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Neuro 1: Nerve Root Disorders

Terms in this set (59)

What IS a Radiculopathy?
Disorder of Ventral or Dorsal Spinal Root or the immediate Proximal Spinal Nerve

S/S: Spontaneous or Event-Linked. Pain localized to neck w/ dermatomal radiation (classic). Paresthesia and sensory loss. Weakness.
What is Spondylolysis?
Fracture that appear in interarticular portion of the vertebral bone, between facets
What is Spondylolisthesis?
Displacement of a vertebral body relative to body beneath it
What is Erb-Duchenne Palsy?
Traction/Trauma to the Upper Trunk (C5-C6)
"Waiter Tip"
Seen in infants during delivery
What is Klumpke's Paralysis?
Lesion of Lower Trunk (C8-T1)
"Total Claw" (loss of fxn of all lumbricals, finger flx, ext unopposed)
Often d/t tumor
What is Saturday Night Palsy?
Injury to Radial Nerve (typically midshaft humerus)
"Extensor Weakness"
D/T sleeping funny, or crutches
What is Parsonage-Turner Syndrome?
Brachial Plexitis
Neuralgia and Amyotrophy
What are three causes of Nerve Root compression?
Herniated Disc
Osteophytes
Thickened Ligamentum Flavum
Patient presents with slowly evolving shoulder pain, especially on the medial border of the scapula. What should this instantly make you think?
Cervical Radiculopathy, insidious = tumor
-> This distribution is common
Patient presents with neck pain w/ movement, especially when rotating their head to the right. They also report tingling in their right arm. They report recently falling off a trampoline. What should this make you think of instantly?
Cervical Radiculopathy, acute = herniated disc or injury
-> Likely on the right in this patient
(rotated towards = pain)
What are the Arm Dermatomes?
Patient presents with pain in the neck, shoulder, lateral arm. They have sensory loss over the lateral arm. Their biceps reflex is decreased. They show weakness of the deltoid and w/ Elbow Flexion.

What Nerve root is impinged?
C5 (C4-5 interspace)
3rd Most Common
What would C5 nerve root impingement display as?
Patient presents with pain in the neck, shoulder, lateral arm. They have sensory loss over the lateral arm. Their biceps reflex is decreased. They show weakness of the deltoid and w/ Elbow Flexion.
Patient presents with pain in the neck, radial arm, and thumb. They have sensory loss over the lateral forearm and thumb. Their brachioradialis reflex is decreased. They show weakness of the biceps and w/ wrist flexion.

What Nerve Root is impinged?
C6 (C5-6 interspace)
*Most Common Herniated Cervical Disc
What would C6 Nerve Root impingement present as?
Patient presents with pain in the neck, radial arm, and thumb. They have sensory loss over the lateral forearm and thumb. Their brachioradialis reflex is decreased. They show weakness of the biceps and w/ wrist flexion.
Patient presents with pain in the neck, radial forearm, and middle finger. They have sensory loss over the dorsal forearm and middle finger. Their *triceps* reflex is decreased. They show weakness of the tricepstricepsresents with pain in the *neck, radial forearm, and middle finger*. They have sensory loss over the *dorsal forearm and middle finger*. Their *triceps* reflex is decreased. They show weakness of the *triceps* and w/ wrist extension.

What Nerve Root is Impinged?
C7 (C6-7 Interspace)
What would a C7 Nerve Root impingement look like?
Patient presents with pain in the neck, radial forearm, and middle finger. They have sensory loss over the dorsal forearm and middle finger. Their *triceps* reflex is decreased. They show weakness of the tricepstricepsresents with pain in the *neck, radial forearm, and middle finger*. They have sensory loss over the *dorsal forearm and middle finger*. Their *triceps* reflex is decreased. They show weakness of the *triceps* and w/ wrist extension.
Review UE strength testing and what results would mean for the following?

Detoid
Biceps
Triceps
Wrist Ext
Wrist Flex
Finger Ext
Finger Flex
Interossei
Detoid = C5
Biceps = C5,C6
Triceps = C7
Wrist Ext = C6
Wrist Flex = C7
Finger Ext = C7
Finger Flex = C8
Interossei =T1
Review UE Reflexes and what results would mean for the following?

Biceps
Brachioradialis
Triceps
Biceps: C5
Brachioradialis: C6
Triceps: C7
What benefit is there of Spurling's Test?
Not a good screening test (low specificity)
Good if you suspect disc issue (high sensitivity)
How can you blow the minds of your preceptors using simple shoulder abduction?
Patient w/ Cervical Radiculopathy?
Arm Abduction will relieve -> Medial Disc
Arm Hanging will relieve -> Lateral Disc
Compare the benefits of CT and MRI for imaging the Cervical Spine?
CT -> Good for Bone
MRI -> Good for Soft Tissue

NOTE: If imaging w/ Xr, you must visualize all 7 vert.
What are the Thoracic Dermatomes of note?
All Bands Across Torso

T4 -> Teat Pore (Across Nipples)
T7 -> Xiphoid
T10 -> Belly But-TEN
T12 -> Belt line
What are the two MCC of Thoracic Radiculopathy?
DM and Degenerative Disc Disease
Pressure on what nerve causes Meralgia Paresthetica?
Lateral Femoral Cutaneous Nerve of the Thigh
Do Lumbar Nerves exit above or below their respective vertebrae?
Below
What will Straight Leg raising tell you?
Good Sens, not Spec
-> L5 Disc Herniation

F/U with a Opposite Leg Raise (good Spec, not Sens)
Review Sensitivity and Specificity AGAIN?
Sensitivity -> Good screening test
100% Sen -> ALL Negative are TRUE Negative

Specificity -> Good confirmatory test
100% Spec -> All Positive are TRUE Positive
What will the Milgram Test tell you?
Have pt. raise both legs for 30s (in supine position)
-> If causes pain, they have increased intrathecal pressure
What is a Hx equivalent of the Milgram test?
Valsalva causes pain
-> Increases intrathecal pressure
Patient presents with pain in the anterior lower leg. They have decreased sensation over the anterior medial foot. Their patellar reflex is decreased. and They have weakened quadriceps, and Knee Extension.

What nerve root is impinged?
L4 (L3-4 interspace)
What would a L4 nerve impingement look like?
Patient presents with pain in the anterior lower leg. They have decreased sensation over the anterior medial foot. Their patellar reflex is decreased. and They have weakened quadriceps, and Knee Extension.
Patient presents with pain in the side of the leg. They have sensory deficits on the anterior lower leg, dorsum of the foot, and great toe. You don't note reflex issues. Muscle strength testing reveals decreased dorsiflexion, great toe extension, and hip abduction.

What nerve root is impinged?
L5 (L4-5 interspace)
What would an L5 impingement look like?
Patient presents with pain in the side of the leg. They have sensory deficits on the anterior lower leg, dorsum of the foot, and great toe. You don't note reflex issues. Muscle strength testing reveals decreased dorsiflexion, great toe extension, and hip abduction.
Patient presents with pain on the back of leg, sole, and side of foot. They have sensory deficits on the lateral foot and 5th digit. Their Achilles reflex is decreased. Motor testing reveals decreased Ankle Eversion, and Plantar Flexion.

What nerve is impinged?
S1 (L5-S1 interspace)
What would an S1 impingement look like?
Patient presents with pain on the back of leg, sole, and side of foot. They have sensory deficits on the lateral foot and 5th digit. Their Achilles reflex is decreased. Motor testing reveals decreased Ankle Eversion, and Plantar Flexion.
Review LE strength testing and what results would mean for the following?

Tibialis Anterior (Inversion)
Extensor Digitorum Longus (Dorsiflexion)
Peroneus Longus (Eversion)
Tibialis Anterior -> L4
Extensor Digitorum Longus -> L5
Peroneus Longus -> S1
Review LE DTR testing and what results would mean for the following?

Patellar Tendon
Achilles Tendon?
Patella -> L4
Achilles -> S1
Review Foot Sensation Testing?
Medial -> L4
Dorsum/Big Toe -> L5
Lateral/Pinkie Toe -> S1
Review LE Dermatomes?
Just remember L2-L3 for anterior hip
and shift (with overlap) the numbers single segment for the next joint, so anterior knee will be L3-L4 and anterior ankle will be L4-L5

For the posterior innervation it's same as anterior but with downward shift (without overlap)
So posterior hip is L4-L5, posterior knee L5-S1, posterior ankle S1-S2
What does Hip Flexion test?
L2,3 (Iliopsoas)
What does Knee Extension test?
Femoral Nerve (Quads)
What does Hip Abduction test?
L4,5 (Glutei and TFL)
What does Hip Extension test?
L4,5 (Glutei)
What does Knee Flexion test?
L5,S1 (Hamstrings)
What does Hip Adduction test?
L2,3,4 (Adductor)
Obturator Nerve
Review the LE Muscle Str Test?

Hip Flexion/Ext
Hip Abd/Add
Knee Flx/Ext
HF: L2,3
HE: L4,5
HAb: L4,5
HAd: L2,3,4
KFx: L5,S1
KEx: L2,3,4
What does Plantar Flexion Test?
S1-2 (Tibial Nerve)
What does Dorsiflexion Test?
L4,L5 (Peroneal Nerve)
What does Foot Inversion Test?
L4 (Tibial and Peroneal Nerve)
What does Foot Eversion Test?
S1 (Peroneal erve)
Describe Cauda Equina Syndrome?
Pain, Motor, Sensory, Reflexes, Bladder
Pain: Common, Asymmetric, Dermatome, Worsen Supine
Motor Weakness: Asymmetric
Sensory: Asymmetric, Dermatomal, Saddle Region
Reflexes: Achilles Absent, +/- Patellar
Bladder: Late Sphincter Dysfunction
Describe Conus Medullaris Syndrome?
Pain, Motor, Sensory, Reflexes, Bladder
Pain: Uncommon, Symmetric, Vague Distribution
Motor: Symmetric, Distal>Proximal
Sensory: Symmetric, Saddle Region
Reflexes: +/- Reflexes, May be Hypertonic
Bladder: Early Sphincter Dysfunction
Given ONE piece of information about your patient with leg pain/paresthesia and probably lower spinal cord issue. WHAT would you want ot know?
Have they any Bladder issues?
Early -> Conus Medullaris
Late -> Cauda Equina
What is one big giveaway regarding Neurogenic Claudication?
Standing Discomfort
Describe Neurogenic Claudication?
Sensory: +/- Dermatomal
Symptoms: when Standing, walking, exercising
Relief w/ rest: Slow and Variable
Relief when Flexing Forward: Present
Distal LE ischemic changes: Absent
Describe Vascular Claudication?
Sensory: Never Dermatomal
Symptoms: Walking/Exercising a fixed distance, - Stand
Relife w/ rest: Immediate
Relief when Flexing Forward: No Change
Distal LE Ischemic Changes: Present
(e.g. Skin color, temp, pulse changes)
What causes neuroclaudication?
Spinal Stenosis
Compare Cancer and Radiation Plexopathy?
Cancer: Painful

Radiation: Painless
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