Radicular Syndrome

Darwin Amir
Bgn Ilmu Penyakit Saraf
Fakultas Kedokteran
Universitas Andalas

Peripheral Nerves and Nerve

Plexuses
Cervical plexus
Brachial plexus

C1
C2
C3
C4
C4
C4
C4
C4
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1

Lumbar plexus

L2
L3

Sacral plexus

L4
L5
S1
S2
S3
S4
S5
Co1

Phrenic nerve
Axillary nerve
Musculocutaneous nerve
Thoracic nerves

Radial nerve
Ulnar nerve
Median nerve

Lateral femoral cutaneous nerve

Genitofemoral nerve
Femoral nerve

Pudendal nerve
Sciatic nerve

See ANS
lecture

Radicular Syndrome
Definition:
a combination of changes usually
seen with compromise of a spinal
root within the intraspinal canal;
these include neck or back pain and,
in the affected root distribution
dermatomal pain, parasthesia or
both decreased deep tendon reflex,
occasionally myotomal weakness

Radicular Syndrome
Arises due to compression or
herniation of the
nerve roots are branching of the spinal
cord that
transmits signals throughout the body
Radicular
at every Syndrome Symptome
level along
theand
spine
Leads
to pain
other signs like lack
of
sensation, tingling and a sense of
weakness felt
in the upper or lower regions of the
body like

Radicular Syndrome Symptomes

Sensory-related symptomes are more
prevalens
as compared to motor-related
symptomes, and
muscular weakness is generally as
indicator
The
nature of
and kind of pain could
the
increased
severity of nerve
differ
ranging
compression
from
dulling, throbbing pain and
complex to
localize , and even sharp-shooting and
burning

Radicular pain:
Less common than somatic pain
The hallmark of radiculopathy, any
pathologic condition affecting the
nerve roots
Arises from the nerve roots or
dorsal root ganglia
Herniated disk is by far the most
common cause

Radicular pain:
Lancinating or electric quality
Moves in bands and usually radiates
down the limbs
Associated symptoms of
paresthesias are very helpful
determining the identity of the
involved nerve root better than site
of pain
Symptoms of weakness and objective
findings of sensory loss, weakness
and reflex loss may occur

Radicular pain:
Inflammation is important as a pain
mechanism:
Phospholipase A and E, NO, TNF,
other pro-inflammatory mediators are
released by a herniated disk
The dura surrounding the ventral and
dorsal nerve root is bathed in this
exudate
Inflammation or prior injury to nerve
root is necessary to cause
compression to generate continued
pain

Types of peripheral nerve

injury:

Neurapraxia: Segmental loss of

myelin coating on nerve root/nerve
Weakness, but no atrophy

Axonotmesis: Loss of axons and

myelin but at least some supporting
structures are preserved
Weakness and muscle atrophy if
severe

Neurotmesis: Loss of axons, myelin,

and complete disruption of
supporting structures (transection)

Dermatome
Each nerve root
supplies cutaneous
sensation to a
specific area of
skin, known as a
dermatome

Overlaps somewhat, so wont lose

All sensation, but will feel paresthesia

Myotome
If radicular pain sever
could affect myotome
Each nerve root
supplies motor
innervation to certain
muscles,
known as a myotome

 In the cervical spine:

Nerve roots exit above
their named vertebral
body
I.e., C7 exits below C6 and
above C7-so lateral disk
herniation here gets C7

In the lumbar spine:

Spinal cord ends at L1 or
L2
Nerve roots travel long
distances then exit below
their named vertebral
body
The lumbosacral nerve
roots are susceptible to
injury at multiple locations

1. Cervical Radiculopathy
C7 most common

Cervical HNP
Classic presentation is to wake up
with it. Usually no identifiable
factor.
Causes painful limitation of neck motion
and symptoms corresponding to the
affected nerve root(s)

The majority of cervical herniated

discs will catch the nerve root
corresponding to the lower vertebral
level.
Ex: A C6/7 disc herniation will impinge
upon the C7 root.

Cervical HNP
Just as is the case with Lumbar HNP,
conservative therapy is the mainstay
of treatment.
Surgery indicated for those that dont
improve with conservative
management, or with
new/progressive neurologic deficit.

Cervical Spinal Stenosis

(CSS)
Stenosis a constriction or narrowing
of a duct or passage.
Cervical spinal stenosis, thus, is
narrowing of the spinal canal (within
which lies the cervical spinal cord).
This narrowing can be from any of a
multitude of causes. Usually, though, this is
referring to more chronic types of processes,
rather than acute or sudden ones.

Cervical Spinal Stenosis

(CSS)
More than half of adults older than
50 yrs. Will show significant
degenerative cervical spine disease
on radiography (CT/MRI)
(i.e., Everybody has degenerative disc
disease. And probably their dogs and
cats too.

however, only a fraction of these

patients will actually experience any
type of significant neurological

CSS when it causes

problems
Radiculopathy from nerve root
compression.
The term radiculopathy refers to
disease of the nerve roots; LMN signs,
pain/parasethesias.

Myelopathy from spinal cord

compression.
The term myelopathy refers to
pathological changes of the spinal cord
itself.

2. HNP Lumbalis
Clinical:
Low back pain wit associated leg symptoms
Positions can induce radicular symptoms
Posterolateral disc pathology most common:
Area where anular fibers least
protected by PLL
Greatest shear forces occur with
forward or lateral bend
Central disc pathology:
Usually with LBP only without radicular
symptoms, unless a large defect is
present
20

low back pain world wide

Common complaint among adults
Lifetime prevalence in working population up to 80%
60% experience functional limitation or disability
Second most common reason for work disability
Despite advances in imaging and surgical techniques

LBP prevalence and its cost are relatively unchanged

intervertebral disc

Internal disruption

3. Cauda Equina Syndrome

Historically

Bilateral sciatica
Expanded to include unilateral sciatica
Sudden, partial or complete loss of voluntary
bladder function due to massive disc
impingement on spinal nerves
The frequency of daily urination is much
greater than bowel evacuation, so

Presently
Bladder dysfunction with a decrease in
perianal sensation

3. Cauda Equina Syndrome

Symptoms
Back pain
Radicular pain
Bilateral
Unilateral

Motor loss
Sensory loss
Urinary dysfunction

Overflow incontinence
Inability to void
Inability to evacuate the bladder
completely

Decrease in perianal sensation

3. Cauda Equina Syndrome

Treatment:
Urgent decompression is mandatory for
prevention of
irreparable / irreversible bladder damage
12 hours is the maximum time prior to
irreversible changes

27

4. Spondylosis
Clinical:
Up to 75 % of involvement of the spine occurs at
2 levels: L5-S1 and L4-L5
Possible factors that contribute to development:

Changes with maturation in:

Nutrition
Disc chemistry
Hormones
Occupational forces
Progression of disc narrowing leads to
degenerative changes of bony structures,
especially posterior components, leading to
spondylosis
28

5. Spondylolisthesis
Clinical:
Progression of spondylolysis with separation
Grades assigned I-IV for level of translation
Most common levels are L5-S1 (70 %) and L4-L5
(25 %)

May be asymptomatic, but can result in

Spondylosis
DDD
Radiculopathy

Treatment:

Medication
Physical Therapy
Injections
Surgery
29

6. Spinal Stenosis
Clinical:
Results from narrowing of spinal canal and / or
neural foramina (CONGENITAL OR DEGENERATIVE)
Most common complaint is leg pain limiting
walking
Neurogenic / Pseudoclaudication = pain in
lower extremities with gait
Relief can occur with:
stopping activity
sitting, stooping or bending forward

Common are complaints of weakness and

numbness of extremities
Usually becomes symptomatic in 6th decade
30

Back Pain Causes

de-conditioning
sprain/strain
spondylolithesis
spondylosis
facet syndrome
disc herniation

disc bulge
spinal stenosis
biomechanical
inflammatory
infection
cancer

CSS - Myelopathy
The goal here is to avoid missing
patients who are myelopathic,
because once stenosis has evolved
to the point that it is compressing
(and causing damage to) the spinal
cord, the progression of symptoms
may be variablebut it is going to
progress.