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MSK Week 3 > ICL 6.1: LE Radiculopathies, Plexopathies & Entrapment > Flashcards

ICL 6.1: LE Radiculopathies, Plexopathies & Entrapment Flashcards

1
Q

what are some of the common causes of lower extremity radiculopathies?

A
  1. herniated nucleus pulposus

typically seen below 50 years of age

  1. spinal stenosis (narrowing of spinal canal)

typically seen above 50 years of age

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2
Q

what are some of the uncommon causes of lower extremity radiculopathies?

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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3
Q

what is the most common lumbosacral nerve root affected in lumbosacral radiculopathies?

A

L5 and S1

this is because your L5 and S1 are a transition zone between different vertebrae and they receive a lot of force

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4
Q

what’s the clinical presentation of a herniated disk?

A

often sudden onset

exacerbated with: Sitting, coughing or sneezing

radiating pain down a limb (not usually back pain)

sensory changes along a dermatome – numbness, tingling, loss of sensation

some complaints of motor weakness

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5
Q

a dis herniation at L4-L5 that is described as a far lateral disc herniation will affect which nerve root?

A

L4

it’s L4 because it’s a lateral type and not a central type

UNDERSTAND THIS; QUIZ QUESTION

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6
Q

what spine movement is most consistent with disc herniation?

A

flexion

pain with flexion of the spine is more likely to be a disc herniation

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7
Q

what do you do during a PE when looking for radiculopathy of the LE?

A

Spine inspection

Spine movement – flexion, extension, rotation and lateral side bending

Manual muscle testing

Sensory examination

Deep tendon reflexes

Provocative maneuvers aka Neural tensions signs

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8
Q

what is the slump test?

A

looking for a radiculopathy

it’s performed with the patient in a flexed seated position and their arms behind their back if possible

examiner passively raises leg to full knee extension with ankle dorsiflexion

the test is considered positive if pain radiates into ipsilateral limb – they get tingling, burning, etc. down the leg to the toes

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9
Q

what is the straight leg raise test?

A

used to test for radiculopathy

patient is laying supine

examiner passively raises leg (hip flexion) with full knee extension

the test is considered positive if pain radiates into ipsilateral limb

cross reference this with the slump test

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10
Q

what is the reduced reflex, weakness and numbness associated with an L4 nerve root radiculopathy?

A

reduced reflex in patellar tendon

weakness with knee extension and ankle dorsiflexion

numbness in the anterolateral thigh/medial ankle

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11
Q

what is the reduced reflex, weakness and numbness associated with an L5 nerve root radiculopathy?

A

reduced reflex in the hamstring

weakness with hallux extension

numbest in the posterolateral thigh/calf and dorsal foot

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12
Q

what is the reduced reflex, weakness and numbness associated with an S1 nerve root radiculopathy?

A

reduced reflex with the achilles tendon

weakness with plantar flexion (patients will say they have weakness walking or pushing the gas pedal)

numbness in the posterior thigh/calf and lateral ankle

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13
Q

what defines a radiculopathy

A

weakness in muscles that are innervated by two different peripheral nerves coming from the same nerve root

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14
Q

how can you differentiate between an L4 radiculopathy and femoral nerve neuropathy?

A

adductor muscles which are L4 and are innervated by the obturator nerve, NOT the femoral nerve

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15
Q

what muscle is good to test for L5 radiculopathy?

A
  1. gluteus medius

have them abduct their hip to see if there’s any weakness

  1. tibialis anterior
  2. medial hamstring
  3. tibialis posterior
  4. peroneus longus
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16
Q

what muscle is good to test for an S1 radiculopathy?

A
  1. gastrocnemius

have them lay down and tell them to push down and plantar flex while resisting you

  1. gluteus maximus

test hip extension by laying them supine and asking them to dig the heel into the bed while you’re trying to lift the heel off the bed

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17
Q

what muscle is good to test for an L1 or L2 radiculopathy?

A
  1. iliopsoas

2. iliacus

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18
Q

what muscle is good to test for an L4 radiculopathy?

A
  1. adductor longus
  2. vastus medialis
  3. rectus femoris
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19
Q

what workup would you do if you think someone has a radiculopathy?

A
  1. Plain films – overused? When is it too early?
  2. MRI – excellent sensitivity for disc herniation diagnosis
  3. CT scan – sensitivity increases with myelogram
  4. electrodiagnostics - really sensitive for radiculopathies!
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20
Q

how does an electrodiagnostic test work?

A

you should examine at least 5 peripheral muscles and the paraspinals

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

know the myotomal maps

paraspinals are affected first

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21
Q

how do you treat radiculopathy?

A
  1. rehab
  2. surgical
  3. epidural steroid injections (more for leg pain)
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22
Q

what is a lumbosacral plexus?

A

it consist of two separate parts: the lumbar and the sacral plexus lying above and below the pelvic rim, respectively,

they are connected by the so-called lumbosacral trunk

the lumbar part of the plexus lies embedded between and in the paraspinal quadratus lumborum and psoas muscles

the sacral plexus lies within the pelvis

L1-L4 = thigh problems

L4-sacral plexus = knee and below problems

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23
Q

which nerve roots are your lumbar plexus?

A

Nerve fibers originating from ventral rami of L1, L2, L3 & L4

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24
Q

which nerve roots are your sacral plexus?

A

Nerve fibers origination from ventral rami of L4, L5, S1, S2, S3 & S4

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25
Q

what are the anterior and posterior divisions of the lumbar plexus?

A

anterior division = obturator nerve

posterior division = femoral nerve, lateral femoral nerve, and cutaneous nerve

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26
Q

what are the anterior and posterior divisions of the sacral plexus?

A

anterior division = tibial portion

posterior division = common perineal nerve

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27
Q

what are some of the common causes of LSPs?

A
  1. tumor
  2. infection
  3. trauma
  4. obstetrics
  5. radiation
  6. hematoma
  7. vascular lesions
  8. inflammatory/microvasculitis
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28
Q

how can neoplasms cause lumbosacral plexopathy?

A

this is the most common cause of non-traumatic lumbosacral plexopathy

patients will complain of subacute onset of pain followed by motor and/or sensory loss in a distribution dependent on which area of the plexus is affected

major differential diagnoses of neoplastic lumbosacral plexopathy include:
Local pelvic bone infection (osteitis pubis)

Avascular necrosis of the hip

Radiation-induced plexopathy

predominant types = direct malignancy, metastases, intra-neural lymphomatosis, perineural spread of prostate cancer, primary nerve sheath tumors, intraneural perineurioma

29
Q

which types of cancers are more likely to cause a lumbosacral plexopathy?

A
  1. direct extension

colorectal, uterine, prostate, ovarian

more proximal –> lumbar plexus more often effected

  1. distant metastatic cause

breast, sarcoma, thyroid and testicular

tends to effect sacral plexus more often

  1. radiation vs. cancer infiltration

patients will complain of weakness, leg pain

30
Q

what is the key presentation symptom to differentiate between a neoplastic plexopathy vs. a radiation plexopathy?

A

pain

radiation plexopathy doesn’t cause any pain while neoplastic plexopathies are painful

31
Q

how can a hematoma cause a LSP?

A

hematoma will compress the plexus as it passes through the iliopsoas muscle

patients are usually on heparin that leads to this hemorrhage

look for unexplained anemia in the CBC or Grey Turner’s sign (confirm with CT)

patients usually complain of abdominal, back or groin pain that’s constant ; they may also complain of pain going down the leg

more often effects the lumbar plexus

32
Q

how can infection cause a LSP?

A

local more common = infection/abscesses in psoas and gluteal musculature, retroperitoneal space, infection in nearby organs such as gastrointestinal or urinary tract, or lumbar spine

systemic = varicella zoster virus, mycobacterium tuberculosis (Pott’s disease), HIV, and hepatitis C

symptoms = pain/neurological symptoms are similar to neoplasm, with symptoms such as fever, malaise, point tenderness, weight loss, and night sweats also being common

33
Q

how can obstetrics cause LPS?

A
  1. difficult delivery

will effect lumbar plexus more often or maybe the femoral nerve

patients will complain of leg weakness post delivery

overall good prognosis though because the injury is so proximal to the muscle involved so they heal really fast

34
Q

how do intravascular injections cause LSP?

A

injections should be lateral but sometimes if they’re more medial you can cause vasospasms of the lumbar plexus

if it’s severe you can get ischemic changes or gangrene around the iliac crest

35
Q

what is diabetic plexopathy?

A

more common in the lower extremity than upper extremity but it can technically happen in both

more common in 50s and 60 years old

patients will complain of anterior thigh pain and proximal leg weakness (quads), severe aching or burning and lancinating pain

patients will also often have diminished or absent patella reflex

may see muscle wasting

36
Q

will diabetic amyotrophy improve with blood sugar control?

A

aka diabetic plexopathy

it’s true!

37
Q

what is traumatic LSP?

A

usually severe, very high velocity and energy at the time of impact –> often associated with pelvic fractures

ex. high-velocity car accident, gunshot wound, and traumatic dislocation of the hip

predominantly involving lower (sacral) portion, particularly at the major branches of the sciatic nerve (fibular > tibial)

common fibular > gluteal > tibial > obturator

38
Q

what would you do during a PE if you’re looking for a LSP?

A
  1. observation: bruising (hematoma), skin changes, muscle bulk atrophy, fasciculations (muscle twitching)
  2. palpation – determine severity of pain
3. thorough neuromuscular exam:
AROM and PROM
Strength testing
Sensory loss
DTR
Tone
  1. gait, balance
  2. UMN vs LMN signs
    Clonus/Babinski
39
Q

how do you treat LPS?

A
  1. neuropathic pain meds
  2. therapyL straightening, gait training, contracture prevention
  3. remove the problem if it’s a hematoma
  4. surgery
40
Q

what nerve roots are associated with the lateral femoral cutaneous nerve?

A

L2 and L3

specifically the posterior division of the lumbar plexus

so it innervates your lateral thigh

41
Q

what is a lateral femoral cutaneous nerve entrapment called?

A

neuralgia paresthetica

42
Q

what causes lateral femoral cutaneous nerve entrapment?

A
  1. repeated low grade trauma
  2. protuberant abdomen (like construction workers tightening their tool belt)
  3. pregnancy
  4. tight clothing
  5. diabetics
  6. tumor infection
43
Q

what are the symptoms of lateral femoral cutaneous nerve entrapment?

A

pure sensory syndrome!

pain, numbness, burning, dull ache

exacerbated w/ hip extension or flexion, prolonged sitting/squatting, or driving

44
Q

how do you treat lateral femoral cutaneous nerve entrapment?

A

rehab

NSAIDS

cortisone injections

surgical release

removal of compressive clothing

45
Q

which nerve roots are associated with your femoral nerve?

A

L2, L3, L4

posterior division of the lumbar plexus

innervates the anterior part of your thigh

46
Q

what could cause a femoral nerve entrapment?

A

trauma, fracture, retroperitoneal hematoma, tumor, inguinal ligament compression, or cardiac catheterization

most common = iatrogenic from abdominal or pelvic surgery

47
Q

what are the symptoms of a femoral nerve entrapment?

A
  1. weakness of knee extension (quads)
  2. knee instability
  3. decreased sensation over whole anterior thigh and medial leg

hip flexion weakness if above inguinal ligament

48
Q

what nerve roots are associated with the sciatic nerve?

A

L4, L5, S1, S2, S3

posterior division of the lumbosacral plexus

innervates your posterior thigh

49
Q

what’s another way to say peroneal nerve?

A

fibular nerve

fibular nerve makes up the outer 2/3 of the sciatic nerve

50
Q

what are some causes of sciatic nerve entrapment?

A

hip trauma

hip replacement

injection

hematoma

pelvic fracture

penetrating wounds

gravid uterus

51
Q

what is piriformis syndrome?

A

related to sciatic nerve entrapment and your piriformis muscle which is right above your sciatic nerve

the piriformis can become really tight and spasm and compress the sciatic nerve!

52
Q

which lower limb muscles are dually innervated?

A
  1. pectineus
  2. adductor magnus
  3. biceps femoris
53
Q

which nerves innervate the pectineus?

A
  1. femoral

2. obturator

54
Q

which nerves innervate the adductor magnus?

A
  1. sciatic (tibial)

2. obturator

55
Q

which nerves innervate the biceps femoris?

A
  1. sciatic nerve (tibial = long head)

2. sciatic nerve (fibular = short head)

56
Q

what are the roots of the tibial nerve?

A

L4, L5, S1, S2

sciatic nerve becomes the tibial nerve

the tibial nerve then branches at the popliteal fossa to officially form the tibial nerve

57
Q

what is the most common entrapment location of the tibial nerve?

A

the tarsal tunnel

the tibial nerve will be compressed underneath the flower retinaculum (which runs from the calcaneus to the malleolus)

58
Q

what symptoms are associated with tibial nerve compression?

A
  1. intrinsic foot weakness
  2. perimalleolar pain
  3. numbness and paresthesias reproduced by ankle inversion
  4. positive Tinel’s

heel sensation is fine though!!!

59
Q

what goes through your tarsal tunnel?

A

Tom Dick And Very Nervous Harry

Tibialis posterior

flexor Digitorum longus

posterior tibial Artery

posterior tibial Vein

tibial Nerve

flexor Hallucis longus

60
Q

what are the nerve roots of the common peroneal nerve?

A

L4-S2

it’s a branch of the sciatic nerve that winds around the fibular head into the deep and superficial portions

61
Q

what does the superficial peroneal nerve innervate?

A
  1. peroneus longus and brevis

2. medial and lateral cutaneous nerve

62
Q

what does the deep peroneal nerve innervate?

A

everything else

  1. tibialis anterior
  2. extensor digitorum longus
  3. extensor hallucis longus
  4. peronenus tertius
  5. extensor digitorum brevis
  6. first dorsal interossei
  7. dorsal distal cutaneous nerve
63
Q

what is the cutaneous innervation of the deep peroneal nerve?

A

the first and second webspace of the foot

64
Q

what is the cutaneous innervation of the superficial peroneal nerve?

A

the anterior lateral part of the leg

65
Q

what is a common entrapment site for the peroneal nerve?

A

the fibular head

if it’s high enough in the fibular nerve it can knock out both the superficial and deep fibular nerve branches

66
Q

what causes peroneal nerve entrapment?

A
  1. compression from prolonged leg crossing
  2. weight loss
  3. poor positioning during surgery
  4. poor cast application
  5. prolonged squatting position (strawberry pickers’ palsy)
  6. metabolic disorders such as diabetes
67
Q

what are the symptoms of peroneal entrapment?

A
  1. complains of the weakness of the dorsiflexors (TA, EDL, EHL)
  2. foot drop
  3. foot slap
  4. steppage gait
  5. it’ll involve all the muscles supplied by the deep and superficial branches of the common fibular nerve

the short head to eh biceps femoris is spared

though

68
Q

what are the common entrapment neuropathies of the lower extremity?

A
  1. lateral femoral cutaneous neuropathy
  2. femoral neuropathy
  3. peroneal neuropathy
  4. tarsal tunnel
69
Q

all of these may cause foot drop except for:

A.
common peroneal neuropathy

B. L4 radiculopathy

C. L5 radiculopathy

D. lumbosacral plexopathy

E. ALS

A

D. lumbosacral plexopathy

with ALS one of the first signs is actually a foot drop!

MSK Week 3 (10 decks)

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