SPINAL NERVE ROOT COMPRESSION AND PERIPHERAL NERVE DISORDERS

Group A – AHD Dr. Gary Greenberg

Objectives

Review Assessment and Management of Important Spinal Nerve Disorders Involving the Cervical, Thoracic and Lumbar Spine.

Review Assessment and Management of Common Peripheral Nerve Disorders.

Review Assessment of Important Mono/Polyneuropathies .

Case 1

70 year old male, history of mild neck pain for 2 yrs. Gradual worsening mid cervical pain for 1 month. Radiating down right arm to hand. Numbness, tingling and weakness. Now pain severe, unremitting. Unable to sleep in spite of taking Tylenol #3.

What historical factors would help you assess this patient?

RED FLAGS

What are some of the RED FLAGS that come up in taking a history that make you think there might be a more serious condition present?

What physical examination findings would you look for?

Case 1

What are some of the causes of Neck Pain + Radicular Pain + Weakness ?

Neck Pain

Can Cervical Disc Disease cause gait disturbance?

Are Neoplastic mets to C-spine common?What is the classic presentation of

Neoplastic mets to the C-spine?Is fever a common finding in infection of the

C-spine?Name important risk factors for infection in

the C-spine.

Cervical Radiculopathy

Describe the incidence , Reflex, Sensory and motor loss for the following levels involved:

C5 radiculopathy.C6 radiculopathyC7 radiculopathy.C8 radiculopathy.

Cervical Imaging

What is the value of a C-spine x-ray?When should an MRI be ordered?When should a CT scan be ordered?

Neck Pain

How long does it take for most neck pain from non pathological causes to resolve?

What factors may extend that time frame?

Thoracic Pain

Name some common causes of persistent thoracic back pain.

What is the most common tumor to cause mets to the thoracic spine?

If a Thoracic Spinal nerve is compressed, is there motor weakness?

If the spinal cord is compressed, what are the clinical findings ?

Case 2

45 year old male. Acute onset low back pain radiating down left leg to toes. Initial Rx Tylenol & Advil. After 1 week, severe constant unremitting pain in left leg. Unable to sit, bend forward , sleep.

What historical features should be asked?

Questions

What levels are the most common sites for fractures of the lumbar spine?

What levels are the most common sites for disc herniations?

What cancers metastasize to the lumbar spine?

RED FLAGS

What are some of the RED FLAGS that might come up in a history of low back pain that make you think there might be a more serious condition present?

Sciatica

How often does sciatica due to disc herniation occur in low back pain patients?

How often does sciatica due to disc herniation go on to develop quada equinae?

Generally what nerve root does the L4-5 disk herniation affect?

Why do most sciatica patients get better over time and do not require surgery?

What is the value of SLR, reflexes in the examination of sciatica?

Assessment

Describe the motor , sensory, reflex findings for the following nerve root compressions:

L1L2L3L4L5 S1S2-4

Imaging

What is the value of plain x-rays of the lumbar spine?

What is the value of a CT scan of the lumbar spine?

What is the value of MRI of the lumbar spine?

Treatment of Back pain

Most patients have non specific low back pain.

Most have pain resolution in 4 weeks.Subacute LBP last 4-2 weeks.Chronic LBP lasts > 12 weeks.

WHAT WOULD BE POSSIBLE TREATMENT OPTIONS FOR LOW BACK PAIN ?

Surgery for Sciatica

What are the indications for surgery for sciatica?

Spinal Stenosis

Describe the features of a patient with Spinal Stenosis?

Cauda Equinae

Describe the clinical features of Cauda Equina.

What are some of the causes?How do you check for anal tone?What amount of residual post void urine

would qualify as urinary retention?What is the imaging of choice?

Other Peripheral Nerve Compression Syndromes

Median Nerve Entrapment- Carpal Tunnel, Pronator Teres Syndromes.

Ulnar Nerve Compression- at elbow, at wrist.

Radial Nerve Compression- Spiral groove, posterior interosseus.

Median Nerve Compression

Describe the causes, symptoms and clinical findings of carpal tunnel syndrome?

Median Nerve- Carpal Tunnel Syndrome

Describe the initial treatment for Carpal Tunnel .

Are NSAIDS useful?Predictive factors for failure of conservative

measures?Place for surgery?

Median Nerve – Pronator Teres Syndrome

What are the different features compared to Carpal Tunnel Syndrome?

Ulnar Nerve Compression

Describe the findings of ulnar nerve compression at the elbow.

Describe ulnar nerve compression at the wrist.

Radial Nerve Compression

Describe the findings of Radial nerve compression at the spiral groove.

Describe the findings of Posterior interosseus Neuropathy.

Mono and Polyneuropathies

Important to know if sensorimotor findings are:

Symmetric or Asymmetric.Distal or distal and proximal.Sensory only, Motor only or mixed.

Guillain-Barre Syndrome

What is Guillain- Barre Syndrome?

Describe the symptoms and findings.

Guillain Barre Syndrome

Describe the lab and imaging abnormalities:

Guillain Barre Syndrome

What is the treatment for GBS?

Distal Symmetric Polyneuropathy

Describe the sensory findings.What are the most common causes.Describe the findings in Diabetic neuropathy:

Diabetic Neuropathy

Describe treatment options for Diabetic Neuropathy.

Mononeuropathy Multiplex

Describe the sensory and motor findingsName the most common 2 causes:

Anterior horn cell Neuronopathy- ALS

Amyotrophic Lateral Sclerosis.

Describe the motor , sensory findings.What are the Upper and Lower motor neuron

signs seen?

ALS

What test confirms the diagnosis.What are treatment options..

Sensory Neuronopathies

What structures are affected.Describe the physical findings.

Sensory Neuronopathy

List some causes and diagnostic aides.