Pre-Learning Spinal Nerve Root Lesions PDF

Pre-Learning Spinal Nerve Root Lesions Chandra Ricks Anatomy Revision Corticospinal Tract  Comprised of UMN and LMN  UMN is motor cortex to spinal level (synapse)  LMN is at spinal level (synapse) to the muscle fibre LMN and UMN Signs  Flaccid weakness or  Spastic...

Pre-Learning Spinal Nerve Root Lesions Chandra Ricks Anatomy Revision Corticospinal Tract  Comprised of UMN and LMN  UMN is motor cortex to spinal level (synapse)  LMN is at spinal level (synapse) to the muscle fibre LMN and UMN Signs  Flaccid weakness or  Spastic weakness or paralysis paralysis  Atrophy  Little atrophy  Fasciculations ◦ disuse over a period of time  Hypo/areflexia  Hyperreflexia or clonus Lower motor neuron Upper motor neuron signs signs Lumbar Spine  Remember conus medullaris ends L1/2  Lumbar nerve roots travel downward via thick sack of dural materal ◦ Dural sac or thecal sac  Must travel vertically to spinal level Lumbar Spine  Spinal nerve exits the IVF below vertebral pedicle  If L4/L5 disc effected ◦ Most likely to impact on L5 nerve root ◦ Occasionally one above (eg L4) but tends to be in more severe herniation Disc prolapse  Definition: Tear in the annular fibres allowing the nucleus pulposus to push outwards ◦ Typically tends to go to the posterior-lateral aspect of discs  Cervical spine – lower cervical most common  Lumbar spine – lower lumbar most common  Thoracic spine rarely affected due to stabilisation of rib cage ◦ May see from trauma or conditions that predispose uneven weight transfer such as Schauermann’s Disc prolapse – Stage classification AKA bulge, slipped disc, prolapse Stages of Disc Herniation  Stage 1 – Disc Degeneration ◦ Due to chemical changes, years of physical labour or acute or chronic stress  Flexion/rotation injury often ◦ Annular fibres weaken, but nucleus remains encased ◦ May be present if had previous prolapse but elasticity in fibres not able to allow for full resorption  EG Older patients on an MRI  EG Someone with repetitive damage to same disc Stages of Disc Herniation  Stage 2 – Prolapsed Disc ◦ The inner disc pushes further into the outer layer of the disc, giving it a prolapsed appearance  This is also considered a bulging disc ◦ The inner nuclear material has still not broken through the fibrous wall ◦ 2 clinical outcomes: 1. The bulge may lead to chemical irritation of nearby nerves without actual compression 2. the bulge itself may compress nearby nerves or other spinal structures Stages of Disc Herniation  Stage 3 – Extrusion ◦ The gel-like nucleus eventually breaks through the outer wall ◦ Even though it breaks through, the nucleus remains within the disc ◦ May have more severe symptoms due to greater damage ◦ Confirmation of MRI finding used to be a clinical indication of surgical requirements in past ◦ Recent evidence extrusion has greatest tendency to decrease in size with conservative management  Benson et al, (2010) Conservatively treated massive prolapsed discs: a 7-year follow-up. Ann R Coll Surg Engl v.92(2); 2010 Mar Stages of Disc Herniation  Stage 4 – Sequestration ◦ The nucleus breaks through the outer wall and eventually spills out of the spinal disc into the spinal canal ◦ The chemical components of the nucleus material can cause nerve inflammation, irritation or pain to:  Effected nerve root  Nerve roots above/below  Cauda equina (if in lumbar spine) Disc prolapse – location classification  Classified by axial (from underneath) view on MRI  Disc = clock ◦ 6 o'clock = central disc herniation ◦ 5 or 7 o’clock – paracentral disc herniation  AKA posterolateral disc herniation ◦ 4 or 8 o’clock – foraminal disc herniation ◦ Located lateral to formina = far lateral disc herniation  Central and paracentral most common  Forminal and far lateral less common but more severe ◦ Conservative care not as beneficial Disc prolapse – location classification Disc prolapse  Typically acute disc occur from 25-50 ◦ Younger discs are stronger unless put into early, heavy challenge or trauma ◦ Older discs desiccate and so are more stable  Disc bulge possible but is due to loss of elasticity in annular fibres  Often not symptomatic  Is a long term flexion/rotation type injury over months-years  Often have an “inciting event” which triggers pain – e.g. lifting ◦ Event may be “non traumatic” – Valsalva type manoeuvre, rotation  Disc prolapse  Hallmark characteristic is burning/electrical LEG or ARM Live pain Long ◦ 2 main pain mechanisms for lower And extremity pain Prosper  Inflammatory mediators irritating nerve root (prostaglandins, leukotrienes, nitric oxide…)  mechanical pressure onto the nerve root Disc prolapse  Symptoms: ◦ Neurogenic pain or paraesthesia in a dermatome consistent and severe (7-8) for 3 weeks  Pain will be aggravated by flexion, IL lateral flexion, IL rotation  Pain may be reduced with CL lateral flexion – will not totally relieve  Valsalva type manoeuvres increase pain – cough strain sneeze ◦ Back pain due to annular tear and muscle spasm  Do NOT remove spasm – is a protective mechanism to prevent further damage! Disc prolapse  Other symptoms: ◦ Myotomal weakness – flaccid type ◦ Reduced reflex ◦ May have exaggerated reflex below level of bulge  if severe and affecting nerve roots below it – lumbar spine more common ◦ Observe antalgic gait – subconscious mechanism by body to avoid putting pressure onto nerve root Disc herniation imaging  If you have severe  MRI 2-3 months via NHS neurological ◦ Many disc herniations compression may likely resorbed require surgery to  Private MRI fast but remove expensive ◦ If minor – won’t change  The longer a nerve is your treatment plan! compressed, the more  30% of population likely permanent =asymptomatic disc damage is to occur herniation ◦ Conservative Rx not ◦ “label” onto patient appropriate effecting behaviour Advantages Disadvantages Disc prolapse – REFER IF…  Significant  Unusually severe functional pain (7-8 normal) weakness (3 or  Recovery not below) meeting  Progressive timeframes neurological deficit  Signs of cauda  More than 1 nerve equina root impacted  If occurred due to trauma – e.g. MVC and fracture suspected Disc prolapse  Natural history ◦ Most disc prolapse will fully resorb on their own ◦ Typically should have symptomatic reduction around 3 weeks ◦ Typically should have resorption and symptomatic resolution 6-8 weeks ◦ Some patients experience symptomatic resolution but “bulging disc” may remain visible on an MRI  Loss of elasticity of annular fibres although disc is healed  NO surgery required typically ◦ Some patients continue to have residual symptoms from bulge remaining as above or nerve not gliding well in its sheath  If due to annular fibres losing elasticity, may need surgery to remove Disc prolapse  Treatment may help to reduce symptomatic period ◦ Improving blood flow ◦ Improving biomechanics around the effected level ◦ Advice to avoid exacerbation of inflammatory cycle  Avoid things that make the pain go towards the extremity (e.g. flexion)  Positions that alleviate the pain or make it disappear from extremities are recommended (antalgic) ◦ Rotatory adjustments at the level - CONTRAINDICATED Thoracolumbar Syndrome  AKA Maigne’s syndrome ◦ Maigne’s syndrome actually a blanket diagnosis also looking at facet irritation in the TL  Definition: Irritation of the cluneal nerves leading to referred pain in the buttocks and hip ◦ Cluneal nerves – purely sensory branches of upper lumbar and lower thoracic nerves  T11 – L5 implicated  Superior cluneal nerves most commonly implicated Thoracolumbar Syndrome  Pathophysiology – not clearly understood 1. Maigne’s syndrome:  TL junction is less stable – bottom 2 ribs are not attached  Facet orientation changes in this region from frontal plane in thoracic to sagital plane in lumbar  May predispose area to overload leading to facet and capsular irritation which irritate SCN 2. Cluneal nerve entrapment  SCN has to pass through the psoas major, lumbar paraspinals and QL  Then passes through TL fascia  Hypertonic muscles and thickening of fascial may lead to neural tension or compression  Middle cluneal nerve Cluneal Nerves compression looks like SIJ; Inferior cluneal nerve compression = persistent groin pain Thoracolumbar syndrome  Who gets it? ◦ Very little known – highly underdiagnosed condition ◦ Instability – trauma or hypermobility may predispose ◦ Hypomobility of the TL junction – degeneration or vertebral compression fractures may predispose  Women 64+ may be common population group  Symptoms ◦ Pain will be aggravated by prolonged walking, extension and rotation of the spine  If other aspects of nerve irritated, may see flexion/squatting/sitting – less common ◦ Pain characterised typically as deep and aching Thoracolumbar Syndrome Referral pattern and visual representation of cluneal nerves as they pertain to diagnostic criteria. Numbers indicate referral regions as posterior pelvis (1), lateral thigh (2), and inguinal region (3). DiMond ME. Rehabilitative Principles in the Management of Thoracolumbar Syndrome: A Case Report. J Chiropr Med. 2017 Dec;16(4):331-339 Thoracolumbar Syndrome  3 and 7 CM away from  3 and 7 CM away from spine (laterally) on spine (laterally) on iliac crest iliac crest  Use fingers 2-4  Use fingers 2-3  Palpate in an  Small forceful, inferior/superior repetitive tapping motion (small over point repeated rub)  Sharp pain may be  Sharp pain may be elicited elicited Palpation Tinnels Thoracolumbar Syndrome Stand on side opposite to one   Imaging is typically testing negative for this  Hands together with thumbs at  spine and fingers 2-4 laterally High risk of incidental towards the waist findings not related to  Raise skin with fingers and fold presentation due to skin with thumb moving toward typical age this may fingers (like massage) present   Looking for changes to Diagnosis of exclusion sensitivity comparing this area  to same area opposite side of Gold standard – body injection into the  Can do a similar check over the affected facet will greater trochanter area provide relief of pain Skin rolling Medically Thoracolumbar Syndrome  Treatment ◦ Case studies – suggest that conservative care may help  Manipulation of TL – hypomobility  Strengthening/stabilisation of TL – instability  Graston and myofascial release – muscles/fascia  Stretching of muscles  Cluneal nerve flossing (modified sciatic floss) ◦ Medically – facet injection provides short term relief ◦ Radio frequency ablation may provide longer results Spinal Stenosis  Stenosis = narrow ◦ Can be anything from a cyst, tumour, syrinx ◦ Most commonly is degenerative changes to the spine  In class – this is the type we are discussing!  3 major types: 1. Central –Compresses the central cord 1. Discussed in the spinal cord lecture 2. Lateral –compression as it exits the spinal canal 3. Foraminal – compression around the IVF ◦ Foraminal and lateral look exactly the same clinically – unilateral presentation on a nerve root Spinal Stenosis Central stenosis – bilateral symptoms Lateral stenosis – unilateral symptoms Severe lumbar stenosis can lead to cauda equina – rare but RF Spinal stenosis  Pathophysiology ◦ Osteoarthritis  → formation of synovial cysts  → hypertrophy of the facet joints enclosing IVF  → bone spur formation (osteophyte) Lateral Spinal Stenosis  Effect 65+ unless have risk factors for earlier degeneration ◦ Trauma, contact sports, smoking…  May report insidious, intermittent diffuse, crampy pain with paraesthesia ◦ If outright nerve compression: Burning or electrical pain  Flaccid weakness, atrophy, a/hyporeflexia  Would be relieved by opening manoeuvres ◦ Flexion, contralateral lateral flexion  Aggravated by closing manoeuvres ◦ Extension, ipsilateral lateral flexion Condition Revision – Flashcard!  On your flashcard put in:  What is it – basic definition  Who gets it – main population or risk factors  Hallmark symptoms – things that HAVE to be there  Hallmark tests – primary testing you would do with the expected abnormal results References  Cluneal neuralgia, National Library of Medicine: Paracha U, Hendrix JM. Cluneal Neuralgia. [Updated 2023 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK587348/  Testing – physio tutors, Thoracolumbar Pain Syndrome/Maigne’s Syndrome  Dal Farra F, Risio RG, Vismara L, Bergna A. Effectiveness of osteopathic interventions in chronic non-specific low back pain: A systematic review and meta-analysis. Complementary Therapies in Medicine. 2021 Jan 1;56:102616.  GÜNEŞ, Musa; YANA, Metehan. Acute effects of thoracolumbar fascia release techniques on range of motion, proprioception, and muscular endurance in healthy young adults. Journal of Bodywork and Movement Therapies, 2023, 35: 145-150.  DiMond ME. Rehabilitative Principles in the Management of Thoracolumbar Syndrome: A Case Report. J Chiropr Med. 2017 Dec;16(4):331-339