Peripheral Nervous

System
 The ventral and dorsal roots of the spinal cord unite
to form the mixed spinal nerve roots, which than
travels through the intervertebral foramen. There are
8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1
coccygeal spinal segments. There are 3 nervous
plexuses: cervical, brachial and lumbosacral
The peripheral nerves emerging from these plexuses
each contain fibers from multiple nerve roots.
Each root supplies a specific area of the skin
(dermatoma) and innervates a characteristic group of
muscles (myotoma)
 Radicular syndroms
Clinical manifestations:
pain and sensory deficit in the corresponding
dermatoma
motor deficits and in severe cases muscle
atrophy
osteotendinous reflexes diminished/abolished
Causes: stenosis processes through the
intervertebral foramina, disc protrusion, disc
herniation, infectious processes of the vertebral
bodies, tumors, trauma.
Hal Blumenfeld - Neuroanathomy
through clinical cases
Radicular syndroms-cervical
roots
The most common cause is the disc herniation. The roots most
commenly involved: C7 (70%), C6 (20%), C5 and, C8 (10%)

C5 radiculopathy (C4-C5 disc): pain in the shoulder and trapezius region,

weakness of the supra- and infraspinatus muscles (inability to abduct the
arm and rotate it externally with the shoulder adducted), deltoid, biceps,
brachioradialis ,diminished sensation on the deltoid muscle, diminished
biceps reflex.
C6 radiculopathy (C5-C6 disc): pain on the trapezius region and tip of
the shoulder, iradiating into the anterior-upper part of the arm, radial
forearm, thumb and lateral index, paresthesia and sensory impairment in
the same region, weakness of the serratus ant, biceps, flexor carpi radialis,
brachioradialis, extensor carpi radialis longus, supinator, extensor carpi
radialis brevis, weakness in flexion and pronation of the forearm, finger
and wrist extension, diminished/abolished biceps and stiloradial
reflexes.
 Radicular syndroms
C7 radiculopathy (C6-C7 disc): pain in the shoulder blade,
spine of the scapula, post-lat upper arm, iradiating in the
elbow, dorsal forearm, index and middle fingers, paresthesia
and sensory loss mostly in the index and middle fingers,
weakness of the serratus ant, pectoralis major, latissimus
dorsi, pronator teres, flexor carpi radialis, triceps, extensors
of the forearm and some times of the wrist, weakness of the
forearm extension, triceps reflex diminished/abolished.
C8 radiculopathy (C7-T1 disc): pain on the medial side of
the forearm, sensory loss in the distibution area of medial
cutaneous nerve of the forearm and the ulnar nerve in the
hand, weakness of the intrinsec muscles supplied by the
ulnar nerve (flexors muscles), triceps reflex diminished.
Hal Blumenfeld -
Neuroanathomy through
 Radicular syndroms-lumbar
roots
The roots most commonly involved: L5, S1.

L5: pain in the region of the hip and post-lat thigh (sciatica), lat calf,
dorsal surface of the foot and the I- IV toes, paresthesia and sensory
diminished in lat calf, dorsal surface of the foot, I-IV toes, weakness
in the extensors of the haluce and foot and the foot invertors, (thigh
adduction, knee flexion, dorsiflexion of the foot and toes), reflexes
are normal. Weakness of extension muscles of the foot and toes
(plantar extension).
S1: pain in the midgluteal region, post tight, post calf to the heel,
lateral plantar surface , and V toe. Paresthesia and sensory loss in
the lower part post-inf of the calf, planta and II-V toes, weakness in
plantar flexor muscles of the foot and toes, abductors of the toes and
hamstring muscles (hip extension). Achilles reflex
diminished/abolished . Weakness of plantar flexion muscles.
Radicular syndroms-lumbar
roots
L3, L4: pain in the ant part of the
tight and knee, anteromedial part of
the calf, sensory loss in the
corespondent dermatomas, patellar
reflex is diminished/abolished. L3:
weakness of the quadriceps, tight
adductor, ileopsoas. L4: anterior
tibial innervated muscles.
L1: pain in the groin
L2: pain in the lateral hip
 CAUDA EQUINA SYNDROME
-compression of the lumbar and sacral roots below the
L3 vertebral level
-radicular pain in the distribution of the lumbosacral
roots; may be unilateral/asymmetric
- asymmetric, flaccid, hypotonic, areflexic paralysis
(peripheral type of paraplegia)
- asymmetric sensory loss in the saddle region (anal,
perineal, genital regions, dorsal aspect of the thigh)
-Achilles reflexes are lost, the patellar reflexes are
variable
-sphincter dysfunction (urinary retention, constipation)
-impaired erection
 Diagnosis
Spine MRI
Needle EMG : fibrillation potentials in
denervated muscles after about 10
days
 Lumbar stenosis
Osteoarthritic and degenerative changes in the
lumbar region lead to compression of one or more
lumbar and sacral roots.
neurogenic claudication=gradual onset of
numbness and weakness of the legs in standing or
walking. Often asymetrical sciatic, calf or buttock
discomfort. The achilles reflex disappear after
walking a distance. The patient is forced to sit down.
DD with vascular claudication : appearance in the
standing position, relief sitting or leaning forward, in
about 5-15 min, numbness, loss of reflexes after
walking, preservation of distal leg pulses.
 Brachial plexopathies
Lesions of the entire BP
entire arm is paralyzed and hangs at
the side
all the arm muscles undergo rapid
atrophy
complete sensory loss below a line
extending from the tip of the shoulder
diagonally down to the medial arm
halfway to the elbow. reflexes are lost
 Upper BP paralysis (C5,C6)
Erb Duchenne palsy
muscles affected: biceps, deltoid, brachioradialis,
brachialis, supraspinatus, infraspinatus
the arm hangs at a side, internally rotated and extended at
the elbow, the forearm is extended and pronated, the palm
facing out and backward
the patient cannot make shoulder abduction, elbow flexion,
external rotation of the arm and forearm supination.
sensory loss overlying the deltoid muscle
loss of stiloradial and bicipital reflexes
Causes: birth injury, rucksack paralysis, cadet palsy
(pressure on the shoulder), idiopathic plexitis
 Lower BP paralysis (C8-T1)
Dejerine-Klumpke palsy
muscles affected: small muscles of the hand
(clawhand)
the patient cannot make wrist and finger flexion
sensory loss on the medial arm, medial forearm,
ulnar aspect of the hand
loss of cubitopronator reflex
autonomic signs: Horner syndrome ipsilateral
Causes: trauma: arm traction in abduction,
surgical procedures, lung tumors (Pancoast Tobias)
Parsonage-Turner Syndrome
acute, severe pain located in the shoulder and
radiating into the arm, neck and back
the arm is held in a position of flexion at the elbow
and adduction at the shoulder (to avoid pain)
in several hours to days: weakness of the shoulder
and proximal arm muscles
sensory loss is mild
the pain usually disappears within several days
and it is followed by the atrophy of the muscles
Causes: idiopathic, viral illness, immunizations,
surgery
Hal Blumenfeld - Neuroanathomy
 Nerve Syndroms
RADIAL (C5-C8) NEUROPATHY
- wrist drop
- weakness of all extensors of the forearm, hand,
and fingers below the shoulder, and of the
forearm supinations
- sensory loss in a radial nerve distribution mostly
dorsal aspect of the I interossousus space
- loss of triceps reflex
Causes: Saturday night palsy, compression in
the axilla by improper crutch use, fracture of the
humerus, tight wrist bands or handcuffs.
 Nerve Syndroms
MEDIAN (C6-T1) NEUROPATHY
preachers hand
weakness of the wrist flexion and
abduction, opposition of the thumb, flexion
of the II and III digits
sensory loss in palmar aspects of I-III
fingers and thenar area.
Causes: honeymooner palsy, fractures of
the humerus/distal radius, entrapment
neuropathy (carpal tunnel syndrome)
CARPAL TUNNEL SYNDROME
compression of the median nerve as it passes under the flexor retinaculum
on the flexor surface of the wrist.
- median nerve innervate : Lumbricals I and II, Opponens pollicis, Abductor
pollicis brevis, Flexor pollicis brevis (LOAF)
- the patient cannot make the abduction of the thumb perpendicular to the
plane of the palm, thumb flexion and opposition also may be weak
- important pain and paresthesia mostly during the night (brahialgia
parestezica nocturna)
sensory loss in I- III fingers and thenar surface
- thenar atrophy in severe cases
- Tinel sign, Phalen sign are present

Causes: activities like typing (repetitive stress injury), pregnancy,

hypothyroidism, arthritis, uremia, diabetes, amyloidosis, trauma of the wrist.

Treatment: immobilization by a removable wrist splint, antiinflamatory,

surgical decompression.
 Nerve Syndroms
ULNAR ( C7-T1) NEUROPATHY
ulnar claw
weakness of the wrist flexion and adduction, fingers adduction and abduction,
and flexion of the IV and V fingers
Fromment sign
cubito-pronator reflex diminished/abolished
sensory loss and paresthesias in an ulnar distribution
atrophy and fasciculations in the hypothenar eminence in severe cases

Causes: most common-entrapment at the elbow in cubital canal (ulnar

groove) because of the trauma, degenerative changes, maintaining the elbow on a
hard table

Compression in the hand as the nerve passes over the hamate bone in Guyon
canal (prolonged cycling):
- Weakness of finger adduction and abduction
- no sensory loss
Hal Blumenfeld - Neuroanathomy through
clinical cases
Nerve Syndroms

SCIATIC NEUROPATHY (L4,L5,S1,S2)

2 divisions: tibial and peroneal nerves
-motor innervation: hamstring muscles and all
the muscles below the knee
-sensory loss: post aspect of the thight, post -
lat aspect of the leg, and the entire sole
-loss of reflexes
Causes: fractures of the pelvis or femur,
fracture/dislocation of the hip, hip arthroplasty,
tumors of the pelvis, lotus position for a long time
Nerve Syndroms

COMMON PERONEAL NEUROPATHY

(peroneal muscles, anterior tibialis, extensor digitorum
longus and brevis, extensor hallucis longus muscles)
-weakness: extension of the foot (foot drop) and foot
eversion
! Inversion is spared and make the difference beetween L5
and peroneal nerve lesions
-sensory impairment in the dorsum of the foot and ant-lat
aspect of the calf
Causes: pressure during an operation/sleep, prolonged
crossing of the legs while seated, tight knee boots
! The point of compression of the nerve is where it passes
over the head of the fibula
Nerve Syndroms

TIBIAL NEUROPATHY (plantar

flexors and invertors of the foot and
toes muscles, small muscles of the
food)
-weakness of the plantar flexors and
foot invertors
-loss of sensation over the plantar
aspect of the foot
 DIAGNOSIS

ELECTROMIOGRAPHY AND NERVE

CONDUCTION STUDIES
 POLYNEUROPATHY
DIABETIC NEUROPATHY
- common complication of diabetes mellitus
Clinical types;
1. -impairment of cranial nerves: III, VI, VII unilateral. In diabetic
ophthalmoplegia: weakness of the extraocular muscles but with pupil spared.
Acute/subacute evolution
2. -mononeuropathy : commonly affected: ulnar, radial, crural and common
peroneal nerves. Acute/subacute evolution
3. -mononeuritis multiplex: characteristic lumbar roots involved. Pain can be
severe, expecially at night. Early muscular atrophy and patellar reflexes abolished
are associated signs. Subacute evolution
4. -the distal, symetrical, primarily sensory form of PNP is the most common
type. The patient complains of persistent and distressing numbness and tingling
confined to the feet and lower legs. The Achillian and sometimes patellar reflexes
are diminished/lost . Characteristic sensory loss of the distal parts of the lower and
upper extremities. Chronic evolution
5. -the symetrical, proximal type of PNP with motor weakness and sensory
loss, usually without pain. Chronic evolution
 DIABETIC NEUROPATHY

6. -autonomic type: orthostatic

hypotension, fixed ventricular rate
unresponsive to the effort, impairment of
sweating and vascular reflexes,
gastroparesis, bladder dysfunction
7. -painfull thoracoabdominal
radiculopathy: severe pain in one/several
dermatomas of the chest or abdomen,
usually unilateral with sensory loss over the
involved areas. Can mimic acute abdomen
 GUILLAIN-BARRE SYNDROME (acute
inflammatory demyelinating polyneuropathy)

Clinical manifestations:
-paresthesias and slight numbness in the toes and fingers
- muscle and back pain increased by the elongation
maneuvres
-weakness of the proximal as well as distal muscles of the
limbs usually the lower extremities are affected first than
paralysis ascends to the upper extremities (Landry
ascending paralysis); the trunk, intercostal, neck, cranial
muscles may be affected later
-sensory loss in the distal parts of the limbs (deep and
superficial sensibility)
-reduced and abolished tendon reflexes occurs earlier and
are important findings
 GUILLAIN-BARRE
SYNDROME
-autonomic dysfunction: sinus
tachycardia/bradycardia,
hypertension/hypotension, loss of
sweating, urinary retention, paralytic
ileus
-respiratory failure
-facial diplegia occurs in more than
half cases
- amyotrophias are rarely and occurs
later
 This is an acute/subacute illness
A mild respiratory/gastrointestinal
infection or immunization may
precedes the onset of the GB sy by 1-
3 weeks
-hypothesis: campylobacter jejuni,
viral illnesses (herpetic vv)
Clinical types of GB sy:
-acute inflammatory demyelinating
poly radiculopathy most common
-sensorymotor acute axonal
neuropathy
-motor acute axonal neuropathy
-Miller-Fisher syndrome
(opftalmoplegia, ataxia and areflexia)
 Diagnosis GB syndrome
5-7 days from onset CSF
examination: elevated protein and
only a few cells (albumino-
cytological dissociation)
EMG examination: reduction in the
amplitude of muscle action
potentials, slowed conduction
velocity, conduction block in motor
nerves, prolonged distal latencies,
prolonged or absent F responses
 VARIANTS OF GB
SYNDROME
Limited weakness of the pharingeal-
cervical-brachial muscles: difficulty in
swallowing, dysphonia, with neck
and proximal arm weakness
Miller Fisher syndrome
Facial diplegia
Bilateral abducens palsy +/- facial
palsy
TREATMENT OF THE GB SYNDROME

Intensive care unit: monitoring of the

respiratory, autonomic and motor function
About 25% requires mechanical ventilation
Plasma exchange perform early relieves
respiratory symptoms and decreased the risk
of sequelae
IV Ig: 0,4g/kg per day for 5 consecutive days
Physical therapy (passive and active
movements)
! Corticosteroids are no longer be used
 The outcome is favorable in about
70%-full recovery but the recovery is
slow (weeks/months)
In some cases may be an incomplete
remission followed by a chronic,
fluctuating, slowly progressive
neuropathy: chronic inflammatory
demyelinating
polyradiculoneuropathy-CIDP