Radiculopathy
Radiculopathy is a condition due to a compressed nerve in the spine that can cause pain, numbness, tingling, or weakness along the course of the nerve. Radiculopathy can occur in any part of the spine, but it is most common in the lower back (lumbar radiculopathy) and in the neck (cervical radiculopathy). It is less commonly found in the middle portion of the spine (thoracic radiculopathy).
At Aptiva Health, we offer same-day and walk-in appointments for spine injuries and conditions to evaluate, diagnose, and make the appropriate referral for additional treatment based upon your specific spine injury or condition. We treat spine injuries and conditions in our Spine, Pain Management, General Medicine, Orthopedics, and Physical Therapy departments.
Causes and Symptoms
Radiculopathy is caused by compression or irritation of the nerves as they exit the spine. This can be due to mechanical compression of the nerve caused by a disc herniation, bone spur (osteophytes) from osteoarthritis, or from thickening of surrounding ligaments. Inflammation from trauma or degeneration can also lead to radiculopathy from direct irritation of the nerves.
symptoms
The symptoms of radiculopathy depend on which nerves are affected. The nerves exiting from the neck (cervical spine) control the muscles of the neck and arms where they supply sensation. The nerves from the middle portion of the back (thoracic spine) control the muscles of the chest and abdomen where they supply sensation. The nerves from the lower back (lumbar spine) control the muscles of the buttocks and legs where they supply sensation.
The most common symptoms of radiculopathy are pain, numbness, and tingling in the arms or legs. It is common for patients to also have localized neck or low back pain that accompany radiculopathy. Lumbar radiculopathy that causes pain that radiates down a lower extremity is commonly referred to as sciatica. Thoracic radiculopathy causes pain from the middle back that travels around to the chest.
Some patients develop a hypersensitivity to light touch that causes pain in the area involved. Less commonly, patients can develop weakness in the muscles controlled by the affected nerves, which can cause serious and possibly permanent nerve damage.
Diagnosis and Treatment
The diagnosis of radiculopathy begins with a medical history and physical examination by a spine specialist. During the medical history, the doctor will ask you questions about the type and location of symptoms, how long they have been present, what makes them better and worse, and what other medical problems may be present. By identifying the exact location of your symptoms, the doctor can help localize the nerve that is responsible. Your physical examination with a member of our Spine Department will also focus on the extremity involved. The specialist will check the your muscle strength, sensation, and reflexes to see if there are any abnormalities.
You may be asked to obtain imaging studies to look for a source of the radiculopathy. Typically, our spine specialists start with digital x-rays. These can often identify the presence of trauma or osteoarthritis and early signs of tumor or infection. If the x-ray does not reveal any obvious signs to help diagnose the cause of the radiculopathy, an MRI scan will likely be recommended. (Dependent upon your insurance, you may be required to first fail a trial round of physical therapy before an MRI is approved.) This study provides the best look at the soft tissues around the spine including the nerves, discs, and the ligaments. If the patient is unable to obtain an MRI, they may obtain a CT scan instead to explore possible compression of the nerves.
In some cases, your spine specialist may order a nerve conduction study or electromyogram (EMG). These studies look at the electrical activity along the nerve and can show if there is damage to the nerve that is causing radiculopathy.
STEP 1 EARLY TREATMENTS
Medications may include:
Analgesics and NSAIDS
Opioid medications prescribed by a physician (opioids should be used only for a short period of time and under a physician’s supervision, as opioids can be addictive, aggravate depression, and have other side effects)
Anticonvulsants—prescribed drugs primarily used to treat seizures—may be useful in treating people with sciatica
Antidepressants such as tricyclics and serotonin, and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain (prescribed by a physician)
Self-management:
Hot or cold packs
Resuming normal activities as soon as possible may ease pain; bed rest is not recommended
Exercises that strengthen core or abdominal muscles may help to speed recovery from chronic low back pain. Always check first with a physician before starting an exercise program and to get a list of helpful exercises.
STEP 2 CONSERVATIVE TREATMENT OPTIONS:
Transcutaneous electrical nerve stimulation (TENS) involves wearing a battery-powered device which places electrodes on the skin over the painful area that generate electrical impulses designed to block or modify the perception of pain
Physical therapy programs to strengthen core muscle groups that support the low back, improve mobility and flexibility, and promote proper positioning and posture are often used in combination with other interventions
Traction involves the use of weights and pulleys to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Some people experience pain relief while in traction but the back pain tends to return once the traction is released.
Spinal manipulation and spinal mobilization are approaches in which doctors of chiropractic care use their hands to mobilize, adjust, massage, or stimulate the spine and the surrounding tissues. Manipulation involves a rapid movement over which the individual has no control; mobilization involves slower adjustment movements. The techniques may provide small to moderate short-term benefits in people with chronic low back pain but neither technique is appropriate when a person has an underlying medical cause for the back pain such as osteoporosis, spinal cord compression, or arthritis.
Dry needling is moderately effective for chronic low back pain. It involves inserting thin needles into precise points throughout the body and stimulating them (by twisting or passing a low-voltage electrical current through them), which may cause the body to release naturally occurring painkilling chemicals such as endorphins, serotonin, and acetylcholine.
Behavioral approaches include:
Biofeedback involves attaching electrodes to the skin and using an electromyography machine that allows people to become aware of and control their breathing, muscle tension, heart rate, and skin temperature; people regulate their response to pain by using relaxation techniques
Cognitive therapy involves using relaxation and coping techniques to ease back pain
STEP 3 INTERVENTIONAL INJECTION OPTIONS:
Interventional pain management injections to include:
Trigger point injections can relax knotted muscles (trigger points) that may contribute to back pain. An injection or series of injections of a local anesthetic and often a corticosteroid drug into the trigger point(s) can lessen or relieve pain.
Epidural steroid injections into the lumbar area of the back are given to treat low back pain and sciatica associated with inflammation. Pain relief associated with the injections tends to be temporary and the injections are not advised for long-term use.
Facet Joint Injections. The facet joints are small joints in the back of the spine that form connections between each vertebra. If these joints are blocked or numbed, they will not be able to transfer the painful sensation to the brain. Therefore, this procedure is completed to see if your back (or neck) pain is caused by the facet joints.
SI Joint Injections. Sacroiliac (SI) joint pain is easily confused with back pain from the spine. Sometimes injecting the SI joint with lidocaine may help your doctor determine whether the SI joint is the source of your pain. If the joint is injected and your pain does not go away, it may be coming from a different source. During the procedure, a mixture of local anesthetic and steroid is injected into the SI joint. The local anesthetic will numb the area, and steroid may help lower the swelling. The steroid should reduce the pain and improve the motion in your hip or buttock.
Medial branch blocks injection used to determine if the facet joint is causing the patient's back pain. Facet joints are pairs of small joints between the vertebrae in the back of the spine.
Radiofrequency ablation involves inserting a fine needle into the area causing the pain through which an electrode is passed and heated to destroy nerve fibers that carry pain signals to the brain. Also called a rhizotomy, the procedure can relieve pain for several months.
STEP 4 SURGICAL INTERVENTION
Surgery
When other therapies fail, surgery may be considered to relieve pain caused by worsening nerve damage, serious musculoskeletal injuries, or nerve compression. Specific surgeries are selected for specific conditions/indications. Surgical options include:
Vertebroplasty and kyphoplasty for fractured vertebra are minimally invasive treatments to repair compression fractures of the vertebrae caused by osteoporosis. Vertebroplasty uses three-dimensional imaging to assist in guiding a fine needle through the skin into the vertebral body, the largest part of the vertebrae. A glue-like bone cement is then injected into the vertebral body space, which quickly hardens to stabilize and strengthen the bone and provide pain relief. In kyphoplasty, prior to injecting the bone cement, a special balloon is inserted and gently inflated to restore height to the vertebral structure and reduce spinal deformity.
Spinal laminectomy (also known as spinal decompression) is done when a narrowing of the spinal canal causes pain, numbness, or weakness. During the procedure, the lamina or bony walls of the vertebrae are removed, along with any bone spurs, to relieve pressure on the nerves.
Discectomy and microdiscectomy involve removing a herniated disc through an incision in the back (microdiscectomy uses a much smaller incision in the back and allows for a more rapid recovery). Laminectomy and discectomy are frequently performed together and the combination is one of the more common ways to remove pressure on a nerve root from a herniated disc or bone spur.
Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can narrow the space where the spinal nerve exits and press on the nerve. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve pressure on the nerve.
Nucleoplasty, also called plasma disc decompression (PDD), is a type of laser surgery that uses radiofrequency energy to treat people with low back pain associated with mildly herniated discs. Under x-ray guidance, a needle is inserted into the disc. A plasma laser device is then inserted into the needle and the tip is heated to 40-70 degrees Celsius, creating a field that vaporizes the tissue in the disc, reducing its size and relieving pressure on the nerves.
Radiofrequency denervation uses electrical impulses to interrupt nerve conduction (including pain signaling). Using x-ray guidance, a needle is inserted into a target area of nerves and the region is heated, which destroys part of the target nerves and offers temporary pain relief.
Spinal fusion is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together. Spinal fusion has been associated with an acceleration of disc degeneration at adjacent levels of the spine.
Artificial disc replacement is an alternative to spinal fusion for treating severely damaged discs. The procedure involves removing the disc and replacing it with a synthetic disc that helps restore height and movement between the vertebrae.
SI-Joint fusion. The goal of this procedure is to completely eliminate movement at the sacroiliac joint by grafting together the ilium and sacrum. Sacroiliac fusion involves the use of implanted screws or rods, as well as a possible bone graft across the joint. Minimally-invasive procedures have been developed in recent years that improve outcomes in pain and disability, and reduce recovery time.
Interspinous spacers are small devices that are inserted into the spine to keep the spinal canal open and avoid pinching the nerves. It is used to treat people with spinal stenosis.
Implanted nerve stimulators
Spinal cord stimulation uses low-voltage electrical impulses from a small implanted device that is connected to a wire that runs along the spinal cord. The impulses are designed to block pain signals that are normally sent to the brain.
Dorsal root ganglion stimulation also involves electrical signals sent along a wire connected to a small device that is implanted into the lower back. It specifically targets the nerve fibers that transmit pain signals. The impulses are designed to replace pain signals with a less painful numbing or tingling sensation.
Peripheral nerve stimulation also uses a small implanted device and an electrode to generate and send electrical pulses that create a tingling sensation to provide pain relief.