Radiculopathy and Chiropractic This section was compiled by Frank M. Painter, D.C.
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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.
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.
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
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]
The cascade of events leading to radicular pain:
Thanks to the University of Pennsylvania for access to this slide!
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. 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]
Several surgical websites claim that surgery provides relief of radicular pain/leg pain for 83% to 90% of patients.
However, review of numerous peer-reviewed studies reveals that this is NOT the case.
Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects: An Historical Cohort Study
SPINE (Phila Pa 1976) 2011 (Feb 15); 36 (4): 320–331
Researchers (from the Division of Epidemiology and Biostatistics, Department of Environmental Health, at the University of Cincinnati College of Medicine) reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.
Even after two years, only 26 percent of those who had surgery had actually returned to work. That’s compared to 67 percent of patients who didn’t have the surgery, even though they had the same exact diagnosis!
In another troubling finding, the researchers determined that there was a 41 percent increase in the use of painkillers, particularly opiates, in those who had the surgery. Last year we reported that deaths from addictive painkillers has doubled in the last 10 years.
Money and Spinal Surgery: What Happened to the Patient?
Journal of the American Medical Association 2010 (Apr 7); 303 (13): 1259–1265
There is a lack of evidence-based support for the efficacy of complex fusion surgeries over conservative surgical decompression for elderly stenosis patients. There is, however, a significant financial incentive to both hospitals and surgeons to perform the complex fusions. Spinal stenosis is the most frequent cause for spinal surgery in the elderly. There has been a slight decrease in these surgeries between 2002 and 2007. However, there has also been an overall 15 fold increase in the more complex spinal fusions (360 degree spine fusions). Deyo et. al. in yesterday’s issue (April 7, 2010) of the Journal of the American Medical Association concludes that “It is unclear why more complex operations are increasing. It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just 6 years. The introduction and marketing of new surgical devices and the influence of key opinion leaders may stimulate more invasive surgery, even in the absence of new indications…financial incentives to hospitals and surgeons for more complex procedures may play a role…” There is a significant difference in mean hospital costs for simple decompression versus complex surgical fusion. The cost of decompression is $23,724 compared to an average of $80,888 for complex fusion. Despite the much higher cost, there is no evidence of superior outcomes and there is greater morbidity associated with the complex fusion. The surgeon is typically reimbursed only $600 to $800 for simple decompression and approximately ten times more, $6,000 to $8,000 for the complex fusion.
In a JAMA editorial that accompanied this study and was written by Dr. Carragee of Stanford University School of Medicine, the following comment was made “In 2007, the final year of data reported in the study by Deyo et al, Consumer Reports rated spinal surgery as number 1 on its list of overused tests and treatments. This was a harsh rebuke given the benefit associated with many common spinal surgeries. However, the findings from the study by Deyo et al should not only remind patients, surgeons, and payors that the efficacy of basic spinal techniques must be assessed carefully against the plethora of unproven but financially attractive alternatives, but also should serve as an important reminder that as currently configured, financial incentives and market forces do not favor this careful assessment before technologies are widely adopted. When applied broadly across medical care in the United States, the result is a formidable economic and social problem.”
“It is unclear why more complex operations are increasing. It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just 6 years. The introduction and marketing of new surgical devices and the influence of key opinion leaders may stimulate more invasive surgery, even in the absence of new indications… financial incentives to hospitals and surgeons for more complex procedures may play a role…” There is a significant difference in mean hospital costs for simple decompression versus complex surgical fusion.
The cost of decompression is $23,724 compared to an average of $80,888 for complex fusion.
It's not so hard to figure out why there has been a 15-fold increase in this specific surgery, when you look at the bottom line. Cui bono? Follow the Money!
Failed Back Surgery Syndrome: Diagnostic Evaluation
J Am Acad Orthop Surg 2006 (Sep); 14 (9): 534–543
Failed back surgery syndrome is a common problem with enormous costs to patients, insurers, and society. The etiology of failed back surgery can be poor patient selection, incorrect diagnosis, suboptimal selection of surgery, poor technique, failure to achieve surgical goals, and/or recurrent pathology. Successful intervention in this difficult patient population requires a detailed history, precise physical examination, and carefully chosen diagnostic tests. The diagnostic evaluation should endeavor to accurately identify symptoms, rule out extraspinal causes, identify a specific spinal etiology, and assess the psychological state of the patient. Only after these factors have been assessed can further treatment be planned.
Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence
Journal of Occupational and Environmental Medicine 2011 (Apr); 53 (4): 396–404
Medical researchers at the University of Massachusetts compared the health outcomes and/or disability episodes of patients with work-related low back pain, depending on what type of provider they saw. They focused primarily on MD (medical physician), PT (physical therapist), and DC (chiropractor) care.
The disability statistics were quite interesting:
For PTs: HR = 2.0 For MDs: HR = 1.6 For DCs: HR = 1.0
Statistically, this means you are twice as likely to end up disabled if you got your care from a PT, rather than from a chiropractor.
You’re also 60% more likely to be disabled if you choose an MD to manage your care, rather than a chiropractor.
The medical authors concluded:
“In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than with chiropractic services or no treatment”.
(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 ~ No Longer Available on Medscape
(6) Corticosteroids in The Treatment of Acute Low Back Pain
http://www.spineuniverse.com/displayarticle.php/article1835.html
(7) Chicago Institute of Neurosurgery and Neuroresearch
www.cinn.org/pain/types-of-neck-pain.html
Chiropractic Management of Radicular Pain
A Nonsurgical Approach to the Management of Patients With Lumbar Radiculopathy Secondary to Herniated Disk: A Prospective Observational Cohort Study With Follow-Up
J Manipulative Physiol Ther 2009 (Nov); 32 (9): 723–733
A randomized trial by researchers at an outpatient rehabilitation department in Italy involving 210 patients with chronic, nonspecific low back pain compared the effects of spinal manipulation, physiotherapy and back school. The participants were 210 patients (140 women and 70 men) with chronic, non-specific low back pain, average age 59. Back school and individual physiotherapy were scheduled as 15 1-hour-sessions for 3 weeks. Back school included group exercise and education/ergonomics. Individual physiotherapy included exercise, passive mobilization and soft-tissue treatment. Spinal manipulation included 4-6 20-minute sessions once-a-week. Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.
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.
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.
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.
Spine (Phila Pa 1976) 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.
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.
Nonsurgical Management
Spine J 2006 (Jul); 6 (4): 459–463
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.
Manipulation: A Retrospective Study in a Private Practice Setting
J Manipulative Physiol Ther 2003 (Nov); 26 (9): E19
This study revealed a statistically significant reduction in pain as quantified by visual analogue scores. The mean number of treatments required was 13.2 +/- 8.2, with a range of 6 to 37. Only 3 persons required more treatments than the mean plus 1 standard deviation. The results of this study show promise for chiropractic and manual therapy techniques such as flexion distraction, as well as demonstrating that other, larger research studies must be performed for cervical radiculopathy.
Caused by Large-volume Herniated Disks
J Manipulative Physiol Ther 2002 (Mar); 25 (3): 188–192
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. 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.
Observations on the Importance of the Direction of the Thrust
J Manipulative Physiol Ther 1997 (Nov); 20 (9): 622–627
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. 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.
J Manipulative Physiol Ther 1994 (Feb); 17 (2): 119–123
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.
Caused by a Herniated Cervical Disc
J Manipulative Physiol Ther 1994 (Feb); 17 (2): 119–123
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. 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.
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