Darwin Amir
Bgn Ilmu Penyakit Saraf
Fakultas Kedokteran
Universitas Andalas
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
Lumbar plexus
L2
L3
Sacral plexus
Radial nerve
L1
L4
L5
S1
S2
S3
S4
S5
Co1
Ulnar nerve
Median nerve
Lateral femoral cutaneous nerve
Genitofemoral nerve
Femoral 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
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 sharpshooting and burning sensation could be
felt




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




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

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

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 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:

In the lumbar 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
◦ 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
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

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.


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.

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.

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.

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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.

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.

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
21
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 tuft
4. 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

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

Treatment:
 Urgent decompression is mandatory for prevention of
irreparable / irreversible bladder damage
 12 hours is the maximum time prior to irreversible
changes
30
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
Cauda Equina Syndrome


Motor
- Flaccid lower extremities
- Knee and ankle jerk absent
Sensory
- Asymmetrical sensory loss
- Saddle anasthesia
- Loss of sensation arround perineum, anus &
genital
Cauda Equina Syndrome
Autonomic
- Loss of bladder and bowel funsction
- Urinary retention

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
34
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
35
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
36

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

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
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