • GI
  • Prostate
  • Ovarian
• Endochondroma

Cancer Affecting Lumbosacral Nerve Roots

• Carcinomatosis of the meninges (all cancers)
• Leukemia
• Hodgkin's and non-Hodgkin's lymphoma
• Myxopapillary ependymoma
• Metastases
• Prostate
• Lung
• Ovarian
• GI tract
• Renal carcinoma
• Any solid tumor

Systemic Disease

• Diabetes mellitus:
  • Amyotrophy
  • Vasculitis
• Connective tissue disease (similar to other roots)
• Amyloid
• AIP, variegate porphyria and coproporphyrinuria
• Endometriosis
• Sarcoid

Immune Disease (Similar to Cervical Root Illness)

Toxins/Anesthesia

• Epidural anesthesia (bupivacaine; direct trauma)
• Pantopaque (contrast)
• Metronidazole (contrast)

Trauma Specific to Lumbosacral Nerve Roots

• Surgery to decompress of nerve roots
• Transverse vertebral body displacement (MVA)
• Laparoscopy (higher pelvic roots > L5–S1)
• Instrumentation (plate and pedicle screw placement)
• Obstetrical–Gyn Surgery
• Hip replacement surgery (L4–S1)
• Decompressive laminectomy

Vascular Disease (similar to other roots)

• AVM of the root
• Dural AVM
• Dilated vein compression of the root
• Klippel–Weber–Trenaunay
• Infections (similar to other roots)
  • Cytomegalic virus infection more common in lumbosacral roots (late stage HIV)
  • Brucellosis (L5)
  • Lyme's (L5)

Miscellaneous

• CRPS I
• Pyriformis syndrome (L4–S1)
• Osteomalacia
• Sacrum ala compression
• T1 damage causes Horner's syndrome (C8–T1)
• T2 damage (sympathetic symptoms noted in the upper extremity abnormal sweating, pain, swelling, autonomic dysfunction)

Differential Diagnosis of Cauda Equina Syndrome or Polyradiculopathy

• Spondylosis (multilevel neuroforaminal stenosis)
• Spondylolisthesis (congenital and acquired)
• Disc disease
• Spondylolysis
• Spinal stenosis
• Trauma (falls, skiing accidents, MVA)
• Primary spinal cancer
• Metastatic cancer; dropped metastasis
• Carcinomatosis of the meninges
• Neurofibromatosis "en plaque"
• Bone cysts
• Tarlov (perineural cysts)
• Pathologic fracture
• HIV
• CMV
• HZ; HS
• Lyme's Disease
• Brucellosis
• Mycobacterium
• Syphilis (HIV patient population)
• Complication of spinal anesthesia
• Tethered cord
• Congenital defects
• Arachnoiditis
• CIDP
• HSMN (I/II)