![Page 1: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/1.jpg)
Myelopathy
vs
Radiculopathy
Sarah Sullivan, DO
Northwest NeuroSpecialists
April 6, 2012
![Page 2: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/2.jpg)
Spinal cord
Anatomy
Terminates at L1-2 - conus/filum terminale
Segments with dorsal/ventral rootlets, form roots, fuse to form spinal nerve - 31 pairs
Gray matter: posterior/lateral/anterior columns
![Page 3: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/3.jpg)
Spinal cord
Vascular: 1 anterior spinal aa/2 posterior
spinal aa; anterior and posterior spinal veins
![Page 4: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/4.jpg)
Spinal Cord Syndromes
Complete cord transection
Brown Sequard Syndrome
Anterior Spinal Artery Syndrome
Posterolateral Column Syndrome
![Page 5: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/5.jpg)
Spinal Cord Syndromes
Central Lesion
Posterior Column Syndrome
Anterior Horn Cell Syndrome
Combined Anterior Horn cell Pyramidal
Syndrome
![Page 6: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/6.jpg)
Conus vs Cauda
Conus medullaris lesion
symmetric sensory/motor; bladder/bowel/sexual fxn early; sudden
and bilateral
Cauda equina lesion
pain more prominent; gradual and unilateral
![Page 7: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/7.jpg)
Infectious/Inflammatory
Myelopathy
Acute/subacute sx’s
MRI: intramedullary lesions without
evidence of extrinsic cord compression
Sx: fever, meningismus, encephalopathy,
known systemic infection, rash, immunocomp
Infectious: Viral/Bacterial
![Page 8: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/8.jpg)
Infectious/Inflammatory
myelopathy
Inflammatory: most commonly demyelinating
MS, NMO, post-infections/vaccinial, ADEM,
auto-immune disease associated,
neoplastic/paraneoplastic
IV steroids, plasmapheresis, disease-
modifying medication
![Page 9: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/9.jpg)
Hereditary Myelopathy
Spinocerebellar degeneration
Motor neuron disorders
Leukodystrophies
Distal motor-sensory axonopathy
![Page 10: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/10.jpg)
Vascular Myelopathy
Spinal cord ischemia
Sx: sensory first, then weakness (flaccid)
Cause: physical activity, vascular manipulation, systemic hypotension
Dx/Management: MRI/prevent recurrence
Hemorrhagic
Sx: sudden, severe pain; meningeal irritation
Cause: ? spinal angioma; vascular malformations
Dx/ Management: MRI, LP/alleviate the local cause of hemorrhage
![Page 11: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/11.jpg)
Metabolic/Toxic MyelopathyNutrient Deficiency Geographic
Predilection/ToxinNon-Geographic Predilection/Toxin
May present as Metabolic Myelopathy
Vit B12 deficiency Lathyrism Cehmotherapy related myelopathy
Adult polyglucosan body disease
NO toxicity Fluorosis Organophosphate toxicity Mitochondrial disorders
Folate deficiency Tropical myeloneuropathies
Superficial siderosis-related myelopathy
Hexosaminidase A deficiency
Vitamin E deficiency Recurrent optic neuromyelitis with endocrinopathy
Hepatic myelopathy Arginase deviciency (AR)
AIDS-assoc myelopathy Biotinidase deficiency (AR)
Copper deficiency
Continuum: Lifelong Learning. June 2008. Volume 14 (3)
![Page 12: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/12.jpg)
Compressive/Traumatic
Myelopathy
Causes:
Neoplastic - spinal mets, intradural tumors
Non-neoplastic - cervical spondylosis
Traumatic
Imaging: MRI, CT Myelogram
Management: potentially treatable!
![Page 13: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/13.jpg)
Compressive Myelopathy
Image
![Page 14: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/14.jpg)
Spinal Nerve Root Disease:
Anatomy
Spinal nn roots: sensory and motor axons as they exit
the spinal cord
oligodendroglial myelination to Schwann cell myelination
31 pairs of spinal nn roots: 8 cervical, 12 thoracic, 5
lumbar, 5 sacral, 1 coccygeal
Nutrients from arterial circulation and diffusion from
CSF
Vascular from dorsal branch of segmental aa
![Page 15: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/15.jpg)
Spinal Nerve Root
Disease
Image
![Page 16: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/16.jpg)
Nerve Root Disease:
Pathophysiology
Vulnerability to entrapment, compression,
transection, invasion, ischemia
Compression
focal demyelination-conduction block vs
conduction velocity slowing
axon loss
![Page 17: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/17.jpg)
Radiculopathy
Leading cause of nerve root disease:
intervertebral disc disease and spondylosis
damage at the disc, uncovertebral joints,
facet joints
Risk factors: physical exertion or trauma,
male
L5/S1, C7
Localization: significant variability
![Page 18: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/18.jpg)
Radiculopathy
Clinical diagnosis: H&P
neck/shoulder; back/buttock
exacerbation with Valsalva, Spurling’s, straight-leg raise
Reconsider with Lhermitte’s, bowel/bladder
pain, paresthesias, weakness
Diagnostic testing
MRI/CT myelogram
EMG/NCS
![Page 19: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/19.jpg)
Radiculopathy: Clinical findings
Root Pain/Sensory Weakness Reflex
C5 Neck/shoulder Shoulder abduction; ext rotation; forearm
supination
Biceps/brachioradialis
C6 Lat arm/forearm/thumb As with C5 and pronation
Biceps/brachioradialis
C7 Middle finger/hand WE/WF/forearm pronation
Triceps
C8 Medial forearm/hand Finger/wrist extension/abduction/a
dduction
Triceps
L2-3-4 Back/ant thigh/medial LE Hip flexion/adduction/knee
extension
Patella
L5 Buttock/lat thigh/dorsum foot/great toe (webspace)
Hip abduction; DF, foot inversion/eversion
S1 Buttock/lat-post thigh/post calf/lat-plantar foot
Hip extension/ PF Achilles
Continuum: Lifelong Learning in Neurology. June 2008. Volume 14 (3)
![Page 20: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/20.jpg)
Radiculopathy
Image
![Page 21: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/21.jpg)
Cervical Radiculopathy:
Management
Acute Sensory Cervical imagingAvoid triggers and bedrestNSAIDs, steroid taperCervical traction if foraminal stenosisRe-eval in 4 weeks
Acute Motor Cervical imagingNeruosx/ortho consultAvoid triggers, avoid bedrestNSAIDs, steroidsCervical traction if foraminal stenosis
Subacute Chronic PTTENSNeurosx/Ortho consult
Continuum: Lifelong Learning in Neurology. June 2008. Volume 14(3)
![Page 22: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/22.jpg)
Lumbar Radiculopathy:
Acute Management
Pain/Sensory Loss NSAIDs, brief narcotics, brief Bedrest (<2 days), avoid trigger, oral steroids x 10-14
days, gradual mobilization
Mild Motor Deficit As above with MRI, EMG if no improvement in 3 weeks, PT when pain is stable
Marked Motor Deficit As above with urgent MRI, neurosx/ortho consult, EMG in 3 weeks, PT when pain is stable
Continuum: Lifelong Learning in Neurology. June 2008. Volume 14 (3)
![Page 23: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/23.jpg)
Lumbar Radiculopathy:
Subacute Management
Medical/Neurologic Re-eval
MRI +/- Neurosx/Ortho eval
More agressive mobilization/PT
Medical management: NSAIDs, prn gabapentin, Lyrica, Cymbalta, tricyclics for neuropathic pain
Continuum: Lifelong Learning in Neurology. June 2008. Volume 14 (3)
![Page 24: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/24.jpg)
Polyradiculopathy
Damage to multiple root segments
simultaneously or progressively
single limb/bilaterally/diffusely
![Page 25: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/25.jpg)
Polyradiculopathy:
Differential DiagnosisMyelopathy Polyradiculopathy Polyneuropathy
Diabetes + +
Adrenal Insufficiency + +
Paraneoplastic syndrome + + +
Lyme disease + + +
Viral infxn (HSV, CMV, VZV, EBV)
+ + +
Spinal cord infarction +
Motor Neuron Disease + +
Vasculitis + + +
Syrinx, MS +
Continuum: Lifelong Learning in Neurology. June 2008. Volume 14 (3)
![Page 26: Myelopathy Radiculopathy - Tucson Osteopathic Medical ... · PDF fileSpinal Cord Syndromes ... Conus vs Cauda Conus medullaris lesion ... Cauda equina lesion pain more prominent; gradual](https://reader031.vdocuments.us/reader031/viewer/2022030417/5aa2f3887f8b9ada698d8f81/html5/thumbnails/26.jpg)
Questions?
http://www.adzuna.co.uk/blog/2012/01/24/graduate-competition-intensifies-how-are-you-managing/end-is-near-cartoon-9/