[13] Radiculopathy Flashcards
What is a radiculopathy?
A conduction block in the axons of a spinal nerve or its roots
What does the impact of radiculopathy on motor axons cause?
Weakness
What does the impact of radiculopathy on sensory neurones cause?
Paresthesia and/or anaesthesia
What is radicular pain?
Pain deriving from damage or irritation of the spinal nerve tissue, particularly the dorsal root ganglion
Is radiculopathy associated with radicular pain?
It may or may not be
Where do the anterior and posterior roots of the spinal nerves unite?
Within the intervertebral foramina
Where do the anterior and posterior roots of the spinal nerve originate from?
Both roots originate from the cord
What happens to the anterior and posterior roots of the spinal nerves once they have originated from the cord?
They pass to their appropriate intervertebral foramine, where each evaginates the dura mater separetely before uniting to form the mixed spinal nerve
What is radiuclopathy most commonly a result of?
Nerve compression
What can cause nerve compression?
- Intervertebral disc prolapse
- Degenerative diseases of spine
- Fracture
- Malignancy
- Infection
What causes intervertebral disc prolapse?
Repeated minor stresses that predispose to rupture of the annulus fibrosis and sequesteration of the disc material (the nucleus pulposus)
Which region of the spine is predominantly affected by intervertebral disc prolapse?
The lumbar spine
How can degenerative diseases of the spine cause nerve compression?
It can lead to neuroforaminal or spinal canal stenosis
Which section of the spine is most likely to have degenerative changes?
Cervical spine - degenerative changes are a normal part of the ageing process
Why is the cervical spine the most susceptible to degenerative change?
Because it is the most mobile segment
What % of the population over 55 years old have degenerative change between C5/6 and C6/7?
80%
What kind of malignancy is most commonly found in the spine?
Most commonly metastatic
What infections can cause nerve compression?
- Extradural abscesses
- Osteomyelitis (most commonly TB)
- Herpes Zoster
What are the clinical features of radiculopathy?
- Sensory features, including paresthesia and numbness
- Motor features, including weakness
- Radicular pain
What is radicular pain typically described as?
Lancinating, burning, deep, strap-like, or narrow pain
It is not uncommon for radicular pain to be intermittent
Why should ‘red flag’ symptoms be asked for in patients presenting with suspected radiculopathy?
It may indicate emergency or sinister pathology
What is it important to identify on examination in radiculopathy?
Dermatomal and myotomy involvement
What should be excluded on examination of radiculopathy?
Cauda equina syndrome
How is cauda equina syndome assessed for on examination?
- Pinprick sensation in the perianal dermatomes
- Anocutaneous reflex
- Anal tone
- Rectal pressure sensation
What will be found on assessment of the perianal dermatones in cauda equina syndrome?
Reduced
What will be found on assessment of the anocutaneous reflex in cauda equina syndrome?
Diminished or absent
What will be found on assessment of the anal tone in cauda equina syndrome?
Reduced
What will be found on assessment of rectal pressure sensation in cauda equina syndrome?
Reduced
What red flag symptoms are associated with cauda equina syndrome?
- Faecal incontinence
- Urinary retention (painless with secondary overflow incontinence)
- Saddle anaesthesia
What red flags are associated with infection in radiculopathy?
- Immunosuppression
- Intravenous drug abuse
- Unexplained fever
What red flag is associated with fracture or infection in radiculopathy?
Chronic steroid use
What red flags are associated with fracture in radiculopathy?
- Significant trauma
- Osteoporosis or metabolic bone disease
What red flag is associated with malignancy in radiculopathy?
New onset after 50 years old
What red flag is associated with metastatic disease in radiculopathy?
History of malignancy
What should the differential diagnosis for radicular pain include?
Pseudoradicular pain syndromes
What are pseudoradicular pain syndromes?
Conditions that do not directly arise from nerve root dysfunction, but do cause radiating limb pain in an approximate radicular pattern
What conditions do pseudoradicular pain syndromes include?
- Referred pain
- Myofascial pain
- Thoracic outlet syndrome
- Greater trochanteric bursitis
- Iliotibial band syndrome
- Meralgia paresthetica
- Piriformis syndrome
Give three examples of referred pain?
- Into the arm from myocardial ischaemia
- Into the right shoulder from hepatobiliary disdase
- Into the flank, groin, or thigh from urinary tract and perinephric symptoms
Give two examples of how myofascial pain can mimic radiculopathy
- Hip muscles can mimic pain from lumbar radiculopathy
- Shoulder girdle muscles can produce pain radiating into the upper extremity
How can myofascial pain be differentiated from radicular pain?
Examine for tenderness at specific muscle sites which when palpated produce radiating pain
What is thoracic outlet syndrome?
Compression or irritation of the stuctures between the base of the neck and axilla due to anatomical variations
How can greater trochanteric bursitis be differentiated from radiculopathy?
Usually palpation will reveal the area of imflammation, typically over the superolateral aspect of the trochanter
What causes illiotibial band syndrome?
Excessive friction between the iliotibila band and underlying bursa, often in long distance runners or cyclists
What is iliotibial band syndrome often associated with?
Tightness of the iliotibial tract
Where is the pain felt in iliotibial band syndrome?
2-3cm proximal to the knee joint
What is meralgia paresthetica?
Compression of the lateral cutaneous nerve of the thigh as it passes under the inguinal ligament
How does meralgia paresthetica present?
With a clearly demarcated area of paresthesia and/or numbness in the anterolateral aspect of the thigh
What happens in piriformis syndrome?
Anatomic variations in either the muscle or the sciatic nerve can cause pain in the region of the sacroiliac joint or the sciatic notch
What determines the definitive long-term management of radiculopathy?
The underlying cause
Which of the conditions causing radiculopathy require emergency surgical treatment?
Cauda equina syndrome
Can most IV disc prolapses be managed non-operatively?
Yes
What are the indications for surgical treatment of IV disc prolapse?
- Unremitting pain despite comprehensive non-surgical management
- Progressive weakness
- New or progressive myelopathy
What analgesia is used in radiculopathy?
The WHO analgesic ladder can be utilised, however neuropathic pain medications are frequently utilised. Amitriptyline is usually first line, which may then be added to GABA antagonists such as pregabalin or gabapentil.
How can muscle spasms that may be experienced by radiculopathy patients be managed?
With benzodiazepines and/or baclofen
