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RADICULOPATHIES, PLEXOPATHIES, AND MONONEUROPATHIES
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narrowing The sinuvertebral nerves innervate the anterior and posterior longitudinal ligaments of the spine, the spinal dura mater, the walls of intraspinal blood vessels, and, to a lesser extent, the outer annular bers of the intervertebral disks Compression of these nerves, as well as the structures that these innervate, provides additional potential pain generators Although there is a rich anastomotic blood supply to the spinal cord and nerve roots, ischemic injury resulting from radicular vascular compression may represent an alternative mechanism of nerve root injury The anatomy of the lumbosacral nerve roots varies from both their cervical and thoracic counterparts A number of these aspects are potentially clinically signi cant Correlation between nerve root and disk space involvement is more dif cult in the lumbosacral spine than in the cervical spine The differing anatomy in the lumbosacral region also offers a greater predisposition to multiple and bilateral root involvement than is the case in the cervical region The reasons for these variations are as follows Nerve roots in the cervical spine exit the spinal cord in what is essentially a perpendicular vector to the longitudinal trajectory of the spinal cord In the cervical spine, a disk hernation is exposed to a single nerve root traversing directly over and parallel with the herniated disk For example, a disk herniation at the fth and sixth cervical vertebral interspace virtually always compresses the sixth cervical nerve root whose bers run parallel to and immediately above the C5 6 disk space The disk herniation may be paramedian, posterolateral, or far lateral in its trajectory, but the sixth cervical root remains in jeopardy in each case As the conus medullaris ends between the rst and second lumbar vertebrae in the majority of individuals, the nerve roots innervating the lower extremities travel together in an oblique but largely vertical course (Fig 22 2) Unlike the cervical spine, the nerve root exiting between two vertebral bodies typically shares the numerical label of the upper of the two vertebrae, the numbering scheme having been disturbed by eight cervical nerve roots and only seven cervical vertebrae It is not this nerve root that exits at that level that typically falls in harms way For example, the L4 root exits in the foramen created by the L4 and L5 pedicles As this root approaches this foramen with a largely longitudinal trajectory, it immediately wraps around the L4 pedicle in close proximity in a space that is actually slightly rostral to the actual disk More typically, an L4 5 disk herniation will affect the L5 root, which is still descending and traveling over the affected disk structure This correlation is not, however, universal A far lateral disk herniation at L4 5 may affect the L4 root preferentially, whereas a paramedian disk herniation at L4 5 may actually affect the more medially placed S1 root In addition, large disk herniations in the lumbosacral region are quite capable
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of affecting multiple nerve roots, simultaneously affecting one or both lower extremities as well as sphincteric and sexual function Radiculopathy occurring as a consequence of spondylosis also differs in its phenotypic expression in the lumbosacral and cervical regions due to differing anatomy Spondylytic bars in the cervical region are common Although these may affect the nerve roots bilaterally at that interspace, the phenotype is typically dominated by myelopathic features In the lumbosacral region, spondylytic narrowing of the central canal typically manifests as a polyradiculopathy, due to the orientation of the cauda equina and the absence of a spinal cord to provide myelopathic signs and symptoms6 Spondylosis producing a monoradiculopathy in the lumbosacral spine is most likely to affect the nerve root exiting at that level, rather than the one immediately below Using the same example as above, narrowing of the lateral recess at L4 5 resulting from any or all of the spondylytic mechanisms listed above puts the L4 root at greatest risk, whereas the L5 root is most likely to be affected by a disk herniation occurring at the same level Another implication of lumbosacral nerve root anatomy is its possible effect on electrodiagnostic studies Sensory nerve action potentials (SNAPs) in the legs may be abnormal in lumbosacral root disease, an apparent contradiction of the general principles of EDX emphasized in 27 Dorsal root ganglia typically lie in or just lateral to the neural foramina, although there is considerable anatomic variation in this regard8 As a result, the dorsal nerve roots within the spinal canal, ie, the cauda equina, are typically preganglionic Consequently, Wallerian degeneration most commonly occurs in a centripetal rather than centrifugal direction with resultant SNAP preservation as is the case in the cervical spine On occasion, the dorsal root ganglia are proximally located, or disk herniations occur suf ciently lateral so that the dorsal root ganglion is affected Accordingly, SNAPs may be reduced in otherwise typical root disease and serve as an electrodiagnostic confounder7 There is considerable variation in the anatomy of the lumbosacral plexus (Fig 22 3) It may have contributions from as many as 11 spinal nerves but is typically composed of eight (L1 S3) The lumbar plexus is predominantly composed of branches from L1 to L4, with variable contributions from T11, T12, and L5 Typically, the majority of L4 bers travel with the lumbar plexus, with a much smaller contribution from L4 joining with L5 to form the lumbosacral trunk In a pre- xed plexus, the plexus shifts downward so that there is more of an L1 contribution to the lumbar plexus, the femoral and obturator nerves become more L2 3- rather than L3 4-innervated structures, and the majority of L4 bers end up in the sacral plexus In the so-called post xed plexus, the plexus is shifted upward so that virtually all
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