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Radiculopathy vs. Radiculopathy vs.
Peripheral NeuropathyPeripheral Neuropathy
What to do with arm pain?What to do with arm pain?
Miriana G. Popadich RN, MSNMiriana G. Popadich RN, MSNClinical Care CoordinatorClinical Care Coordinator
Brachial Plexus ProgramBrachial Plexus Program
Department of NeurosurgeryDepartment of NeurosurgeryUniversity of MichiganUniversity of Michigan
Defining Arm Pain Defining Arm Pain
TimingTiming�� AcuteAcute
�� ChronicChronic
LocationLocation�� GeneralizedGeneralized
�� SpecificSpecific
TypesTypes�� AchingAching
�� BurningBurning
�� LancinatingLancinating
Arm PainArm Pain
Is it from the cervical spinal nerve roots ?Is it from the cervical spinal nerve roots ?
Is it from the brachial plexus ?Is it from the brachial plexus ?
Is it from to peripheral nerve entrapment ?Is it from to peripheral nerve entrapment ?
Are weakness and sensory loss present ?Are weakness and sensory loss present ?
What Do We Mean What Do We Mean
by Peripheral Neuropathy?by Peripheral Neuropathy?Peripheral neuropathy is a disorder of the Peripheral neuropathy is a disorder of the
nerves that carry information to and from the nerves that carry information to and from the
brain and spinal cord. This can produce pain, brain and spinal cord. This can produce pain,
loss of sensation, and weakness.loss of sensation, and weakness.
Most peripheral nerves have motor and Most peripheral nerves have motor and
sensory functions.sensory functions.
Peripheral neuropathy may affect a single nerve Peripheral neuropathy may affect a single nerve
(mononeuropathy) or multiple nerves (mononeuropathy) or multiple nerves
(polyneuropathy)(polyneuropathy)..
What Do We Mean by What Do We Mean by
Radiculopathy?Radiculopathy?
Radiculopathy Radiculopathy –– a condition in which one a condition in which one
or more spinal nerves, e.g. C6, are affected or more spinal nerves, e.g. C6, are affected
and do not function properly.and do not function properly.
The emphasis is on the The emphasis is on the spinal nerve root spinal nerve root
((RadixRadix = "root").= "root").
This can result in radiating pain (radicular This can result in radiating pain (radicular
pain), weakness, numbness, decreased pain), weakness, numbness, decreased
reflexes, or difficulty controlling specific reflexes, or difficulty controlling specific
muscles.muscles.
Causes of Peripheral NeuropathyCauses of Peripheral Neuropathy
InjuryInjury�� CompressionCompression
�� LacerationLaceration
Systemic diseaseSystemic disease�� DiabetesDiabetes
Infection, inflammation Infection, inflammation �� AIDSAIDS
Exposure to poisonous substancesExposure to poisonous substances�� Sniffing glueSniffing glue
�� Excessive alcohol useExcessive alcohol use
DrugsDrugs�� ChemotherapyChemotherapy
What Causes Arm Pain?What Causes Arm Pain?
Diagnosis and Treatment Relies UponDiagnosis and Treatment Relies Upon
Identification of the nerve Identification of the nerve
affectedaffected
Site of injurySite of injury
Severity of the injurySeverity of the injury
Anatomy Anatomy -- Cervical RootCervical Root
The The cervical nervescervical nerves are the are the
spinal nerves from the cervical spinal nerves from the cervical
spinal cord.spinal cord.
There are eight cervical nerves There are eight cervical nerves
(C1(C1--8). 8).
Posterior distribution includes Posterior distribution includes
the paraspinal muscles.the paraspinal muscles.
Anterior distribution leads to the Anterior distribution leads to the
brachial plexus (C5brachial plexus (C5--C8/T1).C8/T1).
Anatomy Anatomy -- Brachial PlexusBrachial Plexus
The brachial plexus is a complex network of The brachial plexus is a complex network of
nerves extending from the spinal nerve (roots) nerves extending from the spinal nerve (roots)
into the neck and down into each arm.into the neck and down into each arm.
This nerve network controls movement and This nerve network controls movement and
sensation in thesensation in the�� ShoulderShoulder
�� ArmArm
�� WristWrist
�� HandHand
�� FingersFingers
Anatomy Anatomy -- Brachial PlexusBrachial Plexus
5 Roots (C5 5 Roots (C5 –– T1)T1)
3 Trunks3 Trunks
�� Superior/UpperSuperior/Upper
�� MiddleMiddle
�� Inferior/LowerInferior/Lower
6 Divisions6 Divisions
�� 3 x anterior3 x anterior
�� 3 x posterior3 x posterior
3 Cords3 Cords
�� LateralLateral
�� PosteriorPosterior
�� MedialMedial
5 Terminal Branches/Peripheral 5 Terminal Branches/Peripheral
NervesNerves
�� MusculocutaneousMusculocutaneous
�� AxillaryAxillary
�� RadialRadial
�� MedianMedian
�� UlnarUlnar
Anatomy Anatomy -- Terminal BranchesTerminal Branches
Musculocutaneous Nerve (C5,6,7) Musculocutaneous Nerve (C5,6,7)
Axillary Nerve Axillary Nerve
(C5(C5--6)6)
Radial Nerve Radial Nerve
(C5,6,7,8,T1)(C5,6,7,8,T1)
Median Nerve Median Nerve
(C5,6,7,8,& T1)(C5,6,7,8,& T1)
Ulnar Nerve Ulnar Nerve
(C8 &T1)(C8 &T1)
What Causes Arm Pain?What Causes Arm Pain?
Diagnosis and Treatment Relies UponDiagnosis and Treatment Relies Upon
Identification of the nerve Identification of the nerve
affectedaffected
Site of injurySite of injury
Severity of the injurySeverity of the injury
AnatomyAnatomy -- Nerve InjuryNerve Injury
NeurapraxiaNeurapraxia�� Interruption of the nerve conduction Interruption of the nerve conduction
without interruption of nerve or its myelin without interruption of nerve or its myelin
sheathsheath
AxonotmesisAxonotmesis�� Interruption of the axon with interruption of Interruption of the axon with interruption of
the myelin sheath but no interruption of the myelin sheath but no interruption of
the nerve itselfthe nerve itself
Neurotmesis Neurotmesis �� Most severe form of nerve injury Most severe form of nerve injury ––
interruption of the axon along with interruption of the axon along with
encapsulating connective tissue and or encapsulating connective tissue and or
transection of the nerve transection of the nerve
Myelin sheath
Axon
Basement membrane
Principles Based on AnatomyPrinciples Based on Anatomy
Each peripheral nerve Each peripheral nerve
is composed of fibers is composed of fibers
from more than one from more than one
spinal nerve root.spinal nerve root.
Each spinal nerve Each spinal nerve
contributes to more contributes to more
than one peripheral than one peripheral
nerve.nerve.
Peripheral Nerve Anatomy ImpliesPeripheral Nerve Anatomy Implies
Weakness and severe Weakness and severe
atrophy of muscles atrophy of muscles
innervated by a specific innervated by a specific
peripheral nerveperipheral nerve
““HardHard”” borders of sensory borders of sensory
disturbances in the disturbances in the
distribution of a specific distribution of a specific
peripheral nerveperipheral nerve
Cervical Root Anatomy ImpliesCervical Root Anatomy Implies
Weakness Weakness –– of muscles innervated by that nerve of muscles innervated by that nerve
root root
Pain Pain –– in the distribution of that nerve root, in the distribution of that nerve root,
dermatomal sensory disturbances and neck paindermatomal sensory disturbances and neck pain
Sensory changes Sensory changes –– numbness and tingling / numbness and tingling /
paresthesias outlined by that specific dermatome paresthesias outlined by that specific dermatome
Decreased reflexes Decreased reflexes –– affected by that nerve rootaffected by that nerve root
Sensory DistributionSensory Distribution
Peripheral Nerve vs. Dermatome Peripheral Nerve vs. Dermatome
Understand the Relevant AnatomyUnderstand the Relevant Anatomy
Listen to the PatientListen to the Patient
Directed Physical ExamDirected Physical Exam
How to Clinically Diagnose How to Clinically Diagnose
the Cause of Arm Painthe Cause of Arm Pain
HistoryHistory
Quality and timing of injury/symptomsQuality and timing of injury/symptoms�� Motor disturbance Motor disturbance –– onset, location, severityonset, location, severity
�� Sensory disturbance Sensory disturbance –– onset, location, severityonset, location, severity
�� Paresthesias Paresthesias –– type, locationtype, location
�� Pain Pain –– onset, location, severity, typeonset, location, severity, type
Physical ExaminationPhysical Examination
Inspection Inspection
VascularVascular
Range of Motion Range of Motion
Motor Motor
SensationSensation
ReflexesReflexes
TinelTinel’’ss
Physical Examination: Inspection Physical Examination: Inspection
Bruises / abrasion / lacerationBruises / abrasion / laceration
SwellingSwelling
Physical Examination:Physical Examination:
Inspection Inspection
AtrophyAtrophy
HornerHorner’’s syndromes syndrome
Physical Examination: VascularPhysical Examination: Vascular
PulsePulse
SwellingSwelling
ColorColor
Physical Examination: Physical Examination:
Range of MotionRange of Motion
Passive Range of Motion Passive Range of Motion
(PROM)(PROM)
Active Range of Motion Active Range of Motion
(AROM)(AROM)
ContracturesContractures
Physical Examination: Physical Examination:
Motor Function Motor Function
Voluntary movementVoluntary movement
PowerPower
Characteristic posturesCharacteristic postures
Reflexes Reflexes
Physical Examination: SensationPhysical Examination: Sensation
Paresthesia (numbness, tingling, pricking, Paresthesia (numbness, tingling, pricking,
pins and needles of a limb) pins and needles of a limb)
Allodynia (pain resulting from a stimulus Allodynia (pain resulting from a stimulus
which would not normally provoke pain)which would not normally provoke pain)
Anesthesia (sensation blocked)Anesthesia (sensation blocked)
Physical Examination: Physical Examination:
TinelTinel’’s Signs Sign
Is a way to detect irritated Is a way to detect irritated
nerves. nerves.
Is performed by lightly Is performed by lightly
tapping (percussing) over tapping (percussing) over
the nerve to elicit a the nerve to elicit a
sensation of tingling or "pins sensation of tingling or "pins
and needles" in the and needles" in the
distribution of the nerve.distribution of the nerve.
Takes its name from French Takes its name from French
neurologist Jules Tinel. neurologist Jules Tinel.
So, What is the Cause of Arm So, What is the Cause of Arm
Pain?Pain?
Cervical radiculopathyCervical radiculopathy
�� C6C6
Peripheral (entrapment) neuropathyPeripheral (entrapment) neuropathy
�� Median Neuropathy / CTSMedian Neuropathy / CTS
Brachial plexopathyBrachial plexopathy
�� Upper TrunkUpper Trunk
Cervical RadiculopathyCervical RadiculopathyIncidence of cervical Incidence of cervical
radiculopathy is about radiculopathy is about
85/100,000.85/100,000.
Cervical radiculopathy is a Cervical radiculopathy is a
dysfunction of a cervical dysfunction of a cervical
nerve root.nerve root.
C7 radiculopathy ~ 60%C7 radiculopathy ~ 60%
C6 radiculopathy ~ 25%C6 radiculopathy ~ 25%
C8
C7
C6
C6 Cervical RadiculopathyC6 Cervical Radiculopathy
HistoryHistory
�� Neck pain Neck pain –– acute or chronicacute or chronic
�� Radicular pain Radicular pain –– exacerbated by movement, specific posturing exacerbated by movement, specific posturing
of the neckof the neck
�� Weakness in the distribution of myotomeWeakness in the distribution of myotome
C6 Cervical RadiculopathyC6 Cervical Radiculopathy
Physical ExaminationPhysical Examination
Motor deficit Motor deficit –– elbow flexion, elbow flexion,
wrist extensionwrist extension
Sensory deficit Sensory deficit –– in C6 in C6
dermatome/the thumb /neck dermatome/the thumb /neck
pain from the paraspinalspain from the paraspinals
Decreased reflexes Decreased reflexes –– Biceps Biceps
brachii, brachioradialisbrachii, brachioradialis
Peripheral NeuropathyPeripheral Neuropathy
Median Neuropathy Median Neuropathy
(Carpal Tunnel Syndrome)(Carpal Tunnel Syndrome)
Incidence Incidence -- 50 /1000 in the 50 /1000 in the
US; women >men 3:1; US; women >men 3:1;
age 45age 45--6060
Etiology Etiology -- compression of compression of
the median nerve in the the median nerve in the
carpal tunnel.carpal tunnel.
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
History and Physical ExaminationHistory and Physical Examination
Nocturnal pain and paresthesia Nocturnal pain and paresthesia
relieved by relieved by ““flickingflicking””
Symptoms evoked by hyper Symptoms evoked by hyper
flexed wrist and repetitive motionflexed wrist and repetitive motion
Motor Motor –– weakness and atrophy of weakness and atrophy of
the thenar eminencethe thenar eminence
Sensory Sensory -- pain, numbness and pain, numbness and
tingling in radial 3 tingling in radial 3 ½½ fingers fingers
C6 Radiculopathy CTS C6 Radiculopathy CTS –– PNPN
Median NerveMedian NerveMotor Motor –– deficit deficit
weakness/weakness/atrophy atrophy of thenar of thenar
eminence (the thumb)eminence (the thumb)
Sensory deficit Sensory deficit -- pain, pain,
numbness and numbness and tingling in tingling in
radial 3 radial 3 ½½ fingers fingers
Nocturnal pain and Nocturnal pain and
paresthesia relieved by paresthesia relieved by
““flickingflicking””
Symptoms evoked by Symptoms evoked by
hyperflexed wrist and hyperflexed wrist and
repetitive motionrepetitive motion
Motor deficit Motor deficit –– elbow elbow
flexion, wrist extensionflexion, wrist extension
Sensory deficit Sensory deficit –– in C6 in C6
dermatome/the dermatome/the thumb thumb
/neck pain from the /neck pain from the
paraspinalsparaspinals
Decreased reflexes Decreased reflexes ––
Biceps brachii, Biceps brachii,
brachioradialisbrachioradialis
Peripheral NeuropathyPeripheral Neuropathy
Brachial Plexus Brachial Plexus
Upper Trunk Brachial Upper Trunk Brachial
Plexus Palsy Plexus Palsy �� C5 ,C6 C5 ,C6 –– Roots affectedRoots affected
Decreased shoulder Decreased shoulder
abduction abduction
Decreased elbow flexionDecreased elbow flexion
Decreased forearm Decreased forearm
supinationsupination
Fingers and hand function Fingers and hand function
normalnormal
Brachial Plexus Injury Brachial Plexus Injury ––
Variable Signs and SymptomsVariable Signs and Symptoms
MotorMotor�� Weakness Weakness -- variable distribution variable distribution
and severity because of the and severity because of the
complexity of the brachial plexus complexity of the brachial plexus
�� For example : mild weakness in For example : mild weakness in
biceps and profound weakness biceps and profound weakness
in the handin the hand
SensorySensory�� Variable hypesthesia, Variable hypesthesia,
paresthesia, anesthesia and paresthesia, anesthesia and
painpain
ReflexesReflexes�� Lost or decreasedLost or decreased
Brachial Plexus Palsy Brachial Plexus Palsy
History of Birth History of Birth
7 lb 4oz7 lb 4oz
Hand movement only at birthHand movement only at birth
Uncomplicated pregnancyUncomplicated pregnancy
Initial EvaluationInitial Evaluation
3 months of age3 months of age�� Minimal shoulder activityMinimal shoulder activity
�� Minimal external rotation Minimal external rotation
�� NO elbow flexion NO elbow flexion
�� No supination of the handNo supination of the hand
Ancillary StudiesAncillary Studies
Electrophysiologic studiesElectrophysiologic studies�� EMGEMG
Radiologic studiesRadiologic studies�� CT CT –– myelogrammyelogram
�� XX--rayray
�� U/SU/S
Graft Repair Graft Repair
C5 - suprascapular nerveC5 - posterior division of upper trunk
C6 - anterior division of upper trunk
BP Post BP Post -- Surgical ManagementSurgical Management
Splint to protect repair / Splint to protect repair /
reconstructionreconstruction
Assist and promote Assist and promote
normal function of the normal function of the
child within limits of the child within limits of the
splintsplint
Parent education with Parent education with
respect to splint carerespect to splint care
Continue OT/PT after Continue OT/PT after
braced is D/C(6braced is D/C(6--8 wks.) 8 wks.)
Brachial Plexus Brachial Plexus
Pediatric Brachial Plexus Pediatric Brachial Plexus ––
Multidisciplinary Team Multidisciplinary Team Neurosurgery
John E McGillicuddy, MDLynda J-S Yang, MD, PhD
Physical Medicine and RehabilitationVirginia Nelson, MD, MPH
ElectrodiagnosisEdward Hurvitz, MD
James Leonard, MDKathy Spires, MD
Hand / Plastic SurgeryKevin Chung, MD, MS
Orthopedic SurgeryKelly Vanderhave, MD, MS
Occupational TherapyDenise Justice, OTRLynnette Rasmussen, OTR
Nursing Clinical Care CoordinatorMiriana Popadich, RN, MSN
Program CoordinatorConnie McGovern
Summary Summary
Diagnosing PN Lesions vs. Diagnosing PN Lesions vs.
RadiculopathyRadiculopathy
Knowledge of motor and sensory distribution of the Knowledge of motor and sensory distribution of the
cervical nerve roots and peripheral nerves is cervical nerve roots and peripheral nerves is
essential in order to correctly diagnose and treat essential in order to correctly diagnose and treat
arm pain.arm pain.
Careful, directed physical examination is the most Careful, directed physical examination is the most
useful diagnostic test. useful diagnostic test.
Do NOT rely on imaging alone.Do NOT rely on imaging alone.
Obtain ancillary (electrophysiologic, radiologic) Obtain ancillary (electrophysiologic, radiologic)
studies when needed.studies when needed.
Take Home PointsTake Home Points
Muscle atrophy / severe weakness is often more Muscle atrophy / severe weakness is often more
prominent with peripheral nerve lesion than with prominent with peripheral nerve lesion than with
radiculopathy.radiculopathy.
Boundaries of peripheral nerve sensory deficits are Boundaries of peripheral nerve sensory deficits are
““harderharder”” and more exact than those of cervical and more exact than those of cervical
radiculopathy.radiculopathy.
Thank You !Thank You !
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