Prevalence of Lyme neuroborreliosis among patients with painful radiculopathy visiting a teaching hospital in a Lyme endemic region

The Dutch guideline for Lyme borreliosis states that in patients with painful
radiculopathy, serological testing is only indicated if the symptoms are not
explained by nerve root compression on MRI and the patient remembers a tick
bite or EM. Sometimes the EM is still present at physical examination, but it
is also known that many patients with Lyme neuroborreliosis have not noticed
either the tick bite or EM. Positive Borrelia serology in patients with
radiculopathy indicates cerebrospinal fluid examination. Lyme neuroborreliosis
is defined as the presence of CSF pleocytosis and/or intrathecal IgM and/or IgG
Borrelia-specific antibody production.

Although meningoradiculitis, with symptoms of painful radiculopathy is the most
common presentation of early Lyme neuroborreliosis, it is unknown how often
Lyme neuroborreliosis is the cause of painful radiculopathy in the absence of
nerve root compression. A Danish study demonstrated that phycisians often not
consider Lyme neuroborreliosis as a cause of painful radiculopathy, leading to
treatment delay. Possibly, Lyme neuroborreliosis is currently underdiagnosed as
a cause of painful radiculopathy. If a substantial number of patients with
painful radiculopathy turns out to have positive Lyme serology, we advise to
update the Lyme guidelines including standard serological testing for Lyme
borreliosis in patients with painful radiculopathy.

Primary objective:
The study objective is to assess whether there is a difference in prevalence of
positive Lyme serology in patients with painful radiculopathy with nerve root
compression versus patients with painful radiculopathy without nerve root
compression.

Secondary objectives:
1. To assess the prevalence of Lyme neuroborreliosis in patients with painful
radiculopathy without nerve root compression.
2. To assess a difference in patient characteristics (i.e. difference in type
of pain, location pain, additional symptoms (headache/meningeal irritation),
previous tick bite, previous EM, tick exposure activities, month of
presentation) of patients with radiculopathy caused by Lyme neuroborreliosis
versus patients with painful radiculopathy due to nerve root compression.

The design is an observational cross-sectional study among patients who are
referred to the neurology outpatient clinic of Gelre hospitals for the
indication of radiculopathy. All patients who undergo an MRI scan of (a part
of) the spinal column for the suspected radiculopathy will be eligible for
inclusion in the study.

In patients who are willing to participate, serology will be tested for
Borrelia, irrespective of history of tick bite or history of EM. In case of
positive Borrelia serology in the absence of nerve root compression on MRI, the
patient will be offered a lumbar puncture for diagnosis of Lyme
neuroborreliosis. If Lyme neuroborreliosis is diagnosed, the patient will be
treated according to the guidelines. In case of negative Borrelia serology
within eight weeks of symptom onset, in the absence of nerve root compression,
Borrelia serology will be tested again after eight weeks of symptom onset. If
seroconversion occurs, a lumbar puncture will be offered.

Risk associated with participation are minimal, as a venipuncture is the only
procedure patients will undergo. The benefit is that underdiagnosis of Lyme
neuroborreliosis is unlikely and these patients receive timely and adequate
treatment.