Radiculopathy

Question 1

EPIDEMIOLOGY:

Answer 1

• Most commonly lumbar spine(150 per 100 000/year)
• cervical spine(20 per 100 000/year)
• Common sites L5/S1 and C5/C6

Question 2

AETIOLOGY:

Answer 2

Common:

1. Acute disc
   - younger people
   - history of straining/injury
2. Spondylosis

Rare:

1. Tumour
   - Primary: neurofibroma/meningioma
   - Secondary: breast, bronchus, prostate, kidney, thyroid, lymphoma
2. Inflammation
   - Shingles
   - Inflammatory/malignant meningitis

Question 3

SYMPTOMS AND SIGNS:

Answer 3

1. Pain
   - usually acute, related to physical exertion in disc prolapse.
   - pain exacerbated by movement that stretches nerve root, increase in intraspinal pressure ie coughing, sneezing, straining.
2. Weakness
   - involves muscles innervated
   - wasting/fasciculation
3. Loss of reflexes
   - innervated muscles
4. Altered/loss of sensation
   - distribution of affected nerve root
5. UMN/sensory signs below level of radiculopathy imply compression of spinal cord and nerve roots(myeloradiculopathy)

*Polyradiculopathy: cauda equina involvement(ie central disc prolapse), inflammatory cause ie Guillian-Bare, inflammatory meningitis ie sarcoidosis, neoplastic process, malignant meningitis

Question 4

LOCALISATION OF SX. BASED ON NERVE ROOTS

1. C5
2. C6
3. C7
4. C8
5. T1
6. L3
7. L4
8. L5
9. S1

Answer 4

1. Biceps reflex, biceps and deltoid, lateral arm.
2. Biceps, supinator reflex. Biceps and supinator. lateral forearm including thumb and index finger
3. triceps reflex, all extensors, middle finger
4. Finger flexors, medial forearm
5. All intrinsic hand muscles, Horner’s syndrome, medial arm.
6. Knee reflex, knee extensor, hip adductor. Knee area, medial knee.
7. Knee reflex, knee extensor, ankle dorsiflexor, medial leg
8. Toe dorsiflexor, foot evertor, lateral leg including dorsal foot
9. Ankle reflex, ankle plantarflexor, toe invertor, knee flexor, lateral foot area, plantar surface of foot.

Question 5

INVESTIGATIONS:

Answer 5

1. MRI spine at level of suspected radiculopathy
2. Electromyography
3. Nerve conduction studies
   - exclude neuropathy
4. CSF examination
   - suspicion of systemic illness
   - in polyradiculopathy

Question 6

MANAGEMENT(LUMBAR DISC DISEASE)

Answer 6

1. Rest then mobilization, education
2. Consider surgical intervention
   - Microdiscectomy
   - Laminectomy
   - Consider earlier if presence of neurological deficit that is severe/progressive.
   - also consider if persistent radicular pain in leg.

Question 7

MANAGEMENT(CERVICAL SPINE)

Answer 7

1. Conservative therapy
   - Physio, soft collar/traction
2. Surgery if pain persists
   - single-level discectomy - anterior approach w bone grafting

Question 8

MANAGEMENT(OTHER CAUSES)

1. Benign compressive tumours
2. Malignant tumours

Answer 8

1. Surgical decompression

2. Radio/chemotx/surgery

Question 9

LUMBAR CENTRAL DISC PROLAPSE

Answer 9

• affects all roots of cauda equina
• severe back pain radiating into both legs(sciatic distribution)
• bilat. foot drop, weakness of hips and knee flexors
• sphincter disturbance
• loss of ankle jerks, sacral reflex
• sensory loss in feet, sacra; anaesthesia
• Mx with urgent surgical decompression.

Question 10

LUMBAR CANAL STENOSIS

Answer 10

• older patients
• neurogenic claudication
• stooped posture, easier to walk uphill then on flat.
• surgical decompression(laminectomy)

Question 11

SPINA BIFIDA

Answer 11

• paraparesis
• supportive management
• Prevent complications ie pressure sores and urinary infections.

Question 12

IMPORTANT DERMATOME MARKERS:

1. C5
2. C6
3. C7
4. C8
5. T1
6. L1
7. L2
8. L3
9. L4
10. L5
11. S1

Answer 12

1. Anterolat. shoulder
2. Thumb
3. Middle finger
4. Little finger
5. Medial arm
6. -
7. Medial thigh
8. Medial knee
9. Medial ankle, big toe
10. Dorsum of foot
11. Lateral foot

Question 13

IMPORTANT SEGMENT-POINTER MUSCLES:

1. C5
2. C6
3. C7
4. C8
5. T1
6. L1
7. L2
8. L3
9. L4
10. L5
11. S1

Answer 13

1. Deltoid, biceps
2. Brachioradialis, extensor carpi radialis longus
3. triceps, extensor carpi ulnaris, extensor digitorum
4. wrist and finger flexors
5. intrinsic muscles of hand
6. -
7. -
8. Quadriceps
9. Quadriceps, tibialis anterior
10. Extensor hallucis longus
11. Gastrocnemius