Transcript Group A – AHD Dr. Gary Greenberg

Group B – AHD
Dr. Gary Greenberg
SPINAL NERVE ROOT COMPRESSION AND
PERIPHERAL NERVE DISORDERS
Objectives
 Review Assessment and Management of
Important Spinal Nerve Disorders Involving
the Cervical, Thoracic and Lumbar Spine.
 Review Assessment and Management of
Common Peripheral Nerve Disorders.
 Review Assessment of Important
 Mono/Polyneuropathies .
Case 1
 70 year old male, history of mild neck pain for 2 yrs.
 Gradual worsening mid cervical pain for 1 month.
 Radiating down right arm to hand.
 Numbness, tingling and weakness.
 Now pain severe, unremitting.
 Unable to sleep in spite of taking Tylenol #3.
 What historical factors would help you assess
this patient?
Historical Factors?
 1) Trauma – recent falls.
 2) Cancer- remote/recent history.
 3) Cervical spondylosis.
 4) Fever, weight loss.
 5) Immunosuppression.
 6) Bone thinning disease ( Rheumatoid
arthritis, Multiple Myeloma ).
RED FLAGS
 What are some of the RED FLAGS that come up
in taking a history that make you think there
might be a more serious condition present?
RED FLAGS
 Significant trauma pt. < 50 yrs.
 Mild trauma pt. > 50 yrs.
 Unexplained weight loss.
 Unexplained fever.
 Immunosupression.
 Cancer Hx.
 Night pain.
 IV drug use.
Red Flags
Osteoporosis.
Prolonged Steroid use.
Age >70.
Focal Neuro Deficits.
Disabling symptoms.
Duration > 6 weeks.
Pain not relieved by laying supine.
What physical
examination findings
would you look for?
Physical Examination
TENDERNESS CERVICAL SPINE.
MOTION IN THE NECK
FOCAL WEAKNESS
SENSORY LOSS
REFLEX LOSS
Case 1
 What are some of the causes of Neck Pain +
Radicular Pain + Weakness ?
Causes: Neck pain + Radicular pain + Weakness
 Idiopathic- congenital spinal stenosis.
 Traumatic- fracture.
 Degenerative- Disc herniation, foraminal
stenosis, cervical spondylosis.
 Neoplasm.
 Infection.
Neck Pain
 Can Cervical Disc Disease cause gait disturbance?
Important notes
 Central Disc Disease – can cause gait disturbance,
neurogenic bladder, loss of anal tone.
Neck Pain
 Are Neoplastic mets to C-spine common?
Important notes
 Neoplasm- mets to C-spine 8-20% of all spinal mets.
Neck Pain
 What is the classic presentation of Neoplastic mets
to the C-spine?
Important notes
 Neoplasm- neuro symptoms + severe pain.
Neck Pain
 Is fever a common finding in infection of the C-
spine?
Important notes
 Infection- C-spine least common site, only 50 % have
fever.
Neck Pain
 Name important risk factors for infection in the C-
spine.
Important notes
 Infection risk factors- IV drug use, diabetes,
alcoholism, malignancy, corticosteroids.
Cervical Radiculopathy
 Describe the incidence , Reflex, Sensory and motor
loss for the following levels involved:
 C5 radiculopathy.
 C6 radiculopathy
 C7 radiculopathy.
 C8 radiculopathy.
What level of Cervical radiculopathy is involved ?
 C5 – 2% incidence. Reflex loss- Biceps.
 C6- 22% incidence. Reflex loss- None.
 C7- 70% incidence. Reflex loss- Triceps.
 C8- 6% incidence.
Reflex loss- None.
Cervical Radiculopathy
Sensory loss
C5 - proximal lat. arm
 C6- lat. Forearm/thumb.
 C7 -2-4th fingers.
 C8 - 5th finger.
Cervical Radiculopathy
 Motor loss
 C5- Deltoid, infra/supraspinatus, biceps.
 C6- Biceps, deltoid, brachioradialis, pronator teres.
 C7 – Triceps , wrist flexors and extensors.
 C8- Thumb abduction, finger flexion and extension.
Cervical Imaging
 What is the value of a C-spine x-ray?
IMAGING
 X-rays- fractures, confirms degenerative changes.
Cervical Imaging
 When should an MRI be ordered?
IMAGING
 MRI- shows foramina and discs best.
Cervical Imaging
 When should a CT scan be ordered?
IMAGING
 CT- Only good for occult fractures.
Neck Pain
 How long does it take for most neck pain from non
pathological causes to resolve?
Neck pain
 Most neck pain resolves in 3-6 weeks.
Neck Pain
 What factors may extend that time frame?
Neck pain
 Automobile related neck injuries- 20-70% have pain
after 6 months.
 Work related neck injuries- may last years if not
resolved in 8 weeks.
Thoracic Pain
 Name some common causes of persistent thoracic
back pain.
Thoracic Spinal Nerves
 Causes:
 Diskitis
 Thoracic disc bulge.
 Compression fractures- trauma, osteoporosis.
 Tumour- most common site in spine .
Thoracic Pain
 What is the most common tumor to cause mets to
the thoracic spine?
Thoracic Spinal Nerves
 Tumour: Lung, Breast, Prostate, Kidney, Thyroid.
Thoracic Pain
 If a Thoracic Spinal nerve is compressed, is there
motor weakness?
Thoracic Spinal Nerves
 Most usually have pain without motor weakness.
Thoracic Pain
 If the spinal cord is compressed, what are the clinical
findings ?
Thoracic Spinal Nerves
 If motor Involvement- often complete weakness of
both legs with areflexia due to spinal cord
compression.
Case 2
 45 year old male.
 Acute onset low back pain radiating down left leg to
toes.
 Initial Rx Tylenol & Advil.
 After 1 week, severe constant unremitting pain in left leg.
 Unable to sit, bend forward , sleep.
 What historical features should
be asked?
Historical Factors?
 1) Trauma – recent falls.
 2) Cancer- remote/recent history.
 3) Lumbar spondylosis.
 4) Fever, weight loss.
 5) Immunosuppression.
 6) Bone thinning disease ( Rheumatoid
arthritis, Multiple Myeloma ).
RED FLAGS
 What are some of the RED FLAGS that might
come up in a history of low back pain that make
you think there might be a more serious
condition present?
RED FLAGS
 Significant trauma pt. < 50 yrs.
 Mild trauma pt. > 50 yrs.
 Unexplained weight loss.
 Unexplained fever.
 Immunosupression.
 Cancer Hx.
 Night pain.
 IV drug use.
Red Flags
Osteoporosis.
Prolonged Steroid use.
Age >70.
Focal Neuro Deficits.
Disabling symptoms.
Duration > 6 weeks.
Pain not relieved by laying supine.
Historical features
RED Flags +
Saddle anaesthesia
Bowel symptoms
Bladder symptoms
Questions
 What levels are the most common sites for fractures
of the lumbar spine?
 What levels are the most common sites for disc
herniations?
 What cancers metastasize to the lumbar spine?
Answers
 Most common site for fractures are L1, L2.
 Most common site for Disc herniations are L4-5, L5-
S1.
 Cancers that metastasize to lumbar spine are:
 Colorectal, Breast, Cervical, Lymphoma, Sarcoma.
Sciatica
 How often does sciatica due to disc herniation occur
in low back pain patients?
 How often does sciatica due to disc herniation go on
to develop quada equinae?
 Generally what nerve root does the L4-5 disk
herniation affect?
Notes
 Sciatic pain secondary to disk herniation occurs in only2%
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of patients with low back pain.
< 1% of sciatica goes on to develop cauda equinae.
Nerve roots exit below vertebra body, above the disk.
Eg. L4-5 disk affects the L5 nerve root.
95 % lumbar disk herniations occur from L4-S1 levels.
Sciatica
 Why do most sciatica patients get better over time
and do not require surgery?
Notes
 Many patients have degenerative changes in the vertebrae,
especially the facet joints.
 With age- disk dehydration, loss of disk height, disk
herniation can result in nerve root compression.
 As the disk desicates over time, it shrinks, pulling away
from the nerve root.
Sciatica
 What is the value of SLR, reflexes in the examination
of sciatica?
Sciatica
 + SLR only if lifting leg causes increased LEG pain.
 Radicular sciatica goes beyond the knee.
 Check sensation with sharp objects, not light touch.
 Reflexes not useful especially in the elderly.
Assessment
 Describe the motor , sensory, reflex findings for the
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following nerve root compressions:
L1
L2
L3
L4
L5
S1
S2-4
Assessment- Sensory
 Sensory findings for the following nerve root
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compressions: reduced pin prick
L1- inguinal area
L2-middle inner thigh
L3- distal medial thigh.
L4- inner aspect calf, medial aspect big toe.
L5- 1st web space between 1st & 2nd toes
S1- lateral aspect of foot, 5th toe.
S2-4 – perianal area.
Assessment- Reflex
 Reflex findings for the following nerve root
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compressions:
L1-loss of superficial anal reflex, cremasteric reflex.
L2-loss of superficial anal reflex, cremasteric reflex.
L3- no reflex loss.
L4- loss of patellar tendon reflex.
L5- no reflex loss.
S1- loss of achilles tendon reflex.
S2-4 – no reflex loss
Assessment- Motor
 Root
 L1,L2
 L3,L4
Muscle
Iliopsoas
Quadriceps
 Action
 Hip flexion
 Knee extension
 L5
Ext. Hallucis
 Big toe extension
 S1
Biceps femoris
 Knee flexion
 S1
 S1,S2
 S2-S4
Peroneal
Soleus, gastroc.
Rectal sphincter
 Foot eversion
 Plantar flexion ankle
 Sphincter tone
Assessment
 Root
 L1
 L2,L3
 L4
 L5
 S1
 S2-S4
Sensory Area
Inguinal crease
Medial thigh
Medial calf
1st web space ( 1st – 2nd toes )
Lateral aspect of foot
Perianal sensation
Imaging
 What is the value of plain x-rays of the lumbar spine?
Imaging
 X-rays if:
 <18 , > 50 yrs. old.
 Hx Cancer- won’t show change till 30% bone
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destruction.
Hx fever, IV drug use, immunocompromise.
Major trauma.
Osteoporosis.
Symptoms > 6 weeks.
Imaging
 What is the value of a CT scan of the lumbar spine?
Imaging
 Can be used for known fractures.
Imaging
 What is the value of MRI of the lumbar spine?
Imaging
MRI better than CT ( no radiation exposure )
Better resolution of soft tissue, spinal cord, epidural
space.
Treatment of Back pain
 Most patients have non specific low back pain.
 Most have pain resolution in 4 weeks.
 Subacute LBP last 4-2 weeks.
 Chronic LBP lasts > 12 weeks.
 WHAT WOULD BE POSSIBLE TREATMENT
OPTIONS FOR LOW BACK PAIN ?
Literature Review- NO BENEFIT
 Firmer mattress
 TENS
 Lumbar support
 Ultrasound
 Muscle relaxants
 Traction
 Benzodiazepines
 Short wave diathermy
 Gabapentin
 Low level laser
 Bed rest
 Interferential
 Epidural corticosteroids
Recommend
 NSAIDS + Acetominophen for acute exacerbations of
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subacute and chronic LBP.
Opoids only for short duration in pts. with low
vulnerability for drug abuse.
Trycyclics are good for chronic LBP.
Home & supervised exercise program ( stretching
and strengthening ).
Some people may benefit from Cognitive behavioural
therapy, Yoga, massage, spinal manipulation ( all
moderately more effective than sham/placebo Rx ).
Surgery for Sciatica
 What are the indications for surgery for sciatica?
Surgery for Sciatica
 50 % of sciatica pts. get better in 6 weeks on their
own.
 Surgery is good for :
 Intractable pain.
 Worsening neuro deficits.
 No improvement in 6 weeks with conservative
treatment.
Spinal Stenosis
 Describe the features of a patient with Spinal
Stenosis?
Spinal Stenosis
 Local segmental or generalized narrowing of the
central spinal canal by bone or soft tissue elements
( Hypertrophic facets, thick ligamentum flavum ).
Features: Diffuse back pain in older patient.
Transient tingling in legs ( both ).
Ambulation induced pain in calf/lower leg.
Resolves with sitting, forward flexion, rest.
Worse with back extension.
SLR + ve in 50%.
Treatment conservative unless failed Rx > 3 months.
Cauda Equinae
 Describe the clinical features of Cauda Equina.
 What are some of the causes?
Cauda Equinae
 Loss of Bowel / Bladder control ( 90 % have retention )
 Saddle anaesthesia.
 Reduced rectal tone.
 Weakness in lower extremities.
 Related to compression of spinal nerve roots due to:
 Tumour, bony stenosis or disc herniation ( central ).
 Tumours- Prostate, colorectal, non Hodgkins lymphoma,
sarcoma, GYN tumours, Renal Cell Ca, multiple
myeloma.
Cauda Equinae
 How do you check for anal tone?
 What amount of residual post void urine would
qualify as urinary retention?
 What is the imaging of choice?
Cauda Equinae
 Check anal tone – resistance to finger entering.
- buttock squeeze test.
 Post void test – if > 200 cc ( urinary retention ).
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 MRI imaging of choice
 Refer to Neurosurgeon if confirmed.
Other Peripheral Nerve Compression Syndromes
 Median Nerve Entrapment- Carpal Tunnel, Pronator
Teres Syndromes.
 Ulnar Nerve Compression- at elbow, at wrist.
 Radial Nerve Compression- Spiral groove, posterior
interosseus.
Median Nerve Compression
 Describe the causes, symptoms and clinical findings
of carpal tunnel syndrome?
Median Nerve- Carpal Tunnel Syndrome
 Compression of median nerve thru carpal tunnel ( axonal dysfunction ).
 Causes: Pain, Paraethesias in hands and later weakness of median
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nerve.
Assoc. Conditions- pregnancy, diabetes, hypothyroid, renal failure.
Usually caused by overuse- swelling of flexor tendons.
Findings: Sensory loss volar 1st 3 fingers + lat. 4th finger, normal thenar
Motor loss: weak thumb abduction, flexion MCP jts.
Examination: Tinel sign ( taping tunnel ) 50-60%sens. 67-77% specific.
Phalens sign ( palmar flexion > 30 sec. ) 70 % sens., 47-73 % specific.
Median Nerve- Carpal Tunnel Syndrome
 Describe the initial treatment for Carpal Tunnel .
 Are NSAIDS useful?
 Predictive factors for failure of conservative
measures?
 Place for surgery?
Median Nerve – Carpal Tunnel Treatment
 Conservative: Nocturnal splinting, oral
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corticosteroids ( 2 weeks ), corticosteroid injections,
Yoga.
NSAIDS no help compared to placebo.
Prediction of failure Conservative RX:
Age > 50, Duration > 10 months, constant
paraethesias, impaired 2 point discrimination, +ve
Phalens sign < 30 seconds, Prolonged motor and
sensory latency on NCS& EMG.
Surgery- Best long term relief of symptoms.
Median Nerve – Pronator Teres Syndrome
 What are the different features compared to Carpal
Tunnel Syndrome?
Median Nerve- Pronator Teres Syndrome
 Median nerve entrapment in proximal forearm.
 Forearm flexor pain.
 Same findings as carpal tunnel EXCEPT:
 Numbness thenar eminence and weak thenar
muscles.
 Treatment: rest, corticosteroid inj., surgery if
persistent symptoms.
Ulnar Nerve Compression
 Describe the findings of ulnar nerve compression at
the elbow.
 Describe ulnar nerve compression at the wrist.
Ulnar Nerve Compression
 At the Elbow: at the epicondylar groove.
 Leaning on the elbow.
 Numbness 4th-5th fingers.
 Weak finger and wrist FLEXION, Ulnar deviation
wrist., weak abduction of the index finger.
 At the wrist: in Guyon’s canal.
 Numbness 4th-5th fingers.
 Weak interossei, Finger FLEXION Spared.
Radial Nerve Compression
 Describe the findings of Radial nerve compression at
the spiral groove.
 Describe the findings of Posterior interosseus
Neuropathy.
Radial Nerve Compression
 At Spiral Groove: Saturday night palsy- shoulder vs arm
of sofa.
 Numbness 1st web space dorsally
 Weak wrist ( drop ) and finger extension, brachioradialis.
Triceps spared.
 Recovery with wrist splint in 6-8 weeks.
 Posterior Interosseus Neuropathy- a branch of radial
nerve proximal to elbow, innervates forearm extensorsweak 3rd finger extension and forearm supination.
Nerve Conduction studies
 Good for delineation of severity of Median,Ulnar or
Radial nerve dysfunction.
Mono and Polyneuropathies
 Important to know if sensorimotor findings are:
 Symmetric or Asymmetric.
 Distal or distal and proximal.
 Sensory only, Motor only or mixed.
Guillain-Barre Syndrome
 Acute Inflammatory Polyradiculoneuropathy.
 Immune mediated inflammation of peripheral
nerves disrupting myelin and causing axonal loss.
 Most common acute motor neuropathy.
 Usually has a preceding history of a URI or GI illness
preceeding the onset.
 Describe the symptoms and findings.
Guillain Barre Syndrome
 Progressive Symmetric WEAKNESS of proximal +
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distal muscles .
May involve cranial nerves in up to 50 % cases.
Loss of DTR.
Variable sensory findings ( can occur in 33%)
Sparing of anal tone.
May have urinary retention ( autonomic
dysfunction).
Patients with primarily sensory signs are unlikely to
have respiratory distress.
Guillain Barre Syndrome
 50% have autonomic dysfunction- fluctuating BP,
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pulse.
Peaks at 1 week.
Some cranial nerve dysfunction ( 7th nerve ).
33 % require respiratory support.
3% mortaility / recurrence rate.
Describe the lab and imaging abnormalities:
Guillain Barre Syndrome
 CSF analysis: Elevated protein, no increased WBC.
 EMG/NCS- show demyelination disorder, loss of 80
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% of normal muscle action potential suggests poor
prognosis.
MRI shows enhancement of anterior spinal nerve
roots.
FEV1.0, ABG, to check for CO2 retention.
May need prophylactic intubation.
Check for extensor neck strength.
Guillain Barre Syndrome
 What is the treatment for GBS?
Treatment
 Plasmapheresis.
 Pooled IV gammaglobulin.
 Supportive care.
 Ventilatory help if needed.
 Corticosteroids not helpful.
Distal Symmetric Polyneuropathy
 Stocking glove sensory distribution.
 Motor findings lag behind sensory.
 Progress distal to proximal.
 Causes: Diabetes, Alcoholism, Neoplasm, HIV,
Toxins, drugs.
 Describe the findings in Diabetic neuropathy:
Diabetic Neuropathy
 Dysaesthesias ( tingling, burning ) plantar aspect
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feet.
Weakness big toe extension 1st motor sign.
Followed by weak dorsiflexion ankle, foot drop, loss
of ankle jerks.
Sensory loss moves to knees and fingers.
DTR eventually lost.
Proprioception loss and may develop sensory ataxia.
Diabetic Neuropathy
 Treatment:
 Tricyclics ( Elavil 25 mg qhs ).
 Tegretol 200mg Q8h.
 SSRI ( Paroxetine ).
 No help from Trazadone, Dilantin, topical capsaicin.
Mononeuropathy Multiplex
 Asymmetric Sensorimotor peripheral neuroathy.
 Sensory findings match the motor findings.
 May have reflex loss depending on the nerve
involved.
 Causes:
 Diabetes most common, vasculitis second.
 Others Neoplasm, Lyme disease, HIV, Sarcoid
Anterior horn cell Neuronopathy- ALS
 Amyotrophic Lateral Sclerosis.
 Asymmetrical distal motor weakness with no sensory
loss.
 Subclinical Autonomic dysfunction.
 Has both Upper and Lower motor neuron signs.
 What are they?
ALS
 Upper Motor Neuron findings:
 Hyperreflexia – sustained ankle clonus
 Spasticity.
 Positive Babinski.
 Lower motor Neuron findings:
 Fasiculations.
 Cramps.
 Asymmetrical distal weakness with atrophy.
ALS
 EMG confirms the diagnosis.
 Treatment supportive only.
Sensory Neuronopathies
 Affects dorsal root ganglions.
 Pure sensory syndrome.
 No motor weakness.
 Loss of DTR.
 Loss of proprioception.
 Sensory ataxia.
Sensory Neuronopathy
 Causes: Herpes Simplex, Paraneoplastic syndromes,
Sjogrens, Vitamin deficiencies.
 Diagnoses via MRI of the spinal cord.