bilateral radicular pain?

[cbrons]

How common is it for general practice neurologists to see young people with a sole complaint of bilateral radicular pain? I'm talking about the 18-35 year old range... Have you seen this and where do you usually start with them - assuming there are no other symptoms other than "I have radiating pain on both sides of my body, upper and lower extremities."

I would think that very, very few things would cause this specific type of pain bilaterally, and the only thing I can think of would be cervical radiculopathy but to be honest I am simply unsure.

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[neurologist]

That's a pretty unusual presentation, but as always, the devil is in the details
Would start w/ that often-overlooked test, the history-and-exam-o-gram. Especially tempo of symptoms (duration of symptoms? started all at once everywhere? started in one limb and then spread? etc). Strength? Atrophy? Sensory changes? Coordination? Reflexes?
If exam all stone cold normal, and history not making sense, would have rather lower suspicion at least for anything life-or-limb threatening.
MRI of cervical and lumbar spines to look for diffuse anatomic changes (would get both w/ and w/o contrast to assess for any nerve root enhancement, since this is apparently such a diffuse process, it could be infectious/inflammatory).
I guess there is a small chance it could be purely a c-spine issue, but would expect to see some myelopathic changes on exam as well if that were the case.
If imaging unrevealing, could consider EMG and/or LP to look for evidence of diffuse radiculitis or peripheral neuropathies of autoimmune or infectious etiology (yes, this REALLY COULD BE Lyme disease . . . ).
If all normal, refer to Big Academic Medical Center.

 

[cbrons]

That's a pretty unusual presentation, but as always, the devil is in the details
Would start w/ that often-overlooked test, the history-and-exam-o-gram. Especially tempo of symptoms (duration of symptoms? started all at once everywhere? started in one limb and then spread? etc). Strength? Atrophy? Sensory changes? Coordination? Reflexes?
If exam all stone cold normal, and history not making sense, would have rather lower suspicion at least for anything life-or-limb threatening.
MRI of cervical and lumbar spines to look for diffuse anatomic changes (would get both w/ and w/o contrast to assess for any nerve root enhancement, since this is apparently such a diffuse process, it could be infectious/inflammatory).
I guess there is a small chance it could be purely a c-spine issue, but would expect to see some myelopathic changes on exam as well if that were the case.
If imaging unrevealing, could consider EMG and/or LP to look for evidence of diffuse radiculitis or peripheral neuropathies of autoimmune or infectious etiology (yes, this REALLY COULD BE Lyme disease . . . ).
If all normal, refer to Big Academic Medical Center.

Strength normal, no atrophy, no sensory changes, coordination and reflexes appear totally normal. Apparently this started all at once (and everywhere), and gets worse at night, is better with NSAIDs. Lasted ~1week, not any better and not any worse over that period.

Lyme titer negative, but maybe C6LPE ELISA should be done next. Again its a 25 year old, but

 

[cbest]

Is the radicular pain in any particular dermatomal distribution in any of the extremities? How distally does the patient's pain radiate? Any secondary gain issues?

 

[neurologist]

Is this really "pain" or is it more "paresthesias/weird discomfort"?
I ask b/c of the "gets worse at night" comment, and I've had a few patients who basically have what seems to be a whole-body variant of restless leg that actually responded really well to some mirapex.

 

[cbrons]

Is the radicular pain in any particular dermatomal distribution in any of the extremities? How distally does the patient's pain radiate? Any secondary gain issues?

No, it appears to be in the upper and low extremity and shifts around. Sharp, radiating ("lancing") pain. Elbow to face, calf to hip seem to be 2 of the more popular ones. I apologize if I am not describing adequately, just a medical student trying to learn.

Secondary gain issues I do not think so, its a law student who studies all of the time, he seems like he is mildly paranoid he has a serious illness and its affecting his ability to concentrate on his studies.

 

[cbrons]

Is this really "pain" or is it more "paresthesias/weird discomfort"?
I ask b/c of the "gets worse at night" comment, and I've had a few patients who basically have what seems to be a whole-body variant of restless leg that actually responded really well to some mirapex.

It's being described quite specifically as painful and radiating.

I had a thought that it might potentially be related to the fact that he studies for long periods of time. When we asked him what that was like, he told the attending that he "splays" himself out on the couch, sometimes at odd angles for long periods of time. He came into the office with a printed sheet of symptoms, including the fact that he has a cat (apparently did some webmd searches and found certain parasitic infections can nerve pain). At any rate, I immediately thought the way he described his posture was similar to me in early med school, you know you just lose track of time in a weird position and maybe you entrap a nerve. A girl in my class got sciatica from the way she sat on her leg at the library for long periods of time. But anyway, sorry for the digression.

The reason this intrigues me is because I just simply did not think very many things at all can cause bilateral radicular quality pain. In fact, I thought the list of potential causes for that specific type and distribution of pain is very limited. But, I believe I could be wrong so I thought this would be a good place to ask.

 

[soulofmpatel]

"history-and-exam-o-gram"

-This would be my recommendation as well

 

[TUGM]

Any imaging been done on this guy? Any ocular dysfunction? CSF testing for oligoclonal bands? Jumping to big guns but I'm always on the look out for MS for some reason lol. If the history-and-exam-o-gram is inconclusive, then MRI!

Also does he sleep on a particular side at night? Maybe compression leading to ischemia or radiculopathy? Is he an athlete?