1. Group A – AHD Dr. Gary Greenberg
Spinal Nerve Root Compression and Peripheral Nerve Disorders

2. Objectives
Review Assessment and Management of Important Spinal Nerve Disorders Involving the Cervical, Thoracic and Lumbar Spine.
Review Assessment and Management of Common Peripheral Nerve Disorders.
Review Assessment of Important
Mono/Polyneuropathies .

3. Case 1 What historical factors would help you assess this patient?
70 year old male, history of mild neck pain for 2 yrs.
Gradual worsening mid cervical pain for 1 month.
Radiating down right arm to hand.
Numbness, tingling and weakness.
Now pain severe, unremitting.
Unable to sleep in spite of taking Tylenol #3.
What historical factors would help you assess this patient?

4. RED FLAGS
What are some of the RED FLAGS that come up in taking a history that make you think there might be a more serious condition present?

5. What physical examination findings would you look for?

6. Case 1
What are some of the causes of Neck Pain + Radicular Pain + Weakness ?

7. Neck Pain Can Cervical Disc Disease cause gait disturbance?
Are Neoplastic mets to C-spine common?
What is the classic presentation of Neoplastic mets to the C-spine?
Is fever a common finding in infection of the C-spine?
Name important risk factors for infection in the C-spine.

8. Cervical Radiculopathy
Describe the incidence , Reflex, Sensory and motor loss for the following levels involved:
C5 radiculopathy.
C6 radiculopathy
C7 radiculopathy.
C8 radiculopathy.

9. Cervical Imaging What is the value of a C-spine x-ray?
When should an MRI be ordered?
When should a CT scan be ordered?

10. Neck Pain
How long does it take for most neck pain from non pathological causes to resolve?
What factors may extend that time frame?

11. Thoracic Pain
Name some common causes of persistent thoracic back pain.
What is the most common tumor to cause mets to the thoracic spine?
If a Thoracic Spinal nerve is compressed, is there motor weakness?
If the spinal cord is compressed, what are the clinical findings ?

12. What historical features should be asked?
Case 2
45 year old male.
Acute onset low back pain radiating down left leg to toes.
Initial Rx Tylenol & Advil.
After 1 week, severe constant unremitting pain in left leg.
Unable to sit, bend forward , sleep.
What historical features should be asked?

13. Questions
What levels are the most common sites for fractures of the lumbar spine?
What levels are the most common sites for disc herniations?
What cancers metastasize to the lumbar spine?

14. RED FLAGS
What are some of the RED FLAGS that might come up in a history of low back pain that make you think there might be a more serious condition present?

15. Sciatica
How often does sciatica due to disc herniation occur in low back pain patients?
How often does sciatica due to disc herniation go on to develop quada equinae?
Generally what nerve root does the L4-5 disk herniation affect?
Why do most sciatica patients get better over time and do not require surgery?
What is the value of SLR, reflexes in the examination of sciatica?

16. Assessment
Describe the motor , sensory, reflex findings for the following nerve root compressions: L1 L2 L3 L4 L5 S1
S2-4

17. Imaging What is the value of plain x-rays of the lumbar spine?
What is the value of a CT scan of the lumbar spine?
What is the value of MRI of the lumbar spine?

18. Treatment of Back pain Most patients have non specific low back pain.
Most have pain resolution in 4 weeks.
Subacute LBP last 4-2 weeks.
Chronic LBP lasts > 12 weeks.
WHAT WOULD BE POSSIBLE TREATMENT OPTIONS FOR LOW BACK PAIN ?

19. Surgery for Sciatica
What are the indications for surgery for sciatica?

20. Spinal Stenosis
Describe the features of a patient with Spinal Stenosis?

21. Cauda Equinae Describe the clinical features of Cauda Equina.
What are some of the causes?
How do you check for anal tone?
What amount of residual post void urine would qualify as urinary retention?
What is the imaging of choice?

22. Other Peripheral Nerve Compression Syndromes
Median Nerve Entrapment- Carpal Tunnel, Pronator Teres Syndromes.
Ulnar Nerve Compression- at elbow, at wrist.
Radial Nerve Compression- Spiral groove, posterior interosseus.

23. Median Nerve Compression
Describe the causes, symptoms and clinical findings of carpal tunnel syndrome?

24. Median Nerve- Carpal Tunnel Syndrome
Describe the initial treatment for Carpal Tunnel .
Are NSAIDS useful?
Predictive factors for failure of conservative measures?
Place for surgery?

25. Median Nerve – Pronator Teres Syndrome
What are the different features compared to Carpal Tunnel Syndrome?

26. Ulnar Nerve Compression
Describe the findings of ulnar nerve compression at the elbow.
Describe ulnar nerve compression at the wrist.

27. Radial Nerve Compression
Describe the findings of Radial nerve compression at the spiral groove.
Describe the findings of Posterior interosseus Neuropathy.

28. Mono and Polyneuropathies
Important to know if sensorimotor findings are:
Symmetric or Asymmetric.
Distal or distal and proximal.
Sensory only, Motor only or mixed.

29. Guillain-Barre Syndrome
Acute Inflammatory Polyradiculoneuropathy.
Immune mediated inflammation of peripheral nerves disrupting myelin and causing axonal loss.
Most common acute motor neuropathy.
Usually has a preceding history of a URI or GI illness preceeding the onset.
Describe the symptoms and findings.

30. Guillain Barre Syndrome
Describe the lab and imaging abnormalities:

31. Guillain Barre Syndrome
What is the treatment for GBS?

32. Distal Symmetric Polyneuropathy
Stocking glove sensory distribution.
Motor findings lag behind sensory.
Progress distal to proximal.
Causes: Diabetes, Alcoholism, Neoplasm, HIV, Toxins, drugs.
Describe the findings in Diabetic neuropathy:

33. Diabetic Neuropathy
Describe treatment options for Diabetic Neuropathy.

34. Mononeuropathy Multiplex
Asymmetric Sensorimotor peripheral neuroathy.
Sensory findings match the motor findings.
May have reflex loss depending on the nerve involved.
Name the most common 2 causes:

35. Anterior horn cell Neuronopathy- ALS
Amyotrophic Lateral Sclerosis.
Asymmetrical distal motor weakness with no sensory loss.
Subclinical Autonomic dysfunction.
Has both Upper and Lower motor neuron signs.
What are they?

36. ALS
What test confirms the diagnosis.
What are treatment options..

37. Sensory Neuronopathies
Affects dorsal root ganglions.
Describe the physical findings.

38. Sensory Neuronopathy
List some causes and diagnostic aides.