Radiculopathy

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Radiculopathy
C5-C6, followed by C6-C7, is the most common location for radiculopathy in the neck.
SpecialtyNeurosurgery

Radiculopathy (from

neuropathy). Radiculopathy can result in pain (radicular pain), weakness, altered sensation (paresthesia) or difficulty controlling specific muscles.[1] Pinched nerves arise when surrounding bone or tissue, such as cartilage, muscles or tendons, put pressure on the nerve and disrupt its function.[2]

In a radiculopathy, the problem occurs at or near the root of the nerve, shortly after its exit from the spinal cord. However, the pain or other symptoms often radiate to the part of the body served by that nerve. For example, a nerve root impingement in the neck can produce pain and weakness in the forearm. Likewise, an impingement in the lower back or lumbar-sacral spine can be manifested with symptoms in the foot.

The radicular pain that results from a radiculopathy should not be confused with

spinal nerve root
is affected.

Causes

Brachial plexus. C6 and C7 nerves affected most frequently.

Radiculopathy most often is caused by mechanical compression of a

]

Repeated, longer term exposure (5 years or more) to certain work-related activities may put people at risk of developing lumbosacral radiculopathy.[5] These behaviours may include physically demanding work, bending over or twisting at the trunk, lifting and carrying, or a combination of these activities.[5]

Less common causes of radiculopathy include injury caused by tumor (which can compress nerve roots locally) and diabetes (which can effectively cause ischemia or lack of blood flow to nerves).[medical citation needed]

Diagnosis

projectional radiograph of a man presenting with pain by the nape and left shoulder, showing a stenosis of the left intervertebral foramen of cervical spinal nerve 4, corresponding with the affected dermatome
.
axial plane). There is also spondylosis of the facet joint
between C2 and C3, with some foraminal stenosis at this level (upper arrow), which appears to be asymptomatic.

Signs and Symptoms

Radiculopathy is a diagnosis commonly made by physicians in primary care specialties,

cervical radiculopathy [fr], Spurling's test may elicit or reproduce symptoms radiating down the arm. Similarly, in the case of lumbosacral radiculopathy, a straight leg raise maneuver or a femoral nerve stretch test may demonstrate radiculopathic symptoms down the leg.[3] Deep tendon reflexes (also known as a Stretch reflex) may be diminished or absent in areas innervated by a particular nerve root.[citation needed
]

Diagnosis typically involves

facial palsy or Lyme carditis.[12] Lyme can also cause a milder, chronic radiculopathy an average of 8 months after the acute illness.[3] Lyme can be confirmed by blood antibody tests and possibly lumbar puncture.[9][3] If present, the above conditions should be treated immediately.[3]

Although most cases of radiculopathy are compressive and resolve with conservative treatment within 4–6 weeks, guidelines for managing radiculopathy recommend first excluding possible causes that, although rare, require immediate attention, among them the following.

diabetes mellitus; onset is sudden causing pain usually in multiple dermatomes quickly followed by weakness.[citation needed
]

Investigations

If symptoms do not improve after 4–6 weeks of conservative treatment, or the person is more than 50 years old, further tests are recommended.

posterior root ganglion. Needle EMG is the more sensitive portion 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. Given the key role of electrodiagnostic testing in the diagnosis of acute and chronic radiculopathies, the American Association of Neuromuscular & Electrodiagnostic Medicine has issued evidence-based practice guidelines, for the diagnosis of both cervical and lumbosacral radiculopathies.[14][15] The American Association of Neuromuscular & Electrodiagnostic Medicine has also participated in the Choosing Wisely Campaign and several of their recommendations relate to what tests are unnecessary for neck and back pain.[16]

Treatment

Ideally, effective treatment aims to resolve the underlying cause and restores the nerve root to normal function. Conservative treatment may include

analgesics may be prescribed.[3] A systematic review found moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy[17] and cervical radiculopathy.[18] Only low level evidence was found to support spinal manipulation for the treatment of chronic lumbar radiculopathies, and no evidence was found to exist for treatment of thoracic radiculopathy.[17] Evidence also supports consideration of epidural steroid injection with local anesthetic in improving both pain and function in cases of lumbosacral radiculopathy.[19]

Cervical traction machine

Rehabilitation

With a recent injury (e.g. one that occurred one week ago), a formal physical therapy referral is not yet indicated. Often mild to moderate injuries will resolve or greatly improve within the first few weeks. Additionally, patients with acute injuries are often too sore to participate effectively in physical therapy so soon after the insult. Waiting two to three weeks is generally recommended before starting formal physical therapy. In acute injury resulting in lumbosacral radiculopathy, conservative treatment such as acetaminophen and NSAIDs should be the first line of therapy.[1]

Therapeutic exercises are frequently used in combination with many of the previously mentioned

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.[21] The first part of the stabilization procedure is achieving a pain free full range of motion which can be accomplished through stretching exercises. Subsequently, a strengthening exercise program should be designed to restore the deconditioned cervical, shoulder girdle, and upper trunk musculature.[22] As reliance on the neck brace diminishes, an isometric exercise regimen should be introduced.[medical citation needed] This is a preferred method of exercise during the sub-acute phase because it resists atrophy and is least likely to exacerbate the condition. Single plane resistance exercises against cervical flexion, extension, bending, and rotation are used.[citation needed
]

Surgery

While conservative approaches for rehabilitation are ideal, some patients will not improve and surgery is still an option.[23] Patients with large cervical disk bulges may be recommended for surgery; however, most often, conservative management will help the herniation regress naturally.[24] Procedures such as foraminotomy, laminotomy, or discectomy may be considered by neurosurgeons and orthopedic surgeons. Regarding surgical interventions for cervical radiculopathy, the anterior cervical discectomy and fusion procedure is more commonly performed than the posterior cervical foraminotomy procedure.[25] However, both procedures are likely equally effective and without significant differences in their complication rates.[25]

Epidemiology

Cervical radiculopathy has an annual incidence rate of 107.3 per 100,000 for men and 63.5 per 100,000 for women, whereas lumbar radiculopathy has a prevalence of approximately 3-5% of the population.

AHRQ's 2010 National Statistics for cervical radiculopathy, the most affected age group is between 45 and 64 years with 51.03% of incidents.[citation needed] Females are affected more frequently than males and account for 53.69% of cases. Private insurance was the payer in 41.69% of the incidents followed by Medicare with 38.81%. In 71.61% of cases the patients' income was considered not low for their zipcode. Additionally over 50% of patients lived in large metropolitans (inner city or suburb). The South is the most severely affected region in the US with 39.27% of cases. According to a study performed in Minnesota, the most common manifestation of this set of conditions is the C7 monoradiculopathy, followed by C6.[28]

See also

References

  1. ^ a b "Cervical Radiculopathy (Pinched Nerve)". OrthoInfo by American Academy of Orthopaedic Surgeons. June 2015. Retrieved 22 September 2017.
  2. ^ "Pinched Nerve Symptoms & Treatment | Advanced Neurosurgery". Advanced Neurosurgery Associates. Retrieved 2020-12-14.
  3. ^
    S2CID 15518713. Archived from the original
    (PDF) on 2019-02-20.
  4. .
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  9. ^
    PMID 24785207. Archived from the original
    (PDF) on 19 October 2016.
  10. ^ "Lyme Disease Data and surveillance". Lyme Disease. Centers for Disease Control and Prevention. 2019-02-05. Retrieved April 12, 2019.
  11. ^ "Lyme Disease risk areas map". Risk of Lyme disease to Canadians. Government of Canada. 2015-01-27. Retrieved May 8, 2019.
  12. PMID 27161773
    .
  13. ^ Malanga GA. "Cervical Radiculopathy Workup". Retrieved 2017-06-29. Updated: Dec 14, 2016
  14. PMID 16921635. Archived from the original
    (PDF) on 2016-08-20. Retrieved 2015-08-25.
  15. .
  16. ^ "American Association of Neuromuscular & Electrodiagnostic Medicine". Choosing Wisely. 2015-02-10. Retrieved 2018-04-05.
  17. ^
    PMID 21292148
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Further reading

External links