New Insights in Lumbosacral Plexopathy Kerry H. Levin, MD Gérard Said, MD, FRCP P. James B. Dyck, MD Suraj A. Muley, MD Kurt A. Jaeckle, MD 2006 COURSE C AANEM 53rd Annual Meeting Washington, DC Copyright © October 2006 American Association of Neuromuscular & Electrodiagnostic Medicine 2621 Superior Drive NW Rochester, MN 55901 PRINTED BY JOHNSON PRINTING COMPANY, INC. C-ii New Insights in Lumbosacral Plexopathy Faculty Kerry H. Levin, MD P. James. B. Dyck, MD Vice-Chairman Associate Professor Department of Neurology Department of Neurology Head Mayo Clinic Section of Neuromuscular Disease/Electromyography Rochester, Minnesota Cleveland Clinic Dr. Dyck received his medical degree from the University of Minnesota Cleveland, Ohio School of Medicine, performed an internship at Virginia Mason Hospital Dr. Levin received his bachelor of arts degree and his medical degree from in Seattle, Washington, and a residency at Barnes Hospital and Washington Johns Hopkins University in Baltimore, Maryland. He then performed University in Saint Louis, Missouri. He then performed fellowships at a residency in internal medicine at the University of Chicago Hospitals, the Mayo Clinic in peripheral nerve and electromyography. He is cur- where he later became the chief resident in neurology. He is currently Vice- rently Associate Professor of Neurology at the Mayo Clinic. Dr. Dyck is chairman of the Department of Neurology and Head of the Section of a member of several professional societies, including the AANEM, the Neuromuscular Disease/Electromyography at Cleveland Clinic. Dr. Levin American Academy of Neurology, the Peripheral Nerve Society, and the is also a professor of medicine at the Cleveland Clinic College of Medicine American Neurological Association. His current research interests include of Case Western Reserve University. His current research interests include pathological studies of peripheral nerve disorders and clinical trials in myasthenia gravis, polyneuropathy, and radiculopathy. peripheral neuropathies. Gérard Said, MD, FRCP Suraj A. Muley, MD Professor and Chief Assistant Professor Service of Neurology Department of Neurology University Hospital of Bicêtre University of Minnesota Medical Center Paris, France Minneapolis, Minnesota Dr. Said is Secretary-general of the European Neurological Society (ENS) Dr. Muley received his medical degree from the University of Bombay, and which he co-founded in 1986. He has also organized the yearly ENS later performed a residency in neurology and a fellowship in clinical neu- congress since 1988. He has been Professor and Chief of the Service of rophysiology and neuromuscular diseases at the University of Minnesota. Neurology of the University Hospital of Bicêtre since 1987. Starting in He is currently Assistant Professor at the University of Minnesota and 2006, Professor Said became the Director of the Research Group on Neuromuscular Director at the Minneapolis Veteran’s Administration Neuromuscular Disorders of the World Federation of Neurology, and from Medical Center. He is involved in clinical studies of diabetic amyotrophy 1998 through 2000 he was President of the Peripheral Nerve Society. His and is leading the nerve biopsy program and the University of Minnesota. main fields of investigation are disorders of the peripheral nervous system, Dr. Muley is also the Director of the Myasthenia Gravis Program at the diabetic neuropathy, vasculitic neuropathy, and infectious neuropathies. University. His current research includes a clinical study of the use of in- travenous immunoglobulin in myasthenia gravis, as well as a multicenter study about thymectomy in myasthenia gravis. C-iii Kurt A. Jaeckle, MD Professor Departments of Neurology and Oncology Mayo Clinic Jacksonville, Florida Dr. Jaeckle is currently Professor of Neurology and Professor of Oncology at the Mayo Clinic Jacksonville and has had an interest in clinical research involving primary and metastatic central nervous system cancer for over 20 years. After completing his residency at Vanderbilt University, he re- ceived his training in neuro-oncology at Memorial Sloan-Kettering Cancer Center, which was followed by faculty appointments at the University of Utah and, subsequently, the University of Texas M.D. Anderson Cancer Center in Houston. Dr. Jaeckle has served as a past chair for the American Academy of Neurology’s section on neuro-oncology and was instrumental in the development of a subspecialty certification and acccreditation program neuro-oncology. That program recently received United Council of Neurologic Subspecialties approval. His initial research interests involved the study of paraneoplastic disorders, and in particular, anti-yo antibody-positive cerebellar degeneration and limbic encephalitis. His current research focus involves clinical trial development as chair of the Neuro-oncology Committee of the North Central Cancer Treatment Group, and the study of the neurologic complications of cancer. Authors had nothing to disclose. Course Chair: Kerry H. Levin, MD The ideas and opinions expressed in this publication are solely those of the specific authors and do not necessarily represent those of the AANEM. Please be aware that some of the medical devices or pharmaceuticals discussed in this handout may not be cleared by the FDA or cleared by the FDA for the specific use described by the authors and are “off-label” (i.e., a use not described on the product’s label). “Off-label” devices or pharmaceuticals may be used if, in the judgement of the treating physician, such use is medically indicated to treat a patient’s condition. Information regarding the FDA clearance status of a particular device or pharmaceutical may be obtained by reading the product’s package labeling, by contacting a sales representative or legal counsel of the manufacturer of the device or pharmaceutical, or by contacting the FDA at 1-800-638-2041. C-iv C-v New Insights in Lumbosacral Plexopathy Contents Faculty i Objectives ii Course Committee iv Update on Lumbosacral Plexopathy: Anatomy and Electrodiagnostic Considerations 1 Kerry H. Levin, MD Diabetes and the Lumbosacral Plexus 9 Gérard Said, MD, FRCP Nondiabetic Lumbosacral Radiculoplexus Neuropathy 13 P. James B. Dyck, MD Treatment Strategies in Lumbosacral Plexopathy 23 Suraj A. Muley, MD Lesions of the Lumbosacral Plexus 27 Kurt A. Jaeckle, MD CME Self-Assessment Test 35 Evaluation 39 O BJECTIVES —After attending this course, participants will understand the anatomy of the lumbosacral plexus and electrodiagnostic testing available to uncover lesions of the lumbosacral plexus. Participants will learn how to differentiate diabetic from nondiabetic idiopathic lumbosacral plexus disease and will learn about treatment strategies for these conditions. Participants will learn about other lesions of the lumbosacral plexus and their diagnosis. P REREQUISITE —This course is designed as an educational opportunity for residents, fellows, and practicing clinical EDX physicians at an early point in their career, or for more senior EDX practitioners who are seeking a pragmatic review of basic clinical and EDX principles. It is open only to persons with an MD, DO, DVM, DDS, or foreign equivalent degree. A CCREDITATI O N S TATEMENT —The AANEM is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. CME C REDIT —The AANEM designates this activity for a maximum of 3.25 hours in AMA PRA Category 1 Credit(s)TM. This educational event is approved as an Accredited Group Learning Activity under Section 1 of the Framework of Continuing Professional Development (CPD) options for the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. Each physician should claim only those hours of credit he or she actually spent in the educational activity. CME for this course is avail- able 10/06 - 10/09. C-vi 2005-2006 AANEM COURSE COMMITTEE Kathleen D. Kennelly, MD, PhD Jacksonville, Florida Thomas Hyatt Brannagan, III, MD Dale J. Lange, MD Jeremy M. Shefner, MD, PhD New York, New York New York, New York Syracuse, New York Hope S. Hacker, MD Subhadra Nori, MD T. Darrell Thomas, MD San Antonio, Texas Bronx, New York Knoxville, Tennessee Kimberly S. Kenton, MD Bryan Tsao, MD Maywood, Illinois Shaker Heights, Ohio 2005-2006 AANEM PRESIDENT Janice M. Massey, MD Durham, North Carolina Update on Lumbosacral Plexopathy: Anatomy and Electrodiagnostic Considerations Kerry H. Levin MD Vice-Chairman, Department of Neurology Head, Section of Neuromuscular Disease/EMG Cleveland Clinic Cleveland, Ohio ANATOMY OF THE LUMBOSACRAL PLEXUS Ilioinguinal Nerve The lumbosacral plexus is constituted from the L1-S4 spinal nerve The ilioinguinal nerve is constituted from L1 nerve fibers and roots, with a minor contribution from the T12 spinal nerve root. travels with the iliohypogastric nerve, giving off motor branches The structure can be divided into the lumbar and sacral plexus to lower abdominal wall muscles. Its sensory branches supply the (Figure 1). The lumbosacral plexus is further divided anatomically skin over the symphysis, root of the penis, upper scrotum (men), into an anterior division that contains motor fibers innervating skin over the mons pubis and labia majora (women), and proximal muscles responsible for flexion and adduction, and a posterior divi- medial thigh (Figure 3). Aside from the lesions previously noted, sion innervating muscles responsible for extension and abduction. the ilioinguinal nerve