Radicular Syndrome Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas.

Radicular Syndrome

Darwin AmirBgn Ilmu Penyakit Saraf

Fakultas Kedokteran Universitas Andalas

Peripheral Nerves and Nerve Plexuses

Cervical plexus

Brachial plexus

C1C2C3C4C4C4C4C4T1T2T3T4T5T6T7

T8

T9

T10

T11

T12

Lumbar plexus

Sacral plexus

L1

L2

L3

L4

L5

S1

S2S3

S4

S5Co1

Phrenic nerve

Axillary nerve

Musculocutaneous nerve

Thoracic nerves

Radial nerve

Ulnar nerveMedian nerve

Lateral femoral cutaneous nerveGenitofemoral nerveFemoral 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

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

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 don’t 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.

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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

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

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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

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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

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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

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6. Spinal StenosisClinical:

• 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

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 variable…but it is going to progress.