What is Radicular Pain (Radiculopathy)?
Radiculopathy is characterized by motor and/or sensory changes in the neck and arms or the legs and feet, which results from extrinsic pressure on the nerve root. This pressure is typically caused by disc material, swelling, or osteophytes. A large study in Rochester, Minnesota, has reported the annual incidence of cervical radicular symptoms to be 83.2 per 100,000 population, and its prevalence most significant within a 50- to 54-year age group. In the study, 90 percent of patients were asymptomatic or only mildly incapacitated. Surgery is not often required for resolution of cervical radiculopathy symptoms.
Symptoms
Radicular pain, the characteristic symptom of cervical radiculopathy, is often confused with radiating pain in clinical practice. Because specific treatments are exclusively indicated for radicular pain, an accurate distinction is important. True radicular pain follows dermatomal patterns and is usually— though not always— unilateral. Onset is often insidious but may also be abrupt, and the pain is frequently aggravated by arm position and extension or lateral rotation of the head. [4]
There are three primary types of pain:
1. Local Pain is caused by irritation to the structures in the back including bone, muscles, ligaments and joints. The pain is usually steady, sharp or dull, felt in the effected area of the spine and may change with changes in position or activity.
2. Referred Pain can be pain caused by non-spinal pathology that is referred to the back, such as an abdominal aortic aneurysm. Referred pain can also be pain originating in the spine that is felt in distant structures. For instance upper lumbar pain is frequently felt in the upper thighs, and lower lumbar pain is felt in the lower buttocks. Sacroiliac joint pain is often referred to the inguinal and antero-lateral thigh area. Referred pain rarely extends below the knees, where as nerve root pain can be felt in the calf or foot.
3. Radicular Pain is caused by irritation of the nerve roots (radix) and is usually more severe than referred pain, and may have a more distal radiation. Radicular pain usually circumscribes the territory of innervation of the given nerve root (in a dermatomal distribution). This type of pain is often deep and steady, and can usually be reproduced with certain activities and positions, such as sitting or walking. [1] In addition, radicular pain is frequently exacerbated by any maneuver that raises the pressure of cerebrospinal fluid (or the interabdominal pressure), such as valsalva, sneezing, or cough. [2]
Radicular Pain Distribution
Radicular pain radiates into the extremity (thigh, calf, and occasionally the foot or to the arm, forearm or hand) directly along the course of a specific spinal nerve root. The most common symptom of radicular pain is sciatica (pain that radiates along the sciatic nerve - down the back of the thigh and calf into the foot) and arm pain and paresthesia of the hand. Sciatica is one of the most common forms of pain caused by compression of a spinal nerve in the low back. It may result from compression of the lower spinal nerve roots (L5 and S1). With this condition, the leg pain is typically much worse than the low back pain, and the specific areas of the leg and/or foot that are affected depends on which nerve in the low back is affected. Compression of higher lumbar nerve roots such as L2, L3 and L4 can cause radicular pain into the front of the thigh and the shin.
Diagnosis of Radicular Pain
Radiculopathy is caused by compression, inflammation and/or injury to a spinal nerve root, typically within the vertebral foramina.
Causes of Radicular Pain, in their order of prevalence, include:
Herniated disc with nerve compression - by far the most common cause of radiculopathy
Foraminal stenosis (narrowing of the hole through which the spinal nerve exits due to bone spurs or arthritis) – more common in elderly adults
- Diabetes
- Nerve root injuries (Traction injuries and Whiplash injuries)
- Scar tissue from previous spinal surgery that is affecting the nerve root [2]
- Herpes Simplex Virus Type I Infection [3]
Here is a PowerPoint presentation of the cascade of events that leads to radicular pain:
http://repository.upenn.edu/cgi/viewcontent.cgi?filename=1&article=1002&context=be_papers&type=additional
Treatment of Radicular Pain
The Medical Approach:
It is usually recommended that a course of conservative treatment (such as physical therapy, medications, and selective spinal injections, among others) should be conducted for six to eight weeks. If conservative treatment does not alleviate the pain, decompressive surgery, such as laminectomy and/or discectomy/microdiscectomy, may be recommended. This type of surgery typically provides relief of radicular pain/leg pain for 85% to 90% of patients. For patients with severe leg pain or other serious symptoms such as progressive muscle weakness, this type of surgery may be recommended prior to six weeks of non-surgical treatment. Back surgery for relief of radicular pain (leg pain) is much more reliable than for relief of low back pain.
Recent testing has demonstrated that treatment with Steroids offer no benefit compared with bupivacaine alone in chronic radicular pain. [5] Multiple adverse effects have been associated with prolonged steroid use, including suppression of the hypothalamic-pituitary-adrenal axis, immunosuppression, psuedotumor cerebri and psychoses, cataracts and increased intraocular pressure, osteoporosis, aseptic necrosis, gastric ulcers, fluid and electrolyte disturbances and hypertension, and impaired wound healing. [6]
(1) Low Back Pain and Sciatica: Radicular Pain
http://www.spine-health.com/topics/cd/hurt/h04.html
(2) Lower Back Pain
http://www.ferne.org/Lectures/low%20back%20pain%200501.htm
(3) Cervical Radicular Pain Caused by Herpes Simplex Virus-Type 1 Infection: A Case Report
http://www.mssm.edu/msjournal/69/v69_1&2_107_108.pdf
(4) Types of Neck Pain
http://www.cinn.org/pain/neck-pain.html
(5) Steroids May Offer No Additional Benefit to Bupivacaine for Periradicular Infiltration
http://www.medscape.com/viewarticle/503738
(6) Corticosteroids in The Treatment of Acute Low Back Pain
http://www.spineuniverse.com/displayarticle.php/article1835.html
Chiropractic Management Results
Rotary Manipulation for Cervical Radiculopathy: Observations on the Importance of the Direction of the Thrust
Hubka MJ, Phelan SP, Delaney PM, Robertson VL
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
Brouillette DL, Gurske DT
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
Constantoyannis C, Konstantinou D, Kourtopoulos H, Papadakis N
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
Murphy DR
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.
