Myelopathy vs Radiculopathy – Great Review!

hi thank you for watching my video today today I’m going to discuss as part of this mini med lecture a the difference between myelopathy and radiculopathy now myelopathy is defined as any pathological condition of the spinal cord where radiculopathy is defined as any pathological condition of a spinal nerve root now with myelopathy we are talking about any condition that will affect the integrity of the spinal cord itself most commonly it’s going to be some kind of compression or injury so for example a herniated disc in the spinal column will will cause pressure on either a spinal nerve root or ace or the spinal cord itself now when the spinal cord is being compressed or injured somehow it is going to result in a collection of signs or symptoms known as upper motor neuron disease so upper motor neurons now if you remember from Anatomy the upper motor neurons begin in the motor cortex in the cerebrum and extend their axons down through the internal capsule through the brainstem in the cerebral spinal tract and down through the spinal cord and they eventually will synapse on the lower motor neurons at the individual spinal levels so the upper motor neurons are found within the central nervous system the brain or spinal cord whereas the lower motor neurons are the neurons that extend out of the spinal column in the peripheral nerves okay so depending on whether it’s an upper motor neuron or a loader lower motor neuron that’s being compressed the signs and symptoms are going to differ so with upper motor neuron disease you are going to have motor weakness a positive Babinski sign spasticity reflects eeeh and clonise now if you remember a Babinski sign the way you elicit a Babinski response is take something like like the back end of your reflex hammer stroke it up the bottom of the patient’s foot and watch what the toes do now with a positive or abnormal Babinski sign you are going to see the large toe come up and the smaller toes will flare or fan out and this is abnormal and can suggest spinal cord pathology now a normal Babinski sign would be the toes curling down now spasticity would be increased tone in the musculature hyperreflexia means the the reflexes the deep tendon reflexes are going to be stronger than normal so you’d be recording it as a 3 + or a 4 + reflex and with myelopathy it’s especially evident in the lower extremity deep tendon reflexes like the patellar reflex or the Achilles reflex now with clonise if you remember the way you elicit abnormal ankle clonus as you quickly dorsiflex the patient’s ankle and you will get a little bounce back as a type of reflex now one or two pulses back at you is normal but if you hold if you hold that ankle in dorsiflexion and that foot continues to bounce or their sustained bouncing of the foot against your hand that is an abnormal ankle clonus and also is suggestive of upper motor neuron signs which are all consistent with myelopathy now radiculopathy is going to be compression or disease of the lower motor neurons and it’s going to produce the following signs motor weakness which is similar to the myelopathy but you can get weakness with either you with sustained or severe radiculopathy you can end up getting muscle fasciculations or little fast twitch fasciculations of the muscle fibers themselves or even muscle atrophy because the muscle will eventually start to die and shrink because of the lack of use because the nerve is so compressed and with lower motor neuron disease you will get hyporeflexia I mean meaning the reflexes will be diminished or even totally blunted okay so again cervical myelopathy versus cervical radiculopathy now now I say cervical because that’s

going to be what we’re going to be talking about as our examples in this lecture but you can have myelopathy or radiculopathy at all of the levels in the at the cervical thoracic or lumbar spine okay so in the cervical and lumbar spine obviously the spinal cord is present at all of those levels as well as spinal nerve roots at each spinal level in the lumbar spine it’s a little bit different so in our picture over here on the right you can see that at about this level is l1 the l1 vertebra okay so the spinal cord is continuous from the brainstem down through the foramen magnum and down through the spinal column and ends at about l1 and all adults okay now the because the spinal cord ends at l1 it is possible to have a lumbar myelopathy if you have some severe pathology at l1 that would compress the conus medullaris and you would get something called conus medullaris syndrome okay now the majority of neural tissue compression in the lumbar spine is going to be a radiculopathy simply because you from l1 down there is no spinal cord to compress it’s all spinal nerve roots the cauda equina okay now so if you have a herniated disc or a mass or significant lumbar stenosis in the lumbar region that’s going to produce mostly radicular signs or symptoms okay now we’re going to talk mostly for the rest of this leg so we’re going to talk about cervical myelopathy versus cervical radiculopathy okay know you can get cervical excuse me thoracic myelopathy and radiculopathy it is just less common because the the ribcage actually provides so much structural support to the thoracic spine the thoracic spine doesn’t see a whole lot of movement or degeneration most of the myelopathy or radiculopathy stemming out of the thoracic spine is due to major trauma now let’s talk about cervical myelopathy now here’s a hypothetical case let’s say you have a 58 year old male patient come into your clinic with a chief complaint of weakness and difficulty with walking now as you interview him you discover that he has the following signs and symptoms weakness and sensory disturbances in the arms so he’s got some numbness and tingling as well as he feels that his arms are just weak both arms he also complains of clumsiness and parish seizures in the hands okay so he he might say that his dexterity in the hands is decreased for example some patients might say that when they’re eating food with a fork they’re just having real difficulty handling that fork with their hand and they may also our patient will also possibly complain and spasticity in the legs they’ll just feel like his legs are heavy and and almost elastic like and has difficulty walking and that we would call that a gait we’ll talk a little bit more about that okay so based on our interview with the patient and his signs and symptoms several disorders should come to our mind as part of our differential diagnosis one of them being amyotrophic lateral sclerosis ALS also known as Lou Gehrig’s disease now patients with Lou Gehrig’s disease will complain of progressing weakness in the extremities the difference and kind of the Cardinal difference between myelopathy versus ALS is that ALS will be strictly motor on you will not have a sensory deficit so if the patient is having numbness and tingling in the hands of his chief complaint it’s less likely that ALS is on your differential but you need to keep it in mind multiple sclerosis can also cause upper motor neuron symptoms because of demyelination within the central nervous system so that needs to stay on your differential diagnosis now a carpal tunnel syndrome if your patient is complaining a pretty significant numbness and tingling in the hands that can all obviously be indicative of a carpal tunnel syndrome the main difference here is that if your patient has symptoms in the lower extremities as well as they will with myelopathy then it’s less likely that it’s just carpal tunnel syndrome now Siringo meliha excuse me Siringo my alia is when there is a syrinx that forms within the spinal cord and this can can be spontaneous or due to trauma and can result in upper motor neuron

symptoms and that will show up on an MRI now Gyan bere syndrome should remain on your differential diagnosis anytime a patient shows up with weakness in the extremities characteristic with Gyan bere is that the weakness will kind of begin distally and extend gradually progress proximally so remember that now spinocerebellar degeneration that you can see with patients with a history of chronic alcohol use should also be on the differential although this mainly presents as gait ataxia balance problems difficulty walking but does need to be considered traumatic myelopathy should be considered a transverse myelitis needs to be considered because that will have upper motor neuron signs and of course our cervical myelopathy so when you have a patient that presents with these signs and symptoms you do need to consider getting an MRI of the cervical spine or even the cervical and thoracic spine now with the further characteristic of cervical myelopathy usually this will be a painless process compression of the spinal cord itself is not painful for the most part that being said patients will occasionally have painful sensations some patients will get what we call a lair meets sign which is when they bend their neck down their chin down to your down to their chest they’ll get almost like a shock like electrical sensation through the body especially down the spine or sometimes patients will also present with kind of aching pains in the shoulders and and trapezius region and present with a myelopathy so while it is painless for the most part patients can have some pain now it’s usually slowly progressive it can be sudden onset for example if a patient has a whiplash injury and has a massive herniated disc in the neck causing a spinal cord compression that’s obviously can be a myelopathy but due to degenerative changes alone it’ll be slowly progressing now with severe cases or cases that have progressed slowly over years the patient can have bowel and bladder dysfunction they’ll you know they’ll start dribbling urine they’ll have a hard time emptying their bladder completely they might even have episodes of bowel incontinence so that is something to consider as well on your exam you’re going to find spasticity in the upper and lower extremities the muscles are going to have increased tone their gait is going to be or almost what we describe as a scissor like gait as if their legs are very very tight and kind of quick movements of the legs while they walk might have balance problems as well the extremities are oftentimes going to be weak you’ll you’ll be able to to pull against them and they’ll they’ll give way somewhat easily in the arms and legs and they may have sensory disturbances in the extremities pretty common with a severe cervical stenosis is something called central cord syndrome where the patient will have numbness and tingling in the hands and that may or may not improve after surgical intervention you’ll also notice hyperreflexia like we talked about though especially in the legs they’ll their patella reflex is going to be extremely strong so make sure you are standing to the side and so you don’t get kicked there you’ll see a positive Babinski sign often and you’ll have abnormal ankle clonus often as well and then we already talked about this lemonade sign that looks like I miss placed my apostrophe there but again lower means is when you have them bend their chin down to their chest and they’ll get almost a shock like sensation and that’s that’s kind of an ominous sign as it does suggest pretty severe spinal cord compression but can also be found in conditions like multiple sclerosis for example now in this diagram this is representing some spinal cord compression now as you can see right here where it’s circled this is representing maybe some bone spurring that can happen with cervical spondylosis a degenerative change of the cervical spine and you’ll get from the vertebral body of the cervical vertebra posterior bone spurring so the the spinal column where the the central canal where the spinal cord travels will be decreased in its AP diameter due to this pair of central spurring you can also get something called ligamentum flavum hypertrophy which is the ligamentum flavum here on the posterior

arch will start to thicken and hypertrophy and causes compression of the spinal cord from behind and so any compression of the spinal cord there can cause this upper motor neurons disease or cervical myelopathy sorry you can maybe hear the thunder outside having a thunderstorm now this is an MRI of a patient with severe cervical myelopathy or cervical stenosis now as you can see here where the brainstem turns into the spinal cord and leaves the that leaves the cranium the here at the c12 level there is plenty of space for the spinal cord there’s a lot of the white is the cerebral spinal fluid and there’s a lot of fluid in front of and behind the cord so there’s a lot of room there but as you get down into this c3 4 and C 4 5 and even the c5 6 level you can see there is pretty severe spinal cord compression now this is due to degenerative changes long term changes we there’s some hypertrophy of the ligamentum flavum flav them back here and there is cervical spondylosis with degenerative disc disease here coming from anterior so we’ve kind of got compression from both anterior and posterior now if you can see right in here at the c34 level right inside the cord there is almost a lighter area inside the cord a hyper intense area now that is suggestive of a possible cervical cord contusion and that can result in more long term problems meaning it’s suggest some permanent damage that’s been done within the cord even after decompression so now with a patient with such severe cervical stenosis like this surgical intervention is needed it’s just going to get worse it’s not going to get better on its own so surgery in this case now on this slide is this is the same patient after surgery this is an immediate post-op x-ray and this patient underwent what we would call a front back surgery meaning they had an anterior decompression as well as a posterior decompression because their stenosis was severe so severe now here in the front the front approach is what we call an AC DF or an anterior cervical disc ectomy and fusion now here from C 3 4 & 5 so at the C 3 4 level the intervertebral disk was removed as well as at the c-45 level so from a approach from the front the intervertebral discs are removed to decompress the spinal cord and they usually try to shave off a little bit of the bone as well while they’re in there to get rid of the bone spurs that are also pushing on the cord they replace the intervertebral discs with some kind of a bone graft oftentimes it’s an autologous bone graft from a cadaver or the like a cage of some form from a company that might produce these intervertebral cage grafts and then a plate is placed on the front that’s usually a titanium plate with titanium screws to hold everything together while it heals so this is an anterior cervical disc ectomy infusion for anterior decompression of the spinal cord now this patient also went under for a posterior decompression and you can see back here on the back actually there’s a skin staple still present in this x-ray and and right here you can see what is the drain that is still in the patient postoperatively that will be removed now the as part of a posterior decompression the spinous processes of the the c3 c4 and c5 vertebrae have been removed removed as well as the lamina so this is what we’d call a cervical laminectomy which does a posterior decompression now this is a post-op MRI of the same patient if you remember here from the c3 through c5 area there was some significant compression of the spinal cord and in this post-op MRI the spinal cord has been completely freed and decompressed there is possibly a little tiny cord contusion here at this level it’s hard to tell really but for the most part this vinyl cord is fully decompressed you can see here there’s bone missing in the back and it’s all fused in the front for structural stability but postoperatively a very nice decompression

so again cervical myelopathy results from compression of the spinal cord resulting in an upper motor neuron presentation with a positive Babinski spasticity weakness in the extremities even some hyperreflexia and abnormal clonus and you can along with those get sensory deficits like numbness and tingling in the hands and even into the legs now let’s contrast that with the radiculopathy like we talked which radiculopathy is a compression of the spinal nerve roots now this produces a lower motor neuron presentation with weakness fasciculations atrophy and hyporeflexia now most of the time with a acute radiculopathy you’re going to get pain paresthesias as well as possibly weakness and hyporeflexia the fasciculations in the atrophy are severe signs that don’t develop until it’s been a prolonged compression of that nerve now our hypothetical case for cervical radiculopathy a 42 year old female patient presents to your clinic with chief complaint of neck and arm pain as you interview her you discover that she has the following signs and symptoms she complains of sharp shooting almost electrical like shooting pains down into her right arm coming from the neck she also has some numbness and tingling along that same route in the arm she also complains of some weakness with the right hand when she is gripping onto objects she feels that her hand is actually weak she does not complain of any problems with the legs or with the left arm and slowly her right arm that is bothering her and the pain in her arm is made worse with certain neck movements and we’ll talk about that a little bit more I think but specifically if you were to have a patient with a cervical radiculopathy tip their head laterally towards the arm that is bothering them they may have a reaper of that sharp shooting pain into their arm and that is what we would call a positive Sperling sign which is indicative of a cervical radiculopathy of some sort now also on your differential diagnosis when a patient presents with these kinds of signs or symptoms you need to keep in mind other options including shoulder pathology obviously if the pain is only in the shoulder region you need to keep in mind possibly like an AC joint injury a glint Leno humeral subluxation fractures in the in the joint a slap lesion rotator cuff injury so keep that in mind as well carpal tunnel syndrome if your patients having numbness and tingling in the hand you need to make sure it’s not just a carpal tunnel syndrome a Pancoast tumor is something that is maybe oftentimes left off of the differential in this situation but it should not be especially if your patient has a long history of smoking or has a lot of recent coughing a Pancoast tumor which is a lung cancer a neoplasm in the apex of the lung if that tumor is strategically located and large can press on the brachial plexus as it’s leaving the cervical spine region and if that tumor is pushing hard enough on this brachial plexus you’ll get radicular signs and symptoms down into the the that extremity on that side and so Pancoast tumor needs to be on the differential diagnosis for radicular symptoms now an ulnar neuropathy at the elbow needs to be considered as well as the ulnar nerve travels through the cubital tunnel at the elbow it can be compressed due to hypertrophy of that lip that ligament just like carpal tunnel syndrome the difference with ulnar neuropathy is that your patient for the most part is going to pinpoint the elbow as the epicenter of their pain and they’ll have a often times a positive Tinnell sign Oh over the cubital tunnel a brachial plexus needs to be considered as well this is also called a parsonage Turner syndrome it’s something that’s oftentimes forgotten it’s not a very common diagnosis but can be severe and quite painful for patients and it’ll present with shoulder and arm pain and paresthesias and even weakness in the extremity it’s most of the time idiopathic or we don’t know what causes it possibly a virus but it’s a

inflammation of the brachial plexus and now oftentimes these patients will present just like a classic radiculopathy they’ll get a cervical MRI and that MRI won’t explain their symptoms the next step should be in that situation referral to a neurologist for electro diagnostic studies an EMG which will help differentiate whether it’s a specific nerve root involved or whether it’s the whole brachial plexus like it would be in parsonage Turner syndrome now further characteristics of cervical radiculopathy it can be sudden onset or gradual onset if if your patient for example is lifting something or in a certain way and all of a sudden there’s a sharp neck pain with going down into their arm that can suggest like a herniated or bulging disc gradual onset due to degenerative changes in the disc and intermittent in nature is a probably most common actually a patient will present saying you know everyone smile every couple months I have this arm pain that just flares up and it’s severe but then it’ll go away but this time it’s just not going away so that’s something to keep in mind it can be sudden gradual or intermittent in nature now the specific symptoms defendent depend on which level is involved so we’re going to talk about those levels and the specific findings with each of those levels on physical exam with a cervical radiculopathy you might notice motor weakness along certain Maya homes that are involved in that nerve root you may also have paresthesia along a certain dermatome now if it’s severe long-term you may notice muscle atrophy like we already talked about you may also have hyporeflexia which will be unilateral so for example a patient with a c7 radiculopathy on the right side their left triceps reflex might be normal but the right tricep reflux might be totally blunted now with a cervical radiculopathy their gait will be unaffected because the spinal cord is not being pinched and the lower extremities will not be involved either now with c-45 pathology you will have a c5 radiculopathy so it’s a little different than it is in the lumbar region because the in the cervical region this the c5 nerve root will exit just above the pedicle for which it is named so at c4 5 you will have the c5 nerve root exiting and so if you have got a herniated disc at c4 5 it’s going to hit the c5 nerve root as it exits so with a c5 radiculopathy you’re going to see pain that goes from the neck into the shoulder and maybe into the proximal arm over the deltoid region you might have some deltoid weakness so weakness with AB adduction of that arm and you might even see some bicep weakness you may also see a weak biceps reflex more commonly with a c6 radiculopathy however so with a C’s 5 6 pathology you’ll get a c6 radiculopathy which will result in a pain and paresthesias into the arm more specifically the shoulder lateral arm and radial side of the forearm with paresthesia as possible in the thumb and index finger so thumb and index finger think c6 now you’ll get a week by Sept with a c6 radiculopathy as well as some weak wrist extension and possibly a loss of the biceps reflex with a c6 seven pathology you’ll get a c7 radiculopathy which will result in pain in the scapula possibly even into the lateral chest wall or axillary region the medial arm and ulnar forearm you’ll get oftentimes of paresthesias in the index middle or ring finger most commonly the middle finger and you can get a tricep muscle weakness as well as a loss of the tricep reflex with a c7 t1 pathology we’ll get a c8 radiculopathy remember there are eight cervical nerve roots so c8 radiculopathy will result in pain in the scapula region medial arm and ulnar forearm as well with paresthesias into the ring and more commonly the little finger but classic 2a c8 radiculopathy is weakness in the intrinsic muscles of the hand so you’ll get kind of classically a weak grip

strength with c8 as well now this diagram nicely covers a certain aided cervical disc so right here it’s showing pathology where the the herniation from the cervical disc is pushing out and hitting that nerve root as it’s exiting the spinal column notice that the spinal cord itself is not being compressed just the spinal nerve now here on our sagittal MRI it looks somewhat similar to our cervical myelopathy example in that there’s there’s some bulging coming from the anterior side of the central canal but more specifically when you look at the axial cuts you can see that the disc herniation that’s being pointed out with this arrow is hitting the nerve root as it exits and for the most part leaving the spinal cord uninvolved the spinal cord itself is not being compressed against this back wall it’s just hitting that nerve root there at that side this is another example you can see this this the spinal cord here with the cerebral spinal fluid around it and then you you can see the herniated disc on this side hitting the nerve root as it’s exiting now the the surgical intervention for a cervical radiculopathy is usually reserved for severe cases or unrelenting cases a lot of time especially with younger patients the cervical radiculopathy due to like a bulged herniated disc is going to resolve with time and conservative treatment such as NSAIDs pain medications maybe physical therapy rest may be time off from work if needed if they have a strenuous job and oftentimes something like steroid medrol dose pack can really help these patients however if the patient has significant motor weakness due to this spinal nerve root compression that’s an indication for surgery because that that means it’s it’s severe and probably not going to get better or if the symptoms are just worsening and not resolving quickly with conservative treatment surgery can be performed now the surgery for a cervical radiculopathy is similar to an anterior approach for a cervical myelopathy in that it’s an AC DF or an anterior cervical disc ectomy reading meaning removal of the disc now here we’ve got a so this is C two three four and five six so this is a C five six anterior cervical disc ectomy infusion the surgeon approaches from the front removes the intervertebral discs at that level decompressing that spinal nerve root replacing that that intervertebral disc with this bone graft or a cage of some sort and then placing a titanium cervical plate across the anterior vertebral bodies and fixing it with two screws at each level so that’s an anterior cervical disc actin me and fusion for treatment of a cervical radiculopathy due to a herniated disc or other degenerative changes at that level so just in quick review we’ve got cervical myelopathy which results in upper motor neuron signs due to compression of the spinal cord these are the the signs of upper motor neuron disease with cervical or you know any kind of radiculopathy it results due to compression of the spinal nerve roots resulting in lower motor neuron signs as well as paresthesias along that same route so cervical myelopathy versus cervical radiculopathy hopefully this has been very educational for you so thank you very much for watching this presentation I hope you’ve enjoyed it and found it to be educational and helpful please feel free to subscribe to my channel and enjoy in my other videos I hope to share a lot more in the future thank you