Radicular Syndrome Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas Peripheral Nerves and Nerve Plexuses Cervical plexus Brachial plexus C1 C2 C3 C4 C4
C4 C4 C4 T1 T2 T3 T4 T5 T6 T7 T8 T9 Phrenic nerve Axillary nerve
Musculocutaneous nerve Thoracic nerves T10 T11 T12 L1 Lumbar plexus Radial nerve L2 Ulnar nerve
L3 Sacral plexus Median nerve L4 L5 S1 S2 S3 S4 S5 Co1
Lateral femoral cutaneous nerve Genitofemoral nerve Femoral nerve Pudendal nerve Sciatic nerve See ANS lecture Radicular Syndrome Definition: a combination of changes usually seen with compromise of a spinal root within the
intraspinal canal; these include neck or back pain and, in the affected root distribution dermatomal pain, parasthesia or both decreased deep tendon reflex, occasionally myotomal weakness Radicular Syndrome Arises due to compression or herniation of the nerve roots are branching of the spinal cord that transmits signals throughout the body at every level along the spine Radicular Syndrome Symptome Leads to pain and other signs like lack of sensation, tingling and a sense of weakness felt in the upper or lower regions of the body like
the arms or legs Radicular Syndrome Symptomes Sensory-related symptomes are more prevalens as compared to motor-related symptomes, and muscular weakness is generally as indicator of the increased severity of nerve compression The nature and kind of pain could differ ranging from dulling, throbbing pain and complex to localize , and even sharp-shooting and burning sensation could be felt Radicular pain: Less common than somatic pain The hallmark of radiculopathy, any pathologic
condition affecting the nerve roots Arises from the nerve roots or dorsal root ganglia Herniated disk is by far the most common cause Radicular pain: Lancinating or electric quality Moves in bands and usually radiates down the limbs Associated symptoms of paresthesias are very helpful determining the identity of the involved nerve root better than site of pain Symptoms of weakness and objective findings of sensory loss, weakness and reflex loss may
occur Radicular pain: Inflammation is important as a pain mechanism: Phospholipase A and E, NO, TNF, other proinflammatory mediators are released by a herniated disk The dura surrounding the ventral and dorsal nerve root is bathed in this exudate Inflammation or prior injury to nerve root is necessary to cause compression to generate continued pain Types of peripheral nerve injury: Neurapraxia: Segmental loss of myelin coating
on nerve root/nerve Weakness, but no atrophy Axonotmesis: Loss of axons and myelin but at least some supporting structures are preserved Weakness and muscle atrophy if severe Neurotmesis: Loss of axons, myelin, and complete disruption of supporting structures (transection) weakness and atrophy Dermatome Each nerve root supplies cutaneous
sensation to a specific area of skin, known as a dermatome Overlaps somewhat, so wont lose All sensation, but will feel paresthesia Myotome If radicular pain sever could affect myotome Each nerve root supplies motor innervation to certain muscles, known as a myotome
In the cervical spine: Nerve roots exit above their named vertebral body I.e., C7 exits below C6 and above C7-so lateral disk herniation here gets C7 In the lumbar spine: Spinal cord ends at L1 or L2 Nerve roots travel long distances then exit below their named vertebral body The lumbosacral nerve roots are susceptible to injury at multiple locations
T11-L1anterior horn 1. Cervical Radiculopathy C7 most common Root C5 C6 C7 C8 T1 Pain (*less reliable for
localization) Neck, shoulder Paresthesias/Numbness Weakness (*more reliable for localization) Lateral arm Shoulder abduction and external rotation, elbow flexion and forearm supination Neck, shoulder, Lateral forearm, thumb Shoulder abduction and external lateral arm and and index finger rotation, elbow flexion and forearm forearm, lateral supination and pronation
hand Neck, shoulder, Index and middle Elbow and wrist extension, forearm middle finger, fingers, palm pronation, wrist flexion hand Shoulder, Medial forearm and Finger extension, some wrist medial forearm, hand, fourth and fifth extension, distal finger and thumb fourth and fifth digits flexion, finger abduction and digits adduction Medial arm and Medial forearm; also
Thumb abduction most affected; forearm, sometimes fourth and finger abduction and adduction axillary chest fifth digits wall Reflex loss Biceps, brachioradialis Biceps, brachioradialis Triceps None
None Cervical HNP Classic presentation is to wake up with it. Usually no identifiable factor. Causes painful limitation of neck motion and symptoms corresponding to the affected nerve root(s) The majority of cervical herniated discs will catch the nerve root corresponding to the lower vertebral level. Ex: A C6/7 disc herniation will impinge upon the C7 root.
Cervical HNP Just as is the case with Lumbar HNP, conservative therapy is the mainstay of treatment. Surgery indicated for those that dont improve with conservative management, or with new/ progressive neurologic deficit. Cervical Spinal Stenosis (CSS) Stenosis a constriction or narrowing of a duct or passage. Cervical spinal stenosis, thus, is narrowing of the spinal canal (within which lies the cervical spinal cord). This narrowing can be from any of a multitude of
causes. Usually, though, this is referring to more chronic types of processes, rather than acute or sudden ones. Cervical Spinal Stenosis (CSS) More than half of adults older than 50 yrs. Will show significant degenerative cervical spine disease on radiography (CT/MRI) (i.e., Everybody has degenerative disc disease. And probably their dogs and cats too. however, only a fraction of these patients will actually experience any type of significant neurological symptoms.
CSS when it causes problems Radiculopathy from nerve root compression. The term radiculopathy refers to disease of the nerve roots; LMN signs, pain/parasethesias. Myelopathy from spinal cord compression. The term myelopathy refers to pathological changes of the spinal cord itself. Pain and sensory changes in the back of the head, neck, and shoulders. 2. HNP Lumbalis Clinical: Low back pain wit associated leg symptoms
Positions can induce radicular symptoms Posterolateral disc pathology most common: Area where anular fibers least protected by PLL Greatest shear forces occur with forward or lateral bend Central disc pathology: Usually with LBP only without radicular symptoms, unless a large defect is present 20 low back pain world wide Common complaint among adults Lifetime prevalence in working population up to 80% 60% experience functional limitation or disability
Second most common reason for work disability Despite advances in imaging and surgical techniques LBP prevalence and its cost are relatively unchanged intervertebral disc Internal disruption 3. Cauda Equina Syndrome Historically Bilateral sciatica Expanded to include unilateral sciatica Sudden, partial or complete loss of voluntary bladder function due to massive disc impingement on spinal
nerves The frequency of daily urination is much greater than bowel evacuation, so Presently Bladder dysfunction with a decrease in perianal sensation 3. Cauda Equina Syndrome Symptoms Back pain Radicular pain Bilateral Unilateral
Motor loss Sensory loss Urinary dysfunction Overflow incontinence Inability to void Inability to evacuate the bladder completely Decrease in perianal sensation 3. Cauda Equina Syndrome Treatment: Urgent decompression is mandatory for prevention of irreparable / irreversible bladder damage 12 hours is the maximum time prior to irreversible
changes 27 4. Spondylosis Clinical: Up to 75 % of involvement of the spine occurs at 2 levels: L5-S1 and L4-L5 Possible factors that contribute to development: Changes with maturation in: Nutrition Disc chemistry Hormones Occupational forces
Progression of disc narrowing leads to degenerative changes of bony structures, especially posterior components, leading to spondylosis 28 5. Spondylolisthesis Clinical: Progression of spondylolysis with separation Grades assigned I-IV for level of translation Most common levels are L5-S1 (70 %) and L4-L5 (25 %) May be asymptomatic, but can result in Spondylosis DDD Radiculopathy
Treatment: Medication Physical Therapy Injections Surgery 29 6. Spinal Stenosis Clinical:
Results from narrowing of spinal canal and / or neural foramina (CONGENITAL OR DEGENERATIVE) Most common complaint is leg pain limiting walking Neurogenic / Pseudoclaudication = pain in lower extremities with gait Relief can occur with: stopping activity sitting, stooping or bending forward Common are complaints of weakness and numbness of extremities Usually becomes symptomatic in 6th decade 30
Back Pain Causes de-conditioning sprain/strain spondylolithesis spondylosis facet syndrome disc herniation
disc bulge spinal stenosis biomechanical inflammatory infection cancer CSS - Myelopathy
The goal here is to avoid missing patients who are myelopathic, because once stenosis has evolved to the point that it is compressing (and causing damage to) the spinal cord, the progression of symptoms may be variablebut it is going to progress.
