Radiculopathy

Doctors use the term radiculopathy to specifically describe pain, and other symptoms like numbness, tingling, and weakness in your arms or legs that are caused by a problem with your nerve roots. The nerve roots are branches of the spinal cord that carry signals to the rest of the body at each level along the spine. This term comes from a combination of the Latin word "radix," which means the roots of a tree, and the Latin word "pathos," which means a disease. This disease is often caused by direct pressure from a herniated disc or degenerative changes in the lumbar spine that cause irritation and inflammation of the nerve roots.

Radiculopathy usually creates a pattern of pain and numbness that is felt in your arms or your legs in the area of skin supplied by sensory fibers of the nerve root, and weakness in the muscles that are also supplied by the same nerve root. The number of roots that are involved can vary, from one to several, and it can also affect both sides of the body at the same time.

Symptoms

The most common symptom of lumbar radiculopathy is sciatica. This is a pain that radiates from your back into your buttocks, and down your legs to the feet. Sensory symptoms are more common than motor symptoms, and muscle weakness is usually a sign that the nerve compression is more severe.

The quality and type of pain can vary, from dull, aching, and difficult to localized, sharp, burning, and easy to pinpoint. Radiculopathy can create hypersensitivity to touch as well as numbness in the area of skin that is supplied by the nerve root. Symptoms such as numbness and tingling, and especially weakness in your leg muscles in the presence of back pain are warning signs that your problem may be more serious and you should see a doctor.

Diagnosis

There are several different causes of radiculopathy, but the correct diagnosis of the cause of your symptoms begins with a complete physical examination of the entire body, with special emphasis on the back and lower extremities. Your doctor will examine your back for flexibility, range of motion, and the presence of certain signs that suggest that a particular nerve root is being affected. This often involves testing the strength of your muscles and checking your reflexes to make sure that they are still working normally. You will often be asked to fill out a diagram that asks you where your symptoms of pain, numbness, tingling and weakness are occurring.

A routine set of x-rays is also usually ordered when a patient with back pain goes to see a doctor. An MRI scan or a CT scan (CAT scan) can also be part of the evaluation for the causes of radiculopathy. An MRI scan is very useful for determining where the nerve roots are being compressed because this type of a scan is designed to show the details of soft-tissue structures, like nerves and discs. A CT scan is often used to evaluate the bony anatomy in the lumbar spine, which can show how much space is available for the nerve roots. The nerve roots exit the spinal canal through a bony tunnel called the neuroforamen, and it is at this point that the nerve roots are especially vulnerable to compression.

Treatment

The doctor will be able to discuss with you what your diagnosis means in terms of treatment options. For most people who do not have evidence of nerve root compression with muscle weakness, the first line of therapy includes non-steroidal anti-inflammatory drugs, rest, and physical therapy. A soft back brace or lumbar support is often prescribed in order to allow the back to have a chance to rest.

Surgery for radiculopathy is offered as an early option for people who have evidence of muscle weakness that is being caused by nerve root compression. This is because muscle weakness is a definite sign that the nerves are being injured (more seriously than when pain is the only symptom) and relieving the pressure on the nerves can be more of a priority. In most other situations, surgery is offered only after physical therapy, rest, and medications have failed to adequately relieve the symptoms of pain, numbness and weakness over a significant period of time.

Failed Surgery Back Pain

Failed back syndrome or post-laminectomy syndrome is a condition characterized by persistent pain following back surgeries. Failed back syndrome (FBS), also called "failed back surgery syndrome" (FBSS), refers to chronic back and/or leg pain that occurs after back (spinal) surgery. It is characterized as a chronic pain syndrome. Multiple factors can contribute to the onset or development of FBS.

Contributing factors include but are not limited to residual or recurrent disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness and spinal muscular deconditioning. An individual may be predisposed to the development of FBS due to systemic disorders such as diabetes, autoimmune disease and peripheral blood vessels (vascular) disease. Smoking is a risk for poor recovery.

Symptoms

Common symptoms associated with FBS include diffuse, dull and aching pain involving the back and/or legs. Abnormal sensibility may include sharp, pricking, and stabbing pain in the extremities. The term “post-laminectomy syndrome” is used by some doctors to indicate the same condition as failed back syndrome.

Treatment

The treatments of post-laminectomy syndrome include physical therapy, minor nerve blocks, transcutaneous electrical nerve stimulation (TENS), behavioral medicine, non-steroidal anti-inflammatory (NSAID) medications, membrane stabilizers, antidepressants, spinal cord stimulation, and intracathecal morphine pump. Use of epidural steroid injections may be minimally helpful in some cases. The targeted anatomic use of a potent anti-inflammatory anti-TNF therapeutics is being investigated.

Epidural Fibrosis: Scar Tissue Near Nerve Roots After Surgery

Epidural fibrosis refers to the formation of scar tissue near the nerve root following back surgery. Symptoms of epidural fibrosis typically occur within 6-12 weeks after surgery, and can get better with time (usually within 3 months). If symptoms do not improve, the spine surgery is unlikely to have been successful.

Symptoms

symptoms associated with epidural fibrosis appear at 6 to 12 weeks after back surgery. This is often preceded by an initial period of pain relief, after which the patient slowly develops recurrent leg pain. Sometimes, the improvement occurs immediately after back surgery, but occasionally the nerve damage from the original pathology makes the nerve heal more slowly.

In general, if the patient experiences continued leg pain directly after spine surgery, but starts to improve over the next three months, he or she should continue to improve. If, however, there is no improvement by three months postoperatively, the spine surgery is unlikely to have been successful, and the patient will continue to have back pain or leg pain.

Treatment

Stretching the nerve root while the body is healing (scarring in) after back surgery can help limit epidural fibrosis from becoming a clinical problem. Most scar tissue forms within the first 6 to 12 weeks after back surgery. The theory is that if the nerve is kept mobile while the wound heals, the nerve will not be bound down by adhesions and the scar tissue that develops should not become a problem. Routinely pumping the ankle while stretching the hamstrings will move the nerve across the operative disc site.

Degenerative Disc

Degenerative disc disease (DDD) is part of the natural process of growing older. Unfortunately, as we age, our intervertebral discs lose their flexibility, elasticity, and shock absorbing characteristics. The ligaments that surround the disc called the annulus fibrosis, become brittle and they are more easily torn. At the same time, the soft gel-like center of the disc, called the nucleus pulposus, starts to dry out and shrink. The combination of damage to the intervertebral discs, the development of bone spurs, and a gradual thickening of the ligaments that support the spine can all contribute to degenerative arthritis of the lumbar spine.

Symptoms

The most common symptom of degenerative disc disease is back pain. When DDD causes compression of the nerve roots, the pain often radiates down the legs or into the feet, and may be associated with numbness and tingling. In severe cases of lumbar DDD, where there is evidence of nerve root compression, individuals may experience symptoms of sciatica and back pain, and sometimes even lower extremity weakness.

Diagnosis

The diagnosis of degenerative disc disease begins with a physical examination of the body, with special attention paid to the back and lower extremities.Your doctor will examine your back for flexibility, range of motion, and the presence of certain signs that suggest that your nerve roots are being affected by degenerative changes in your back. This often involves testing the strength of your muscles and your reflexes to make sure that they are still working normally.You will often be asked to fill out a diagram that asks you where your symptoms of pain, numbness, tingling, and weakness are occurring. x-rays or a magnetic resonance imaging (MRI) may be ordered.

Treatment

Most people with lumbar degenerative disc disease find relief through nonsurgical options, such as exercise or physical therapy. But for those who need surgery, spinal fusion is a proven choice. And for those who choose spinal fusion, there's a therapy that can eliminate a second surgery.

Peripheral Causalgia

Causalgia is a rare pain syndrome related to partial peripheral nerve injuries. The peripheral nervous system encompasses nerves that extend from the central nervous system of the brain and spinal cord to serve limbs and organs. Severe cases are called major causalgia. Minor causalgia describes less severe forms, similar to reflex sympathetic dystrophy (RSD). RSD includes muscular and joint pain symptoms, and changes in bone density.

Causalgia is usually caused by brachial plexus injuries, involving nerves that run from the neck to the arm. The disruption of neural signals causes pain and increased release of the neurotransmitter norepinephrine, which causes vascular symptoms.

Symptoms

Symptoms usually involve burning pain prominent in the hand or foot within 24 hours of injury. Almost any sensory stimulation worsens the pain. Vascular changes include either increased or decreased blood flow due to dilation or constriction of blood vessels. Other symptoms include dry, scaly skin; still joints; tapering fingers; ridged nails; long, coarse hair or hair loss; and changes in sweating.

Diagnosis

Diagnosis entails a thorough medical history and physical examination. Physical exams can be difficult to perform due to pain.

Treatment

Intrathecal Drug Delivery for Chronic Pain Intrathecal Drug Delivery (IDD) directs prescribed pain medications to the spinal cord—affecting primarily the presynaptic and postsynaptic receptors in the gelatinosa of the posterior horn of the spinal cord.Intrathecal Drug Delivery (IDD) directs prescribed pain medications to the spinal cord—affecting primarily the presynaptic and postsynaptic receptors in the gelatinosa of the posterior horn of the spinal cord. Pain medications delivered directly to the intrathecal space are particularly effective because they don't circulate systemically to reach the cerebrospinal fluid (CSF). As a result, effective pain relief may be achieved using much smaller doses than are used in orally administered analgesics (for example, approximately 1/300 of an oral morphine dose),1,2 thus reducing the frequency of side effects. Spinal Cord Stimulation Spinal cord stimulation alleviates pain by electrically activating pain-inhibiting neuronal circuits in the dorsal horn and inducing a tingling sensation (paresthesia) that masks the sensations of pain. As an intervention for chronic back and/or leg pain, spinal cord stimulation can be an effective alternative or adjunct treatment to other interventions that have failed to manage pain on their own. Spinal cord stimulation alleviates pain by electrically activating pain-inhibiting neuronal circuits in the dorsal horn and inducing a tingling sensation (paresthesia) that masks the sensations of pain.

Arachnoiditis

Arachnoiditis is a neuropathic disease caused by the inflammation of the arachnoid, one of the membranes that surround and protect the nerves of the central nervous system, including the brain and spinal cord. The arachnoid can become severely inflamed because of adverse reactions to chemicals, blood, and/or steroids, infection from bacteria or viruses, as the result of direct injury to the spine, chronic compression of spinal nerves, or complications from spinal surgery or other invasive spinal procedures such as epidural steroid injections.

Lumbar patches (also known as blood patches), which are often useful in relieving painful headaches associated with spinal taps and epidural anesthesia, have been found to be significant potential causative agents in some cases and may warrant avoidance of the procedure where possible. Multiple blood patches may amplify the probability of contracting arachnoiditis. It is also noteworthy that blood has been found to be a significant inflammatory agent in the nervous system. Inflammation can sometimes lead to the formation of scar tissue and adhesions which can cause the spinal nerves to "stick" together.

Symptoms

The swollen arachnoid can lead to a host of painful and debilitating symptoms. Chronic pain is common, including neuralgia. Numbness and tingling of the extremities is frequent in patients due to spinal cord involvement. Bowel, bladder, and sexual functioning can be affected if the lower part of the spinal cord is affected. While arachnoiditis has no consistent pattern of symptoms, it frequently affects the nerves that supply the legs and lower back.

Many sufferers find themselves unable to sit for long (or even short) periods of time, often due to severe pain as well as efferent neurological symptoms, such as difficulties controlling limbs. This can be particularly problematic for those patients who exhibit difficulties standing or walking for protracted periods, as wheelchairs are not helpful for this group. Some sufferers benefit from relatively new inventions, such as the Segway or the less expensive Stand'n'Ride alternative. Standing wheelchairs are also available, although often quite expensive and limited compared to these alternatives. However, standing endurance and vibration tolerance should be taken into account before a motorized assistance device is selected.

It is critical for patients to realize that the symptoms of arachnoiditis are highly varied and are not all experienced by all sufferers. Consequently, while typically significantly life-altering, the outcome, especially with physical therapy, appropriate psychotherapy, and medication, may be better than many patients fear upon receiving the diagnosis.

Treatment

Arachnoiditis is a chronic disorder and there is no known cure at this time. Pain management techniques may provide some relief to patients. Prognosis may be hard to determine because of the lack of correlation between the beginning of the disease and the start of symptoms. For many, arachnoiditis is a disabling disease that causes chronic pain and neurological deficits. It may also lead to other spinal cord conditions, such as syringomyelia. Arachnoiditis is a difficult condition to treat. Treatment is limited to alleviation of pain and other symptoms. Surgical intervention generally has a poor outcome and only provides temporary relief. Steroid injections administered either intrathecally or epidurally have been linked as a cause of the disease, therefore they are generally discouraged as a treatment and may even worsen the condition.

Cancer Pain

Cancer pain can result from the cancer itself. Cancer can cause pain by growing into or destroying tissue near the cancer. Cancer pain can come from the primary cancer itself — where the cancer started — or from other areas in the body where the cancer has spread (metastases). As a tumor grows, it may put pressure on nerves, bones or other organs, causing pain.

Cancer pain may not just be from the physical effect of the cancer on a region of the body, but also due to chemicals that the cancer may secrete in the region of the tumor. Treatment of the cancer can help the pain in these situations. Pain begins with sensory cells, or neurons, called nociceptors. A pain message is transmitted along these neurons to the spinal cord. In the spinal cord, chemical messengers called neurotransmitters are released and act on other “ascending” neurons. Eventually, these ascending neurons carry the signal to the brain where it is perceived as pain. Oral medications may relieve pain but often cause serious side effects that dramatically affect the life of a patient and his or her family. Side effects include sedation, confusion, fatigue, constipation, nausea and vomiting.

Treatment

A drug pump (also called an intrathecal drug delivery system) sends pain medication directly to the fluid around the spinal cord, providing pain relief with a small fraction of the medication needed if taken orally.