Differential Diagnosis:

Unilateral:

Mononeuropathy: e.g. Meralgia paresthetica, sciatic or peroneal neuropathy

Lumbosacral radiculopathy

MSK focal

Bilateral:

Polyneuropathy (stocking distribution like a diabetic polyneuropathy)

Polyradiculopathy (Central stenosis – neurogenic claudication)

Thoracic cord lesion (upper motor neuron signs)

Multifocal MSK

HISTORY:

• Pain history: back, buttock, leg – distribution, aggravating, relieving
• Paresthesia:
  • Are upper extremities involved?
  • Are legs symmetric or is one side worse than the other?
  • Saddle symptoms: numbness, tingling, burning in genitalia or anal area
• Are pain or paresthesias worse with walking? Better with leaning forward (shopping cart sign)
• Bowel/Bladder changes:
  • Bowel severe constipation; urgency/incontinence
  • Bladder: poor stream, hesitancy, frequency, incontinence
• Gait/Balance
• Previous investigations: MRI, CT spine; neuropathy bloodwork

PHYSICAL EXAMINATION:

• Reflexes upper and lower limbs
• Ankle clonus/Plantar responses (especially if brisk reflexes)
• Vibration sense at first MTP joint
• Proprioception at first MTP joint
• Pin Sensation: L2-S1 dermatomes, sensory gradient (stocking loss)
• Power:
  • Hip flexion, abduction
  • Knee extension; squats
  • Knee flexion
  • Plantarflexion: toe walk; single leg heel raises
  • Ankle dorsiflexion, inversion, eversion
  • Toe flexion/extension
• Straight leg raise/forward slump test to reproduce leg symptoms
• MSK examination – focused depending on complaints