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1.12 Cervical and Low Back Pain and Radiculop

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Cervical and low back pain and radiculopathy Jenice Robinson, MD Assistant Professor of Neurology Penn State College of Medicine NBS725 January 12, 2009
Transcript
Page 1: 1.12 Cervical and Low Back Pain and Radiculop

Cervical and low back pain and radiculopathy

Cervical and low back pain and radiculopathy

Jenice Robinson, MD

Assistant Professor of Neurology

Penn State College of Medicine

NBS725 January 12, 2009

Jenice Robinson, MD

Assistant Professor of Neurology

Penn State College of Medicine

NBS725 January 12, 2009

Page 2: 1.12 Cervical and Low Back Pain and Radiculop

Learning Objectives:After reviewing the content of the lecture, the student will be able to:1) Distinguish somatic and radicular neck and low back pain by mechanism of

pain and by associated clinical symptoms and signs2) Describe the anatomy of the ventral and dorsal nerve roots, the location of

the cell bodies in the ventral horn and dorsal root ganglia, and the formation of the spinal nerves

3) List common symptoms and signs of cervical and lumbosacral disk herniation causing nerve root compression

4) Draw the anatomy of the nerve roots at the L4-L5 and L5-S1 levels and demonstrate how a disk herniation at these levels may compress the nerve roots

5) Describe diagnostic imaging methods for use to evaluate radicular pain6) Describe basic treatment of radiculopathy caused by disc herniation7) List ‘red flags’ in the evaluation of neck and low back pain indicating

increased risk for a possible serious underlying cause of the pain

Page 3: 1.12 Cervical and Low Back Pain and Radiculop

Back and neck pain:• Very common• Up to 50% of working

adults have had a back injury in the past year

• Back symptoms most common cause of disability in patients <45

• Neck pain also very common

• Societal cost of back pain estimated to be > $20 billion dollars per year

Page 4: 1.12 Cervical and Low Back Pain and Radiculop

Somatic pain:

• Most cervical and low back pain fall into the category of somatic pain

• Somatic pain arises from the stimulation of A (small myelinated) and C (unmyelinated) nociceptive nerve endings– Activation can be chemical via tissue damage – Direct mechanical stimulation

Page 5: 1.12 Cervical and Low Back Pain and Radiculop

Pain sensitive structures:

• Muscles• Ligaments

Page 6: 1.12 Cervical and Low Back Pain and Radiculop

Pain sensitive structures:

• Muscles• Ligaments• Facet joints

(zygapophyseal)• Dura mater• Intravertebral discs:

annulus fibrosis• Epidural veins

Page 7: 1.12 Cervical and Low Back Pain and Radiculop

Somatic pain:• Aching/expanding pressure• Felt locally in area of injury, but also my be

referred to other areas• Referred to areas innervated by the same

spinal cord segment• Mechanism is convergence in spinal cord

and thalamus– Afferents from the primary source of pain

converge with afferents from the site of referral

Page 8: 1.12 Cervical and Low Back Pain and Radiculop

Referred pain from stimulation of zygapophyseal joints

Page 9: 1.12 Cervical and Low Back Pain and Radiculop

Somatic pain: Summary• Aching/pressure quality• Occurs in broad areas reflecting areas of

referral from the same spinal segment, severe could radiate to limbs

• Otherwise known as back strain and etc.• Does NOT:

– Travel in bands– Have a lancinating or electric shock quality– Have associated neurologic signs on

examination

Page 10: 1.12 Cervical and Low Back Pain and Radiculop

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

Page 11: 1.12 Cervical and Low Back Pain and Radiculop

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

Page 12: 1.12 Cervical and Low Back Pain and Radiculop

dura

Page 13: 1.12 Cervical and Low Back Pain and Radiculop
Page 14: 1.12 Cervical and Low Back Pain and Radiculop

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

Page 15: 1.12 Cervical and Low Back Pain and Radiculop

Dermatome

• Each nerve root supplies cutaneous sensation to a specific area of skin, known as a dermatome

Overlaps somewhat, so won’t loseAll sensation, but will feel paresthesia

Page 16: 1.12 Cervical and Low Back Pain and Radiculop
Page 17: 1.12 Cervical and Low Back Pain and Radiculop

Myotome

• If radicular pain sever could affect myotome

• Each nerve root supplies motor innervation to certain muscles,

known as a myotome

Page 18: 1.12 Cervical and Low Back Pain and Radiculop

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

Page 19: 1.12 Cervical and Low Back Pain and Radiculop

Radiculopathy: Summary• Pain and paresthesias radiating in the

distribution of a nerve root, often associated with sensory loss and paraspinal muscle spasm

• Sensory loss (often vague or ill defined)

• Weakness (often subjective, not present, or mild)

• Reflex loss (may be present or absent)

Page 20: 1.12 Cervical and Low Back Pain and Radiculop

Radiculopathy: Provocative maneuvers

• Valsalva– Cough, laughter, voluntary contraction of abdominal wall

muscles, when straining, make radicular pain worse

• Stretching the involved nerve root—L1S1—sitting worsens, C5C6—abduct arm over head relieves

• Straight leg raise—L5L6 worsens

Page 21: 1.12 Cervical and Low Back Pain and Radiculop

Reflexes:

• C5-C6 Biceps• C5-C6 Brachioradialis• C7 Triceps• L3-L4

Quadriceps/patellar• S1 Ankle

60s—no ankle jerks—could be normal if on both sides, but if only on one side With pertinent symptoms on that side--significant

Page 22: 1.12 Cervical and Low Back Pain and Radiculop

• In the cervical 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

Page 23: 1.12 Cervical and Low Back Pain and Radiculop

• L4-L5 lateral disk herniation– Usually will compress the

L5 nerve root

• L5-S1 lateral disk herniation– Usually will compress the

S1 nerve root

• These are the general rules and anatomy to remember for the cervical and lumbosacral spine…

Page 24: 1.12 Cervical and Low Back Pain and Radiculop

But in the LS spine there are exceptions!

Large disk herniation, far lateral,

Nerve roots

Page 25: 1.12 Cervical and Low Back Pain and Radiculop

Cauda equina and conus medullaris syndromes:

Severe radiating pay, L4L5 lvl herniated midline, all nerve roots are pinched

Page 26: 1.12 Cervical and Low Back Pain and Radiculop

Cauda equina and conus medullaris syndromes:

• Large midline disk herniation can cause symptoms in both legs in the distribution of multiple nerve roots, bilateral, large full bladder– Cauda equina syndrome:

• multiple nerve roots bilaterally are affected below the end of the spinal cord at L1-2

– Conus medullaris syndrome: • the end of the spinal cord from about T11-L1

Page 27: 1.12 Cervical and Low Back Pain and Radiculop

Cauda equina and conus medullaris syndromes:

• Both are potentially surgical emergencies depending on the cause

• Warning signs that one of these may be present are: – Rapidly progressive bilateral lower extremity

weakness– Saddle anesthesia– Loss of ability to urinate voluntarily with a large

bladder and overflow incontinence– Loss of rectal tone

Page 28: 1.12 Cervical and Low Back Pain and Radiculop

Cauda equina and conus medullaris

• Differentiating the two is difficult, and they may coexist:– Cauda equina: More pain, asymmetric at onset, bladder

dysfunction not initially as severe– Conus medullaris: Often little pain, symmetric at onset,

severe bladder dysfunction

• Key points: – Emergent imaging with MRI is essential – Make sure to image high enough to see the full conus! To

at least T10

Page 29: 1.12 Cervical and Low Back Pain and Radiculop

Root Pain (*less reliable for localization)

Paresthesias/Numbness (*more reliable for localization)

Weakness Reflex loss

L2 Groin Anterolateral thigh Hip flexion None L3 Anterior thigh

to knee Medial thigh and knee Hip flexion

and adduction, knee extension

Quadriceps

L4 Anterior thigh to medial leg

Medial leg to medial ankle

Hip adduction, knee extension, foot dorsiflexion

Quadriceps

L5 Lateral thigh and leg to dorsum of foot

Lateral leg, dorsum of foot and great toe

Hip abductors, ankle inversion, eversion, foot and toe dorsiflexion

None

S1 Posterior thigh, calf and heel

Sole and lateral foot and ankle, lateral 2 toes

Hip extension, knee flexion, foot plantarflexion and toe flexion

Ankle

Summary: Neurologic features of LS radiculopathy

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Summary: Neurologic features of cervical radiculopathy

C7 most common

Page 31: 1.12 Cervical and Low Back Pain and Radiculop

Radiculopathy: Etiology besides herniate disk which is most

common

• Structural– Disk (MC)– Spondylosis (degenerative changes)– Tumor (mass lesion)– Abscess– Hematoma

Page 32: 1.12 Cervical and Low Back Pain and Radiculop

Radiculopathy: Etiology

• Non-structural, or infiltrative– Tumor (carcinomatous or lymphomatous

meningitis)– Granulomatous tissue (e.g., sarcoid)– Infection (e.g., Lyme disease, herpes zoster,

cytomegalovirus, herpes simplex). – Acute inflammatory demyelinating neuropathy– Infarction

• Vasculitic neuropathy• Diabetic polyradiculopathy

Page 33: 1.12 Cervical and Low Back Pain and Radiculop

Severe radicular pain in All extermities, lime diseaseWhite over everything

Page 34: 1.12 Cervical and Low Back Pain and Radiculop

Differential diagnosis of radiculopathy:

• I do not expect you to know these next two slides in detail, however, please be familiar with the concepts

• Radiculopathy always must be distinguished from other peripheral nerve or plexus problems

• Root lesion (radiculopathy) vs plexus lesion– C5/6 vs Upper trunk– C8 vs Lower trunk– L3/4 vs Lumbar plexus– L5/S1 vs Sacral plexus

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Differential diagnosis of radiculopathy:

• Root lesion (radiculopathy) vs entrapment neuropathy– C6/7 vs carpal tunnel syndrome (med. n. at wrist)– C8 vs ulnar neuropathy at the elbow– L3/4 vs femoral neuropathy– L5 vs peroneal n. at the fibular neck

• Bilateral L5-S1 radiculopathy vs early peripheral polyneuropathy

• Could be appropriate by EMG/NSV

Page 36: 1.12 Cervical and Low Back Pain and Radiculop

Imaging: Indications

• Somatic back and neck pain:– Often not helpful and not indicated unless

the patient has risk factors for a serious underlying cause of back pain

• Incidence of spine abnormalities such as disk bulges/minor herniations is about 25-50% in asymptomatic people!

• Current techniques are not helpful in identifying the source of the somatic pain

Page 37: 1.12 Cervical and Low Back Pain and Radiculop

Imaging: Indications

• Imaging is appropriate in the following patients:– Trauma– Risk factors for serious underlying etiology – Symptoms present for >4 weeks– Neurologic deficit

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Imaging: Modalities

• X-rays: most useful in trauma to exclude fracture, not sensitive for nerve root or spinal cord pathology

• CT: most useful study for bony anatomy• MRI: most useful study for imaging disk, nerve

root and spinal cord pathology– Contrast is used if patient has had prior spine surgery in

the affected area b/c can light up scar tissue, or if tumor, infection, or other inflammatory etiology is suspected

• CT myelogram, CT/w dye injected into spine: in patients who cannot obtain MRI, often the best study for imaging the nerve roots of a selected area

Page 39: 1.12 Cervical and Low Back Pain and Radiculop

‘Red flags’:• Risk factors for a possible serious underlying cause of low back or neck pain include (b/c <1% of ppl with neck/back pain have underlying etiology except these):– Age >50 years– Prior diagnosis of cancer

• Lung, breast, colon, prostate, lymphoma, renal cancers especially– History of serious medical condition (i.e., AIDS, TB, artificial heart valve,

severe COPD, etc.)– Use of glucocorticosteroids – Chronic/frequent pulmonary or urinary infections– History of intravenous drug use– Duration of pain > 1 month– Urinary or bowel urgency or incontinence

• Risk factors for a possible serious underlying cause of low back pain additionally include:– Pain is worsened or not improved by lying down

• Signs associated with a potentially serious etiology of low back or neck pain:– Unexplained weight loss– Percussion tenderness over the spine– Rapidly progressive neurologic deficit

Page 40: 1.12 Cervical and Low Back Pain and Radiculop

Treatment of radiculopathy:• Natural history of lumbosacral and cervical

radiculopathy:– Up to 75% spontaneously improve– Length of time required for improvement may

be several weeks or up to years!

• If there is a progressive neurologic deficit or intractable pain, surgical referral is appropriate

• Otherwise, most patients can avoid surgery

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Empiric treatment of radiculopathy:

• Medications:– Pain control with NSAIDS and narcotic

medications as necessary– Short course of corticosteroids in selected

patients; justification is to decrease inflammation around the nerve root

Page 42: 1.12 Cervical and Low Back Pain and Radiculop

Empiric treatment of radiculopathy:

• Gentle physical therapy (mobilization and stretching)

• Bed rest• TENS unit, heating pads, ultrasound,

gentle massage• Traction for the cervical spine• Epidural steroid injections for the LS spine

– Risks are higher in cervical spine

• Transforaminal steroid injections for the LS spine


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