Radiculopathy vs. Radiculopathy vs.

Peripheral NeuropathyPeripheral Neuropathy

What to do with arm pain?What to do with arm pain?

Miriana G. Popadich RN, MSNMiriana G. Popadich RN, MSNClinical Care CoordinatorClinical Care Coordinator

Brachial Plexus ProgramBrachial Plexus Program

Department of NeurosurgeryDepartment of NeurosurgeryUniversity of MichiganUniversity of Michigan

Defining Arm Pain Defining Arm Pain

TimingTiming�� AcuteAcute

�� ChronicChronic

LocationLocation�� GeneralizedGeneralized

�� SpecificSpecific

TypesTypes�� AchingAching

�� BurningBurning

�� LancinatingLancinating

Arm PainArm Pain

Is it from the cervical spinal nerve roots ?Is it from the cervical spinal nerve roots ?

Is it from the brachial plexus ?Is it from the brachial plexus ?

Is it from to peripheral nerve entrapment ?Is it from to peripheral nerve entrapment ?

Are weakness and sensory loss present ?Are weakness and sensory loss present ?

What Do We Mean What Do We Mean

by Peripheral Neuropathy?by Peripheral Neuropathy?Peripheral neuropathy is a disorder of the Peripheral neuropathy is a disorder of the

nerves that carry information to and from the nerves that carry information to and from the

brain and spinal cord. This can produce pain, brain and spinal cord. This can produce pain,

loss of sensation, and weakness.loss of sensation, and weakness.

Most peripheral nerves have motor and Most peripheral nerves have motor and

sensory functions.sensory functions.

Peripheral neuropathy may affect a single nerve Peripheral neuropathy may affect a single nerve

(mononeuropathy) or multiple nerves (mononeuropathy) or multiple nerves

(polyneuropathy)(polyneuropathy)..

What Do We Mean by What Do We Mean by

Radiculopathy?Radiculopathy?

Radiculopathy Radiculopathy –– a condition in which one a condition in which one

or more spinal nerves, e.g. C6, are affected or more spinal nerves, e.g. C6, are affected

and do not function properly.and do not function properly.

The emphasis is on the The emphasis is on the spinal nerve root spinal nerve root

((RadixRadix = "root").= "root").

This can result in radiating pain (radicular This can result in radiating pain (radicular

pain), weakness, numbness, decreased pain), weakness, numbness, decreased

reflexes, or difficulty controlling specific reflexes, or difficulty controlling specific

muscles.muscles.

Causes of Peripheral NeuropathyCauses of Peripheral Neuropathy

InjuryInjury�� CompressionCompression

�� LacerationLaceration

Systemic diseaseSystemic disease�� DiabetesDiabetes

Infection, inflammation Infection, inflammation �� AIDSAIDS

Exposure to poisonous substancesExposure to poisonous substances�� Sniffing glueSniffing glue

�� Excessive alcohol useExcessive alcohol use

DrugsDrugs�� ChemotherapyChemotherapy

What Causes Arm Pain?What Causes Arm Pain?

Diagnosis and Treatment Relies UponDiagnosis and Treatment Relies Upon

Identification of the nerve Identification of the nerve

affectedaffected

Site of injurySite of injury

Severity of the injurySeverity of the injury

Anatomy Anatomy -- Cervical RootCervical Root

The The cervical nervescervical nerves are the are the

spinal nerves from the cervical spinal nerves from the cervical

spinal cord.spinal cord.

There are eight cervical nerves There are eight cervical nerves

(C1(C1--8). 8).

Posterior distribution includes Posterior distribution includes

the paraspinal muscles.the paraspinal muscles.

Anterior distribution leads to the Anterior distribution leads to the

brachial plexus (C5brachial plexus (C5--C8/T1).C8/T1).

Anatomy Anatomy -- Brachial PlexusBrachial Plexus

The brachial plexus is a complex network of The brachial plexus is a complex network of

nerves extending from the spinal nerve (roots) nerves extending from the spinal nerve (roots)

into the neck and down into each arm.into the neck and down into each arm.

This nerve network controls movement and This nerve network controls movement and

sensation in thesensation in the�� ShoulderShoulder

�� ArmArm

�� WristWrist

�� HandHand

�� FingersFingers

Anatomy Anatomy -- Brachial PlexusBrachial Plexus

5 Roots (C5 5 Roots (C5 –– T1)T1)

3 Trunks3 Trunks

�� Superior/UpperSuperior/Upper

�� MiddleMiddle

�� Inferior/LowerInferior/Lower

6 Divisions6 Divisions

�� 3 x anterior3 x anterior

�� 3 x posterior3 x posterior

3 Cords3 Cords

�� LateralLateral

�� PosteriorPosterior

�� MedialMedial

5 Terminal Branches/Peripheral 5 Terminal Branches/Peripheral

NervesNerves

�� MusculocutaneousMusculocutaneous

�� AxillaryAxillary

�� RadialRadial

�� MedianMedian

�� UlnarUlnar

Anatomy Anatomy -- Terminal BranchesTerminal Branches

Musculocutaneous Nerve (C5,6,7) Musculocutaneous Nerve (C5,6,7)

Axillary Nerve Axillary Nerve

(C5(C5--6)6)

Radial Nerve Radial Nerve

(C5,6,7,8,T1)(C5,6,7,8,T1)

Median Nerve Median Nerve

(C5,6,7,8,& T1)(C5,6,7,8,& T1)

Ulnar Nerve Ulnar Nerve

(C8 &T1)(C8 &T1)

What Causes Arm Pain?What Causes Arm Pain?

Diagnosis and Treatment Relies UponDiagnosis and Treatment Relies Upon

Identification of the nerve Identification of the nerve

affectedaffected

Site of injurySite of injury

Severity of the injurySeverity of the injury

AnatomyAnatomy -- Nerve InjuryNerve Injury

NeurapraxiaNeurapraxia�� Interruption of the nerve conduction Interruption of the nerve conduction

without interruption of nerve or its myelin without interruption of nerve or its myelin

sheathsheath

AxonotmesisAxonotmesis�� Interruption of the axon with interruption of Interruption of the axon with interruption of

the myelin sheath but no interruption of the myelin sheath but no interruption of

the nerve itselfthe nerve itself

Neurotmesis Neurotmesis �� Most severe form of nerve injury Most severe form of nerve injury ––

interruption of the axon along with interruption of the axon along with

encapsulating connective tissue and or encapsulating connective tissue and or

transection of the nerve transection of the nerve

Myelin sheath

Axon

Basement membrane

Principles Based on AnatomyPrinciples Based on Anatomy

Each peripheral nerve Each peripheral nerve

is composed of fibers is composed of fibers

from more than one from more than one

spinal nerve root.spinal nerve root.

Each spinal nerve Each spinal nerve

contributes to more contributes to more

than one peripheral than one peripheral

nerve.nerve.

Peripheral Nerve Anatomy ImpliesPeripheral Nerve Anatomy Implies

Weakness and severe Weakness and severe

atrophy of muscles atrophy of muscles

innervated by a specific innervated by a specific

peripheral nerveperipheral nerve

““HardHard”” borders of sensory borders of sensory

disturbances in the disturbances in the

distribution of a specific distribution of a specific

peripheral nerveperipheral nerve

Cervical Root Anatomy ImpliesCervical Root Anatomy Implies

Weakness Weakness –– of muscles innervated by that nerve of muscles innervated by that nerve

root root

Pain Pain –– in the distribution of that nerve root, in the distribution of that nerve root,

dermatomal sensory disturbances and neck paindermatomal sensory disturbances and neck pain

Sensory changes Sensory changes –– numbness and tingling / numbness and tingling /

paresthesias outlined by that specific dermatome paresthesias outlined by that specific dermatome

Decreased reflexes Decreased reflexes –– affected by that nerve rootaffected by that nerve root

Sensory DistributionSensory Distribution

Peripheral Nerve vs. Dermatome Peripheral Nerve vs. Dermatome

Understand the Relevant AnatomyUnderstand the Relevant Anatomy

Listen to the PatientListen to the Patient

Directed Physical ExamDirected Physical Exam

How to Clinically Diagnose How to Clinically Diagnose

the Cause of Arm Painthe Cause of Arm Pain

HistoryHistory

Quality and timing of injury/symptomsQuality and timing of injury/symptoms�� Motor disturbance Motor disturbance –– onset, location, severityonset, location, severity

�� Sensory disturbance Sensory disturbance –– onset, location, severityonset, location, severity

�� Paresthesias Paresthesias –– type, locationtype, location

�� Pain Pain –– onset, location, severity, typeonset, location, severity, type

Physical ExaminationPhysical Examination

Inspection Inspection

VascularVascular

Range of Motion Range of Motion

Motor Motor

SensationSensation

ReflexesReflexes

TinelTinel’’ss

Physical Examination: Inspection Physical Examination: Inspection

Bruises / abrasion / lacerationBruises / abrasion / laceration

SwellingSwelling

Physical Examination:Physical Examination:

Inspection Inspection

AtrophyAtrophy

HornerHorner’’s syndromes syndrome

Physical Examination: VascularPhysical Examination: Vascular

PulsePulse

SwellingSwelling

ColorColor

Physical Examination: Physical Examination:

Range of MotionRange of Motion

Passive Range of Motion Passive Range of Motion

(PROM)(PROM)

Active Range of Motion Active Range of Motion

(AROM)(AROM)

ContracturesContractures

Physical Examination: Physical Examination:

Motor Function Motor Function

Voluntary movementVoluntary movement

PowerPower

Characteristic posturesCharacteristic postures

Reflexes Reflexes

Physical Examination: SensationPhysical Examination: Sensation

Paresthesia (numbness, tingling, pricking, Paresthesia (numbness, tingling, pricking,

pins and needles of a limb) pins and needles of a limb)

Allodynia (pain resulting from a stimulus Allodynia (pain resulting from a stimulus

which would not normally provoke pain)which would not normally provoke pain)

Anesthesia (sensation blocked)Anesthesia (sensation blocked)

Physical Examination: Physical Examination:

TinelTinel’’s Signs Sign

Is a way to detect irritated Is a way to detect irritated

nerves. nerves.

Is performed by lightly Is performed by lightly

tapping (percussing) over tapping (percussing) over

the nerve to elicit a the nerve to elicit a

sensation of tingling or "pins sensation of tingling or "pins

and needles" in the and needles" in the

distribution of the nerve.distribution of the nerve.

Takes its name from French Takes its name from French

neurologist Jules Tinel. neurologist Jules Tinel.

So, What is the Cause of Arm So, What is the Cause of Arm

Pain?Pain?

Cervical radiculopathyCervical radiculopathy

�� C6C6

Peripheral (entrapment) neuropathyPeripheral (entrapment) neuropathy

�� Median Neuropathy / CTSMedian Neuropathy / CTS

Brachial plexopathyBrachial plexopathy

�� Upper TrunkUpper Trunk

Cervical RadiculopathyCervical RadiculopathyIncidence of cervical Incidence of cervical

radiculopathy is about radiculopathy is about

85/100,000.85/100,000.

Cervical radiculopathy is a Cervical radiculopathy is a

dysfunction of a cervical dysfunction of a cervical

nerve root.nerve root.

C7 radiculopathy ~ 60%C7 radiculopathy ~ 60%

C6 radiculopathy ~ 25%C6 radiculopathy ~ 25%

C8

C7

C6

C6 Cervical RadiculopathyC6 Cervical Radiculopathy

HistoryHistory

�� Neck pain Neck pain –– acute or chronicacute or chronic

�� Radicular pain Radicular pain –– exacerbated by movement, specific posturing exacerbated by movement, specific posturing

of the neckof the neck

�� Weakness in the distribution of myotomeWeakness in the distribution of myotome

C6 Cervical RadiculopathyC6 Cervical Radiculopathy

Physical ExaminationPhysical Examination

Motor deficit Motor deficit –– elbow flexion, elbow flexion,

wrist extensionwrist extension

Sensory deficit Sensory deficit –– in C6 in C6

dermatome/the thumb /neck dermatome/the thumb /neck

pain from the paraspinalspain from the paraspinals

Decreased reflexes Decreased reflexes –– Biceps Biceps

brachii, brachioradialisbrachii, brachioradialis

Peripheral NeuropathyPeripheral Neuropathy

Median Neuropathy Median Neuropathy

(Carpal Tunnel Syndrome)(Carpal Tunnel Syndrome)

Incidence Incidence -- 50 /1000 in the 50 /1000 in the

US; women >men 3:1; US; women >men 3:1;

age 45age 45--6060

Etiology Etiology -- compression of compression of

the median nerve in the the median nerve in the

carpal tunnel.carpal tunnel.

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

History and Physical ExaminationHistory and Physical Examination

Nocturnal pain and paresthesia Nocturnal pain and paresthesia

relieved by relieved by ““flickingflicking””

Symptoms evoked by hyper Symptoms evoked by hyper

flexed wrist and repetitive motionflexed wrist and repetitive motion

Motor Motor –– weakness and atrophy of weakness and atrophy of

the thenar eminencethe thenar eminence

Sensory Sensory -- pain, numbness and pain, numbness and

tingling in radial 3 tingling in radial 3 ½½ fingers fingers

C6 Radiculopathy CTS C6 Radiculopathy CTS –– PNPN

Median NerveMedian NerveMotor Motor –– deficit deficit

weakness/weakness/atrophy atrophy of thenar of thenar

eminence (the thumb)eminence (the thumb)

Sensory deficit Sensory deficit -- pain, pain,

numbness and numbness and tingling in tingling in

radial 3 radial 3 ½½ fingers fingers

Nocturnal pain and Nocturnal pain and

paresthesia relieved by paresthesia relieved by

““flickingflicking””

Symptoms evoked by Symptoms evoked by

hyperflexed wrist and hyperflexed wrist and

repetitive motionrepetitive motion

Motor deficit Motor deficit –– elbow elbow

flexion, wrist extensionflexion, wrist extension

Sensory deficit Sensory deficit –– in C6 in C6

dermatome/the dermatome/the thumb thumb

/neck pain from the /neck pain from the

paraspinalsparaspinals

Decreased reflexes Decreased reflexes ––

Biceps brachii, Biceps brachii,

brachioradialisbrachioradialis

Peripheral NeuropathyPeripheral Neuropathy

Brachial Plexus Brachial Plexus

Upper Trunk Brachial Upper Trunk Brachial

Plexus Palsy Plexus Palsy �� C5 ,C6 C5 ,C6 –– Roots affectedRoots affected

Decreased shoulder Decreased shoulder

abduction abduction

Decreased elbow flexionDecreased elbow flexion

Decreased forearm Decreased forearm

supinationsupination

Fingers and hand function Fingers and hand function

normalnormal

Brachial Plexus Injury Brachial Plexus Injury ––

Variable Signs and SymptomsVariable Signs and Symptoms

MotorMotor�� Weakness Weakness -- variable distribution variable distribution

and severity because of the and severity because of the

complexity of the brachial plexus complexity of the brachial plexus

�� For example : mild weakness in For example : mild weakness in

biceps and profound weakness biceps and profound weakness

in the handin the hand

SensorySensory�� Variable hypesthesia, Variable hypesthesia,

paresthesia, anesthesia and paresthesia, anesthesia and

painpain

ReflexesReflexes�� Lost or decreasedLost or decreased

Brachial Plexus Palsy Brachial Plexus Palsy

History of Birth History of Birth

7 lb 4oz7 lb 4oz

Hand movement only at birthHand movement only at birth

Uncomplicated pregnancyUncomplicated pregnancy

Initial EvaluationInitial Evaluation

3 months of age3 months of age�� Minimal shoulder activityMinimal shoulder activity

�� Minimal external rotation Minimal external rotation

�� NO elbow flexion NO elbow flexion

�� No supination of the handNo supination of the hand

Ancillary StudiesAncillary Studies

Electrophysiologic studiesElectrophysiologic studies�� EMGEMG

Radiologic studiesRadiologic studies�� CT CT –– myelogrammyelogram

�� XX--rayray

�� U/SU/S

Graft Repair Graft Repair

C5 - suprascapular nerveC5 - posterior division of upper trunk

C6 - anterior division of upper trunk

BP Post BP Post -- Surgical ManagementSurgical Management

Splint to protect repair / Splint to protect repair /

reconstructionreconstruction

Assist and promote Assist and promote

normal function of the normal function of the

child within limits of the child within limits of the

splintsplint

Parent education with Parent education with

respect to splint carerespect to splint care

Continue OT/PT after Continue OT/PT after

braced is D/C(6braced is D/C(6--8 wks.) 8 wks.)

Brachial Plexus Brachial Plexus

Pediatric Brachial Plexus Pediatric Brachial Plexus ––

Multidisciplinary Team Multidisciplinary Team Neurosurgery

John E McGillicuddy, MDLynda J-S Yang, MD, PhD

Physical Medicine and RehabilitationVirginia Nelson, MD, MPH

ElectrodiagnosisEdward Hurvitz, MD

James Leonard, MDKathy Spires, MD

Hand / Plastic SurgeryKevin Chung, MD, MS

Orthopedic SurgeryKelly Vanderhave, MD, MS

Occupational TherapyDenise Justice, OTRLynnette Rasmussen, OTR

Nursing Clinical Care CoordinatorMiriana Popadich, RN, MSN

Program CoordinatorConnie McGovern

Summary Summary

Diagnosing PN Lesions vs. Diagnosing PN Lesions vs.

RadiculopathyRadiculopathy

Knowledge of motor and sensory distribution of the Knowledge of motor and sensory distribution of the

cervical nerve roots and peripheral nerves is cervical nerve roots and peripheral nerves is

essential in order to correctly diagnose and treat essential in order to correctly diagnose and treat

arm pain.arm pain.

Careful, directed physical examination is the most Careful, directed physical examination is the most

useful diagnostic test. useful diagnostic test.

Do NOT rely on imaging alone.Do NOT rely on imaging alone.

Obtain ancillary (electrophysiologic, radiologic) Obtain ancillary (electrophysiologic, radiologic)

studies when needed.studies when needed.

Take Home PointsTake Home Points

Muscle atrophy / severe weakness is often more Muscle atrophy / severe weakness is often more

prominent with peripheral nerve lesion than with prominent with peripheral nerve lesion than with

radiculopathy.radiculopathy.

Boundaries of peripheral nerve sensory deficits are Boundaries of peripheral nerve sensory deficits are

““harderharder”” and more exact than those of cervical and more exact than those of cervical

radiculopathy.radiculopathy.

Thank You !Thank You !

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