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Questions and Answers
How many pairs of spinal nerves are present in the human body?
Where does the C8 nerve root exit in relation to the cervical vertebrae?
Which spinal region does the cauda equina consist of?
At what vertebral levels does the spinal cord typically end in adults?
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Which of the following statements about the exit of spinal nerve roots is true?
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What describes radicular pain experienced by patients?
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Which examination test is most commonly used to diagnose cervical radiculopathy?
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What is the typical presentation of L5 radiculopathy?
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Which nerve root reflex is tested at the C6 level?
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What occurs in the shoulder abduction test that indicates a positive result?
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For which nerve do the symptoms of S1 radiculopathy commonly present?
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What is a common risk factor for developing radiculopathy?
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Which treatment is often part of managing radiculopathy?
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What does a 0 rating mean in the reflex scoring system?
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Which imaging method is NOT typically used in evaluating radiculopathy?
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Which factor differentiates non-degenerative radiculopathies from compressive etiologies?
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What is the significance of the Bowstring sign in examination findings?
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What does the term 'myotome' refer to?
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Which statement about spondylosis is true?
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What is typically the predominant mechanism causing radiculopathy?
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In which part of the cervical spine is the spinal canal widest?
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Which of the following statements about disc herniation is correct?
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Which nerve roots are most commonly involved in radiculopathy due to disc protrusion?
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What is the primary reason for the prevalence of radiculopathies at the L4-L5 and L5-S1 levels?
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Which symptom is most commonly associated with radiculopathy?
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What is a significant risk factor for developing radiculopathy?
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The reflex exam is valuable in diagnosing radiculopathy because it assesses what?
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Why do symptoms develop more acutely when caused by a herniated disc?
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Which cervical nerve root is most frequently affected by compression?
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How does the presence of pain affect motor examination in radiculopathy?
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What role does history play in diagnosing radiculopathy?
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Study Notes
Spinal Cord Anatomy
- 31 pairs of spinal nerves, each with a specific path and function
- Cervical nerves exit above their corresponding vertebrae, expect for C8 nerve which exits below C7
- Thoracic, lumbar, and sacral nerves exit below their corresponding vertebrae
- The spinal cord ends between L1 and L2 in adults
- Lumbar and sacral roots descend caudally forming the cauda equina
Terminology
- Dermatome: the specific area of skin innervated by a single spinal nerve root
- Myotome: a group of muscles primarily innervated by a single nerve root
- Paresthesia: Subjective tingling sensation caused by nerve or nerve pathway pathology
- Radiculopathy: Pathology affecting a nerve root, often caused by compression
Causes of Radiculopathy
- Spondylosis: Degenerative spinal changes, often leading to stenosis but not always interchangeable
- Disc Herniation: Protrusion of the nucleus pulposus through the annulus, often caused by degeneration and pressure
Risk factors for developing radiculopathy:
- Manual labor involving heavy lifting, driving, or operating vibrating equipment
- History of chronic smoking
Cervical Spine
- The spinal canal is widest in the upper cervical spine (C1-C3)
- Canal narrows significantly with neck extension
- Spondylotic disease most commonly occurs in the lower cervical spine
Lumbar Spine
- Most susceptible to disc herniations due to flexion, extension, and torsion movements
- L4-L5 and L5-S1 are most vulnerable to injury, accounting for 90-95% of compressive radiculopathies
Nerve Root Compression Symptoms
- Acute onset with herniated disc
- Slower onset with spondylosis
- Pain typically radiates in a dermatomal pattern
- Sensory loss may be mild or absent due to overlapping dermatomes
Common Symptoms:
- Paresthesia or numbness in a root distribution (80% of cases)
- Subjective weakness is less common
- Symptoms exacerbated by Valsalva maneuvers (cough, sneeze, strain)
Cervical Radiculopathy Statistics:
- C7 is the most frequently affected nerve root (approx. 70% of cases)
- C6 root involvement occurs in approximately 20% cases
Physical Exam:
- Spurling test: compression of the affected nerve root
- Shoulder abduction test: tests C5-C7 nerve root compression, relief of symptoms is a postive test
- Valsalva maneuver
- Neck distraction test: traction on the neck
Reflexes:
- C5 - biceps and brachioradialis
- C6 - brachioradialis
- C7 - triceps
- L4 - quadriceps
- S1 - Achilles
Lower Extremity Examination:
- Straight leg test: assesses lower lumbar nerve root involvement (L4 to S1)
- Reverse straight leg: assesses L2 to L4 nerve roots
- Slump test: can reproduce radicular symptoms
Bowstring sign:
- Relief of radicular pain when the knee is flexed during a positive straight leg raise
Key Points to Remember:
- Cervical radiculopathy is usually unilateral
- Comparing reflexes side to side is vital
- Reduced strength of muscles innervated by the affected nerve is a significant finding
L1 Radiculopathy:
- Uncommon
- Symptoms: pain, paresthesia, sensory loss in the inguinal region
- Rare: minor hip flexion weakness
L2/L3/L4 Radiculopathy
- Difficult to differentiate due to overlapping innervation
- Commonly involved in older patients with spinal stenosis symptoms
L5 Radiculopathy:
- Most common lumbosacral radiculopathy
- Symptoms: back pain radiating down the lateral leg into the foot
- Weakness: foot dorsiflexion, toe extension, foot inversion/eversion, and sometimes leg abduction
S1 Radiculopathy
- Pain radiates down the posterior leg into the foot
- Weakness: plantar flexion (gastrocnemius muscle), leg extension, and knee flexion
S2/S3/S4 Radiculopathy:
- Less common
- Symptoms: sacral or buttock pain radiating down the posterior leg or into the perineum
- Minimal weakness but urinary and fecal incontinence and sexual dysfunction may be present
Diagnostic Evaluation:
- Plain x-rays
- CT scan
- MRI
- EMG/NCS
- Myelogram
Treatment:
- Pain control
- Muscle relaxants
- Physical therapy
- Epidural steroid injections
- Surgical intervention
Non-Degenerative Radiculopathies
- Often affect the ventral and dorsal roots more diffusely
- May also affect the dorsal root ganglion
- Deficits may span multiple myotomes and dermatomes
Non-Degenerative Causes of Radiculopathy:
- Diabetes mellitus
- Nerve root trauma
- Nerve root infarction
- Nerve root avulsion
- Infectious or granulomatous conditions:
- Herpes zoster
- Lyme disease
- Tuberculosis
- HIV
- Syphilis
- Brucellosis
- Cytomegalovirus
- Histiocytosis X
- Sarcoid
- Infiltrative conditions:
- Lymphoma
- Carcinomatous meningitis
- Inflammatory conditions:
- Guillain-Barré syndrome
- Chronic inflammatory demyelinating polyneuropathy
- Vasculitis with nerve root infarction
Herpes Zoster
- Caused by varicella zoster virus
- Symptoms:
- Erythematous vesicular maculopapular rash
- Sensory changes: burning or tingling pain
- Most commonly affects thoracic dermatomes and face
Herpes Zoster Risk Factors:
- Age > 60 years
- Underlying malignancy
- Immunosuppression
- Diabetes
- Surgical trauma
- UV light
Herpes Zoster Disease Course:
- 80-90% resolve spontaneously within 6 months
- Chronic pain (Post-Herpetic Neuralgia):
- Pain lasting greater than 2-3 months after rash
- Occurs in about 5% of cases
- Severity correlates with the severity of the rash and acute pain
Herpes Zoster Treatment:
- Prevention with the Shingrix vaccine
- Antiviral medication started
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