Transcript
Page 1: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Radicular SyndromeDarwin Amir

Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Page 2: Darwin Amir Bgn 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

S2

S3

S4

S5Co1

Phrenic nerve

Axillary nerve

Musculocutaneous nerve

Thoracic nerves

Radial nerve

Ulnar nerve

Median nerve

Lateral femoral cutaneous nerveGenitofemoral nerveFemoral nerve

Pudendal nerve

Sciatic nerve

Page 3: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

See ANS lecture

Page 4: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 5: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 6: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 7: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 8: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 9: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 10: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 11: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 12: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Myotome• If radicular pain sever

could affect myotome • Each nerve root supplies

motor innervation to certain muscles, known as a myotome

Page 13: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 14: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 15: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 16: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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 HNP

Page 17: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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)

Page 18: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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.

Cervical Spinal Stenosis (CSS)

Page 19: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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.

CSS – when it causes problems…

Page 20: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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.

CSS - Myelopathy

Page 21: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

21

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

2. HNP Lumbalis

Page 22: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 23: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

intervertebral disc

Page 24: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

vascular supply to the disc space from

the cartilaginous endplate

1. segmental radicular artery

2. interosseous artery

3. capillary tuft4. disc anulus

Page 25: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Internal disruption

Page 26: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Back Pain Causes

• de-conditioning• sprain/strain• spondylolithesis• spondylosis• facet syndrome• disc herniation

• disc bulge• spinal stenosis• biomechanical• inflammatory• infection• cancer

Page 27: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas
Page 28: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

◦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

Page 29: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

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

Page 30: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

30

Treatment: Urgent decompression is mandatory for prevention of

irreparable / irreversible bladder damage 12 hours is the maximum time prior to irreversible

changes

3. Cauda Equina Syndrome

Page 31: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Caude equina: Begins at L2 disc space distal to conus medullare

Cauda equina syndrome occur due to - Acute disc herniation- Epidural hematoma- Tumor

Incomplete Cord Syndrome

Cauda Equina Syndrome

Page 32: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Motor- Flaccid lower extremities- Knee and ankle jerk absent

Sensory- Asymmetrical sensory loss- Saddle anasthesia- Loss of sensation arround perineum, anus & genital

Incomplete Cord Syndrome

Cauda Equina Syndrome

Page 33: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Autonomic- Loss of bladder and bowel funsction- Urinary retention

Incomplete Cord Syndrome

Cauda Equina Syndrome

Page 34: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

34

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

4. Spondylosis

Page 35: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

35

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

Page 36: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

36

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

6. Spinal Stenosis

Page 37: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Imaging: Indications

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

Page 38: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Differential diagnosis of radiculopathy:

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

Page 39: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

Differential diagnosis of radiculopathy:

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

Page 40: Darwin Amir Bgn Ilmu Penyakit Saraf Fakultas Kedokteran Universitas Andalas

The End

TERIMA KASIH


Recommended