Cervical and low back pain and radiculopathy

Jenice Robinson, MD Assistant Professor of Neurology Penn State College of Medicine NBS725 January 12, 2009

Learning Objectives:
After reviewing the content of the lecture, the student will be able to: 1) Distinguish somatic and radicular neck and low back pain by mechanism of pain and by associated clinical symptoms and signs 2) Describe the anatomy of the ventral and dorsal nerve roots, the location of the cell bodies in the ventral horn and dorsal root ganglia, and the formation of the spinal nerves 3) List common symptoms and signs of cervical and lumbosacral disk herniation causing nerve root compression 4) Draw the anatomy of the nerve roots at the L4-L5 and L5-S1 levels and demonstrate how a disk herniation at these levels may compress the nerve roots 5) Describe diagnostic imaging methods for use to evaluate radicular pain 6) Describe basic treatment of radiculopathy caused by disc herniation 7) List red flags in the evaluation of neck and low back pain indicating increased risk for a possible serious underlying cause of the pain

Back and neck pain:

Very common Up to 50% of working adults have had a back injury in the past year Back symptoms most common cause of disability in patients <45 Neck pain also very common Societal cost of back pain estimated to be > $20 billion dollars per year

Somatic pain:
Most cervical and low back pain fall into the category of somatic pain Somatic pain arises from the stimulation of A (small myelinated) and C (unmyelinated) nociceptive nerve endings
Activation can be chemical via tissue damage Direct mechanical stimulation

Pain sensitive structures:

Muscles Ligaments

Pain sensitive structures:

Muscles Ligaments Facet joints (zygapophyseal) Dura mater Intravertebral discs: annulus fibrosis Epidural veins

Somatic pain:
Aching/expanding pressure Felt locally in area of injury, but also my be referred to other areas Referred to areas innervated by the same spinal cord segment Mechanism is convergence in spinal cord and thalamus
Afferents from the primary source of pain converge with afferents from the site of referral

Referred pain from stimulation of zygapophyseal joints

Somatic pain: Summary

Aching/pressure quality Occurs in broad areas reflecting areas of referral from the same spinal segment, severe could radiate to limbs Otherwise known as back strain and etc. Does NOT:
Travel in bands Have a lancinating or electric shock quality Have associated neurologic signs on examination

Radicular pain:
Less common than somatic pain The hallmark of radiculopathy, any pathologic condition affecting the nerve roots Arises from the nerve roots or dorsal root ganglia Herniated disk is by far the most common cause

Radicular pain:
Inflammation is important as a pain mechanism:
Phospholipase A and E, NO, TNF, other pro-inflammatory mediators are released by a herniated disk The dura surrounding the ventral and dorsal nerve root is bathed in this exudate Inflammation or prior injury to nerve root is necessary to cause compression to generate continued pain

dura

Radicular pain:
Lancinating or electric quality Moves in bands and usually radiates down the limbs Associated symptoms of paresthesias are very helpful determining the identity of the involved nerve root better than site of pain Symptoms of weakness and objective findings of sensory loss, weakness and reflex loss may occur

Dermatome
Each nerve root supplies cutaneous sensation to a specific area of skin, known as a dermatome

Overlaps somewhat, so wont lose All sensation, but will feel paresthesia

Myotome
If radicular pain sever could affect myotome Each nerve root supplies motor innervation to certain muscles, known as a myotome

Types of peripheral nerve injury:

Neurapraxia: Segmental loss of myelin coating on nerve root/nerve
Weakness, but no atrophy

Axonotmesis: Loss of axons and myelin but at least some supporting structures are preserved
Weakness and muscle atrophy if severe

Neurotmesis: Loss of axons, myelin, and complete disruption of supporting structures (transection) weakness and atrophy

Radiculopathy: Summary
Pain and paresthesias radiating in the distribution of a nerve root, often associated with sensory loss and paraspinal muscle spasm Sensory loss (often vague or ill defined) Weakness (often subjective, not present, or mild) Reflex loss (may be present or absent)

Radiculopathy: Provocative maneuvers

Valsalva
Cough, laughter, voluntary contraction of abdominal wall muscles, when straining, make radicular pain worse

Stretching the involved nerve rootL1S1sitting worsens, C5C6abduct arm over head relieves Straight leg raiseL5L6 worsens

Reflexes:
C5-C6 Biceps C5-C6 Brachioradialis C7 Triceps L3-L4 Quadriceps/patellar S1 Ankle
60sno ankle jerkscould be normal if on both sides, but if only on one side With pertinent symptoms on that side--significant

 In the cervical spine:

Nerve roots exit above their named vertebral body I.e., C7 exits below C6 and above C7-so lateral disk herniation here gets C7

In the lumbar spine:

Spinal cord ends at L1 or L2 Nerve roots travel long distances then exit below their named vertebral body The lumbosacral nerve roots are susceptible

to injury at multiple
locations T11-L1anterior horn

 L4-L5 lateral disk herniation

Usually will compress the L5 nerve root

L5-S1 lateral disk herniation

Usually will compress the S1 nerve root

These are the general rules and anatomy to remember for the cervical and lumbosacral spine

But in the LS spine there are exceptions!

Nerve roots

Large disk herniation, far lateral,

Cauda equina and conus medullaris syndromes:

Severe radiating pay, L4L5 lvl herniated midline, all nerve roots are pinched

Cauda equina and conus medullaris syndromes:

Large midline disk herniation can cause symptoms in both legs in the distribution of multiple nerve roots, bilateral, large full bladder
Cauda equina syndrome:
multiple nerve roots bilaterally are affected below the end of the spinal cord at L1-2

Conus medullaris syndrome:

the end of the spinal cord from about T11-L1

Cauda equina and conus medullaris syndromes:

Both are potentially surgical emergencies depending on the cause Warning signs that one of these may be present are:
Rapidly progressive bilateral lower extremity weakness Saddle anesthesia Loss of ability to urinate voluntarily with a large bladder and overflow incontinence Loss of rectal tone

Cauda equina and conus medullaris

Differentiating the two is difficult, and they may coexist:
Cauda equina: More pain, asymmetric at onset, bladder dysfunction not initially as severe Conus medullaris: Often little pain, symmetric at onset, severe bladder dysfunction

Key points:
Emergent imaging with MRI is essential Make sure to image high enough to see the full conus! To at least T10

Summary: Neurologic features of LS Root Pain (*less radiculopathy Paresthesias/Numbness Weakness Reflex loss
L2 L3 reliable for localization) Groin Anterior thigh to knee Anterior thigh to medial leg (*more reliable for localization) Anterolateral thigh Medial thigh and knee Hip flexion Hip flexion and adduction, knee extension Hip adduction, knee extension, foot dorsiflexion Hip abductors, ankle inversion, eversion, foot and toe dorsiflexion Hip extension, knee flexion, foot plantarflexion and toe flexion None Quadriceps

L4

Medial leg to medial ankle

Quadriceps

L5

Lateral thigh Lateral leg, dorsum of and leg to foot and great toe dorsum of foot

None

S1

Posterior thigh, calf and heel

Sole and lateral foot and ankle, lateral 2 toes

Ankle

Summary: Neurologic features of cervical radiculopathy

C7 most common
Root Pain (*less reliable for localization) Neck, shoulder Paresthesias/Numbness Weakness (*more reliable for localization) Lateral arm Shoulder abduction and external rotation, elbow flexion and forearm supination Neck, shoulder, Lateral forearm, thumb Shoulder abduction and external lateral arm and and index finger rotation, elbow flexion and forearm forearm, lateral supination and pronation hand Neck, shoulder, Index and middle Elbow and wrist extension, forearm middle finger, fingers, palm pronation, wrist flexion hand Shoulder, Medial forearm and Finger extension, some wrist medial forearm, hand, fourth and fifth extension, distal finger and thumb fourth and fifth digits flexion, finger abduction and digits adduction Medial arm and Medial forearm; also Thumb abduction most affected; forearm, sometimes fourth and finger abduction and adduction axillary chest fifth digits wall Reflex loss C5 Biceps, brachioradialis Biceps, brachioradialis

C6

C7

Triceps

C8

None

T1

None

Radiculopathy: Etiology besides herniate disk which is most common

Structural
Disk (MC) Spondylosis (degenerative changes) Tumor (mass lesion) Abscess Hematoma

Radiculopathy: Etiology
Non-structural, or infiltrative
Tumor (carcinomatous or lymphomatous meningitis) Granulomatous tissue (e.g., sarcoid) Infection (e.g., Lyme disease, herpes zoster, cytomegalovirus, herpes simplex). Acute inflammatory demyelinating neuropathy Infarction
Vasculitic neuropathy Diabetic polyradiculopathy

Severe radicular pain in All extermities, lime disease White over everything

Differential diagnosis of radiculopathy:

I do not expect you to know these next two slides in detail, however, please be familiar with the concepts Radiculopathy always must be distinguished from other peripheral nerve or plexus problems Root lesion (radiculopathy) vs plexus lesion
C5/6 vs Upper trunk C8 vs Lower trunk L3/4 vs Lumbar plexus L5/S1 vs Sacral plexus

Differential diagnosis of radiculopathy:

Root lesion (radiculopathy) vs entrapment neuropathy
C6/7 vs carpal tunnel syndrome (med. n. at wrist) C8 vs ulnar neuropathy at the elbow L3/4 vs femoral neuropathy L5 vs peroneal n. at the fibular neck

Bilateral L5-S1 radiculopathy vs early peripheral polyneuropathy Could be appropriate by EMG/NSV

Imaging: Indications
Somatic back and neck pain:
Often not helpful and not indicated unless the patient has risk factors for a serious underlying cause of back pain

Incidence of spine abnormalities such as disk bulges/minor herniations is about 2550% in asymptomatic people! Current techniques are not helpful in identifying the source of the somatic pain

Imaging: Indications
Imaging is appropriate in the following patients:
Trauma Risk factors for serious underlying etiology Symptoms present for >4 weeks Neurologic deficit

Imaging: Modalities
X-rays: most useful in trauma to exclude fracture, not sensitive for nerve root or spinal cord pathology CT: most useful study for bony anatomy MRI: most useful study for imaging disk, nerve root and spinal cord pathology
Contrast is used if patient has had prior spine surgery in the affected area b/c can light up scar tissue, or if tumor, infection, or other inflammatory etiology is suspected

CT myelogram, CT/w dye injected into spine: in patients who cannot obtain MRI, often the best study for imaging the nerve roots of a selected area

 Risk factors for a possible serious underlying cause of low back or neck pain include (b/c <1% of ppl with neck/back pain have underlying etiology except these):
Age >50 years Prior diagnosis of cancer
Lung, breast, colon, prostate, lymphoma, renal cancers especially

Red flags:

History of serious medical condition (i.e., AIDS, TB, artificial heart valve, severe COPD, etc.) Use of glucocorticosteroids Chronic/frequent pulmonary or urinary infections History of intravenous drug use Duration of pain > 1 month Urinary or bowel urgency or incontinence

Risk factors for a possible serious underlying cause of low back pain additionally include:
Pain is worsened or not improved by lying down

Signs associated with a potentially serious etiology of low back or neck pain:
Unexplained weight loss Percussion tenderness over the spine Rapidly progressive neurologic deficit

Treatment of radiculopathy:
Natural history of lumbosacral and cervical radiculopathy:
Up to 75% spontaneously improve Length of time required for improvement may be several weeks or up to years!

If there is a progressive neurologic deficit or intractable pain, surgical referral is appropriate Otherwise, most patients can avoid surgery

Empiric treatment of radiculopathy:

Medications:
Pain control with NSAIDS and narcotic medications as necessary Short course of corticosteroids in selected patients; justification is to decrease inflammation around the nerve root

 Gentle physical therapy (mobilization and stretching) Bed rest TENS unit, heating pads, ultrasound, gentle massage Traction for the cervical spine Epidural steroid injections for the LS spine
Risks are higher in cervical spine

Empiric treatment of radiculopathy:

Transforaminal steroid injections for the LS spine