radiculopathy.pptx saroj chandra spine fellow

radiculopathy

1. Cervical and Lumbar Radiculopathy Presentor : Dr Saroj Chandra Dahal Spine Fellow Moderator: Dr. Rajesh Kumar chaudhary

2. Radiculopathy P ain with radiation and/or sensorimotor deficit syndrome due to compression of a spinal nerve root . disc herniation, spondylosis, instability, trauma, or rarely, tumors.

3. Causes

4. Pathogenesis Two main mechanisms of the nerve root irritation or impingement: a)Mechanical compression: compression of nerve root due to osteophytes , facet joint hypertrophy , disc herniation leads to inflammation b)Chemical mediators: cytokines , prostaglandins and interlukins released from damaged/herniated disc leading to inflammation

5. Classification On the basis of location Cervical radiculopathy Thoracic radiculopathy Lumbar/lumbosacral myelopathy

6. Cervical radiculopathy C7 root (C6-7 herniation) is the most commonly affected, followed by the C6 (C5-6 herniation) C8 (C7-T1 herniation) nerve roots

7. Characteristics /Clinical Presentation Radiating arm pain corresponding to a dermatomal pattern N eck pain P arasthesia M uscle weakness in a myotomal pattern, Reflex impairment/loss, H eadaches S capular pain S ensory and motor dysfunction   in upper extremities and neck

8. Examination Dermatomal testing Myotomal testing Special test

9. Dermatomal and myotomal examination

10. Patterns of nerve root compression syndromes Nerve root Pain pattern/sensory Weakness/motor Reflexes C2 Occipital, eyes C3 Neck, trapezius C4 Neck, trapezius C5 Shoulder, lateral arm Deltoid,elbow flexon Biceps C6 Lateral forearm, first two digits Biceps, wrist extension Brachioradialis absent C7 Posterior forearm, third digit Triceps,wrist fexion Triceps absent C8 Medical forearm, fourth and fifth digit Finger abduction, grip

11. Special tests

12. Special test contd Cervical distraction test

13. Valsalva maneuver Upper limb tension test

14. Diagnostic Procedures Plain Radiographs MRI Electrophysiologic studies ( EMG  +  Nerve Conduction Studies ) to examine the nerve root and nerve conduction velocity  Cervical myelogram Cervical myelogram and CT

15. Management About 85 % of caseof acute radiculopathy resolve without treatment in 8 -12 weeks. Immoblization Traction Pharmacological treatment Physical therapy Epidural steroid Surgery

16. Immoblization Short course of about 1 week immobilization in acute cases Cervical collar has no proven to alter the course of disease.

17. Traction Distract the neural foramen and decompress the nerve root Typically 8 to 12 lb wt with head vin 24 degree of flexion for 10-15 min

18. Physiotherapy Isometric neck muscle stregenthing exercise

19. Pharmacological treatment NSAIDS/ opoids analgesic Steroids Tricyclic antidepressants

20. Transforaminal epidural steroids injection Decrease pain and inflammation Decrease the PG synthesis

21. Surgery Indications: Persistent or recurrent radicular symptoms unresponsive to nonoperative management for atleast 6 weeks Progressive neurological deficit Disabaling motor weakness Instabality or deformity of functional spine unit with radicular symptoms

22. Type of surgery Anterior anterior cervical discectomy with/without fusion Cervical disc arthroplasty Posterior approach: Posterior laminioforaminotomy with /without discetomy

23. Lumbar radiculopathy Clinical features: Pain is the most commonly reported symptom. N umbness or weakness along the dermatome/myotome distribution supplied by the affected nerve root.

24. Examination D ermatomal sensory loss M yotomal weakness  Straight Leg Raise Test and cross straight leg test Femoral nerve Stretch Test and R eflexes.

25. Straight leg-raising test If the hips are normal, raise the leg from the couch while watching the patient’s face. Stop when the patient complains, and confirm that he is complaining of back or leg pain and not hamstring tightness (the test is negative if there is no pain). The production of paraesthesia or radiating root pains is highly significant, indicating nerve root irritation. Pain from S1 generally occurs before that from L5 . Note the site of pain: back pain suggests a central disc prolapse, leg pain a lateral protrusion

26. Special test: Straight leg test

27. Cross straight leg raise test Distinguish and ignore hamstring tightness. Repeat on the good side. If well-leg raising produces pain and paraesthesia on the affected side, this is highly suggestive of a large prolapse close to the midline. Note that pain must be below the knee if the roots of the sciatic nerve are involved.

28. Lasegue test and B owstring test Now lower the leg until pain disappears ( 1), then dorsiflex the foot (2). This increases tension on the nerve roots, generally aggravating any pain or paraesthesia (‘+ ve sciatic stretch test’). Try this, and record the response. Alternatively, once the level of pain has been reached, flex the knee slightly (3) and apply firm pressure with the thumb in the popliteal fossa over the stretched tibial nerve (4): radiating pain and paraesthesia suggest nerve root irritation ( bowstring test ).

29. Flip test : test for malingering If there is some doubt regarding the severity or genuineness of the patient’s complaints, ask him to sit up under the pretext of examining the back from behind. (Flexion of the spine may also be remeasured with the tape in this position.) The malingerer will have no difficulty, but the genuine patient will either flex the knees or fall back on the couch with pain ( flip test ).

30. Aird’s test : A sk the patient to sit with the legs over the edge of the examination couch. Now try to lift the leg until the knee is fully extended, and note the response. If extension is achieved, this is equivalent to a straight leg raising of 90°, and suggests that there is not a sound organic basis for any positive straight leg raising obtained when the patient is supine.

31. Femoral nerve stress test The patient should be prone. Flex each knee in turn with extension of hip joint. This gives rise to pain in the appropriate distributions (by stretching of femoral nerve roots) in high lumbar disc lesions.

32. L1 radiculopathy Pain, paresthesia and sensory loss in inguinal region No significant muscle weakness Occasional subtle hip flexors weakness L2 radiculopathy Pain, paresthesia and sensory loss in anterolateral thigh Hip flexors weakness

33. L3 radiculopathy Pain, paresthesia and sensory loss in medial thigh and knee Weakness of hip flexors, hip adductors and knee extensors Knee jerk maybe decreased

34. L4 radiculopathy L4 Root Compression * Sensory Deficit Posterolateral thigh, anterior knee, and medial leg Motor Weakness Quadriceps (variable) Hip adductors (variable) Anterior Tibial Weakness Reflex change Patellar tendon Anterior tibial tendon (variable) BOX 39.2 *Indicative of L3-4 disc herniation or pathologic condition localized to L4 foramen.

35. L5 radiculopathy L5 Root Compression * Sensory Deficit Anterolateral leg, dorsum of the foot, and great toe Motor Weakness Extensor hallucis longus Gluteus medius Extensor digitorum longus and brevis Reflex Change Usually none Posterior tibial (difficult to elicit) BOX 39.3 *Indicative of L4-5 disc herniation or pathologic condition localized to L5 foramen.

36. Nerve Root Dermatomal area Myotomal area Reflexive changes L1 Inguinal region Hip flexors L2 Anterior mid-thigh Hip flexors L3 Distal anterior thigh Hip flexors and knee extensors Diminished or absent patellar reflex L4 Medial lower leg/foot Tibalis anterior,hip adductors,quardiceps Diminished or absent patellar reflex L5 Lateral leg/foot Hallux extension , hip abductors, extensor digitorium longus and brevis

37. Management History and examination- localization of level X-rays - may indicate tumors, infections, listhesis MRI- localization of nerve root, anatomic location, unilateral or bilateral NCS and EMG

38. Non pharmacological therapies Hot compression Physical therapy Lumbar supports- no evidence to support Bed rest- short duration, increase activity as tolerated

39. Pharmacological therapy NSAIDS Muscle relaxants Tramadol TCA Opioids Interventional techniques like SNRB, epidural steroids, etc

40. Surgical management Indications: Not responding to conservative management Worsening symptoms Signs and symptoms of caudal equina syndrome Disabling pain with poor quality of life

41. Operative treatment 1. Disectomy Traditional open dissectomy with laminectomy Microdisectomy Microscopic discectomy Minimally invasive: endoscopic discectomy

42. Others operative technique Spinal fusion : ALIF LIF PLIF TLIF Disc replacement Other surgeries as per cause