Differential Diagnosis for Radiculopathy

Primary Differential Considerations

The American College of Radiology recommends distinguishing true nerve root compression from plexopathy, peripheral nerve entrapment, and referred somatic pain, as these conditions present with overlapping symptoms but require fundamentally different management approaches 1

Herniated disc with nerve root impingement is the most common cause of true radiculopathy, presenting with dermatomal pain, sensory loss, and motor weakness in a specific nerve root distribution, as reported by the Journal of the American College of Radiology 2, 3
Cervical or lumbar spondylosis with foraminal stenosis from osteophytes or facet arthropathy causes progressive radicular symptoms, according to the Journal of the American College of Radiology 3
Spinal stenosis produces multilevel radiculopathy, particularly in the lumbar spine, with neurogenic claudication, as noted by the Annals of Internal Medicine 5

Brachial plexopathy presents with pain and weakness in multiple peripheral nerve distributions, distinguishing it from cervical radiculopathy, as reported by the Journal of the American College of Radiology 1
Lumbosacral plexopathy causes symptoms in multiple nerve territories, not confined to single nerve root distribution, according to the Journal of the American College of Radiology 1

Vertebral osteomyelitis or discitis presents with fever, elevated ESR/CRP, and history of IV drug use or immunosuppression, as reported by Praxis Medical Insights 4, 8
Epidural abscess causes progressive neurologic deficits with constitutional symptoms and requires emergency MRI, according to the Journal of the American College of Radiology 2, 3
Metastatic disease to spine presents with intractable pain, constitutional symptoms, and history of malignancy, as noted by the Journal of the American College of Radiology 3, 4

The American College of Radiology recommends immediately obtaining MRI if any red flags are present, including constitutional symptoms, elevated inflammatory markers, history of malignancy or immunosuppression, IV drug use, progressive or severe neurologic deficits, intractable pain, or vertebral body tenderness on palpation 2, 3, 4
For acute symptoms without red flags, no imaging is initially recommended, with reassessment at 6-8 weeks, as reported by Praxis Medical Insights 7
For chronic symptoms or consideration for intervention, MRI without contrast is the preferred initial imaging modality, according to the Journal of the American College of Radiology 2, 3

Do not assume degenerative changes on imaging are causative without clinical correlation, as spondylotic changes are present in 85% of asymptomatic individuals over 30 years, as noted by Praxis Medical Insights 4
Do not miss myelopathy masquerading as radiculopathy, always testing for hyperreflexia, Babinski sign, and gait disturbance, according to the Journal of the American College of Radiology 6, 3