limb weakness: radiculopathies and compressive disorders · myotome definition: muscles innervated...
TRANSCRIPT
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LimbWeakness:RadiculopathiesandCompressiveDisorders
SpotthebraincellDr.TheoMobachPGY-4Neurology
Image:Felten,Shetty.Netter’sAtlasofNeuroscience.2nd Edition.
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Objectives• Basicneuroanatomyofperipheralnervoussystem
• Physicalexam:motorandsensorycomponents
• Commonentrapmentneuropathies– MedianNeuropathyattheWrist– UlnarNeuropathyattheElbow– FibularNeuropathy
• Radiculopathies
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UMNvs LMNUpperMotorNeuron Lower MotorNeuron
• Spasticity• Hyperreflexia• Pyramidal patternofweakness
• Babinskisign
• Atrophy• Hypotonia• Decreasedorabsentreflexes
• Fasciculation's
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MotorUnit
Motorneuron SkeletalMuscleFibers
Oftenseveralmotorunitsworktogethertocoordinatecontractionofasinglemuscle
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SpinalRoots
Image:Olson,Pawlina.StudentAtlasofAnatomy.2ndEdition
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Image:Olson,Pawlina.StudentAtlasofAnatomy.2ndEdition
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Dermatome
Definition:
Asensoryregionofskininnervatedbyanerveroot=dermatome
Image:Felten,Shetty.Netter’sAtlasofNeuroscience.2nd Edition.
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SensoryInnervationCutaneous
NerveBranches
Images:Felten,Shetty.Netter’sAtlasofNeuroscience.2nd Edition.
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Myotome
Definition:
Musclesinnervatedbyasinglenerveroot=myotome
NerveRoot
Muscle PeripheralNerve
C5 DeltoidsInfraspinatusBiceps
AxillaryN.SuprascapularN.Musculocutaneous
C6 BicepsWristextensors (ECR)
MusculocutaneousRadialN.
C7 TricepsFingerextensors(EDC)
RadialN.PIN(RadialN.)
C8 Extensor indicis proprius (EIP)Medianinnervatedintrinsichandmuscles(LOAF)
PIN(RadialN.)Median
L4 Quadriceps Femoral
L5 FootdorsiflexionFootinversionFoot eversionHip abduction
Fibular N.FibularN.Tibial N.Gluteal N.
S1 Foot plantarflexion,Hipextension
Tibial N.GlutealN.
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Recall
• Writedown2muscleforeachofthefollowingmyotomes,themusclesMUSTbefromdifferentperipheralnerves:– C6– C8– L5– S1
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AnswerNerveRoot
Muscle PeripheralNerve
C6 BicepsWristextensors (ECR)
MusculocutaneousRadialN.
C8 Extensor indicis proprius (EIP)Medianinnervatedintrinsichandmuscles(LOAF)
PIN(RadialN.)Median
L5 FootdorsiflexionFootinversionFoot eversionHip abduction
Fibular N.FibularN.Tibial N.Gluteal N.
S1 Foot plantarflexion,Hipextension
Tibial N.GlutealN.
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PeripheralNerve
Image:Felten,Shetty.Netter’sAtlasofNeuroscience.2nd Edition.
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MuscleFibers
Pneumonic:Type1:1slowfatredoxType2:2fastskinnywhitebreasts
Attribute Type1Fiber Type2Fiber
Grosscolour Dark Light
Oxidativeenzymes High Low
Lipid High Low
Mitochondria High Low
Glycogen Low High
Function Sustainedcontraction Briefcontraction
TwitchSpeed Slow Fast
Metabolism Aerobic Anaerobic
Fatigue Resistant Sensitive
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MotorExam• Bulk
– Observeforfasciculation's– Assessforatrophy
• Tone– Determinerelationshipwith
velocity(rigidityvs spasticity)
• Strength– MRCscale
• Reflexes– Gradeusinga0-4scale– Babinski,clonus
MRCSCALE0 No movement
1 Flicker2-
2
NotfullROM
Gravityeliminated
3-
3
Not fullROM
AgainstGravity
4-44+
MildresistanceMod.resistanceGoodresistance
5-
5
Questionably full
FullStrength
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MotorExamPearls
• Alwaysexplainbeforetestingstrength
• Adjuststrengthtestingbasedonpatient
• Rememberneckflexionandextension– Usefulcorrelateforrespiratoryweakness
• Screenforbulbar,facial,andeyeweakness
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MotorExamPearls• Whenexaminingsmallmusclesofthehand,uselikeagainstlike,matchingyourcorrespondingmuscle
• Musclearemostpowerfulwhenmaximallyshortened
• Forunilateralweaknessusethecontralateralsideasacontrol
• Alwaysassessthelowerextremitiesevenwhensymptomsareonlyupperextremity.MotororsensorychangesplusUEradiculopathycouldindicatemyelopathyintheC-spine
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SensoryExamSpinothalamic• Standardizedmethodofstarting
withC2andgoingdownthelateralaspectofthearmandupthemedialaspectwithpinprick,thenlighttouch.
DorsalColumn• Vibrationrarelyaffectedinthe
hands,screenwithfeet• Jointpositionsense
Corticalsensation:considerintheappropriatesetting
Image:Felten,Shetty.Netter’sAtlasofNeuroscience.2nd Edition.
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Non-neurologicexamination
• NeckROMandSpurling• Jointexamasindicated(shoulder)• Medialorlateralepicondylitis• PIP/DIPs/CMPsforarthritis• Pressurepointsformyofascialpain
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Non-organicweakness• Effortiserraticandvariable
• Iftheexaminerdecreasesresistancethepatientwithnon-organicweaknessstopstrying
• Non-organicflaccidlimbmayfallslowlywhendroppedtoavoidinjury
• Patientwithnon-organicweaknessmaynotbecalmorindifferenttowardstheweakness
• Hoover’ssign
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MedianNervevsC6Radiculopathy
Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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MedianNerveAnatomy
Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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MedianinnervatedmusclesintheHand
LOAF• Lumbricals 1and2• Opponens pollicus• Abductorpollicus brevis• Flexorpollicus brevis
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MedianNeuropathySensory
Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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MedianNeuropathyattheWristClinical• Common:1-5%ofthepopulation• Women>men• Dominanthand>non-dominant
• Sensory paresthesiafirst3.5digits– Nocturnalparesthesiacommon
• Pain:wrist,mayradiateintotheforearmorarm,rarelyshoulder
• Provokingfactors:wristflexionorextension,activitiesrequiringprolongedhandgrip
• Relievingfactors:shakingtheirhand,wringingitout,warmwater
• Motor:functionallimitationtoMNWisuncommon
Table:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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MedianNeuropathyattheWrist
ProvocativeTesting• Tinel’s Test(50%/77%)• Phalen’s Test(68%/73%)• Manualcarpalcompression(64%/83%)
• Handelevationtest(similarsensitivityandspecificitytotinel andphalen)
Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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MNWDdxPeripheralNervousSystem• Proximalmedianneuropathy• Medialcordorlowertrunklesion• C6radiculopathy
CentralNervousSystem• Stroke:lacunar,corticalhand• Myelopathy• Demyelinatinglesion
Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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MNWTreatment• Conservative– NocturnalCarpelTunnelSplints– Avoidaggravatingactivities– ScreenforDMandHypothyroidism
• CarpelTunnelSurgicalRelease
• Othertherapies– Hydrodissection (mild-moderateseverityCTS)
– Steroidinjection
Image:https://commons.wikimedia.org/wiki/File:Carpal_tunnel_splint.jpg
Image:https://commons.wikimedia.org/wiki/File:Carpal_Tunnel_Syndrome.png
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CervicalRadiculopathyClinical• Painandparesthesia inthedistributionofanerveroot• Associatedparaspinal musclespasmtypicallylimits
movementsthatexacerbatesymptoms
Examination• Sensoryparethesia orhypoesthesiainvolvingadermatome• Weaknessinvolvinganerverootmyotome• Reflexesmaybedepressed• Spurling Test• Horner’ssyndrome
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CervicalRadiculopathyEtiology• Discogenic• Spondylosis• Masslesionssuchasbone
mets orepiduralabscess
Lesscommonetiologies• Leptomeningeal
carcinomatosis• Infection(HSV,VZV,CMV)• Vasculitis• GBS
Image:https://commons.wikimedia.org/wiki/File:728_Herniated_Disk.jpg
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CervicalRadiculopathyTreatment• Conservative
– Physicaltherapy• ROM,stretching,strengthening
– Oralanalgesia:• simpleanalgesia+/- musclerelaxant
– Shorttermsoftcollar– Oralsteroids
• Shortcourseifpainissevere– Avoidanceofprovocativeactivities
• Epiduralsteroidinjections• SurgeryIndication
– Myelopathy– Progressiveweakness– Unremittingradicularpaindespite6-8weeksofconservativetherapy
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MNWvs C6MNW C6radiculopathy
History Noctornal paresthesia NeckpainRadicularpainSx worsewithneckmotion
Sensory PalmarsparingInvolvesdigit3(C7)
Sensorychanges extendpastthewrist
Motor Lumbricles 1&2, FPB,APB,OP
Biceps, brachialis,brachioradialis,wristextension
Reflexes None Biceps,brachioradialis
SpecialTests CarpeltunnelcompressiontestPhalen’sTinel’s
Spurling’sHorner’s
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UlnarNervevsC8Radiculopathy
Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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UlnarNerveAnatomy• DerivedfromC8/T1
Nerveroots
• Nobranchesinthearm
• Ulnargroove:formedbetweenmedialepicondyleandolecrenon
• TravelsthroughthewristviaGuyon’s canal
Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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• Etiology:– CompressionorStretch– Trauma
• Clinical– Motorsymptomsarecommon:lossofdexterityanddecreasedhandgrandpinchstrength– Atrophyofthenar andhypothenar eminence– Sensory:paresthesia orhypoesthesiamedialaspectofthehand– Reflexes:normal
• DifferentialDiagnosis– Medialcord,lowertrunkorC8/T1lesion
• Treatment:– Conservative:
• avoidcompressionandstretch,• helbow pad
– Surgery
UlnarNeuropathyattheElbow
Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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UlnarNeuropathyExam
BenedictssignFroment sign
Wartenberg sign
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Ulnarneuropathyexam
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Ulnarvs C8/T1Ulnar C8/T1radiculopathy
History Compressionorstretchmechanismof injury
NeckpainRadicularpainSx worsewithneckmotion
Sensory Medial dorsalandvolaraspectofthehand
Sensorychanges extendpastthewrist
Motor ADM,dorsal andpalmarinterossei,lumbricles 3&4,adductorpollicus,
Extensor indicespropriusMedianintrinsichandmuscles
Reflexes None FingerFlexor
SpecialTests Tinel’s Spurling’sHorner’s
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FingerFlexorReflex=C8/T1
Image:http://www.sciencedirect.com/topics/page/Hyperreflexia
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Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd EditionImage:http://www.aafp.org/afp/2013/0415/p568.html
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FibularNervevsL5Radiculopathy
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FibularNerveAnatomy
Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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Fibularneuropathy• FibularnerveispredominantlyL5(L4-S1)
• Clinical– Weaknessofankleandtoedorsifexion– Presentswithfootdrop,slapfoot,tripping– Sensorychangesovermidandlowerlateral
calfanddorsumofthefoot
• Etiology– Trauma– Forciblestretchinjury– Compressionfromprolonged
immobilization– Positions:Legcrossing,squating– Tightfittingboots(skiboots)
Image:https://bluestarr.wordpress.com/2011/12/28/230/
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Fibularvs L5Fibular L5Radiculopathy
History Mechanismoftrauma,stretchorcompressionatthefibularhead
BackpainRadicularpainBladderorbowelsymptoms
Sensory Midandlowerlateralcalfanddorsumofthefoot
L5 dermatomeandsymptomsmayextendabovetheknee
Motor Dorsiflexion andeversion Hip abductionAnkleinversion
Reflexes None None
SpecialTests Tinel’s StraightlegraiseCrossedlegraise
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Radiculopathies
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Radiculopathies• Sensoryormotordysfunctiondue
topathologyofanerveroot
• Clinical– Pain– Weaknesswithinamyotome– Sensorychangeswithina
dermatome– Antecedentevents:trauma,heavy
lifting,physicalexertion• Onset
– Acute:suggestsdiscogenic etiology(youngerage,20%)
– Subacute/chronic:suggestsspondylosis (olderage,70%)
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RadiculopathiesCommonCausesofRadiculopathy– Discherniation– Osteophytes– Spinalstenosis– Trauma– Diabetes– EpiduralAbscess– EpiduralMetastases– NerveSheathTumor– Guillain-BarreSyndrome– HerpesZoster– LymeDisease– Cytomegalovirus– IdiopathicNeuritis
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Radiculopathies
CommonLocations– C6andC7mostcommon
cervicalradiculopathies
– L5andS1mostcommonlumbosacralradiculopathies
– 2/3ofdiscogenicradiculopathiesoccurinthelumbosacralregion
Image:Olson,Pawlina.StudentAtlasofAnatomy.2ndEdition
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RadiculopathiesredFlags
• Signs/symptomstosuggestinflammatory,neoplasticorinfectiousetiology– Age>50– Historyofcancer– Fever– Unexplainedweightloss– Immunosuppression– Painthatdoesn’timproveintherecumbentposition– Symptomsthatdon’timprove1monthafterconservativetherapy
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LumbosacralRadiculopathyTreatment• Conservative
– Physicaltherapy• ROM,stretching,strengthening
– Oralanalgesia:• simpleanalgesia• Musclerelaxants• Opioidanalgesia(shortterm)
– Oralsteroids• Shortcourseifpainissevere(5-7days)
– Avoidanceofprovocativeactivities
• Epiduralsteroidinjections– Moderateshorttermbenefit
• SurgeryIndication– Persistentorprogressiveneurologicdeficits– Unremittingradicularpaindespite6-8weeksof
conservativetherapy– Benefitsofsurgeryseemtodecreaseovertime
comparedtonon-surgicalgroups
Image:Olson,Pawlina.StudentAtlasofAnatomy.2ndEdition
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AlternativeEtiologies
• Whiplashinjury• Rheumatoidarthritisofthespine• Fibromyalgia/myofascial syndrome• Polymyalgiarhuematica• Tendonitis,bursitis,arthritis
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Review
QuizCases
Image:Felten,Shetty.Netter’sAtlasofNeuroscience.2nd Edition.
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Quiz
Image:Preston,Shupiro.ElectromyographyandNeuromuscularDisorders.3rd Edition
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QuizCase1:
48yearoldmarriedfemaleworksfulltimeasaadministrativeassistantpresentswith3monthsofnumbnessinD4&5anddecreasedgripstrength.
1. MainDdx:list4anatomicallocations2. Specificexamtests3. Treatment
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AnswertoCase1Ddx:• Ulnarneuropathy• medialcordlesion• lowertrunklesion• C8radiculopathyExamination• Sensory:
– istheresensorylossonthedorsumofthehand(UNE)– doesthesensorylossextendpastthewrist(C8radiculopathy)
• Motor:– isthereweaknessofulnarinnervatedhandmuscles(FLOAD)?– IsthereweaknessofC8musclesbyotherperipheralnerves(EIP
=radial,medianintrinsichandmuscles)• SpecialTests:
– Handpositions(benedicts,wartenberg,
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QuizCase• 64yo malewith4monthhistoryofweaknessandwastingofhisrighthand.Noassociatedpain.Recentlynotedsomelefthandweakness.
• Examshowsatrophyrighthand(thenar,hypothenar,andflexorcompartment),fasciculations,reflexes3+,bilateralhoffmans.Normalsensation.
Muscle Right Left
SA 5 5
EF 5 5
EE 5 5
WF 4+ 5
WE 4+ 5
FDI 4 4+
ADM 4 4+
ABP 4 4+
FDS 4 4+
FDP 2-5 4 4+
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AnswerCase2
ThepatternofprogressiveweaknessandatrophywithbothUMNandLMNfeaturesisconcerningforamotorneuronlocalization.
UMN:• IncreasedreflexesLMN:• Atrophy,fasciculations,weakness
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CaseQuiz357yo Mwithlowbackpainfor20years.Trippedoveradoorledgeanddevelopedsuddenincreaseinright-sidedlowbackpainradiatingdownhislegintotherightbigtoe.
Exam:• Motor:
– 3/5rightextensorhallicus longusandtibialisanterior– 4+/5rightinvertorsandevertors
• Sensory– Decreasedpinprickoverrightanterolateralcalfanddorsumofthefoot
• Positiverightstraightlegraise
Whereisthemostlikelylocalization?Listthefeaturesonhistoryandexamtosupportyourlocalization?Howwouldyoumanagethispatient?
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AnswerQuiz3
Whereisthemostlikelylocalization?• RightL5nerveroot
Listthefeaturesonhistoryandexamtosupportyourlocalization?
• History:traumaticincitingevent,priorhistoryoflowbackpain,radicularsymptoms
• Exam:L5weaknessoutsideofthefibularnerve(namelyinnvertors withweaknessoftibalis posteriorinnervatedbythetibial nerve.
Howwouldyoumanagethispatient?• Conservativetherapy:analgesia,physicaltherapy,avoidprovocative• Surgicalconsiderationifsymptomspersistorprogressorpainisrefractory
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QuizCase4
30yo Mwith4weekstinglingandpaininhisfirstandsecondfinger.Fillintheblanksbelow.
MNW C6radiculopathyHistory
Sensory
Motor
ReflexesSpecialTests
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AnswerCase4MNW C6radiculopathy
History Noctornal paresthesia NeckpainRadicularpainSx worsewithneckmotion
Sensory PalmarsparingInvolvesdigit3(C7)
Sensorychanges extendpastthewrist
Motor Lumbricles 1&2, FPB,APB,OP
Biceps, brachialis,brachioradialis,wristextension
Reflexes None Biceps,brachioradialis
SpecialTests CarpeltunnelcompressiontestPhalen’sTinel’s
Spurling’sHorner’s
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References:Blumenfeld Hal.NeuroanatomythroughClinicalCases.SecondEdition.2010.
PrestonDavid,ShapiroBarbara.ElectromyographyandNeuromuscularDisorders,3rd Edition.2013
DavidFelten,AnilShetty.Netter’sAtlasofNeuroscience.2ndEdition.2003
ToddOlson,Wojchiech Pawlina.StudentAtlasofAnatomy.2nd Edition
Uptodate.comhttp://www.uptodate.com/contents/treatment-and-prognosis-of-cervical-radiculopathy?source=search_result&search=cervical+radiculopathy&selectedTitle=2~32
http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-cervical-radiculopathy?source=search_result&search=cervical+radiculopathy&selectedTitle=1~32
http://www.uptodate.com/contents/ulnar-neuropathy-at-the-elbow-and-wrist?source=search_result&search=median+neuropathy+at+the+wrist&selectedTitle=3~150
http://www.uptodate.com/contents/carpal-tunnel-syndrome-etiology-and-epidemiology?source=search_result&search=median+neuropathy+at+the+wrist&selectedTitle=12~150
http://www.uptodate.com/contents/carpal-tunnel-syndrome-treatment-and-prognosis?source=search_result&search=median+neuropathy+at+the+wrist&selectedTitle=11~150
http://www.uptodate.com/contents/acute-lumbosacral-radiculopathy-pathophysiology-clinical-features-and-diagnosis?source=search_result&search=lumbar+radiculopathy&selectedTitle=1~39