Reflex sympathetic dystrophy syndrome secondary to L5 radiculopathy

A 47-year-old woman developed radiating right lower extremity pain with weakness in the L5 myotomes. A CT scan, subsequent myelogram, and postmyelogram CT scan were reported as negative. Two months of bed rest diminished the radiating symptoms, but the weakness persisted. Three months post onset a severe burning dysesthesia developed in the right foot, and the patient became unable to bear weight on that extremity. Physical examination revealed 4-/5 weakness of the ankle dorsiflexors, foot evertors, toe extensors, and hip abductors. The entire right foot was swollen and had a red, mottled discoloration. An EMG was equivocal, and a three-phase bone scan was positive in the right foot in all three phases, which is characteristic of reflex sympathetic dystrophy. A repeat CT scan and review of the earlier scans revealed a high lateral disc fragment at the exit foramina of the L5 nerve root. Upon laminectomy, a free disc fragment at the exit foramina was removed, and the patient's symptoms resolved completely. Reflex sympathetic dystrophy syndrome is very rarely reported in association with lumbar radiculopathy. This case emphasizes the need to carefully evaluate the far lateral exit foramina on CT scan in patients with symptoms of radiculopathy. Myelogram is characteristically normal in these cases.