plexopathy/ radiculopathy - aanem · radiculopathy/ plexopathy radiculopathy ... surgical...
TRANSCRIPT
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Plexopathy/
Radiculopathy
Holli A. Horak, MD
University of Arizona
August 2015
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Radiculopathy/ Plexopathy
Radiculopathy
Common pathology
Common referral to EMG laboratory
Anatomy
Pathology
NCS/EMG findings
Plexopathy
Much less common
High Index of suspicion
• Referral may not mention plexopathy
• “shoulder pain”
Special tests/study design needed
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Plexopathy/ Radiculopathy
Definition
• Plexopathy
Distal to the ventral primary rami
Distal to the DRG
Proximal to the individual nerve
• Radiculopathy
Proximal to split of dorsal/ventral rami
Proximal to DRG
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EMG/NCS correlation
Radiculopathy
Abnormalities in Motor nerves supplied by that nerve root level
S1 radiculopathy
Tibial nerve
Normal SNAP waveform
• Lesion proximal to DRG
Plexopathy
Multiple motor nerves affected
• All peripheral nerves distal to plexus lesion
SNAPS affected
• Lesion is distal to DRG
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Anatomy: Cervical Plexus:
R-T-D-C-B
Roots: C5-6-7-8-T1
Trunks:Upper, middle, lower
Divisions:3 anterior and 3 posterior
Cords:Lateral, Posterior, medial
Branches: • Musculocutaneous, Median nerves
• Axillary, Radial nerves
• Ulnar, Median nerves
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Stylized Brachial Plexus
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Anatomy: Lumbar Plexus
Ventral Rami L1-2-3-4 spinal nerves
Anterior and posterior divisions
• Posterior: Femoral nerve L2-3-4
• Anterior: Obturator nerve L2-3-4
Lumbosacral trunk:
• L4 (some) and L5 ventral rami
Connect to sacral plexus
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Anatomy: Sacral plexus
Ventral Rami: S1-2-3-4 • Plus Lumbosacral trunk (L4-5)
Anterior and Posterior divisions • Anterior: Tibial nerve
L4-5-S1-2
• Posterior: Common Peroneal nerve L4-5-S1-2
• Posterior: Superior Gluteal nerve
Inferior Gluteal nerve
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Plexopathy pathologies
Brachial Plexus
• Trauma
• Neoplastic
• Post radiation
• Thoracic outlet
• Idiopathic
• Hereditary
Lumbosacral Plexus
• Trauma
• Neoplastic
• Post radiation
• Retroperitoneal hemorrhage
• Diabetic amyotrophy
• Idiopathic
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Etiologies of plexopathy: Trauma
Birth
• Erb’s Upper trunk
• Shoulder dystocia
• High birth weight
• Klumpke’s Lower trunk
• Breech position
• arm 1st position
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Etiologies: traumatic
Brachial plexus
• Falls w/ hyperextension
• High impact trauma
Nerve root avulsion
• Surgical
L-S plexus
• Pelvic fractures
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EMG/NCS correlation
Sensory studies:
• Brachial plexus:
Medial Antebrachial Cutaneous
Lateral Antebrachial Cutaneous
EMG: muscles
• Arising from same nerve root level
• But different peripheral nerve/ cord origins (if possible)
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Brachial Plexus: Neoplastic
Pancoast Tumor
• Lower trunk/medial cord
• Horner’s syndrome • Anhydrosis, miosis and ptosis
Breast Cancer
Lymphoma
• Infiltration in nerve sheaths
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Lumbosacral plexus: neoplastic
Direct tumor spread
• Colon Ca, Cervical Ca, Prostate
Lymphoma
• Nerve sheath spread
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Post-radiation plexopathy
Brachial and L-S plexii can be involved
Difficult to distinguish from neoplastic • 5yrs post XRT
• Subacute to chronic
• Less painful
• Myokymia But not 100%
specific!
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Distinguishing post-XRT from
neoplastic plexopathy
PET scan/ MRIs /CTs spinal cord
serial examination
Look for other sites of metastasis • PET scan
• Bone scan
• Chest/abd CT
Last resort: surgical exploration
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Brachial plexus: Thoracic Outlet
Syndrome
True Neurogenic TOS
• Lower trunk
• Insidious
• Hand muscle wasting
Thenar and intrinsic hand muscles
• Sensory loss in C8-T1 distribution
Cervical rib most common cause
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Brachial Plexus: True TOS
NCS:
• absent Ulnar SNAP
• Absent Medial Antebrachial Cutaneous SNAP
• Reduced Median CMAP
EMG:
• abnormalities in Lower trunk muscles
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Other Thoracic outlet syndromes
Arterial TOS
• Stenosis of subclavian artery
• Ischemia in hand
Venous TOS
• Stenosis/occlusion of subclavian vein
• Swelling of limb
Disputed Neurologic TOS
• Chronic aching and pain
• No objective sensory or motor loss
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Idiopathic etiologies
Neuralgic Amyotrophy UE
• Parsonage-Turner syndrome
• Acute
• Very painful
• May be bilateral
L-S plexus (non-diabetic)
• Less common
• auto-immune?
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Hirayama disease: Monomelic amyotrophy
Hirayama disease • progresses 1-5 yrs
Plateaus
• Distal > proximal weakness
O'Sullivan-McLeod syndrome • longer period of 25 to
40 years
male predominant • Arm > leg
• Typically 1 limb
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Etiologies: Hereditary
Brachial plexopathy
HNA: Hereditary Neuralgic Amyotrophy
• NABP: Neuralgic amyotrophy w/ Brachial plexopathy
• Septin 9 gene
Gene locus 17q25
AD
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Etiologies: vascular
Lumbosacral plexus
Retroperitoneal hematoma
• Hyperacute weakness and pain
May have drop in Hb
• Hospitalized setting
• traumatic
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L-S plexus: Diabetic Amyotrophy
Acute weakness/ pain/ sensory loss • Asymmetric
• But can be bilateral
Painful • Sensory loss as well as direct nerve pain
Weakness
• Femoral nerve/ Quadriceps most affected
• Patients often report “knee buckling”
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NCS/EMG correlation: Diabetic
Amyotrophy
NCS
Low amplitude CMAP
• Proximal lesion
Sural may be spared
Side to side comparison
EMG
Femoral nerve most affected
• Active denervation
• Quadriceps
Paraspinals may be involved
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Diabetic Amyotrophy • Etiology: ?
Associated w/ abrupt change in glucose control
Perhaps vascular (ischemic)
Perhaps inflammatory
• Acute treatment
None proven
• Trial of IV solumedrol
May control pain and/or speed recovery
• Chronic treatment
Typically spontaneous recovery (but prolonged!)
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Plexopathy vs. Radiculopathy
Can there be an overlap between Plex- and Radiculopathy?
• Yes
• Eg. L-S plexus
Dorsal rami can be affected in diabetic amyotrophy
“lumbosacral radiculoplexoneuritis”
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Study Design: Radiculopathy
Brief examination
Motor nerves:
• Carry fibers from suspected nerve root involved
• Compare to unaffected nerves
contralateral studies
Sensory nerves
• Should be unaffected
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Study Design Radiculopathy
EMG
>1 muscle
• Innervated by that nerve root level
• Supplied by different peripheral nerves
Ie.
• Biceps: C5-6 musculocutaneous
• Deltoid: C5-6 axillary
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Study Design: Plexopathy
NCS
Affected motor nerves
Affected sensory nerves • Originate from
cords LABC
MABC
May need side to side comparison
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Study Design: plexopathy
EMG 2 or more muscles
• affected portion of plexus
• Different peripheral nerve
Compare to unaffected muscles • Same nerve root
origin, but different plexus route
• Same peripheral nerve but different plexus route
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Example Study Design: Medial Cord
Plexopathy
Median/ Ulnar Motor
• Side to side comparison
Median, Ulnar and Medial Antebrachial Sensory studies
• Median should be unaffected
EMG
• Median:ABP, PT, FCR
• Ulnar: FDI, FCU,
• Radial: EI, EDC
• Dorsal Rami: paraspinals
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Nerve Root avulsion
Ventral nerve root
• Clinical: acute weakness
• complete paralysis in affected nerve root distribution
Significant trauma
• High velocity injury
Fall
Motorcycle
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Nerve Root Avulsion: EMG changes
Motor NCS
Sensory NCS
Fibs Pos waves
MUPs
Hyperacute
1-3 days NL NL 0 0 None
Acute 7-20 days
absent NL 0 +/- None
Subacute 1-5 mos Absent NL ++ ++ None
Chronic > 6 mos Absent NL ++++ ++++ None
Incl PSP
Inc PSP*
*Dorsal Rami is involved
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Summary:
Radiculopathies
• Common referral to EMG laboratory
• SNAPs should remain intact
• Careful EMG planning
Detect abnormalities in affected root
Exclude problems in unaffected roots
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Summary: Brachial Plexopathies
Consider this for any proximal pain/ weakness referral
• In UE: Idiopathic Brachial plexopathy
• LE: Diabetic amyotrophy
Must differentiate from radiculopathy
• Use Sensory studies
• EMG