SPINAL NERVE ROOT COMPRESSION AND PERIPHERAL NERVE DISORDERS

Group B – 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?

Historical Factors?

1) Trauma – recent falls.2) Cancer- remote/recent history.3) Cervical spondylosis.4) Fever, weight loss.5) Immunosuppression.6) Bone thinning disease ( Rheumatoid

arthritis, Multiple Myeloma ).

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?

RED FLAGS

Significant trauma pt. < 50 yrs.Mild trauma pt. > 50 yrs.Unexplained weight loss.Unexplained fever.Immunosupression.Cancer Hx.Night pain.IV drug use.

Red Flags

Osteoporosis.Prolonged Steroid use.Age >70.Focal Neuro Deficits.Disabling symptoms.Duration > 6 weeks.Pain not relieved by laying supine.

What physical examination findings would you look for?

TENDERNESS CERVICAL SPINE.MOTION IN THE NECK

FOCAL WEAKNESSSENSORY LOSSREFLEX LOSS

Physical Examination

Case 1

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

Causes: Neck pain + Radicular pain + Weakness

Idiopathic- congenital spinal stenosis.Traumatic- fracture.Degenerative- Disc herniation, foraminal

stenosis, cervical spondylosis.Neoplasm.Infection.

Neck Pain

Can Cervical Disc Disease cause gait disturbance?

Important notes

Central Disc Disease – can cause gait disturbance, neurogenic bladder, loss of anal tone.

Neck Pain

Are Neoplastic mets to C-spine common?

Important notes

Neoplasm- mets to C-spine 8-20% of all spinal mets.

Neck Pain

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

Important notes

Neoplasm- neuro symptoms + severe pain.

Neck Pain

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

Important notes

Infection- C-spine least common site, only 50 % have fever.

Neck Pain

Name important risk factors for infection in the C-spine.

Important notes

Infection risk factors- IV drug use, diabetes, alcoholism, malignancy, corticosteroids.

Cervical Radiculopathy

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

C5 radiculopathy.C6 radiculopathyC7 radiculopathy.C8 radiculopathy.

What level of Cervical radiculopathy is involved ?

C5 – 2% incidence. Reflex loss- Biceps.C6- 22% incidence. Reflex loss- None.C7- 70% incidence. Reflex loss- Triceps.C8- 6% incidence. Reflex loss- None.

Cervical Radiculopathy

Sensory loss C5 - proximal lat. arm C6- lat. Forearm/thumb. C7 -2-4th fingers. C8 - 5th finger.

Cervical Radiculopathy

Motor lossC5- Deltoid, infra/supraspinatus, biceps.C6- Biceps, deltoid, brachioradialis, pronator

teres.C7 – Triceps , wrist flexors and extensors.C8- Thumb abduction, finger flexion and

extension.

Cervical Imaging

What is the value of a C-spine x-ray?

IMAGING

X-rays- fractures, confirms degenerative changes.

Cervical Imaging

When should an MRI be ordered?

IMAGING

MRI- shows foramina and discs best.

Cervical Imaging

When should a CT scan be ordered?

IMAGING

CT- Only good for occult fractures.

Neck Pain

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

Neck pain

Most neck pain resolves in 3-6 weeks.

Neck Pain

What factors may extend that time frame?

Neck pain

Automobile related neck injuries- 20-70% have pain after 6 months.

Work related neck injuries- may last years if not resolved in 8 weeks.

Thoracic Pain

Name some common causes of persistent thoracic back pain.

Thoracic Spinal Nerves

Causes: DiskitisThoracic disc bulge.Compression fractures- trauma, osteoporosis.Tumour- most common site in spine .

Thoracic Pain

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

Thoracic Spinal Nerves

Tumour: Lung, Breast, Prostate, Kidney, Thyroid.

Thoracic Pain

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

Thoracic Spinal Nerves

Most usually have pain without motor weakness.

Thoracic Pain

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

Thoracic Spinal Nerves

If motor Involvement- often complete weakness of both legs with areflexia due to spinal cord compression.

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?

Historical Factors?

1) Trauma – recent falls.2) Cancer- remote/recent history.3) Lumbar spondylosis.4) Fever, weight loss.5) Immunosuppression.6) Bone thinning disease ( Rheumatoid

arthritis, Multiple Myeloma ).

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?

RED FLAGS

Significant trauma pt. < 50 yrs.Mild trauma pt. > 50 yrs.Unexplained weight loss.Unexplained fever.Immunosupression.Cancer Hx.Night pain.IV drug use.

Red Flags

Osteoporosis.Prolonged Steroid use.Age >70.Focal Neuro Deficits.Disabling symptoms.Duration > 6 weeks.Pain not relieved by laying supine.

Historical features

RED Flags +Saddle anaesthesiaBowel symptomsBladder symptoms

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?

Answers

Most common site for fractures are L1, L2.Most common site for Disc herniations are

L4-5, L5-S1.Cancers that metastasize to lumbar spine

are:Colorectal, Breast, Cervical, Lymphoma,

Sarcoma.

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?

Notes

Sciatic pain secondary to disk herniation occurs in only2% of patients with low back pain.

< 1% of sciatica goes on to develop cauda equinae.Nerve roots exit below vertebra body, above the

disk.Eg. L4-5 disk affects the L5 nerve root.95 % lumbar disk herniations occur from L4-S1

levels.

Sciatica

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

Notes

Many patients have degenerative changes in the vertebrae, especially the facet joints.

With age- disk dehydration, loss of disk height, disk herniation can result in nerve root compression.

As the disk desicates over time, it shrinks, pulling away from the nerve root.

Sciatica

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

Sciatica

+ SLR only if lifting leg causes increased LEG pain.

Radicular sciatica goes beyond the knee.Check sensation with sharp objects, not light

touch.Reflexes not useful especially in the elderly.

Assessment

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

L1L2L3L4L5 S1S2-4

Assessment- Sensory

Sensory findings for the following nerve root compressions: reduced pin prick

L1- inguinal areaL2-middle inner thighL3- distal medial thigh.L4- inner aspect calf, medial aspect big toe.L5- 1st web space between 1st & 2nd toesS1- lateral aspect of foot, 5th toe.S2-4 – perianal area.

Assessment- Reflex

Reflex findings for the following nerve root compressions:

L1-loss of superficial anal reflex, cremasteric reflex.

L2-loss of superficial anal reflex, cremasteric reflex.

L3- no reflex loss.L4- loss of patellar tendon reflex.L5- no reflex loss.S1- loss of achilles tendon reflex.S2-4 – no reflex loss

Assessment- Motor

Root MuscleL1,L2 IliopsoasL3,L4 QuadricepsL5 Ext. HallucisS1 Biceps

femoris

S1 Peroneal

S1,S2 Soleus, gastroc.S2-S4 Rectal sphincter

ActionHip flexionKnee extensionBig toe extensionKnee flexion

Foot eversionPlantar flexion ankleSphincter tone

Assessment

Root Sensory AreaL1 Inguinal creaseL2,L3 Medial thighL4 Medial calfL5 1st web space ( 1st – 2nd toes

)S1 Lateral aspect of footS2-S4 Perianal sensation

Imaging

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

Imaging

X-rays if:<18 , > 50 yrs. old.Hx Cancer- won’t show change till 30% bone

destruction.Hx fever, IV drug use, immunocompromise.Major trauma.Osteoporosis.Symptoms > 6 weeks.

Imaging

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

Imaging

Can be used for known fractures.

Imaging

What is the value of MRI of the lumbar spine?

Imaging

MRI better than CT ( no radiation exposure )Better resolution of soft tissue, spinal cord,

epidural space.

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 ?

Literature Review- NO BENEFIT

Firmer mattressLumbar supportMuscle relaxantsBenzodiazepinesGabapentinBed restEpidural

corticosteroids

TENSUltrasoundTractionShort wave diathermyLow level laserInterferential

Recommend

NSAIDS + Acetominophen for acute exacerbations of subacute and chronic LBP.

Opoids only for short duration in pts. with low vulnerability for drug abuse.

Trycyclics are good for chronic LBP.Home & supervised exercise program

( stretching and strengthening ).Some people may benefit from Cognitive

behavioural therapy, Yoga, massage, spinal manipulation ( all moderately more effective than sham/placebo Rx ).

Surgery for Sciatica

What are the indications for surgery for sciatica?

Surgery for Sciatica

50 % of sciatica pts. get better in 6 weeks on their own.

Surgery is good for :Intractable pain.Worsening neuro deficits.No improvement in 6 weeks with

conservative treatment.

Spinal Stenosis

Describe the features of a patient with Spinal Stenosis?

Spinal Stenosis

Local segmental or generalized narrowing of the central spinal canal by bone or soft tissue elements

( Hypertrophic facets, thick ligamentum flavum ). Features: Diffuse back pain in older patient.

Transient tingling in legs ( both ). Ambulation induced pain in calf/lower leg. Resolves with sitting, forward flexion, rest. Worse with back extension. SLR + ve in 50%. Treatment conservative unless failed Rx > 3 months.

Cauda Equinae

Describe the clinical features of Cauda Equina.

What are some of the causes?

Cauda Equinae

Loss of Bowel / Bladder control ( 90 % have retention )

Saddle anaesthesia.Reduced rectal tone.Weakness in lower extremities.

Related to compression of spinal nerve roots due to:Tumour, bony stenosis or disc herniation ( central ).Tumours- Prostate, colorectal, non Hodgkins

lymphoma, sarcoma, GYN tumours, Renal Cell Ca, multiple myeloma.

Cauda Equinae

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?

Cauda Equinae

Check anal tone – resistance to finger entering.

- buttock squeeze test.Post void test – if > 200 cc ( urinary retention

).

MRI imaging of choiceRefer to Neurosurgeon if confirmed.

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

Compression of median nerve thru carpal tunnel ( axonal dysfunction ).

Causes: Pain, Paraethesias in hands and later weakness of median nerve.

Assoc. Conditions- pregnancy, diabetes, hypothyroid, renal failure.

Usually caused by overuse- swelling of flexor tendons. Findings: Sensory loss volar 1st 3 fingers + lat. 4th finger, normal

thenar Motor loss: weak thumb abduction, flexion MCP jts. Examination: Tinel sign ( taping tunnel ) 50-60%sens. 67-77%

specific. Phalens sign ( palmar flexion > 30 sec. ) 70 % sens., 47-73 %

specific.

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 – Carpal Tunnel Treatment

Conservative: Nocturnal splinting, oral corticosteroids ( 2 weeks ), corticosteroid injections, Yoga.

NSAIDS no help compared to placebo.Prediction of failure Conservative RX:Age > 50, Duration > 10 months, constant

paraethesias, impaired 2 point discrimination, +ve Phalens sign < 30 seconds, Prolonged motor and sensory latency on NCS& EMG.

Surgery- Best long term relief of symptoms.

Median Nerve – Pronator Teres Syndrome

What are the different features compared to Carpal Tunnel Syndrome?

Median Nerve- Pronator Teres Syndrome

Median nerve entrapment in proximal forearm.

Forearm flexor pain.Same findings as carpal tunnel EXCEPT:Numbness thenar eminence and weak thenar

muscles.Treatment: rest, corticosteroid inj., surgery if

persistent symptoms.

Ulnar Nerve Compression

Describe the findings of ulnar nerve compression at the elbow.

Describe ulnar nerve compression at the wrist.

Ulnar Nerve Compression

At the Elbow: at the epicondylar groove.Leaning on the elbow.Numbness 4th-5th fingers.Weak finger and wrist FLEXION, Ulnar

deviation wrist., weak abduction of the index finger.

At the wrist: in Guyon’s canal.Numbness 4th-5th fingers.Weak interossei, Finger FLEXION Spared.

Radial Nerve Compression

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

Describe the findings of Posterior interosseus Neuropathy.

Radial Nerve Compression

At Spiral Groove: Saturday night palsy- shoulder vs arm of sofa.

Numbness 1st web space dorsallyWeak wrist ( drop ) and finger extension,

brachioradialis. Triceps spared.Recovery with wrist splint in 6-8 weeks.

Posterior Interosseus Neuropathy- a branch of radial nerve proximal to elbow, innervates forearm extensors- weak 3rd finger extension and forearm supination.

Nerve Conduction studies

Good for delineation of severity of Median,Ulnar or Radial nerve dysfunction.

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

Acute Inflammatory Polyradiculoneuropathy.Immune mediated inflammation of peripheral

nerves disrupting myelin and causing axonal loss.

Most common acute motor neuropathy.Usually has a preceding history of a URI or

GI illness preceeding the onset.

Describe the symptoms and findings.

Guillain Barre Syndrome

Progressive Symmetric WEAKNESS of proximal + distal muscles .

May involve cranial nerves in up to 50 % cases.Loss of DTR.Variable sensory findings ( can occur in 33%)Sparing of anal tone.May have urinary retention ( autonomic

dysfunction).Patients with primarily sensory signs are

unlikely to have respiratory distress.

Guillain Barre Syndrome

50% have autonomic dysfunction- fluctuating BP, pulse.

Peaks at 1 week.Some cranial nerve dysfunction ( 7th nerve ).33 % require respiratory support.3% mortaility / recurrence rate.Describe the lab and imaging abnormalities:

Guillain Barre Syndrome

CSF analysis: Elevated protein, no increased WBC.

EMG/NCS- show demyelination disorder, loss of 80 % of normal muscle action potential suggests poor prognosis.

MRI shows enhancement of anterior spinal nerve roots.

FEV1.0, ABG, to check for CO2 retention.May need prophylactic intubation.Check for extensor neck strength.

Guillain Barre Syndrome

What is the treatment for GBS?

Treatment

Plasmapheresis.Pooled IV gammaglobulin.Supportive care.Ventilatory help if needed.Corticosteroids not helpful.

Distal Symmetric Polyneuropathy

Stocking glove sensory distribution.Motor findings lag behind sensory.Progress distal to proximal.Causes: Diabetes, Alcoholism, Neoplasm, HIV,

Toxins, drugs.

Describe the findings in Diabetic neuropathy:

Diabetic Neuropathy

Dysaesthesias ( tingling, burning ) plantar aspect feet.

Weakness big toe extension 1st motor sign.Followed by weak dorsiflexion ankle, foot

drop, loss of ankle jerks.Sensory loss moves to knees and fingers.DTR eventually lost.Proprioception loss and may develop sensory

ataxia.

Diabetic Neuropathy

Treatment:

Tricyclics ( Elavil 25 mg qhs ).Tegretol 200mg Q8h.SSRI ( Paroxetine ).No help from Trazadone, Dilantin, topical

capsaicin.

Mononeuropathy Multiplex

Asymmetric Sensorimotor peripheral neuroathy.

Sensory findings match the motor findings.May have reflex loss depending on the nerve

involved.Causes:Diabetes most common, vasculitis second.Others Neoplasm, Lyme disease, HIV, Sarcoid

Anterior horn cell Neuronopathy- ALS

Amyotrophic Lateral Sclerosis.Asymmetrical distal motor weakness with no

sensory loss.Subclinical Autonomic dysfunction.Has both Upper and Lower motor neuron

signs.

What are they?

ALS

Upper Motor Neuron findings:Hyperreflexia – sustained ankle clonusSpasticity.Positive Babinski.

Lower motor Neuron findings:Fasiculations.Cramps.Asymmetrical distal weakness with atrophy.

ALS

EMG confirms the diagnosis.Treatment supportive only.

Sensory Neuronopathies

Affects dorsal root ganglions.Pure sensory syndrome.No motor weakness.

Loss of DTR.Loss of proprioception.Sensory ataxia.

Sensory Neuronopathy

Causes: Herpes Simplex, Paraneoplastic syndromes, Sjogrens, Vitamin deficiencies.

Diagnoses via MRI of the spinal cord.