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Radicular Syndrome. Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas. Peripheral Nerves and Nerve Plexuses. C 1. C 2. Cervical plexus. C 3. C 4. C 4. C 4. Phrenic nerve. C 4. Brachial plexus. C 4. T 1. T 2. Axillary nerve. T 3. T 4. T 5. T 6. - PowerPoint PPT Presentation
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Radicular SyndromeDarwin Amir
Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas
Peripheral Nerves and Nerve Plexuses
Cervical plexus
Brachial plexus
C1C2C3C4C4C4C4C4T1T2T3T4T5T6T7T8
T9
T10
T11
T12
Lumbar plexus
Sacral plexus
L1
L2
L3
L4L5S1
S2S3S4S5Co1
Phrenic nerve
Axillary nerve
Musculocutaneous nerve
Thoracic nerves
Radial nerveUlnar nerveMedian nerve
Lateral femoral cutaneous nerveGenitofemoral nerveFemoral nerve
Pudendal nerve
Sciatic nerve
See ANS lecture
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
Radicular SyndromeArises 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 SymptomeLeads 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
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 Syndrome Symptomes
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 pro-
inflammatory 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 won’t loseAll 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-L1—anterior horn
1. Cervical Radiculopathy Root Pain (*less
reliable for localization)
Paresthesias/Numbness (*more reliable for localization)
Weakness Reflex loss
C5 Neck, shoulder Lateral arm Shoulder abduction and external rotation, elbow flexion and forearm supination
Biceps, brachioradialis
C6 Neck, shoulder, lateral arm and forearm, lateral hand
Lateral forearm, thumb and index finger
Shoulder abduction and external rotation, elbow flexion and forearm supination and pronation
Biceps, brachioradialis
C7 Neck, shoulder, middle finger, hand
Index and middle fingers, palm
Elbow and wrist extension, forearm pronation, wrist flexion
Triceps
C8 Shoulder, medial forearm, fourth and fifth digits
Medial forearm and hand, fourth and fifth digits
Finger extension, some wrist extension, distal finger and thumb flexion, finger abduction and adduction
None
T1 Medial arm and forearm, axillary chest wall
Medial forearm; also sometimes fourth and fifth digits
Thumb abduction most affected; finger abduction and adduction
None
C7 most common
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 don’t improve with conservative management, or with new/progressive neurologic deficit.
Cervical HNP
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.
Cervical Spinal Stenosis (CSS)
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.
CSS – when it causes problems…
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 variable…but it is going to progress.
CSS - Myelopathy
21
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
2. HNP Lumbalis
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
vascular supply to the disc space from
the cartilaginous endplate
1. segmental radicular artery
2. interosseous artery
3. capillary tuft4. disc anulus
Internal disruption
Back Pain Causes
• de-conditioning• sprain/strain• spondylolithesis• spondylosis• facet syndrome• disc herniation
• disc bulge• spinal stenosis• biomechanical• inflammatory• infection• cancer
◦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
30
Treatment: Urgent decompression is mandatory for prevention of
irreparable / irreversible bladder damage 12 hours is the maximum time prior to irreversible
changes
3. Cauda Equina Syndrome
Caude equina: Begins at L2 disc space distal to conus medullare
Cauda equina syndrome occur due to - Acute disc herniation- Epidural hematoma- Tumor
Incomplete Cord SyndromeCauda Equina Syndrome
Motor- Flaccid lower extremities- Knee and ankle jerk absent
Sensory- Asymmetrical sensory loss- Saddle anasthesia- Loss of sensation arround perineum, anus & genital
Incomplete Cord SyndromeCauda Equina Syndrome
Autonomic- Loss of bladder and bowel funsction- Urinary retention
Incomplete Cord SyndromeCauda Equina Syndrome
34
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
4. Spondylosis
35
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
5. Spondylolisthesis
36
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
6. Spinal Stenosis
Imaging: Indications Somatic back and neck pain:
◦ Often not helpful and not indicated unless the patient has risk factors for a serious underlying cause of back pain
Incidence of spine abnormalities such as disk bulges/minor herniations is about 25-50% in asymptomatic people!
Current techniques are not helpful in identifying the source of the somatic pain
Differential diagnosis of radiculopathy:
Root lesion (radiculopathy) vs entrapment neuropathy◦ C6/7 vs carpal tunnel syndrome (med. n. at wrist)◦ C8 vs ulnar neuropathy at the elbow◦ L3/4 vs femoral neuropathy◦ L5 vs peroneal n. at the fibular neck
Bilateral L5-S1 radiculopathy vs early peripheral polyneuropathy
Could be appropriate by EMG/NSV
Differential diagnosis of radiculopathy:
Please be familiar with the concepts Radiculopathy always must be
distinguished from other peripheral nerve or plexus problems
Root lesion (radiculopathy) vs plexus lesion◦ C5/6 vs Upper trunk◦ C8 vs Lower trunk◦ L3/4 vs Lumbar plexus◦ L5/S1 vs Sacral plexus
The End
TERIMA KASIH