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

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 sharpshooting 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 wont 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-L1anterior horn

1. Cervical Radiculopathy
C7 most common

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 dont

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.

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 variablebut it is going to progress.

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
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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

vascular supply to
the disc space from
the cartilaginous
endplate
1. segmental
radicular artery
2. interosseous
artery
3. capillary tuft
4. disc anulus

Internal disruption

Back Pain Causes

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

disc bulge
spinal stenosis
biomechanical
inflammatory
infection
cancer

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

30

Incomplete Cord Syndrome

Cauda Equina Syndrome

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

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
Autonomic
- Loss of bladder and bowel funsction
- Urinary retention

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

34

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
35

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

36

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 2550% in asymptomatic people!

Current techniques are not helpful in

identifying the source of the somatic pain

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

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

TERIMA
The
KASIH
End