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MSK Week 2 > ICL 4.5: UE Radiculopathies > Flashcards

ICL 4.5: UE Radiculopathies Flashcards

1
Q

what is a radiculopathy?

A

commonly referred to as pinched nerve

refers to a set of conditions in which one or more nerve ROOTS are affected and do not work properly = a neuropathy

this can result in pain (radicular pain), weakness, numbness, or difficulty controlling specific muscles

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2
Q

how many pairs of spinal roots do you have?

A

31

ventral roots come from anterior horn and lateral gray matter = afferent neurons

dorsal roots come from dorsal root ganglion = efferent neurons

the roots combine to form the mixed spinal nerve which then split to form the anterior and posterior rami or divisions

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3
Q

T/F: all nerve roots exit the spinal cord above their corresponding vertebral level

A

false

C1-C7 cross above but then C8 goes below C7 and above T1 and the rest continue to do below

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4
Q

what is a myotome?

A

the muscles supplied by a specific nerve root

myotomes overlap! more than 1 nerve root can innervate a muscle

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5
Q

what is a dermatome?

A

the sensory distribution of a nerve root

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6
Q

what are the testing spots for the dermatomes of C5-T2?

A

C5 = lateral antecubital fossa (anterior shoulder to elbow)

C6 = thumb

C7 = middle finger

C8 = little finger

T1 = medial antecubital fossa (dorsal elbow to fingertips)

T2 = apex of axilla (armpit)

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7
Q

what is the pathophysiology of a radiculopathy?

A
  1. compression can be caused by disk herniation, osseous structures, tumors

presentation can be variable

  1. may have sensory or motor manifestations or both
  2. may have demyelination or axon loss
  3. reflex changes because of desynchronized slowing of the fibers that should be responding = hypo reflexive
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8
Q

what are the types of disc herniations?

A

Type 1 = bulging disc: bulging disc where disc convexity is beyond vertebral margins but annulus fibrosus and nucleus pulposus are intact though

Type 2 = prolapsed disc: fibers of annulus fibrosus rupture internally but outer fibers are intact

Type 3 = extruded disc: there is a tear of the annulus fibrous and nucleus pulposus is extruding out; nucleus pulposus is extending to the posterior longitudinal ligament

Type 4 = sequestered disc: nucleus pulposus is free in the spinal canal

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9
Q

does disc bulging cause radiculopathy?

A

not always; usually it doesn’t cause much of a compression on the spinal cord to cause a radiculopathy

but it can happen if the patient has an osteophyte and the two combined could cause a radiculopathy

so not all disc herniations will compress the nerve root

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10
Q

what patient population usually gets a herniated nucleus pulposus?

A

under 50 years old

can be spontaneous like during lifting activities, coughing, sneezing, bending, twisting

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11
Q

what patient population usually gets spinal stenosis?

A

people over 50 years old

the narrowing

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12
Q

what are the two common causes of radiculopathy?

A
  1. herniated nucleus pulposus = herniated disc
  2. spinal stenosis = narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine
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13
Q

which cervical nerve root is most effected by radiculopathy?

A

C7

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14
Q

what are the uncommon causes of radiculopathy?

A

“Hi Madam”

H – Herpes Zoster

I – Inflammtory: TB, Lyme disease, HIV, syphillis, cryptococcus, sarcoidosis

M – Metastasis

A – Arachnoiditis: myelogram, surgery, steroids, anesthesia

D – Diabetes Mellitus

A – Abscess

M – Mass: meningioma, neurofibroma, leukemia, lipoma, cysts, hematoma

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15
Q

what is the clinical presentation of a radiculopathy?

A
  1. often sudden onset but can be slow onset
  2. exacerbated with: Sitting, coughing or sneezing, flexing neck
  3. radiating pain down a limb; ask a patient to trace the pain down the limb which will tell you which dermatome is being effected!
  4. sensory/neurologic changes along a dermatome – numbness, tingling, loss of sensation
  5. some complaints of only motor weakness
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16
Q

what would look for during a PE of a suspected radiculopathy?

A
  1. spine inspection to see if the have normal lordosis/kyphosis
  2. spine movement: flexion, extension, rotation and lateral side bending to see where they’re having pain
  3. manual muscle testing - weakness
  4. sensory examination to see if there’s impaired light touch or pin prick
  5. deep tendon reflexes; will be hyporeflexive if radiculopathy
  6. Provocative maneuvers aka Neural tension signs:
    - Foraminal compression test or Spurling test
    - Manual cervical distraction
    - Lhermitte sign
17
Q

what is the Spurling test?

A

used to test for radiculopathy

performed by positioning the patient with the neck extended and the head rotated, and then applying downward pressure on the head

test is considered positive if pain radiates into the limb ipsilateral to the side to which the head is rotated (pain on the same side that the head is turned toward)

18
Q

what is the manual cervical distraction test?

A

used to test for radiculopathy

patient in a supine position, gentle manual distraction often greatly reduces the neck and limb symptoms in patients with radiculopathy

so by pulling their neck you are improving their symptoms

19
Q

what is the Lhermitte sign?

A

used to test for radiculopathy

electric shock-like sensation radiating down the spine, and in some patients into the extremities, elicited by flexion of the neck

20
Q

what happens to the reflexes if someone has a radiculopathy?

A

they become hyporeflexive

it’s essential to compare side to side because some people just have weak or strong reflexes

essential to check all reflexes!

21
Q

what are the key upper extremity reflexes?

A

C5 – biceps (and brachioradialis)

C6 – brachioradialis

C7 – triceps

C8 – pronator quadratus (not a true reflex)

22
Q

if there is a C5 nerve root radiculopathy, what will the reduced reflex, action weakness and numbness be?

A

reduced reflex of biceps brachii

weak elbow flexion

numbness in the lateral arm

23
Q

if there is a C6 nerve root radiculopathy, what will the reduced reflex, action weakness and numbness be?

A

reduced reflex of brachioradialis

weak elbow flexion

numbness in the lateral arm

24
Q

if there is a C7 nerve root radiculopathy, what will the reduced reflex, action weakness and numbness be?

A

reduced reflex of triceps brachii

weak elbow extension

numbness in the middle finger

25
Q

if there is a C8 nerve root radiculopathy, what will the reduced reflex, action weakness and numbness be?

A

reduced reflex of pronator quadratus

weak finger flexion

numbness in the medial forearm

26
Q

if the 3rd and 4th nerve roots are effected in a radiculopathy, which vertebrae would be herniated and which muscles are involved?

A

C2-C3 and C3-C4 disc herniation

there’s no muscles to test at this level so it’s more a clinical diagnosis

most patients complain of headaches

27
Q

if the 5th nerve root is effected in a radiculopathy, which vertebrae would be herniated and which muscles are involved?

A

C4-C5 disc herniation

  1. Rhomboids
  2. Deltoid
  3. Bicep
  4. Supraspinatus

Infraspinatus

  1. Brachialis
  2. BR
  3. Supinator
  4. Paraspinals
28
Q

if the 6th nerve root is effected in a radiculopathy, which vertebrae would be herniated and which muscles are involved?

A

C5-C6 herniated disc

  1. Deltoid
  2. Biceps
  3. Brachioradilais
  4. Supraspinatus
  5. Infraspinatus
  6. Supinator
  7. Pronator Teres
  8. Flexor carpi radialis
  9. Extensor digitorum communis

10 .Paraspinals

29
Q

if the 7th nerve root is effected in a radiculopathy, which vertebrae would be herniated and which muscles are involved?

A

C6-C7 herniated disc

  1. Pronator teres
  2. Flexor carpi radialis
  3. Extensor digitorum communis
  4. Triceps
  5. Paraspinals
30
Q

if the 8th nerve root is effected in a radiculopathy, which vertebrae would be herniated and which muscles are involved?

A

C7-T1 herniated disc

  1. Triceps
  2. Flexor carpi ulnaris
  3. Flexor digitorum profundus
  4. Abductor digiti minimi
  5. First dorsal interossei
  6. Pronator quadratus
  7. Abductor pollicis brevis
  8. Paraspinals
31
Q

what workup would you do on a radiculopathy case?

A

IMAGING STUDIES

  1. plain films – overused? you probably won’t see anything or be able to prove they have a radiculopathy
  2. MRI – excellent sensitivity for disc herniation diagnosis
  3. CT scan – sensitivity increased with myelogram

ELECTRODIAGNOSTIC:

  1. Nerve Conduction Studies (NCS)
    - Motor and Sensory
    - H-reflex
  2. Electromyography (EMG)
    - Needle study
32
Q

what is electromyography?

A

EMG is most useful for radiculopathy

after 2-3 weeks following symptoms, it’s the most sensitive test to see changes

you look at different peripheral muscles by putting a wire electrode in the muscle and listen to the sound it makes when at rest vs. when contracted

you want to test both peripheral muscles and paraspinals (they are first effected)

you have to find 2 separate muscles that are affected and innervated by 2 different peripheral nerves but have a common nerve root – for example C7 could cause weakness in axillary nerve and therefore deltoids but C7 also effect distal hand via the radial nerve –> if both of those muscles are effected it would prove it was a C7 radiculopathy

33
Q

45 year old man referred to you for neck and R shoulder pain. On further questioning, pt states that pain is worse in the arm than the neck. Pain starts in the neck but travels to his shoulder blade and arm

Quality of pain: burning and achy

Modifying factors: worsens when he turns his head and when he uses his arm. Some improvement with rest and ibuprofen use

Other factors: Subjective weakness; denies injury or trauma

CERVICAL SPINE EXAM: Decreased cervical spine lordosis, Tenderness to palpation (TTP) over the paraspinals on the right, Limited range of motion (ROM) for forward flexion

-ve Lhermitte’s test

+ve Spurling’s test

EXTREMITY EXAM: Shoulder testing negative except for some tenderness throughout the scapula

MMT (Manual Muscle Testing) – weakness in shoulder abduction and elbow flexion on R compared to L (4/5); other muscles in RUE (5/5)

Sensation impaired in the lateral arm

Reflexes diminished at the R elbow at 1+ compared to the rest of the reflexes in RUE and LUE which are 2+

What nerve root do you suspect is affected in this case? what is your next step?

A

differential diagnosis: musculoskeletal pathology such as rotator cuff, myalgia, cervical radiculopathy, peripheral nerve injury

+ spurling’s test probably means a radiculopathy

shoulder weakness abduction = C5

impaired sensation and diminished reflexes

C5 = weakness in biceps and adduction which are big C5 muscles; also biceps reflex is diminished and lateral arm sensory loss

next step would be physical therapy for your suspicion of a radiculopathy and wait for improvement; if there’s no improvement you can do imaging

34
Q

58 year old man comes in with neck pain shooting down his arm. On further questioning, he informs you that he is have left hand numbness as well extending to his 3rd digit

which cervical nerve root may be the cause for his current complaint? which muscles would you like to test?

A

C7

  1. Triceps –> Radial Nerve
  2. Pronator Teres –> Median Nerve
  3. Finger/Wrist Extensors –> Radial Nerve

so if you test triceps and pronator teres then you’d have 2 muscles from 2 different nerve roots and it would prove it was a C7 radiopathy

35
Q

what is the requirement for something to be classified as a radiculopathy of a specific nerve root?

A

findings in 2 separate muscles innervated by 2 separate peripheral nerves with a common nerve root

example:
C5 & C6 –> upper trunk –> lateral cord –> musculocutaneous nerve –> biceps

C5 & C6 –> upper trunk –> posterior cord –> axillary nerve –> deltoid

36
Q

what are the key C7 muscles?

A

Triceps –> Radial Nerve

Pronator Teres –> Median Nerve

Finger/Wrist Extensors –> Radial Nerve

37
Q

how do you treat a radiculopathy?

A
  1. rehabilitation

appropriate positioning, muscle strengthening, spinal stabilization, patient education

  1. surgery

to try and remove disc herniation or whatever is causing the narrowing

  1. epidural steroid injections

MSK Week 2 (3 decks)

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