Radiculopathy and Plexopathy Radiculopathy and Plexopathy Dr Massud Wasel M.D D.O. N.D Registered osteopath P.G.C.A.P Fellow of Higher Education Academy

Radiculopathy (spinal root lesion)  When a spinal nerve root is damaged  Causes:  Csp and Lsp spondylosis (degenerative changes including disc prolapse, osteophytes)  Trauma

 Tumours-neurofibroma, metastases  Herpes zoster virus (shingles)  Meningeal inflammation  Arachnoiditis

Clinic features:  Pain: sharp, shooting, and or burning pain radiating into the cutaneous distribution (dermatome) or muscle group (myotome) supplied by the root, can be aggravated by movement, straining or coughing  Neurological signs: LMN signs- wasting, flaccid in the affected myotome and sensory impairment in the affected dermatome

Specific radiculopathies  Lateral cervical disc protrusion  Lateral lumbar disc protrusion  Central lumbar disc protrusion

Peripheral nerve lesions  Common:  Radial nerve Radial nerve  Ulnar nerve Ulnar nerve  Median nerve Median nerve

Peripheral nerve lesions  Uncommon:  Long thoracic nerve  Axillary or circumflex nerve  Musculocutaneous nerve  Posterior interosseous nerve  Deep palmar branch of ulnar nerve

Peripheral nerve lesions  Common:  Sciatic nerve  Lateral cutaneous nerve of thigh (MERALGIA PARESTHETICA)  Common peroneal nerve Common peroneal nerve

Peripheral nerve lesions  Uncommon:  Obturator nerve  Femoral nerve  Posterior tibial nerve

Plexopathy  When a plexus is damaged  Spinal nerves from C5-T1 contribute to the brachial plexus, which runs from the lower Csp to the axilla  Spinal nerves from L2-S2 from the lumbosacral plexus which runs in the region of the iliopsoas muscle

Plexopathies  Disease of brachial and lumbosacral plexuses is relatively uncommon  Several specific conditions affect the plexuses  In both pain is a common symptom, together with sensory, motor and DTR loss in the affected limb

Lesions of the brachial plexus  Malignancy: apical lung CA, metastasis,  As a consequence of radiotherapy for breast cancer  Cervical rib, may be associated vascular insufficiency (common in women, symptoms aggravated by carrying heavy)  Brachial neuritis

Brachial plexopathies  Causes:  Trauma  Neuralgic amyotrophy  Malignant infiltration  Radiotherapy  Compression-thoracic outlet syndrome (cervical rib or fibrous band)

Trauma  Most common cause  Upper plexus lesion (C5,C6): injury is usually caused by falling on the shoulder or traction on the neck and shoulder at birth’ Erb’s palsy’. It is associated with the characteristic posture of a ‘ waiter’s tip’ with the arm internally rotated, extended and slightly adducted with loss of shoulder abduction and elbow flexion  Sensory loss occurs in the outer aspect of the shoulder, arm, forearm and thumb in the C5,C6 dermatomes

 Lower plexus lesion (C8,T1): usually caused by forced abduction of the arm, which may occur at birth’ Klumpke’s palsy’ and following trauma in later life, e.g. motorcycle accidents. There is characteristically a’ clawed hand’ with loss of function of the intrinsic muscles of the hand and long flexors and extensors of the fingers as well as loss of sensation in C8 and T1 dermatomes

Lumbosacral plexus  Lesion may be unilateral or bilateral  Diabetic amyotrophy and malignant infiltration in the pelvis are the most common causes  Upper plexus lesions: weakness of hip flexion and adduction, with anterior leg sensory loss  Lower plexus lesion: weakness of the posterior thigh and foot muscles, with posterior sensory loss

Other causes of L.S. plexopathy:  Infiltration by neoplasia, prostate, ovarian, and cervical, can infiltrate or metastasize to the lumbosacral plexus  Trauma following abdominal or pelvic surgery-e.g. hysterectomy  Compression from an abdominal aortic aneurism

Diabetic amyotrophy  Usually seen in older men with mild to moderate DM (with poor glycaemic control  The site of pathology may be in the plexus or in the roots and may have an inflammatory aetiology  Patients present with painful wasting-usually strikingly asymmetrical-of the quadriceps and psoas muscles  Loss of the knee jerks and extreme tenderness in the affected area

 There is usually minimal sensory loss  It resolves with careful control of blood glucose over many months