Radicular Syndrome

Darwin Amir
Bgn Ilmu Penyakit Saraf
Fakultas Kedokteran
Universitas Andalas
Peripheral Nerves and Nerve Plexuses

C1
C2
Cervical plexus C3
C4
C4
C4
C4 Phrenic nerve
Brachial plexus C4
T1
T2
T3 Axillary nerve
T4
T5
T6
T7 Musculocutaneous nerve
T8
T9
Thoracic nerves
T10
T11
T12
L1 Radial nerve
Lumbar plexus L2
L3
Ulnar nerve
L4 Median nerve
L5
S1
Sacral plexus S2
S3
S4
S5
Co1 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 sharp-shooting 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 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
 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
Root Pain (*less Paresthesias/Numbness Weakness Reflex loss
reliable for (*more reliable for
localization) localization)
C5 Neck, shoulder Lateral arm Shoulder abduction and external Biceps,
rotation, elbow flexion and forearm brachioradialis
supination
C6 Neck, shoulder, Lateral forearm, thumb Shoulder abduction and external Biceps,
lateral arm and and index finger rotation, elbow flexion and forearm brachioradialis
forearm, lateral supination and pronation
hand
C7 Neck, shoulder, Index and middle Elbow and wrist extension, forearm Triceps
middle finger, fingers, palm pronation, wrist flexion
hand
C8 Shoulder, Medial forearm and Finger extension, some wrist None
medial forearm, hand, fourth and fifth extension, distal finger and thumb
fourth and fifth digits flexion, finger abduction and
digits adduction
T1 Medial arm and Medial forearm; also Thumb abduction most affected; None
forearm, sometimes fourth and finger abduction and adduction
axillary chest fifth digits
wall
 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.
 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
Internal disruption
 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

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 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
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 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

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 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

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 Back Pain Causes

de-conditioning disc bulge

sprain/strain spinal stenosis
spondylolithesis biomechanical
spondylosis inflammatory
facet syndrome infection
disc herniation cancer
 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.