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 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:
– 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
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 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.
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
variable…but it is going to progress.