13A. Ischias syndrome and cervicobrachialgia (symptoms, warning signs)

Ischias syndrome

Ischias syndrome (sciatica) is one manifestation of spinal cord disease. It’s characterised by the presence of back pain and radiating pain down the leg, but no other neurological symptoms. It’s caused by compression of the L4 – S1 roots.

The other manifestations of spinal cord disease are cervicobrachialgia, chronic back pain, and lumboischialgia (topic 23A).

Etiology

• Spinal disc herniation (most common)
• Trauma to the back
• Spondylosis (age-related arthritis of the spine)
• Spinal stenosis
• Spinal tumour

Clinical features

These patients have lower back pain and pain in the distribution of the sciatic nerve. The pain radiates down the posterior or lateral aspect of the leg, usually to the foot or ankle.

Diagnosis and evaluation

These patients can be diagnosed based on clinical symptoms and a positive Lasegue sign. Diagnostic imaging is only necessary in case of severe symptoms, as surgery is not indicated otherwise.

Treatment

Treatment is normally supportive, with physical therapy and NSAIDs. If the symptoms are very severe, surgical treatment may be an option. Most cases of disk herniation improve spontaneously without treatment.

Cervicobrachialgia

Cervicobrachialgia is another manifestation of spinal cord disease. It’s characterised by the presence of neurological symptoms of the neck and arm, in the distribution of C5 – C8, most commonly C8.

Etiology

• Trauma to the back
• Spondylosis (age-related arthritis of the spine)
• Spinal disc herniation
• Spinal stenosis
• Spinal tumour

Clinical features

The symptoms include weakness, atrophy, sensory loss, and radicular pain in the neck or upper arm. If C8 is affected, we can see the following symptoms:

• Sensory symptoms on little finger
• Motor symptoms of the hand muscles
• Loss of triceps reflex

Diagnosis and evaluation

Diagnosis is based on clinical symptoms. Imaging may be necessary in case of severe symptoms.

Treatment

Treatment is only supportive, with physical therapy and NSAIDs. If the symptoms are very severe, surgical treatment may be an option.

Conus medullaris and cauda equina syndrome

Cauda equina syndrome is a consequence of compression of the cauda equina, the nerve fibres of L3 – S5. Conus medullaris syndrome is a consequence of compression of the conus medullaris, the spinal cord segments T12 – L2. Both are neurological emergencies as they may cause permanent neurological injury if untreated. They are usually caused by spinal disc herniation.

These syndromes are medical emergencies and so any patient with these signs must undergo imaging and decompressive surgery immediately. Urgent neurosurgery to decompress the spine is necessary.

Warning signs

• Saddle anaesthesia
• Paraplaegia
• Urinary retention or incontinence
• Loss of lower extremity reflexes

These signs are suspicious for spinal cord compression, conus medullaris syndrome or cauda equina syndrome.

Clinical features

Conus medullaris syndrome	Cauda equina syndrome
An upper motor neuron lesion	A lower motor neuron lesion
Symmetric symptoms	Asymmetric symptoms
Motor symptoms rare	Paraparesis and loss of patellar and Achilles reflex
Sensory loss of pelvic and perianal region (saddle anaesthesia)
No pain	Radicular pain
Vegetative symptoms like urinary retention, faecal incontinence, erectile dysfunction, loss of anal and bulbocavernosus reflexes