1. Bgn Ilmu Penyakit Saraf
Radicular Syndrome
Darwin Amir
Bgn Ilmu Penyakit Saraf
Fakultas Kedokteran
Universitas Andalas

2. Peripheral Nerves and Nerve PlexusesC1 C2
Cervical plexus C3 C4 C4 C4
Brachial plexus C4
Phrenic nerve C4 T1 T2 T3
Axillary nerve T4 T5 T6
Musculocutaneous nerve T7 T8 T9
Thoracic nerves
T10
T11
T12 L1
Radial nerve
Lumbar plexus L2
Ulnar nerve L3 L4
Median nerve L5 S1
Sacral plexus S2 S3 S4 S5
Lateral femoral cutaneous nerve
Co1
Genitofemoral nerve
Femoral nerve
Pudendal nerve
Sciatic nerve 2

3. See ANS
lecture 4

4. 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

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

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

7. 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

8. 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

9. 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

10. 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) weakness and atrophy

11. Dermatome
Each nerve root supplies cutaneous sensation to a specific area of skin, known as a dermatome
Overlaps somewhat, so won’t lose
All sensation, but will feel paresthesia

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

13. In the cervical spine: In the lumbar 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
T11-L1—anterior horn

14. 1. Cervical Radiculopathy
C7 most common

15. 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.

16. Cervical HNP
Just as is the case with Lumbar HNP, conservative therapy is the mainstay of treatment.
Surgery indicated for those that don’t improve with conservative management, or with new/progressive neurologic deficit.

17. 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.

18. 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 symptoms.

19. 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.
Pain and sensory changes in the back of the head, neck, and shoulders.

20. 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

21. 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

22. intervertebral disc

23. Internal disruption

25. 3. Cauda Equina Syndrome Bilateral sciatica Historically Presently
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

26. 3. Cauda Equina Syndrome Symptoms Back pain Radicular pain Motor loss
Bilateral
Unilateral
Motor loss
Sensory loss
Urinary dysfunction
Overflow incontinence
Inability to void
Inability to evacuate the bladder completely
Decrease in perianal sensation

27. 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

28. 4. Spondylosis Clinical: Changes with maturation in:
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

29. 5. Spondylolisthesis Clinical: May be asymptomatic, but can result in
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

30. 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

31. Back Pain Causes de-conditioning sprain/strain spondylolithesis
spondylosis
facet syndrome
disc herniation
disc bulge
spinal stenosis
biomechanical
inflammatory
infection
cancer

32. 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 variable…but it is going to progress.