Nerve pain due to the impingement of the nerves in the spine with pain radiating from the neck, thoracic, or lumbar spines.
Commonly referred to as pinched nerve.
The process occurs at or near the root of the nerve, shortly after its exit from the spinal cord.
It is most often is caused by mechanical compression of a nerve root usually at the exit foramen or lateral recess.
Nerve root impingement can result from any process that decreases the diameter of the neural foramen causing nerve root compression.
Most cases are caused by disc herniation, especially in older adults.
Other causes include osteophyte formation, facet hypertrophy/degeneration, and ligamentous hypertrophy, spondylolisthesis causing impingement of the nerve root at the level of its exit from the spinal canal.
A combination of these factors may be responsible for symptoms.
Additional causes of radiculopathy include neoplastic disease, infections such as shingles, HIV, or Lyme disease, spinal epidural abscess, spinal epidural hematoma, proximal diabetic neuropathy, Tarlov cysts, or, more rarely, sarcoidosis, arachnoiditis, tethered spinal cord syndrome, or transverse myelitis.
The diagnosis is suggested by symptoms of pain, numbness, and weakness in a pattern consistent with the distribution of a particular nerve root, such as sciatica.
Physical examination may reveal motor and sensory deficits relating to the distribution of the involved nerve root.
Spurling’s test may elicit or reproduce symptoms radiating down the arm in the presence of cervical raficulopathy.
A straight leg raise maneuver or a femoral nerve stretch test may demonstrate radiculopathic symptoms down the leg with a lumbosacral radiculopathy.
Deep tendon reflexes may be diminished or absent in areas innervated by a particular nerve root.
Most cases of radiculopathy are compressive and resolve with conservative treatment within 4-6 weeks.
Cauda equina syndrome should be investigated in case of saddle anesthesia, loss of bladder or bowel control, or leg weakness.
Cancer is considered if there is previous history of it, unexplained weight loss, or low-back pain that does not decrease by lying down or is unremitting.
Spinal epidural abscess may be seen with diabetes mellitus or in the immunocompromised, in intravenous drug users, prior spinal surgery, injection or catheter.
Spinal epidural abscess typically causes fever, leukocytosis and increased erythrocyte sedimentation rate.
Magnetic resonance imaging is recommended for confirmation of the diagnosis.
Proximal diabetic neuropathy onset is sudden causing pain usually in multiple dermatomes quickly followed by weakness.
Proximal diabetic neuropathy diagnosis typically involves electromyography and lumbar puncture.
Shingles radiculopathy is more common among the elderly and immunocompromised; usually pain is followed by appearance of a rash with small blisters along a single dermatome.
Acute Lyme radiculopathy follows a history of outdoor activities in likely tick habitats in the previous 1-12 weeks.
Lyme radiculopathy is usually worse at night and accompanied by extreme sleep disturbance, variable headache, no fever, and sometimes by facial palsy with
lymphocytic meningitis .
Lyme disease can also cause a milder, chronic radiculopathy an average of 8 months after the acute illness.
Radiography is the most appropriate initial study in all patients with chronic neck pain, and additional diagnostic tests that may be of use are magnetic resonance imaging and electrodiagnostic testing.
Magnetic resonance imaging (MRI) of the portion of the spine where radiculopathy is suspected may reveal evidence of degenerative change, arthritic disease, or another explanatory lesion responsible for a patient’s symptoms.
NCS (nerve conduction study) and EMG (electromyography), are powerful diagnostic tool that may show nerve root injury in suspected areas.
On nerve conduction studies, diminished compound muscle action potential and normal sensory nerve action potential may be seen given that the lesion is proximal to the posterior root ganglion.
Needle EMG is the more sensitive aspect of the test, and may reveal active denervation in the distribution of the involved nerve root, and neurogenic-appearing voluntary motor units in more chronic radiculopathies.
Treatment aims to resolve the underlying cause and restores the nerve root to normal function.
Conservative treatments include: bed rest, physical therapy, continuing usual activities, nonsteroidal anti-inflammatory drugs, nonopioid or, in some cases, narcotic analgesics may be prescribed.
Low level evidence supports spinal manipulation for the treatment of chronic lumbar radiculopathies, and no evidence exists for treatment of thoracic radiculopathy.
Mild to moderate injuries often resolve or greatly improve within the first few weeks.
Waiting two to three weeks after injury is generally recommended before starting physical therapy.
In acute injury resulting in lumbosacral radiculopathy, conservative treatment such as acetaminophen and NSAIDs should be the first line of therapy.
Stabilization of the cervicothoracic region is helpful in limiting pain and preventing re-injury.
Cervical and lumbar support braces typically are not indicated for radiculopathy, and may lead to weakness of support musculature.
Achieving a pain free full range of motion which can be accomplished through stretching exercises.
Strengthening exercise programs are designed to restore the deconditioned cervical, shoulder girdle, and upper trunk musculature, as well.
Isometric exercise regimens resist muscle atrophy and is least likely to exacerbate the underlying condition.
Patients with large cervical disk bulges may be require surgery, however most often conservative management will help the herniation regress naturally.
Surgical procedures such as foraminotomy, laminotomy, or discectomy may be considered.
Cervical radiculopathy is less prevalent than lumbar radiculopathy.
Cervical radiculopathy has an occurrence rate of 83 cases per
100,000.
Cervical radiculopathy mostly affects the age group is between 45 and 64 years with greater than 50% of incidents.
Females are affected more frequently than males and account for about 54% of cases.
The most common manifestation of cervical radiculopathy is the C7 monoradiculopathy, followed by C6.