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Radiculopathy vs peripheral neuropathy
- 1. Differentiating Cervical Radiculopathy and PeripheralNeuropathy Adam P. Smith, MD
- 2. I have nofinancial, personal, or professional conflicts of interest to report
- 3. Radiculopathy versus Neuropathy •Radiculopathy – Usually involves one spinal nerve root distribution following “myotomal” and “dermatomal” patterns – Pathology often proximal (disc or osteophyte) • Neuropathy – Usually involves one peripheral nerve branch – Pathology often entrapment distally • “Double Crush” phenomenon – Rare – Both radiculopathy and neuropathy present
- 5. Key Features ofDifferentiation • Neurologic examination • Neurologic examination • Neurologic examination • Supplement exam with tests Willie Sutton
- 6. Roots versus Branches •Roots – C5 – C6 – C7 – C8 – T1 • Branches – Musculocutaneous (C5,6,7) – Axillary (C5,6) – Radial (C5,6,7,8, T1) – Median (C5,6,7,8) – Ulnar (C8, T1) Abundant overlap between motor and sensory distributions
- 7. C8 versus Ulnarnerve- Motor • C8 spinal nerve root – Present in ulnar, median, and radial peripheral nerve branches – Myotome based • Weakness in muscles of one spinal root but multiple peripheral nerve branches, so usually partial or incomplete – Atrophy rare (unless long-standing) – Fasciculations rare (visible “motion” of muscle) – C8 palsy will cause some weakness in nearly all intrinsic hand muscles, including those innervated by median nerve
- 8. C8 versus Ulnarnerve- Motor • Ulnar nerve (C8 and T1) – Muscle based • Weakness usually complete • Worse with use and better with rest – Atrophy “early” – Fasciculations common – Innervates: • 1 ½ muscles in forearm (flexor carpis ulnaris and flexor digitorum profundus 3 & 4) • Majority of hand intrinsic muscles, except LOAF (median)
- 9. Sensory Exam • Sensorydistribution of spinal nerve roots overlap • Sensory distribution of peripheral nerve branches are very discrete Branches Roots
- 10. C8 versus Ulnarnerve- Sensory • C8 – Dermatome based • Sensation to entire ring finger affected (and pinky finger) – Total sensory loss virtually never occurs
- 11. C8 versus Ulnarnerve- Sensory • Ulnar nerve (C8 and T1) – Sensation to only ulnar half of ring finger affected (and pinky finger)
- 12. Reflexes • Radiculopathy – AppropriateDTRs depressed or absent early • Neuropathy – Rare reflex changes – Depends on location of entrapment
- 13. Pain• Radiculopathy – Commonhistory of neck pain (abrupt-disc, slow-osteophyte) – Occasional radiation into suboccipital area and interscapular area – Pain down arm in spinal nerve root distribution – Leaning head away from affected side and neck traction may improve pain – May worsen with valsalva • Neuropathy – Rarely neck or radicular pain – Pain may be distal near joint (entrapment often proximal to joint) – Depends on entrapment • Carpal tunnel- Pain predominant symptom early in course • Cubital tunnel- Pain may or may not be present
- 14. Maneuvers/ Signs • Spurling’stest • Tinel’s test • Phalen’s test • Clawing • Froment’s • Wartenberg’s Radiculopathy Neuropathy Neuropathy
- 15. Electrodiagnostic Studies • Radiculopathy –NCS usually normal • Usually sensory normal • Motor may be abnormal – EMG quite sensitive • Single motor axon can innervate many muscle fibers, the loss of only a few axons can produce detectable EMG changes • “Fibrillations” of muscles at rest supplied by spinal nerve root – Not seen until >3-4 weeks after compression • “Denervation” ipsi paraspinal muscles – Posterior rami (“sensory”) innervates paraspinal muscles » Can only be compressed in foramen
- 17. Electrodiagnostic Studies • Neuropathy –Conduction delay often at site of compression – Absence of denervation in posterior myotomes (paraspinal muscles) • EMG usually normal
- 18. Imaging • Radiculopathy – MRIor CT myelogram – Require clinical and electrodiagnostic correlation • Nearly 28% of asymptomatic adults >40yo have “abnormal” imaging • Neuropathy – Rarely useful
- 19. Most Crucial Differentiations •Difference in distribution of motor and sensory deficits – Neuropathy has weakened muscles and disturbed sensation solely within distribution of one peripheral nerve branch • Discrete • Lack of neck and radicular pain in neuropathy • Neuropathy has absence of denervation in posterior myotomes • Frequent presence of Tinel’s sign at point of entrapment or compression
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- 21. Case Example • 45yomale with neck pain radiating into right arm, right deltoid/bicep weakness, and numbness in right thumb and index finger • No reflex abnormality • + Spurling’s test to the right
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- 26. Key Factors • Neckpain and radiculopathy • Weakness in muscles supplied by same spinal nerve root (C6), but different peripheral nerve branches (deltoid- axillary n., bicep- musculocutaneous n.) • Sensory disturbance concordant with C6 • Reflexes normal • Positive Spurling’s test • Concordant MRI
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- 32. Case Example • 64yo female with diffuse neck pain – Radiates bilateral arms • No weakness or numbness • Slightly hyperactive reflexes • Negative Spurling’s
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- 37. Key Factors • Neckpain and “radiculopathy” into arms • Interscapular pain – Cloward 1959- Disc herniations of lower cervical levels induced spasms of para-scapular muscles • Motor/sensory exam not localizing • Myelopathic with hyperactive reflexes • Negative Spurling’s • Positive discogram – Reproduced pain at levels and no pain at adjacent levels • Concordant MRI
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- 42. Case Example • 58yofemale with right lateral hand numbness, and weakness – Pain thenar eminence, no neck/arm pain – Weakness in opponens pollicis – Numb in first 3 ½ digits – No reflex abnormalities – Negative Spurling’s sign, +Phalen’s/Tinel’s
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- 46. Courtesy of SimonOh, MD Colorado Neurology Specialists Normal Abnormal • Latency < 2.3 ms or difference <0.3ms • demyelination • Amplitude >15μV (ulnar) or >50μV (median) • axonal NCS
- 47. Key Factors • Noneck pain or radiculopathy – Pain present in hand • Weakness in muscles supplied by one peripheral nerve branch • Sensory deficit in one peripheral nerve – More than 1 spinal root involved (C6 and C7) • Reflexes normal • Positive Tinel’s and Phalen’s • Concordant NCS
- 52. Case Example • 60yofemale with left hand numbness and weakness – Weakness hand intrinsics • “Clawing” present • Left pinky weak adduction – Numbness 4th and medial 5th digits – Reflexes normal • Mild neck pain without radiculopathy • No hand pain • Negative Spurling’s • PMHx- Long standing poorly controlled diabetes • History of left hand carpal tunnel release – No symptom improvement 4 Issues • Neck pain • No radiculopathy, but DM • Prior dx carpal tunnel • Motor/sensory findings ulnar problem
- 53. Wartenberg’s Sign • Askpatient to adduct fingers • “Pinky” finger of affected hand cannot adduct • Patient may notice “pinky” caught on pant pocket • Ulnar innervated palmar interossei weak
- 54. Ulnar Clawing • Askpatient to leave fingers “at rest” • 4th and 5th metacarpal-phalangeal joints extend while interphalangeal joints slightly flex but are somewhat paralyzed • Weak medial lumbricales and 3rd/4th flexor digitorum profundus (both ulnar innervated)
- 55. Froment’s Sign • Askpatient to adduct the thumb and index finger so the finger pads touch • Patient flexes interphalangeal joint and finger tips touch • Ulnar innervated adductor pollicis weak so ulnar/median innervated flexor pollicis brevis compensates
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- 60. Stimulate ulnar nerve transcutaneouslyand record EMG/NCS of abductor digiti minimi Across wrist Across elbow
- 61. Courtesy of SimonOh, MD Colorado Neurology Specialists Decreased amplitude (>6mV) Conduction velocity delayed (>51m/sec) NCS
- 62. Key Factors • Minimalneck pain, but no radiculopathy into arms – 60 yo so very common symptom • Weakness of hand intrinsics supplied by ulnar nerve only – Maintained median nerve function • Sensory loss in ulnar nerve distribution – Radial half of ring finger spared- not C8 palsy • No reflex abnormalities • No pain or numbness in median nerve distribution to suggest carpal tunnel syndrome – Failed prior carpal tunnel release • Negative Spurling, but +Tinel’s test at elbow • NCS concordant with ulnar neuropathy at elbow • Non-concordant MRI with spinal root palsy
- 64. Olecrenon Distal Proximal Tricepts m. Ulnar nerve Medialepicondyle Two heads of flexor carpis ulnaris m. Biceps m. Tricepts m. Biceps m. Medial epicondyle Olecrenon
- 70. Preoperative Postoperative Courtesy ofSimon Oh, MD Colorado Neurology Specialists NCS
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