You are on page 1of 32

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
T10
T11
T12
L1

Lumbar plexus

L2
L3

Sacral plexus

L4
L5
S1
S2
S3
S4
S5
Co1

Phrenic nerve
Axillary nerve
Musculocutaneous nerve
Thoracic nerves

Radial nerve
Ulnar nerve
Median nerve

Lateral femoral cutaneous nerve
Genitofemoral nerve
Femoral nerve

Pudendal nerve
Sciatic nerve

See ANS
lecture

in the affected root distribution dermatomal pain. these include neck or back pain and. occasionally myotomal weakness .Radicular Syndrome Definition: a combination of changes usually seen with compromise of a spinal root within the intraspinal canal. parasthesia or both decreased deep tendon reflex.

tingling and a sense of weakness felt in the upper or lower regions of the body like .Radicular Syndrome Arises due to compression or herniation of the nerve roots are branching of the spinal cord that transmits signals throughout the body Radicular at every Syndrome Symptome level along theand spine Leads to pain other signs like lack of sensation.

and even sharp-shooting and burning .Radicular Syndrome Symptomes Sensory-related symptomes are more prevalens as compared to motor-related symptomes. and muscular weakness is generally as indicator The nature of and kind of pain could the increased severity of nerve differ ranging compression from dulling. throbbing pain and complex to localize .

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 .

NO. 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 . TNF.Radicular pain: • Inflammation is important as a pain mechanism: – Phospholipase A and E.

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.Types of peripheral nerve injury: • Neurapraxia: Segmental loss of myelin coating on nerve root/nerve – Weakness. and complete disruption of supporting structures (transection) .

but will feel paresthesia . known as a dermatome Overlaps somewhat. so won’t lose All sensation.Dermatome • Each nerve root supplies cutaneous sensation to a specific area of skin.

Myotome • If radicular pain sever could affect myotome • Each nerve root supplies motor innervation to certain muscles. known as a myotome .

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 ..• In the cervical spine: – Nerve roots exit above their named vertebral body – I.

1. Cervical Radiculopathy C7 most common .

– Ex: A C6/7 disc herniation will impinge upon the C7 root.” 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.Cervical HNP • Classic presentation is to “wake up with it. .

conservative therapy is the mainstay of treatment. . • Surgery indicated for those that don’t improve with conservative management.Cervical HNP • Just as is the case with Lumbar HNP. or with new/progressive neurologic deficit.

Usually. this is referring to more chronic types of processes. is narrowing of the spinal canal (within which lies the cervical spinal cord). • This narrowing can be from any of a multitude of causes. . thus. rather than acute or sudden ones. – Cervical spinal stenosis. though.Cervical Spinal Stenosis (CSS) • Stenosis – a constriction or narrowing of a duct or passage.

Cervical Spinal Stenosis (CSS) • More than half of adults older than 50 yrs.” • …however. And probably their dogs and cats too..e. Will show significant degenerative cervical spine disease on radiography (CT/MRI)… – (i. only a fraction of these patients will actually experience any type of significant neurological . “Everybody has degenerative disc disease.

• . – The term “myelopathy” refers to pathological changes of the spinal cord itself. – The term “radiculopathy” refers to disease of the nerve roots. • Myelopathy – from spinal cord compression.CSS – when it causes problems… • Radiculopathy – from nerve root compression. pain/parasethesias. LMN signs.

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.2. 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. 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 . Cauda Equina Syndrome – Historically • Bilateral sciatica – Expanded to include unilateral sciatica • Sudden.

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 .

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. leading to spondylosis 28 .4. especially posterior components.

but can result in » Spondylosis » DDD » Radiculopathy Treatment: • • • • Medication Physical Therapy Injections Surgery 29 .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.

stooping or bending forward • Common are complaints of weakness and numbness of extremities • Usually becomes symptomatic in 6th decade 30 .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.

Back Pain Causes • • • • • • de-conditioning sprain/strain spondylolithesis spondylosis facet syndrome disc herniation • • • • • • disc bulge spinal stenosis biomechanical inflammatory infection cancer .

CSS . because once stenosis has evolved to the point that it is compressing (and causing damage to) the spinal cord.Myelopathy • The goal here is to avoid missing patients who are myelopathic. . the progression of symptoms may be variable…but it is going to progress.