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Neuropathy, Radiculopathy & Myelopathy

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Neuropathy, Radiculopathy & Myelopathy Neuropathy, Radiculopathy & Myelopathy Jean D. Francois, MD Neurology & Neurophysiology Purpose and Objectives PURPOSE Avoid Confusing Certain Key Neurologic Concepts OBJECTIVES • Objective 1: Define & Identify certain types of Neuropathies • Objective 2: Define & Identify Radiculopathy & its causes • Objective 3: Define & Identify Myelopathy FINANCIAL NONE DISCLOSURE Basics What is Neuropathy? • The term 'neuropathy' is used to describe a problem with the nerves, usually the 'peripheral nerves' as opposed to the 'central nervous system' (the brain and spinal cord). It refers to Peripheral neuropathy • It covers a wide area and many nerves, but the problem it causes depends on the type of nerves that are affected: • Sensory nerves (the nerves that control sensation>skin) causing cause tingling, pain, numbness, or weakness in the feet and hands • Motor nerves (the nerves that allow power and movement>muscles) causing weakness in the feet and hands • Autonomic nerves (the nerves that control the systems of the body eg gut, bladder>internal organs) causing changes in the heart rate and blood pressure or sweating • It May produce Numbness, tingling,(loss of sensation) along with weakness. It can also cause pain. • It can affect a single nerve (mononeuropathy) or multiple nerves (polyneuropathy) Neuropathy • Symptoms usually start in the longest nerves in the body: Feet & later on the hands (“Stocking-glove” pattern) • Symptoms usually spread slowly and evenly up the legs and arms. Other body parts may also be affected. • Peripheral Neuropathy can affect people of any age. But mostly people over age 55 • CAUSES: Neuropathy has a variety of forms and causes. (an injury systemic illness, an infection, an inherited disorder) some of the causes are still unknown. • Most common cause: Diabetes. Other causes: alcohol abuse, poor nutrition, autoimmune processes (where the body’s own immune system attacks parts of the nerves) and genes. Exposure to certain drugs or toxins can lead to neuropathy. Direct pressure or compression of a single nerve, like in CTS, may cause it to malfunction Diabetic Peripheral Neuropathy • Sensory – - Numbness as if wearing gloves or socks – - Loss of balance, especially with the eyes closed – - Painless injuries due to loss of sensation – + Burning, prickling pain, tingling, electric shock–like feelings, aching, or hypersensitivity to touch • Motor – UE: ↓ fine hand coordination (difficulty with opening jars or turning keys) – LE: Foot slapping, toe scuffing, frequent tripping may be early symptoms of foot weakness. – Proximal limb weakness: difficulty climbing up and down stairs, difficulty getting up from a seated or supine position, falls due to the knees giving way, and difficulty raising the arms above the shoulders • Autonomic – GI: Gastroparesis, Dysphagia, Abdominal pain, Diarrhea, Constipation – : Persistent sinus tachycardia, Orthostatic hypotension – Bladder: Poor urinary stream, incomplete emptying, Straining – Sudomotor: sweating of head, neck, and trunk with anhidrosis of lower trunk and extremities Neuropathic Pain • Diagnosis: Clinical presentations / characteristic symptoms • Investigative steps: medical conditions, medications taken, neurologic examination, Blood count, ESR, Blood sugar, Liver and renal function tests, Serum vitamin B12, Paraprotein levels, Thyroid function tests, Vasculitis profile, electromyography and nerve conduction studies…final cause may not be identified • Treatment Options: For most types of neuropathy> no treatment is available to cure or modify condition. Treatments are therefore aimed at addressing certain symptoms…. Physical therapy, TENS unit (a portable device that sends an electrical current to electrodes attached to the skin), assistive devices, addressing the root cause of condition, identified treatable associated medical cause…exercise, Diet… Living with PN: Lifestyle change, review habits(smoking, sleeping hours, smoking, alcohol intake, healthy diet, review meds taken including the so-called natural / OTC meds (excess B6…), Support group… ILLUSTRATION • In polyneuropathy, the sensory deficits generally follow a length-dependent stocking-glove pattern. • By the time sensory disturbances of the longest nerves in the body (lower limbs) have reached the level of the knees, paresthesias are noted in the second- longest nerves (upper limbs) at the tips of the fingers. • When sensory impairment reaches the mid-thigh, involvement of the third- longest nerves, the anterior intercostal and lumbar segmental nerves, leads to a tent-shaped area of hypoesthesia on the anterior chest and abdomen. At this point, the recurrent laryngeal nerves may be affected, resulting in hoarseness. • Motor weakness is greater in extensor foot muscles than in corresponding flexors. For example, heel walking is affected earlier than toe walking. Charcot–Marie–Tooth Disease CMT1 CMT2 • Starts at 20-30 y/o • Begins later 20+, middle age+ • Distal legs: slow progressive • Foot and spinal deformities less weakness, muscle wasting, ↓ prominent sensory • peripheral nerves are not enlarged, • Foot deformities, difficulties in and upper limb involvement, tremor, running or walking resulting from and general areflexia occur less symmetrical weakness and wasting in frequently the intrinsic foot, peroneal, and anterior tibial muscles • ↓ ankle reflexes are universal • frequently ↓ knee and upper limb reflexes • In 2/3 pts, upper limbs involved later in life Causes of Radiculopathies • Radiculopathy is caused by compression or irritation of the nerves as they exit the spine. • This can be due to mechanical compression of the nerve by a disc herniation, a bone spur (osteophytes) from osteoarthritis, or from thickening of surrounding ligaments. • Other less common causes of mechanical compression of the nerves are from a tumor or infection. Either of these can reduce the amount of space in the spinal canal and compress the exiting nerve. Scoliosis can cause the nerves on one side of the spine to become compressed by the abnormal curve of the spine. Inflammation from trauma or degeneration can lead to radiculopathy from direct irritation of the nerves • Radiculopathy is one of (if not )the most common cause of disability in people under 50. 8-10 M people in US seek treatment annually for back pain. 6-8 M with permanent disability Radiculopathies Radix = “root”, Pathos = “suffering or disease”> Nerve root disorder Radiculopathy is a condition due to a compressed nerve in the spine that can cause pain, numbness, tingling, or weakness along the course of the nerve. Radiculopathy can occur in any part of the spine, but it is most common in the lower back (lumbar radiculopathy) and in the neck (cervical radiculopathy). It is less commonly found in the middle portion of the spine (thoracic radiculopathy). Lesions of a single nerve root are easier to recognize. • Radicular pain and paresthesias (tingling, pins & needles) • Sensory loss in the dermatome (skin innervated by a nerve root) • Weakness in the myotome (muscles innervated by a spinal cord segment and its nerve root) • Diminished deep tendon reflex activity at a segmental level However, with multiple roots involved (polyradiculopathy) clinically may resemble: • Disorder of the peripheral nerves – polyneuropathy? • Disorder of the anterior horn cells - progressive muscular atrophy form of ALS? • Supporting evidence for radiculopathy: CSF (↑ protein, ↑ WBCs), paraspinal muscle needle EMG (positive sharp waves and fibrillation potentials), spinal cord MRI (compromise or contrast enhancement of the nerve roots) Causes of Radiculopathies continued… • Symptoms of RADICULOPATHY: The symptoms of radiculopathy depend on which nerves are affected. The nerves exiting from the neck (cervical spine) control the muscles of the neck and arms and supply sensation there (most common radiculopathies in arms: C5-C6). The nerves from the middle portion of the back (thoracic spine) control the muscles of the chest and abdomen and supply sensation there. The nerves from the lower back (lumbar spine) control the muscles of the buttocks and legs and supply sensation there(most common radiculopathies in legs affect L5 & S1 roots). • The most common symptoms of radiculopathy are pain, numbness, and tingling in the arms or legs. • It is common for patients to also have localized neck or back pain as well. Lumbar radiculopathy that causes pain that radiates down a lower extremity is commonly referred to as sciatica. Thoracic radiculopathy causes pain from the middle back that travels around to the chest. It is often mistaken for shingles. • Some patients develop a hypersensitivity to light touch that feels painful in the area involved. Less commonly, patients can develop weakness in the muscles controlled by the affected nerves. This can indicate nerve damage. Risk factors for Radiculopathy Radiculopathy Risk factors include: activities that place an excessive or repetitive load on the spine. Patients involved in heavy labor or contact sports are more prone to develop radiculopathy than those with a more sedentary lifestyle. A family history of radiculopathy or other spine disorders also increases the risk of developing radiculopathy. DIAGNOSIS: • The diagnosis of radiculopathy requires a medical history and physical examination by the physician. (patient will describe the type and location of symptoms, how long they have been present, what makes them better and worse, and what other medical problems present. By knowing the exact location of the patient's symptoms, one
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