Chiropractic Management of Radicular Pain
Pain Patterns and Descriptions in Patients with Radicular Pain:
Does the Pain Necessarily Follow a Specific Dermatome?
Chiropractic & Osteopathy 2009 (Sep 21); 17 (1): 9 ~ FULL TEXT
Two hundred twenty-six nerve roots in 169 patients were assessed. Overall, pain related to cervical nerve roots was non-dermatomal in over two-thirds (69.7%) of cases. In the lumbar spine, the pain was non-dermatomal in just under two-thirds (64.1%) of cases. The majority of nerve root levels involved non-dermatomal pain patterns except C4 (60.0% dermatomal) and S1 (64.9% dermatomal). The sensitivity (SE) and specificity (SP) for dermatomal pattern of pain are low for all nerve root levels with the exception of the C4 level (Se 0.60, Sp 0.72) and S1 level (Se 0.65, Sp 0.80), although in the case of the C4 level, the number of subjects was small (n=5). In most cases nerve root pain should not be expected to follow along a specific dermatome, and a dermatomal distribution of pain is not a useful historical factor in the diagnosis of radicular pain. The possible exception to this is the S1 nerve root, in which the pain does commonly follow the S1 dermatome.
Chiropractic Outcomes Managing Radiculopathy in a Hospital Setting: A Retrospective Review of 162 Patients
J Chiropractic Medicine 2008 (Sep); 7 (3): 115—125
This is a retrospective review of 162 patients with a working diagnosis of radiculopathy who met the inclusion criteria (312 consecutive patients were screened to obtain the 162 cases). Data reviewed were collected initially, during, and at the end of active treatment. The treatment protocol included chiropractic manipulation, neuromobilization, and exercise stabilization. Of the 162 cases reviewed, 85.5% had resolution of their primary subjective radicular complaints. The treatment trial was 9 (mean) treatment sessions.
Cervical Myelopathy:
A Case Report of a “Near-Miss” Complication to Cervical Manipulation
J Manipulative Physiol Ther 2008 (Sep); 31 (7): 553—557
Cases have been reported in which radiculopathy or myelopathy secondary to herniated disk has occurred after cervical manipulation. In each case, it is not possible to determine whether the neurologic symptoms and signs were directly caused by the manipulation or whether they developed as part of the natural history of the disorder. The purpose of this article is to report a case in which a patient with radiculopathy secondary to herniated disk was scheduled to receive manipulation but just before receiving this treatment developed acute myelopathy.
Does Facet Joint Inflammation Induce Radiculopathy? An Investigation Using a Rat Model of Lumbar Facet Joint Inflammation
Spine 2007 (Feb 15); 32 (4): 406–412
The association between lumbar facet joint inflammation and radiculopathy was investigated using behavioral, histologic, and immunohistochemical testing in rats. Both mechanical and chemical factors have been identified as important for inducing radiculopathy. In lumbar spondylosis, facet joint osteophytes may contribute to nerve root compression, which may induce radiculopathy. Furthermore, inflammation may occur in the facet joint, as in other synovial joints. Inflamed synovium may thus release inflammatory cytokines and induce nerve root injury with subsequent radiculopathy. (In this study) when inflammation was induced in a facet joint, inflammatory reactions spread to nerve roots, and leg symptoms were induced by chemical factors. These results support the possibility that facet joint inflammation induces radiculopathy.
Differentiating Radicular and Referred Pain
Chiropractic & Osteopathy 2007; 15: 1746—1340 ~ FULL TEXT
Similar upper extremity symptoms can present with varied physiologic etiologies. However, due to the multifaceted nature of musculoskeletal conditions, a definitive diagnosis using physical examination and advanced testing is not always possible. This report discusses the diagnosis and case management of a patient with two episodes of similar upper extremity symptoms of different etiologies.
Rotary Manipulation for Cervical Radiculopathy: Observations on the Importance of the Direction of the Thrust
J Manipulative Physiol Ther 1997 (Nov-Dec);20 (9):622-627
Los Angeles College of Chiropractic, Whittier, CA, USA
OBJECTIVE: To describe the clinical presentation of eight patients with cervical spine radiculopathy, the manipulation technique used for each patient and the outcomes of treatment.
CLINICAL FEATURES: The cause of radiculopathy in four patients was disc herniation. The other four patients had a combination of spondylosis, disc herniation and sprain injury.
INTERVENTION AND OUTCOME: Six of eight patients had a good outcome associated with receiving manipulation performed by contacting the cervical spine at the level of the radiculopathy, laterally flexing toward the side of radiculopathy, rotating the neck away from the side of the radiculopathy and applying a gentle high-velocity, low-amplitude thrust. Two patients had an exacerbation of arm pain and increased neurological deficit associated with manipulation performed with the neck rotated toward the side of radiculopathy.
CONCLUSION: There is little compelling evidence supporting or disputing the use of manipulation for patients with cervical spine radiculopathy. In our patients, rotary manipulation was associated with a different outcome depending on the direction of neck rotation. Prospective time-series studies and randomized, blind trials are needed to identify the efficacy and effectiveness of different manipulation techniques for this condition.
Chiropractic Treatment of Cervical Radiculopathy Caused by a Herniated Cervical Disc
J Manipulative Physiol Ther 1994 (Feb);17 (2):119-123
OBJECTIVE: To present a case of cervical radiculopathy, caused by an MRI documented herniated cervical disc, which was treated with conservative care including chiropractic manipulative therapy.
CLINICAL FEATURES: A 60-yr-old woman was treated by a chiropractor for symptoms including a deep, constant, burning ache in the left arm, and severe neck and left shoulder pain. A diagnosis of acute herniated cervical disc was made based on the findings of physical examination and an MRI study of the patient's cervical spine. Important orthopedic findings included exacerbation of the radicular symptomatology with the performance of Valsalva's and cervical compression tests. Neurologic findings included absent biceps and hyporeflexive triceps reflexes on the left, as well as C6 sensory deficit and C7 and C8 sensory hypesthesia. The primary finding on the MRI scan was posterior and lateral herniation on the C6-7 disc.
INTERVENTION AND OUTCOME: Treatment included chiropractic manipulative therapy, longitudinal cervical traction and interferential therapy. The patient began a regular schedule of treatments, which started on a daily basis but were gradually reduced as the patient progressed. By the third week of treatment, neck and shoulder pain was completely resolved. Subjective evaluation indicated the radicular pain to be improved by 60% within 6 wk. The patient's pain, numbness and grip strength returned to normal within 5 months.
CONCLUSION: Conservative treatment including chiropractic manipulative therapy seems to be a reasonable alternative to surgery, for cervical radiculopathy caused by a herniated cervical disc. Clinical trials should be performed to evaluate long term success rate, risk of permanent disability, rate of recovery and cost effectiveness of this and other forms of treatment for cervical radiculopathy caused by herniated nucleus pulposus.
Intermittent Cervical Traction for Cervical Radiculopathy Caused by Large-volume Herniated Disks
J Manipulative Physiol Ther 2002 (Mar-Apr); 25 (3):188-192
Department of Neurosurgery, University of Umea, Umea, Sweden
OBJECTIVE: To describe the use of intermittent cervical traction in managing 4 patients with cervical radiculopathy and large-volume herniated disks.
CLINICAL FEATURES: Four patients had neck pain radiating to the arm. The clinical examination was typical in all cases for radiculopathy of cervical origin. Magnetic resonance imaging (MRI) of the cervical spine revealed large-volume herniated disks in all patients.
INTERVENTIONS AND OUTCOME: The treatment consisted of intermittent on-the-door cervical traction under the supervision of our physiotherapists. Complete symptom resolution for each patient occurred within 3 weeks. One patient who had an episode of recurrence 16 months after the first treatment was successfully managed again with cervical traction and physiotherapy.
CONCLUSION: Cervical spine traction could be considered as a therapy of choice for radiculopathy caused by herniated disks, even in cases of large-volume herniated disks or recurrent episodes.
Herniated Disc with Radiculopathy Following Cervical Manipulation: Nonsurgical Management
Spine J 2006 (Jul-Aug); 6 (4): 459-463
Rhode Island Spine Center, and Department of Community Health, Brown University School of Medicine, Providence, RI 02860, USA. rispine@aol.com
BACKGROUND CONTEXT: Spinal manipulation applied to the cervical spine is a relatively safe and effective treatment for neck pain and headache. However, complications of this form of treatment have been reported and these can at times be disabling and on rare occasions can be devastating. A postmanipulation complication being treated with a different form of manipulation has not previously been reported.
PURPOSE: To report a case of a patient who was treated with manipulation and who developed neck, scapular, and arm pain and arm numbness after the sixth visit, which was later attributed to three herniated discs. The patient was subsequently treated with a nonsurgical approach that included, but was not limited to, a different form of manipulation with apparent resolution of the problem.
STUDY DESIGN/SETTING: The patient was a 38-year-old banker who began seeing a chiropractic physician for treatment that included cervical manipulation. On the sixth visit, he developed pain immediately after treatment which became severe and was accompanied by numbness in his arm. He saw a neurosurgeon who recommended surgery, but was subsequently seen by a different chiropractic physician and was treated nonsurgically.
METHODS: The patient was found to have clinical signs of radiculopathy, including motor loss. Magnetic resonance imaging revealed disc herniations at C3-C4, C4-C5, and C5-C6. RESULTS: The patient was treated by the author with an alternate approach that included non-high-velocity, low-amplitude manipulation and exercise with resolution of the problem.
CONCLUSION: This paper reports a case of a patient with radiculopathy secondary to multilevel disc herniations that appeared to be precipitated by cervical manipulation and who was treated nonsurgically with resolution of the problem. It is doubtful that the manipulation actually caused the disc herniations, but it is possible that it caused preexisting asymptomatic disc herniations to become symptomatic. Consideration should be given to nonsurgical referral of patients who have postmanipulative complications but do not need immediate surgery.
References:
7. Chicago Institute of Neurosurgery and Neuroresearch
www.cinn.org/pain/types-of-neck-pain.html
