Title: Severe bilateral motor-predominant lumbosacral radiculopathy following cardiac arrest: a rare case of anterior ramus ischemia

Authors: Ruben Dovlatyan DO1; Joseph Kastrenakes DO1; David Shukhman DO2; Lawrence Markel DO3;  Sidharth Sahni, DO, DPT, CSCS1; Austin Dukat, DO1; Sie Kim, MD1

Affiliations: 1NYU Langone Health, 2Thomas Jefferson University Hospital, 3Mount Sinai Hospital

Introduction:

• Lumbosacral radiculopathy =mixed motor and sensory deficits. 
• Sensory symptoms and EMG findings often precede motorfindings.
• We present a rare, severe, and likely ischemic case of isolated motor-predominant radiculopathy following cardiac arrest, confirmed by electrodiagnostic evidence of ventral ramus injury with sparing of sensory pathways.

Case Description:

• 37-year-old non-binary individual with bipolar disorder, substance use, and suspected overdose was admitted following out-of-hospital cardiac arrest with prolonged downtime. 
• ROSC in ICU at 35 minutes, eventual admission to acute inpatient rehabilitation
• Course complicated by persistent bilateral ankle dorsiflexion weakness, without sensory loss. Exertional-only back pain.
• No compressive lesions on imaging.
• Electrodiagnostic evaluation was obtained due to bilateral foot drop and subjective paresthesia.
• This case report does not contain identifiable patient information and is exempt from IRB review under NYU and NYC-HHC policy. Informed consent was obtained from the patient for academic presentation.

Results:

• Bilateral LE NCV: Motor and sensory WNL
• Lower Extremity EMG: Widespread denervation in L4-S2 anterior rami muscles
• Paraspinal EMG: Minimal abnormality.

Discussion:

Interpretation: Multilevel lumbosacral radiculopathy with selective anterior ramus motor axon loss. Sparing of dorsal ramus fibers. Atypical for a compressive radiculopathy, suggesting preganglionic ventral root or anterior ramus injury, possibly due to prolonged ischemia due to CPR period.

This rare case of bilateral, motor-predominant lumbosacral radiculopathy likely reflects selective ischemic injury to centrally located ventral root fibers. Literature suggests motor fibers may lie centrally within the spinal root and are more vulnerable to ischemia due to relative metabolic demand, size, and perfusion patterns2-4.Understanding this fiber-selective vulnerability may help interventional physicians recognize atypical post-resuscitation radiculopathies and consider nerve root perfusion risks on prolonged surgical position or critical care scenarios.