Clinical Neurology and Neurosurgery 117 (2014) 33–39

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Clinical Neurology and Neurosurgery

journal homepage: www.elsevier.com/locate/clineuro

Review

Foot drop resulting from degenerative lumbar spinal diseases: Clinical

characteristics and prognosis
Yue Wang a,∗ , Andrew Nataraj b
a
Spine Lab, Department of Orthopedic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, PR China
b
Division of Neurosurgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Foot drop is a condition that can substantially add to the disability of patients with degenerative lumbar
Received 28 April 2013 spinal disorders. The most common degenerative conditions associated with foot drop are lumbar disc
Received in revised form herniation and lumbar spinal stenosis. The level most commonly affected is the L4/5 spinal level. Most
22 November 2013
patients are treated with surgery, although there is insufficient evidence to support that surgery is supe-
Accepted 28 November 2013
rior to conservative therapy. In most surgical patients, foot dorsiflexion will improve to some degree. The
Available online 6 December 2013
preoperative power of foot dorsiflexion is the key factor associated with prognosis.
© 2013 Elsevier B.V. All rights reserved.
Keywords:
Foot drop
Lumbar degenerative diseases
Lumbar disc herniation
Lumbar spinal stenosis
Prognosis

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2. Relevant anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3. Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4. Differential diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
5. Associated degenerative lumbar diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
6. Clinical presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7. Imaging and investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
8. Involved spinal level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
9. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
10. Prognosis and associated factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
11. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1. Introduction
Abbreviations: MMT, manual muscle test; EMG, electromyography.
∗ Corresponding author. Tel.: +86 571 87236128; fax: +86 571 87236626. Foot drop, typically defined as significant weakness of ankle and
E-mail addresses: wangyuespine@gmail.com (Y. Wang), toe dorsiflexion, is a prominent presentation of a number of clin-
Andrew.nataraj@albertahealthservices.ca (A. Nataraj). ical disorders. The inability of ankle dorsiflexion and consequent

0303-8467/$ – see front matter © 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.clineuro.2013.11.018
34 Y. Wang, A. Nataraj / Clinical Neurology and Neurosurgery 117 (2014) 33–39
limping gait may lead to multiple falls and injuries, resulting in
substantial impairment of mobility and quality of life. Although
mainly belongs in the domains of neurology or orthopedic surgery,
foot drop due to spinal disorders is not rare in spine clinics. Various
disorders at different segments of the spine may lead to foot drop.
Among the numerous spinal causes of foot drop, the most common
is degenerative lumbar spinal disease.
Foot drop due to degenerative lumbar diseases is an entity sub-
stantially different from that of peripheral neuropathy. Although
case series of foot drop from spinal causes are sporadically reported
in scientific literature, the clinical characteristics, natural history,
treatment, and prognosis are not fully described. The purpose of
this review is to summarize the current knowledge of foot drop
resulting from degenerative lumbar diseases for related clinicians.
2. Relevant anatomy
Nerve roots of the lumbar spine (hereafter referred to as roots)
originating from the lumbosacral enlargement of the spinal cord
descend in the spinal canal. By passing through the intervertebral
foramina, the nerves depart the canal and merge in the anterior
paraspinal region to form the lumbosacral plexus, in which the
nerve fibers are exchanged and redistributed. As a result, the sciatic
nerve arising from the plexus contains fibers from multiple spinal
nerves. The peroneal/fibular nerve, the terminal continuation of the
lateral trunk of the sciatic nerve, predominantly consists of fibers
from the L5 nerve root, although the presence of fibers from the L4
and S1 roots is also common. The peroneal/fibular nerve innervates
foot evertors (peroneus longus and peroneus brevis) and ankle dor-
siflexors [1]. Among the three ankle dorsiflexors, including tibialis
anterior, extensor hallucis longus, and extensor digitorum longus,
the tibialis anterior is the principal dorsiflexor. Although the L5 root
is the predominant nerve root supply to the peroneal/fibular nerve,
it also has significant supply to the tibial nerve, which is the other
terminal branch of the sciatic nerve. The L5 root, via the tibial nerve,
is also the major innervation to ankle inversion.
3. Definition
Whereas in clinical practice, the term “foot drop” generally
refers to significant weakness of ankle and toe dorsiflexion, in
the literature, the degree of weakness of ankle dorsiflexion varies.
Because this may substantially influence the reported prevalence
and prognosis of foot drop, it is necessary to define foot drop in the
context of the objective severity of muscle weakness [2].
Although foot drop can be classified as complete or partial drop,
a better approach to define foot drop and quantify its degree is to
measure the strength of ankle dorsiflexors using the manual muscle
test (MMT) [3]. Aono and colleagues [4] took both the power of
tibialis anterior and the range of ankle motion into account and
further divided MMT grade 3 into two groups (Table 1). Tibialis
anterior having MMT = 3− was also defined as foot drop because
of the associated stumbling gait [4]. In this current review on foot
drop, we have included studies measuring ankle dorsiflexion power
at MMT grade 3 or less.
4. Differential diagnosis
Foot drop is a common symptom of a variety of disorders. The-
oretically, all pathologies affecting the neurological structures that
are involved in ankle dorsiflexion, from the brain, spinal cord,
nerve roots, lumbosacral plexus down to the sciatic nerve and per-
oneal/fibular nerve, may lead to foot drop [5]. Therefore, a good
first step is to classify foot drop into peripheral versus central eti-
ologies. Although involvement of the upper motor neurons in the
Table 1
A scale using manual muscle test (MMT) of tibialis anterior and ankle motion to
define foot drop [4].
Grade Description
0 No contraction of tibialis anterior
1 Slight contraction of tibialis anterior is observed, but no joint
motion of ankle
2 Patient can invert and dorsiflex ankle with gravity eliminated
through full range of motion
3− Patient can dorsiflex and invert ankle against gravity through
partial range of motion
3 Patient can dorsiflex and invert ankle against gravity through
full range of motion
4 Patient can dorsiflex and invert ankle against gravity and
moderate resistance
5 Patient can dorsiflex and invert ankle against gravity and full
resistance
brain and spinal cord leading to foot drop is relatively uncommon,
it can occur in a diverse variety of conditions, including tumor [6],
trauma [7], cervical or thoracic disc herniation [6–9], and inflam-
matory diseases such as multiple sclerosis [10]. Medical history,
positive neurological findings of the upper motor neuron involve-
ment, and other associated symptoms are helpful in identifying a
central lesion.
For lower motor neuron lesions, it is important, as a next step,
to differentiate between a peripheral neuropathy and radiculopa-
thy from spinal causes. Peripheral neuropathies, such as sciatic
or peroneal neuropathy [2,11], are the most common causes of
foot drop. Etiologies include trauma, external compression, nerve
entrapment, infection, mass/tumor, and iatrogenic factors [5]. On
physical examination, testing ankle inversion is an important way
to determine whether foot drop is due to peroneal neuropathy or
L5 radiculopathy. Tibialis posterior, a foot inverter, is innervated
by the same roots as the tibialis anterior (L4, 5) but via the tibial
nerve. Therefore, an acute peroneal neuropathy does not typically
have foot inversion weakness, whereas an L5 radiculopathy does.
Important exceptions can include systematic disturbances, such as
diabetes mellitus [12] and weight loss [13], that may cause both
peroneal neuropathy and foot drop. Occasionally, the cause of per-
oneal neuropathy is unremarkable external pressure associated
with crossing leg or improper posture [5].
There are other associated symptoms that may help in charac-
terizing foot drop due to lumbar degenerative disease. If foot drop
occurs in the context of a radiculopathy, it is usually accompa-
nied by significant pain and numbness along the L5 dermatome.
If it occurs as part of neurogenic claudication and spinal steno-
sis, it is usually accompanied by symptoms of walking-induced leg
cramping and numbness.
Occasionally, differentiating foot drop due to peripheral neu-
ropathy from that due to lumbar disease can be challenging,
especially in elderly patients. Electrodiagnostic examination is of
essential value in the differential diagnosis where the clinical pic-
ture is uncertain. In Fig. 1, we have summarized a flow of clinical
tests used and possible findings helpful in differentiating foot drop
due to lumbar degenerative conditions from that due to peroneal
neuropathy.
5. Associated degenerative lumbar diseases
Disc herniation and spinal canal stenosis are the two most com-
mon degenerative lumbar conditions that can cause foot drop. In a
report of 46 cases of foot drop related to lumbar disease, 52% was
due to disc herniation, and 35% due to spinal stenosis [4]. In two
case series, 57% of patients with foot drop had lumbar disc hernia-
tion, and the remaining had lumbar spinal stenosis [14,15]. When
foot drop is due to lumbar spinal stenosis, radiological signs of
 Y. Wang, A. Nataraj / Clinical Neurology and Neurosurgery 117 (2014) 33–39
Weight loss
Diabetes
Trauma
External pressure
Specific aggravating postures: leg
crossing, squatting, kneeling
History of surgery
Physical examination
Tinel’s sign (+) at fibular neck
Weakness restricted to ankle and
toe dorsiflexion and ankle eversion
Normal ankle inversion
Normal knee and ankle reflexes
Conduction abnormalities at the
level of the fibular neck
Electromyographic abnormalities
restricted to muscles supplied by
peroneal nerve
Due to peroneal neuropathy
Fig. 1. Differential diagnosis for foot drop due to degenerative lumbar spinal disorders and peroneal neuropathy.
stenosis may be identified typically in both the central canal and the
lateral recess [16]. Spondylolysis or spondylolisthesis is a less com-
mon cause of foot drop [4,16]. Other degenerative spinal causes of
foot drop include hematoma [17] and ossification [18] of the lum-
bar ligamentum flavum, lumbar cyst [19] and facet joint cyst [20],
epidural vein thrombosis [21], and even postoperative gas bubbles
[22]. However, foot drop due to these causes is rare.
The frequency of motor deficits or foot drop is typically reported
as the occurrence rate in surgically treated patients. Mild paresis of
foot dorsiflexors is very common in lumbar disc herniation, occur-
ring in approximately 50% of surgical cases [23,24]. The presence
of dorsiflexion weakness, with or without impairment of the ankle
reflex, was reported to be 47.5% in a large series of 2504 cases of
lumbar disc herniation [25]. A similar rate (47.8%) of extensor hallu-
cis longus weakness was observed in another study [26]. However,
an early study reported that motor deficits were found in as high
as 80% of surgically treated patients with disc herniation [27].
The precise incidence foot drop in patients with lumbar disc her-
niation remains unknown and depends upon the group of patients
studied. Complete paralysis or a severe motor deficit of ankle dor-
siflexion has been estimated to be present in 4.4–6.4% of surgical
candidates with lumbar disc herniation [26–28]. In one series of 984
surgical cases of disc herniation, preoperative foot drop, defined
as foot and toe dorsiflexion with MMT ≤ 2, was presented in 83
cases (8%) [29]. Similarly, a preoperative L5 nerve root motor deficit
(MMT ≤ 2) was presented in 8.4% of 416 patients who were treated
surgically for nerve root compression [15]. The highest occurrence
rate was reported in a classic study of foot drop due to disc her-
niation, with complete foot extensor paralysis identified in 17.5%
(65/372) of surgical patients [30]. However, one should keep in
mind that prevalence rate highly depends on the spectrum of
patients selected for surgery.
Similarly, mild or moderate leg weakness is a very common
complaint and finding in patients with degenerative lumbar spinal
stenosis. According to a meta-analysis, objective muscle weakness
35
Foot drop
Medical history or
Low back pain
clinical presentation
Radicular leg pain
Neurogenic claudication
Occasionally painless
Tinel’s sign (-) at fibular neck
Weakness of ankle inversion
Weakened quadriceps, hamstrings,
and plantar flexors, diminished or
absent knee and ankle reflexes, if
multiple nerve roots are involved
Electromyography
Changes of one or multiple nerve
roots lesions
Lumbar spine MRI
Significant degenerative findings,
such as disc herniation and spinal
canal stenosis
Due to degenerative lumbar spinal
disorders
was found in approximately 44% of patients with lumbar steno-
sis [31]. Although spinal stenosis usually affects the L4–S1 levels,
extensor hallucis longus weakness associated with L5 nerve root
compression is the most common type of motor deficit. How-
ever, the occurrence of severe motor deficits, such as foot drop, in
patients with lumbar spinal stenosis is not common. According to
Guigui’s review, the overall incidence of ankle dorsiflexion weak-
ness (MMT ≤ 3) in lumbar stenosis reportedly varies from 5% to 12%
[16].
6. Clinical presentations
The patients’ demographic characteristics are related to the
underlying lumbar conditions. For example, most patients with foot
drop due to disc herniation are between 30 and 60 years old, and
male patients are more common than female ones [30]. In patients
with lumbar stenosis, most patients are 50 years or older, and foot
drop equally occurs in men and women [14,16].
The onset of foot drop can either be acute or progressive [16,30].
Although typically, patients have signs of foot weakness for a few
days or weeks prior to overt foot drop, the onset of foot drop varies
quite dramatically. It may occur suddenly [16,17,19,32] enough to
drive the patient to seek emergency consultation, or it may develop
insidiously that the patient does not even recognize foot drop until
falls occur [5]. Although patients with disc herniation tend to have
an acute onset of foot drop, most patients with lumbar stenosis typ-
ically have a slowly progressive course [16,30]. Also, the insidious
pattern is more common in older patients whose general mobility
has already decreased [5].
In most cases, foot drop caused by degenerative lumbar disor-
ders occurs unilaterally. Yet, bilateral foot drop is not uncommon,
particularly in patients with lumbar spinal stenosis [16,32]. For
example, in Guigui’s report of foot drop due to lumbar stenosis,
approximately a quarter of patients presented with bilateral foot
36 Y. Wang, A. Nataraj / Clinical Neurology and Neurosurgery 117 (2014) 33–39
drop, although the degree of paresis did differ between two sides
[16].
Symptoms of disc herniation and lumbar spinal stenosis, such
as low back pain, “heavy legs,” radiculopathy, neurogenic claudi-
cation, and sensory changes, usually present prior to foot drop.
Occasionally, the pain in the back and leg has ceased by the time
the patients visit a physician [16]. In rare cases, pain was absent
during the whole process [33]. Numbness and paresthesias along
the dermatomes of involved nerve roots are frequent symptoms.
Foot inversion and eversion weakness usually occurs along with
the foot drop because the tibialis posterior and the peronus longus
are also innervated by L5 nerve roots via the tibial nerve and per-
oneal/fibular nerve, respectively. In the case of complex spinal
stenosis, weakness of toe flexion, ankle plantar flexion, knee flex-
ion, and diminished or absent knee and ankle reflexes may also be
noticed.
7. Imaging and investigations
When foot drop is suspected to be a symptom of degenerative
lumbar disease, radiological studies are indicated. Magnetic reso-
nance is the best modality to confirm the lumbar pathology and its
degree. Flexion and extension lumbar radiographies can be help-
ful in understanding the stability of the lumbar spine. Computed
tomography and myelography are useful but less used.
The electrodiagnostic examination, including electromyogra-
phy (EMG) and nerve conduction studies, is a valuable extension of
the subjective neurologic examination for patients with foot drop.
These techniques are helpful in differentiating foot drop of spinal
causes from peripheral and can further localize involved spinal
levels [2,11]. In addition, the quantitative measurements acquired
provide an objective understanding of the severity of nerve insult,
which are essential in predicting recovery [5]. However, such inves-
tigations are not always performed in the evaluation of patients
with foot drop. None of the case series we reviewed performed
EMG studies. In a focused study of motor deficits resulting from
disc herniation, EMG was performed only in some patients [28].
In fact, the absence of EMG examination raises the doubt on the
causal relation between lumbar disorders and foot drop in some
early reports, such as foot drop occurring after hip arthroplasty [34]
or foot drop thought to be resulting from disc herniation but was
not confirmed during surgical exploration [30]. Therefore, a com-
prehensive electrodiagnostic study can be important in managing
foot drop resulting from lumbar pathologies.
8. Involved spinal level
Foot drop may result from the compression of a single nerve
root. Regardless of related lumbar pathologies, the L4/5 segment
(L5 root) is the most common involved spinal level causing foot
drop, followed by the L5/S1 segment (S1 root or L5 root in the case
of lateral disc herniations or foraminal stenosis) (Table 2). Patholo-
gies at L3/4 level or above occasionally lead to foot drop [14,20].
Lesions in the thoracolumbar junction, such as upper lumbar disc
herniation and ossification of the ligamentum flavum, may com-
press the caudal spinal cord and lead to foot drop [7,9]. Although
foot drop typically presents as a result of monoradiculopathy in
lumbar disc herniation [14], the involvement of multiple spinal lev-
els is common in spinal stenosis. Guigui reported that 64% of foot
drop patients due to lumbar spinal stenosis involved two or more
spinal levels [16]. In another case series, stenosis of multiple levels
including L4/5 was present in 75% of patients with foot drop [14].
However, it is occasionally difficult to precisely localize the
spinal segment leading to foot drop. The lumbosacral nerve roots
travel a long course in the spinal canal and may be compressed
anywhere in their passageway. For example, both foraminal steno-
sis of the L4/5 level and a far lateral disc herniation at L5/S1 level
can affect the L5 root. Moreover, a lesion in a narrowed canal may
result in the compression of multiple or bilateral roots. In addi-
tion, although the foot dorsiflexors are typically innervated by the
L5 nerve root, there may be considerable variation, adding to the
difficulty of localization [35].
Segmental motor overlaps and anatomical variations are two
other factors that may explain a nerve root other than L5 caus-
ing foot drop. Segmental overlap refers to a common phenomenon
where fibers from multiple segmental roots innervate a muscle
together. In the lower extremity, most muscles have dual innerva-
tion, with one nerve root being dominant [35]. For example, tibialis
anterior and extensor hallucis longus are found to be innervated by
the L5 root in 90% of cases and the remaining 10% by the S1 root [35].
In addition, there are nerve root variations [36], such as intradural
or extradural anastomosis and divisions [37], in a considerable per-
centage of patients, complicating the relation of the involved spinal
level and foot drop.
9. Treatment
Patients with foot drop, regardless of the cause, may benefit
from wearing a foot orthosis to aid in walking and avoid falling
[5]. Some orthoses are light and small and can fit inside the shoes
to minimize inconvenience. Therefore, patients should be well
informed on the use of ankle orthosis.
To date, because of the rarity, no clinical trial has specifically
examined the efficacy of surgery in treating foot drop due to degen-
erative lumbar diseases. Foot drop seems to be typically viewed as
a sign of seriousness of underlying lumbar pathologies, and almost
all the reported cases were surgically treated (Table 2). As a result,
sound evidence supporting surgical or nonsurgical treatments of
foot drop is absent.
Although there is no specific study regarding the nonsurgical
treatment of foot drop due to lumbar spinal disease, one can refer
to the treatment and outcome of motor deficits due to lumbar dis-
orders in general. Despite nonsurgical approaches such as muscle
relaxants, spinal manipulation, physiotherapy, and epidural steroid
injection are widely used in managing radiculopathy, and none of
them was found to be effective in treating radicular weakness [38].
In an early retrospective study of 549 sciatica patients, complete or
partial recovery of paresis occurred approximately equivalently in
surgical and conservative patients after 7 years [23]. With relatively
accurate muscle power measurements, Weber et al. also reported
that muscular paresis due to disc herniation did not recover better
after surgery than after conservative treatment at 1 year follow-up
[39]. The finding that the recovery of muscle strength in disco-
genic paresis was not related to the treatment approach was further
confirmed in a later study [40] and by others [41]. Recently, a
small randomized controlled trial study added new evidence to
the absence of superiority of surgery over conservative therapy in
treating motor deficits resulting from disc herniation [42]. There-
fore, Sharma et al. concluded in a comprehensive review that there
is a lack of evidence to support that surgical treatment improves
the recovery of radicular weakness in patients with lumbar disc
herniation and spinal stenosis [38].
Therefore, surgical decision making should be based on the over-
all evaluation of the lumbar degenerative disease and not solely on
foot drop. Other clinical findings, such as radiculopathy and neuro-
genic claudication, might be stronger surgical indicators than foot
drop. When back and leg pain are absent and foot drop presents
as the only primary symptom, whether surgery is a good choice
remains unknown. According to Aono, however, 5 of 8 painless foot
drop patients made a full recovery after surgery, and this recovery
 Y. Wang, A. Nataraj / Clinical Neurology and Neurosurgery 117 (2014) 33–39 37

Table 2
Studies of foot drop resulting from degenerative lumbar diseases (MMT: manual muscle test).

Author & year Number of Definition of foot Associated lumbar Involved spine Treatment Prognosis Prognostic factor
cases drop diseases level for recovery

Andersson and 65 Complete foot Disc herniation 64% at L4/5; 35% at Surgery 34.5% cured; 16.4% The onset pattern,
Carlsson (1966) extensor paralysis L5/S1 improved; 49% did duration of foot
[30] not improve; at 1 drop, herniation
year follow up type and patient’s
age were not
related to recovery
Yamomoto et al. 19 Tibialis anterior Disc herniation and 53% at L4/5; 26% at Surgery 68% had a good or Female, severe leg
(1987) MMT ≤ 3 others multiple levels excellent recovery; pain, complete
21% did not change paresis and
multiple roots
involvement are
risk factors for poor
recovery
Davis (1994) [29] 83 Foot and toe Disc herniation 50% at L4/5 Surgery 91.5% of cases Foot drop duration
dorsiflexion recovered is not associated
MMT ≤ 2 with recovery
Jonsson and 35 Extensor hallucis Disc herniation and Not mentioned Surgery The major Foot drop due to
Stromqvist (1995) longus MMT ≤ 2 lumbar spinal improvement disc herniation
[15] stenosis occurs during the recovers better
first 4 months. 75% than that due to
of disc herniation stenosis; lateral
patients and 53% of stenosis recover
stenosis patients better than central
improved to some stenosis
extent after 2 years
Guigui et al. (1998) 46 Extensor hallucis Lumbar stenosis Most at L4/5, 72% Surgery 32.6% complete <65 years, initial
[16] longus MMT ≤ 3 and of cases involved recovery; 54% motor weakness,
spondylolisthesis, multiple levels partial recovery; one level
46% of cases 21.7% remained involvement, <6
observed disc unchanged weeks duration,
herniation in and association
surgery with disc
herniation were
favorable factors
for recovery
Postacchini et al. 35 Tibialis anterior or Disc herniation Most at L4/5, some Surgery 61% of those with a Sex, smoking,
(2002) [28] extensor hallucis at L5/S1 severe deficit had a herniation type,
longus MMT ≤ 3 full recovery comorbid diseases
were not related to
recovery. Greater
initial MMT
associated with
better recovery
Aono et al. (2007) 46 Tibialis anterior 52% of patients Most at L4/5 level, Surgery 61% had some Shorter foot drop
[4] MMT ≤ 3 have disc or an additional degrees of duration and great
herniation; 35% level functional preoperative MMT
have stenosis; and recovery; 30% of are beneficial
others have cases complete factor for recovery
spondylolisthesis recovered; 28% had
no improvement
Ghahreman et al. 37 Ankle dorsiflexion Most disc 73% at L4/5; 20% at Surgery 27% fully Better preoperative
(2009) [20] MMT < 3 herniation L5/S1; 7% at L3/4 recovered; 51% MMT and age <40
improved partially; years associated
21% unchanged with better
recovery; sex and
weakness duration
had no effect on
recovery
Iizuka et al. (2009) 28 Tibialis anterior Disc herniation and 32% at L4/5; 25% at Surgery 75% of disc Greater
[14] MMT ≤ 3 lumbar spinal L5/S1; 32% herniation patients preoperative MMT
stenosis involving multiple recovered in 21 score associated
levels; others at months; 25% of with better
L3/4 level stenosis patients recovery. These
recovered in 18 caused by disc
months follow-up; herniation have a
overall recovery better recovery
rate 54% than caused by
stenosis
38 Y. Wang, A. Nataraj / Clinical Neurology and Neurosurgery 117 (2014) 33–39
rate is not different from that of patients with radicular pain [4]. No
worsening of motor deficits after surgery has been observed [16].
10. Prognosis and associated factors
The prognosis of foot drop related to lumbar degenerative dis-
orders is not well delineated in the scientific literature. Because of
the heterogeneity of underlying lumbar problems, distinct defini-
tions, and different follow-up times, the reported recovery rate of
foot drop varies considerably. Full recovery, typically defined as the
disappearing of foot drop or MMT ≥ 4, was observed in 27–61% of
patients after surgery at varying time points of follow-up (Table 2).
There were 16–51% of patients who had a partial recovery or func-
tional recovery. In less than 30% of patients, the muscular power
remained unchanged after surgery, although the highest nonres-
ponse rate was reported to be 49% (Table 2). The best recovery
was reported by Davis [29]. Among his 984 patients with disc her-
niation, 83 (8%) patients had foot drop (foot and toe dorsiflexion
MMT ≤ 2), and only 8% (7/83) of them still had foot drop after 10
years. However, as the study was focused on surgical outcomes of
disc herniation, details of the foot drop patients were not reported.
The outcome of conservative treatments for foot drop remains
unknown.
The recovery of foot drop can occur quickly after surgery,
although progressive recovery was also observed 1 [39] or 2 years
[4,15] after surgery. Ghahreman et al. reported that most significant
improvement of ankle weakness occurs within the first 6 weeks
after surgery and that none of his patients improved substantially
after that [20]. In contrast, Guigui reported that in half of the cases,
the major improvement occurred within 6 months, and additional
improvement could be observed as late as 2 years after surgery
[16]. In Aono’s observation, the shortest recovery time was 6 weeks,
whereas the longest duration was 2 years [4]. It also seemed that
patients with mild motor deficits recovered more quickly than
those with severe motor weakness [28].
The prognostic factors for recovery are the focus of many reports
on this topic. A number of factors, including age, duration of foot
drop, preoperative muscle power, number of involved spinal levels,
and associated lumbar diseases, have been reported to be associ-
ated with the prognosis of foot drop. However, because of small
sample sizes and heterogeneous clinical scenarios, the conclusions
derived must be interpreted cautiously and in conjunction with the
study protocol. We present the associated details and conclusions
in Table 2.
Greater preoperative muscular power has been consistently
observed to be associated with better recovery of motor deficits
and foot drop (Table 2). A focused report demonstrated that 98%
of patients with preoperative MMT ≥ 3 improved and 71% com-
pletely recovered [43]. In another study, whereas 68% of patients
with ankle dorsiflexion of MMT ≥ 3 recovered completely, only 27%
of those with MMT < 3 had full recovery [20]. Weeker preoperative
muscle power as a risk factor for delayed or incomplete recovery of
foot drop has also been emphasized by others [44,45]. For patients
with foot drop, those with MMT 2 or 3 had a higher chance of recov-
ery than those with MMT 0 or 1 [4]. In addition, foot drop due to
disc herniation generally had a better recovery than that caused
by lumbar spinal stenosis [14–16]. The number of decompressed
level (single-level vs multi-level), however, was not associated with
degree of motor recovery [4].
11. Conclusion
Foot drop resulting from degenerative lumbar diseases is a spe-
cial presentation of a severe motor deficit. The most common
lumbar conditions associated with foot drop are disc herniation
and spinal stenosis. The pathology is typically located at L4/5 spinal
level, although the involvement of L5/S1 and multiple levels is
also common. Electrodiagnostic examination is important in dis-
tinguishing the spinal causes of foot drop from peripheral causes.
Although most cases are treated surgically, evidence supporting
the superiority of surgery over conservative therapy is insufficient.
Most patients will have an improvement to a certain degree during
the postoperative period of 6 weeks to 6 months. Initial preopera-
tive motor deficit status perhaps is the key factor associated with
recovery, and as such, MMT of foot dorsiflexors should be carefully
measured and EMG considered. A foot orthosis is recommended
during the recovery period.
Conflict of interest
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.
Acknowledgment
We thank Dr. Masaho Yoshikawa in Kobe Century Memorial
Hospital (Japan) for his help in interpreting Japanese related lit-
erature.
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