Radiculopathy vs peripheral neuropathy
-
Upload
spineplus -
Category
Health & Medicine
-
view
419 -
download
7
Transcript of Radiculopathy vs peripheral neuropathy
-
Differentiating Cervical Radiculopathy and
Peripheral Neuropathy
Adam P. Smith, MD
-
I have no financial, personal, or professional conflicts of interest to report
-
Radiculopathy versus Neuropathy Radiculopathy
Usually involves one spinal nerve root distribution following myotomal and dermatomal patterns
Pathology often proximal (disc or osteophyte)
Neuropathy Usually involves one peripheral nerve branch Pathology often entrapment distally
Double Crush phenomenon
Rare Both radiculopathy and neuropathy present
-
Key Features of Differentiation
Neurologic examination Neurologic examination Neurologic examination
Supplement exam with tests Willie Sutton
-
Roots versus Branches Roots
C5 C6 C7 C8 T1
Branches Musculocutaneous (C5,6,7) Axillary (C5,6) Radial (C5,6,7,8, T1) Median (C5,6,7,8) Ulnar (C8, T1)
Abundant overlap between motor and sensory
distributions
-
C8 versus Ulnar nerve- Motor C8 spinal nerve root
Present in ulnar, median, and radial peripheral nerve branches
Myotome based Weakness in muscles of one spinal root but multiple peripheral nerve
branches, so usually partial or incomplete
Atrophy rare (unless long-standing)
Fasciculations rare (visible motion of muscle)
C8 palsy will cause some weakness in nearly all intrinsic hand muscles, including those innervated by median nerve
-
C8 versus Ulnar nerve- Motor Ulnar nerve (C8 and T1)
Muscle based Weakness usually complete Worse with use and better with rest
Atrophy early
Fasciculations common
Innervates: 1 muscles in forearm (flexor carpis ulnaris and flexor digitorum profundus 3 & 4) Majority of hand intrinsic muscles, except LOAF (median)
-
Sensory Exam
Sensory distribution of spinal nerve roots overlap Sensory distribution of peripheral nerve branches are very discrete
Branches Roots
-
C8 versus Ulnar nerve- Sensory
C8 Dermatome based
Sensation to entire ring finger affected (and pinky finger)
Total sensory loss virtually never occurs
-
C8 versus Ulnar nerve- Sensory
Ulnar nerve (C8 and T1) Sensation to only ulnar half of ring finger affected (and pinky
finger)
-
Reflexes
Radiculopathy Appropriate DTRs depressed or absent early
Neuropathy Rare reflex changes Depends on location of entrapment
-
Pain Radiculopathy
Common history of neck pain (abrupt-disc, slow-osteophyte) Occasional radiation into suboccipital area and interscapular area Pain down arm in spinal nerve root distribution Leaning head away from affected side and neck traction may
improve pain
May worsen with valsalva
Neuropathy Rarely neck or radicular pain Pain may be distal near joint (entrapment often proximal to joint) Depends on entrapment
Carpal tunnel- Pain predominant symptom early in course Cubital tunnel- Pain may or may not be present
-
Maneuvers/ Signs Spurlings test
Tinels test Phalens test
Clawing Froments Wartenbergs
Radiculopathy
Neuropathy
Neuropathy
-
Electrodiagnostic Studies Radiculopathy
NCS usually normal Usually sensory normal Motor may be abnormal
EMG quite sensitive Single motor axon can innervate many muscle fibers, the loss
of only a few axons can produce detectable EMG changes
Fibrillations of muscles at rest supplied by spinal nerve root Not seen until >3-4 weeks after compression
Denervation ipsi paraspinal muscles Posterior rami (sensory) innervates paraspinal muscles
Can only be compressed in foramen
-
Electrodiagnostic Studies
Neuropathy Conduction delay often at site of compression
Absence of denervation in posterior myotomes (paraspinal muscles)
EMG usually normal
-
Imaging
Radiculopathy MRI or CT myelogram Require clinical and electrodiagnostic
correlation Nearly 28% of asymptomatic adults >40yo have
abnormal imaging
Neuropathy Rarely useful
-
Most Crucial Differentiations Difference in distribution of motor and sensory deficits
Neuropathy has weakened muscles and disturbed sensation solely within distribution of one peripheral nerve branch
Discrete
Lack of neck and radicular pain in neuropathy
Neuropathy has absence of denervation in posterior myotomes
Frequent presence of Tinels sign at point of entrapment or compression
-
Case Examples
-
Case Example
45yo male with neck pain radiating into right arm, right deltoid/bicep weakness, and numbness in right thumb and index finger
No reflex abnormality
+ Spurlings test to the right
-
Spurlings Test
-
C5
C6
Right Left
-
C5-6
-
Key Factors Neck pain and radiculopathy
Weakness in muscles supplied by same spinal nerve root (C6), but different peripheral nerve branches (deltoid- axillary n., bicep- musculocutaneous n.)
Sensory disturbance concordant with C6
Reflexes normal
Positive Spurlings test
Concordant MRI
-
1.5cm
-
C5 C6 C6
C5 C6 C5
-
Case Example
64 yo female with diffuse neck pain Radiates bilateral arms
No weakness or numbness Slightly hyperactive reflexes Negative Spurlings
-
C5-6
C6-7 C5
C6
C7
-
Discography
-
Discography
-
Discography
-
Key Factors Neck pain and radiculopathy into arms
Interscapular pain Cloward 1959- Disc herniations of lower cervical levels induced spasms of para-scapular
muscles
Motor/sensory exam not localizing
Myelopathic with hyperactive reflexes
Negative Spurlings
Positive discogram Reproduced pain at levels and no pain at adjacent levels
Concordant MRI
-
Anterior Cervical Discectomy and Fusion
-
C5
C6
-
Case Example 58yo female with right lateral hand
numbness, and weakness Pain thenar eminence, no neck/arm pain Weakness in opponens pollicis Numb in first 3 digits No reflex abnormalities Negative Spurlings sign, +Phalens/Tinels
-
Tinels Test
-
Phalens Test
-
Courtesy of Simon Oh, MD Colorado Neurology Specialists
Normal Abnormal
Latency < 2.3 ms or difference 15V (ulnar) or >50V (median)
axonal
NCS
-
Key Factors No neck pain or radiculopathy
Pain present in hand
Weakness in muscles supplied by one peripheral nerve branch
Sensory deficit in one peripheral nerve More than 1 spinal root involved (C6 and C7)
Reflexes normal
Positive Tinels and Phalens
Concordant NCS
-
Case Example 60yo female with left hand numbness and weakness
Weakness hand intrinsics Clawing present Left pinky weak adduction
Numbness 4th and medial 5th digits Reflexes normal
Mild neck pain without radiculopathy
No hand pain
Negative Spurlings
PMHx- Long standing poorly controlled diabetes
History of left hand carpal tunnel release No symptom improvement
4 Issues Neck pain No radiculopathy, but DM Prior dx carpal tunnel Motor/sensory findings
ulnar problem
-
Wartenbergs Sign
Ask patient to adduct fingers
Pinky finger of affected hand cannot adduct
Patient may notice pinky caught on pant pocket
Ulnar innervated palmar interossei weak
-
Ulnar Clawing
Ask patient to leave fingers at rest
4th and 5th metacarpal-phalangeal joints extend while interphalangeal joints slightly flex but are somewhat paralyzed
Weak medial lumbricales and 3rd/4th flexor digitorum profundus (both ulnar innervated)
-
Froments Sign
Ask patient to adduct the thumb and index finger so the finger pads touch
Patient flexes interphalangeal joint and finger tips touch
Ulnar innervated adductor pollicis weak so ulnar/median innervated flexor pollicis brevis compensates
-
Testing flexor digitorum profundus 3 and 4
-
Tinels Test
-
C5-6
C4-5
C7-T1
C6-7 C5 C6
C7
T1
C4
-
Stimulate ulnar nerve transcutaneously and record EMG/NCS of abductor digiti minimi
Across wrist
Across elbow
-
Courtesy of Simon Oh, MD Colorado Neurology Specialists
Decreased amplitude (>6mV) Conduction velocity delayed (>51m/sec)
NCS
-
Key Factors Minimal neck pain, but no radiculopathy into arms
60 yo so very common symptom
Weakness of hand intrinsics supplied by ulnar nerve only Maintained median nerve function
Sensory loss in ulnar nerve distribution Radial half of ring finger spared- not C8 palsy
No reflex abnormalities
No pain or numbness in median nerve distribution to suggest carpal tunnel syndrome Failed prior carpal tunnel release
Negative Spurling, but +Tinels test at elbow
NCS concordant with ulnar neuropathy at elbow
Non-concordant MRI with spinal root palsy
-
Olecrenon
Distal
Proximal
Tricepts m.
Ulnar nerve Medial epicondyle
Two heads of flexor carpis ulnaris m.
Biceps m.
Tricepts m.
Biceps m. Medial epicondyle
Olecrenon
-
Preoperative Postoperative Courtesy of Simon Oh, MD Colorado Neurology Specialists
NCS
-
Preoperative Postoperative
-
Thank You
DifferentiatingCervical Radiculopathy and Peripheral NeuropathySlide Number 2Radiculopathy versus NeuropathySlide Number 4Key Features of DifferentiationRoots versus BranchesC8 versus Ulnar nerve- MotorC8 versus Ulnar nerve- MotorSensory ExamC8 versus Ulnar nerve- SensoryC8 versus Ulnar nerve- SensoryReflexesPainManeuvers/ SignsElectrodiagnostic StudiesSlide Number 16Electrodiagnostic StudiesImagingMost Crucial DifferentiationsCase ExamplesCase ExampleSlide Number 22Spurlings TestSlide Number 24Slide Number 25Key FactorsSlide Number 27Slide Number 28Slide Number 29Slide Number 30Slide Number 31Case ExampleSlide Number 33DiscographyDiscographyDiscographyKey FactorsAnterior Cervical Discectomyand FusionSlide Number 39Slide Number 40Slide Number 41Case ExampleTinels TestPhalens TestSlide Number 45NCSKey FactorsSlide Number 48Slide Number 49Slide Number 50Slide Number 51Case ExampleWartenbergs SignUlnar ClawingFroments SignSlide Number 56Slide Number 57Tinels TestSlide Number 59Slide Number 60NCSKey FactorsSlide Number 63Slide Number 64Slide Number 65Slide Number 66Slide Number 67Slide Number 68Slide Number 69NCSSlide Number 71Slide Number 72Thank You