In the name of Allah the

Beneficent the Merciful

 Detecting the Differences

Radiculopathy, Myelopathy and

Dr Zafar Iqbal
Department of Neurosurgery
Abbasi Shaheed Hospital Karachi
Points to note …..
 Radiculopathy, myelopathy, and
peripheral neuropathy have common
overlapping symptoms, but each has a
unique physiological mechanism
underlying the sensory and motor
disturbances associated with each
disorder.
Points to note …..
 While the physical exam should reveal
characteristics that differentiate one
pathology from another, in order to
prevent an incorrect diagnosis, the list of
differential diagnoses should be examined
before treatment is started.
Points to note …..
 Furtherwork-up may be necessitated by
other disease processes that present with
common symptoms, if the patient does not
respond to well regarded treatment or new
symptoms develop during treatment.
Radiculopathy

 Radiculopathyoccurs as a result of
biomechanical pressure on a nerve root
with subsequent biochemical release of
inflammatory mediators

(Starkweather, Witek-Janusek &

Mathews, 2005).
Radiculopathy

Biomechanical pressure at the point of the

dorsal root ganglion (nerve root that
directly dissects from the spinal cord) or
peripheral nerve can be caused by
 disc tissue,
 tumors, or
 bone.
Radiculopathy
 often has a quick onset and is
characterized by a shooting pain that
radiates down the extremity.
 Patients often present with symptoms
present upon awakening in the morning,
without identifiable trauma or stress.
Radiculopathy

Clinical findings include

 pain,
 dermatomal sensory disturbances,
 weakness, and
 hypoactive muscle stretch reflexes in the
distribution of the affected nerve root
Radiculopathy

cervical herniated disc is the most

common reason for upper extremity
radiculopathy
Radiculopathy
Radiculopathy

Motor and sensory loss will be specific to

the nerve root involved
Radiculopathy
Almost all herniated cervical discs cause
painful limitation of neck motion, with
aggravation of pain during neck extension.
Radiculopathy
 Left C–6 radiculopathy occasionally
presents with chest or scapular pain
 C–8 and T–1 nerve root involvement may
cause a partial Horner’s syndrome due to
interruption distal to the superior cervical
ganglion.
 Over 90% of patient with acute cervical
radiculopathy due to cervical disc
herniation will improve without surgery
(Saal, Saal, &Yurth, 1996).
 The recovery period can be treated with
adequate pain medication, mainly non-
steroidal anti-inflammatory types and
muscle relaxants. Short course tapered
steroids and intermittent cervical traction
(10–15 pounds for 10–15 minutes 2–3
times daily) may also be used.
 In patients that have progressive
neurological deficits (i.e. weakness) of the
affected muscle groups, however, surgery
may provide the best long-term outcomes
cervical discectomy
 Anteriorcervical discectomy with fusion
(ACDF) or without fusion (ACD) or
posterior cervical foraminotomy may be
used for resection of a cervical disc
herniation
selection of the surgical procedure
 reasonablybe based on the preference of
the surgeon and tailored to the individual
patient.
cervical disc replacement
 may likely be available to the general
public in the near future. Clinical trials on
the efficacy of disc replacement surgery
have continued with promising outcomes
(Phillips & Garfan, 2005).
Cervical disc replacement
 preserves motion at the instrumented
level/s and can potentially improve load
transfer to the adjacent levels compared
with fusion. There are several different
models that are presently seeking FDA
approval
Risks associated with surgery
 neurological injury,
 dural tear,
 infectionthe
Risks
 long-term voice disturbances
 dysphasia.
 incidence of new-onset dysphasia after
surgery is 29.8% at three months,
 6.9% at six months, and
 6.6% at two years.
Risks
 The use of plates resulted in a 1.6-times
higher incidence and higher rates were
noted following multi-level procedures and
at more cephalic levels.
 a smaller and smoother plate profile
reduced the incidence and severity of
post-operative dysphasia.
 plating affects the adjacent levels
 Most plate designs use oblong holes, and,
as settling occurs, the plate translates
toward the next adjacent non-fused level
(Cervical Spine Research Society, 2005).
Plates within 5 mm of non-fused disc spaces
have been associated with adjacent-level
disc ossification.
Risks
 Thisphenomenon, when occurring within
three months after surgery, is likely to be
progressive. However, Rao and
colleagues (2005) suggest that fusion
does not generally affect adjacent levels in
the cervical spine.
Myelopathy

Functional disturbance or pathological

change in the spinal cord is referred to as
myelopathy
Myelopathy

It is often caused by pressure around the

spinal cord. This syndrome usually has a
prolonged onset, occurring over months to
years
Differential Diagnosis
Patients may present with
 an inability to button their clothes,
 turn doorknobs and
 may complain of dropping objects often.
CSM
 Cervicalspondylosis is the most common
cause of myelopathy in patients over 55
years of age (Greenberg, 2006).
Spondylosis, a term used to describe
widespread degenerative condition of the
discs and vertebrae, can cause direct cord
compression.
Cervical spondylotic myelopathy
 develops in almost all patients with over
30% narrowing of the cross-sectional area
of the cervical spinal canal, although some
patients with severe cord compression do
not develop myelopathy.
CSM

Osteophytes and hypertrophy or enfolding

of the ligamentum flavum may also
contribute to spinal cord compression
These processes

narrow the canal causing ischemia of the

cord and degeneration of the central grey
matter at the level of compression
Damage
 to the posterior columns above the lesion
and demyelination in the lateral columns,
especially the corticospinal tracts, below
the lesion, causes
 changes in sensory and motor function.
Thus, a mixture of
 upper motor and
 lower motor neuron findings in cervical
myelopathy may be found.
Clinical Features

There may be
 weakness and
 wasting of hand muscles
 with slow, stiff opening and closing of the
fists, resembling arthritis.
Clinical Features
 Clumsiness with fine motor skills
 proximal weakness of the lower extremities,
notably iliopsoas weakness occurs in 54%,
and
 spasticity of the lower extremities with most
having hyperactive reflexes (clonus and
Babinski’s sign).
.
Clinical Features
 Glove distribution sensory loss in the
hands may be present and most have loss
of vibratory sense in the lower extremities
Amyotrophic lateral sclerosis (ALS)
 iscommonly misdiagnosed as cervical
spondylosis.
Common findings of ALS
 include:
 atrophic weakness of the hands and forearms
 mild lower extremity spasticity and
 diffuse hyperreflexia, but
 sensory changes are absent.
 Dysarthria or hyperactive jaw-jerk may be the first clue.
 Hyperactive jaw jerk indicates upper motor neuron
lesion above the midpons and distinguishes long tract
findings above the foramen magnum from those below.
Fasciculation of the tongue or in the lower extremities
may also occur in ALS.
Electromyelography (EMG)
 Electromyelography (EMG) is the
diagnostic test used to confirm ALS.
MRI
 Carefulconsideration of chiari
malformation, syringomyelia,
hydrocephalus and cervical spondylosis
with cord compression were used when
evaluating the films.
Surgery
 cervical laminoplasty, a procedure to decompress
the spinal canal by removing a part of the lamina of
the affecting vertebrae.
 Anterior cervical discectomy or vertebrectomy
 with or without fusion may be used to treat anterior
disease up to three levels.
 The posterior approach,
 Decompressive cervical laminectomy
 with or without fusion may be used if the disease is
primarily posterior or if surgery is required in more
than three levels.
cervical laminoplasty
 was associated with better clinical
outcomes (functioning, pain) and less
complications than decompression and
fusion.
Indications for surgery
 areprimarily patients with radiological
evidence of spondylotic degeneration of
the cervical spine with progressive
symptoms, and/or pain.
Severity and Progression
 Thus, the importance of determining
severity and progression of symptoms is
vital as the goal of surgery is to stop the
progression, while recovery of symptoms
is variable.
Laminoplasty
 has gained in popularity for the treatment
of cervical myelopathy secondary to
 ossification of the posterior longitudinal
ligament and
 spondylosis with spinal stenosis
Peripheral neuropathy
 Peripheralneuropathy occurs as nerve
roots, which extend to the distal portion of
each extremity, are damaged.
Etiology
 The exact cause is unknown but is thought
to be mediated by inflammation, ischemia
and demyelination of the larger peripheral
nerves
Etiology
 Diabetes,
 alcohol and
 Guillain-Barre

accounting for 90% of cases

Evaluation

for the initial workup for peripheral

neuropathies of unknown etiology should
include
 Hgb-A1C,
 TSH,
 ESR,
 vitamin B12 and
 EMG studies.
Over 50% of patients with diabetes
mellitus (type I and type II)
 develop neuropathic symptoms (Perkins,
2002). Diabetic neuropathy may be
slowed with tight glucose control, while in
patients with impaired glucose tolerance;
diet and exercise have been shown to
significantly improve neuropathic pain
(Laino, 2004)..
 Even in patients that have diabetes, evaluation
of other causes for neuropathy is advocated.
Gorson and Ropper (2006) found that 53% of
103 diabetic patients with polyneuropathy had
additional causes, such as
 vitamin B deficiencies,
 renal disease,
 alcohol overuse, and
 neurotoxin medications
Drugs
 Thalidomide
 Metronidazole (Flagyl)
 Phenytoin (Dilantin),
 Amitriptyline (Elavil),
 Dapsone
 Nitrofurantoin (Macrodantin)
 Cholesterol Lowering Drugs Such As
1. Lovastatin (Mevacor)
2. Indapamide (Lozol)
3. Gemfibrozil (Lopid)
 Thallium, And
 Chemotherapy (Cisplatin, Vincristine)
Guillain-Barre syndrome
 presentsas an acute onset of peripheral
neuropathy with progressive and
symmetric muscle weakness (more severe
proximally) with areflexia.
Guillain-Barre syndrome

This occurs with focal segmental

demyelination with endoneurial monocytic
infiltration; the exact cause of the disease,
however, remains unknown. Patients are
diagnosed based on presentation and
progression of symptoms, nerve conduction
studies and through cerebral spinal fluid
analysis
Perioperative neuropathies

Most sensory neuropathies that develop

perioperatively or after cardiac
catheterization resolve over time, but
motor neuropathies can be transient or
permanent
Gabapentin

a neuroleptic drug, has been advocated

for treatment of neuropathic pain including
peripheral nerve injury (National Guideline
Clearinghouse, 2003).
Nerve Growth Factor
 Recombinant human Nerve Growth Factor
(rhNGF) may be the first treatment that
actually repairs nerves
 rhNGF is a manufactured form of a
naturally produced chemical that signals
the body to produce, repair and
strengthen small nerves
Conclusion

 Patients presenting with radiculopathy,

myelopathy or peripheral neuropathy may
have several overlapping symptoms. The
physical exam should provide the
practitioner with a differential diagnoses
scheme that will allow correct diagnosis
and treatment
………
 In general, the absence of weakness should
allow the practitioner time for an adequate
work-up of the most common diagnoses
through laboratory or radiological tests. It is
imperative that the practitioner continues to
evaluate treatment regimens for their
effectiveness and revisit the differential
diagnoses so that the patient does not
continue down the wrong treatment path. In
addition, helping patients to recognize
healthy life style habits that may affect their
symptoms is crucial