Radiculopathy Flashcards
Lumbar Radiculopathy - Definition/Description of Lower Radiculopathy
Lumbosacral radiculopathy is a disorder that causes pain in the lower back and hip which radiates down the back of the thigh into the leg. This damage is caused by compression of the nerve roots which exit the spine, levels L1- S4. The compression can result in tingling, radiating pain, numbness, paraesthesia and occasional shooting pain. Radiculopathy can occur in any part of the spine, but it is most common in the lower back (lumbar sacral radiculopathy) and in the neck (cervical radiculopathy). It is less commonly found in the middle portion of the spine (thoracic radiculopathy).
Radiculopathy is not the same as “radicular pain” or “nerve root pain”. Radiculopathy and radicular pain commonly occur together, but radiculopathy can occur in the absence of pain and radicular pain can occur in the absence of radiculopathy.
Radiculopathy can be defined as the whole complex of symptoms that can rise from nerve root pathology, including anaesthesia, paresthesia, hypoesthesia, motor loss and pain.
Radicular pain and nerve root pain can be defined as a single symptom (pain) that can arise from one or more spinal nerve roots.Lumbar sacral radiculopathy is a disorder of the spinal nerve roots from L1 to S4.
Epidemiology /Etiology (lumbar)
Radiculopathy is caused by compression or irritation of the nerves with resultant pain, weakness, and/or sensor impairment in the affected nerve root, may be from direct trauma or from chemical irritation to the affected nerve root[12]. This can be due to mechanical compression of the nerve by a disk herniation, a bone spur (osteophytes) from osteoarthritis, or from thickening of surrounding ligaments. As people age, their spines are subject to increasing degeneration which can cause herniated discs and similar problems such as spinal stenosis, leading to lumbar radiculopathy.
In patients under 50 years, a herniated disc is the most frequent cause. After the age of 50, radicular pain is often caused by degenerative changes in the spine (stenosis of the foramen intervertebrale).
Some patients reports beside radicular leg pain also neurological signs such as paresis, sensory loss or loss of reflexes. If not present, this is not a radiculopathy.
Cervical Radiculopathy - Description -
Cervical radiculopathy is a disease process marked by nerve compression from herniated disk material or arthritic bone spurs. This impingement typically produces neck and radiating arm pain or numbness, sensory deficits, or motor dysfunction in the neck and upper extremities.”
Most of the time cervical radiculopathy appears unilaterally, however it is possible for bilateral symptoms to be present if severe bony spurs are present at one level, impinging/irritating the nerve root on both sides. If peripheral radiation of pain, weakness or pins and needle are present, the location of the pain will follow back to the concerned affected nerve root
The most common level of root compression is C7 (reported percentages 46.3–69%), followed by C6 (19–17.6%); compression of roots C5 (2–6.6%) and C8 (10– 6.2%) are less frequent. One possible explanation is that intervertebral foramina are largest in the upper cervical region and progressively decrease in size in the middle and lower cervical areas, with an exception of the C7-Th1 foramen (C8)
Cervical Radiculopathy - causes/risk factors
Mechanical compression from spondylosis can affect the neuroforamen from all directions, which limits nerve root excursion. Cytokines released from damaged intervertebral discs can also cause this disorder
Inflammatory cytokines such as interleukin-6, interleukin-8, nitric oxide, tumor necrosis factor alfa and prostaglandin E2 are involved in the development of pain associated with cervical radiculopathy and provide the rational for treatment with anti-inflammatory medications. [9]
There is increasing evidence that inflammation itself and/or in association with root compression is the main cause of symptoms and signs. This is proved by the presence of interleukins and prostaglandin in herniated discs and the spontaneous recovery within weeks or months in the majority of patients.
Cervical symtpoms
Symptoms are generally amplified with side flexion towards the side of pain and when an extension or rotation of the neck takes place because these movements reduce the space available for the nerve root to exit the foramen causing impingement .
This often causes the patient to present with a stiff neck and a decrease in cervical spine ROM as movement may activate their symptoms. This may result in secondary musculoskeletal problems which can manifest as a decrease in muscle length of the cervical spine musculature (upper fibres of trapezius, scaleni, levator scapulae), weakness, joint stiffness, capsule tightness and postural defects which can go on to affect movement mechanisms of the rest of the body.
Cervical Diagnosis via tests -
Wainner et a examined the accuracy of the clinical examination and developed a clinical prediction rule to aid in the diagnosis of cervical radiculopathy. Their research demonstrated that these 4 clinical tests, when combined, hold high diagnostic accuracy compared to EMG studies:
- Spurlings Test,
- Upper limb tension-1
- Distraction test
- involved side cervical rotation range of motion less than 60 degrees.
When all 4 of these clinical features are present, the post test probability of cervical radiculopathy is 90%, Where only 3 of the 4 tests are positive the probability decreases to 65
A study conducted by Gumina et al found Arm Squeeze test useful to distinguish between cervical nerve root compression and shoulder disease. The test has 96% for both sensitivity and specificity, inter-observer value of 0.81 and intra-observer value of 0.87. However, the test utilizes subjective measures and needs to be validated.
The sensory examination can distinguish between a C8 radiculopathy and ulnar neuropathy, as there will be splitting of the hyperalgesia in either the third or fourth digit with ulnar neuropathy. With C8 radiculopathy, the entire digit will be affected. Motor examination may or may not show a grade of weakness in the myotome that corresponds to the pathologic nerve.
No myotome corresponds to the upper four cervical nerve roots.
C5 radiculopathy may show weakness in the deltoids (evaluated by testing for shoulder abduction); C6 will show weakness in the biceps and flexor carpi ulnaris (evaluated by testing for wrist extension); C7 weakness occurs in the triceps, as well as the brachioradialis (evaluated by testing for ellbow extension); C8 pathology causes weakness in the intrinsic muscles of the hand, as evaluated by finger abduction and grip.
Muscle stretch reflexes also tend to be decreased in the setting of radiculopathy.
