Radiculopathy

Radiculopathy

What is radiculopathy?

Radiculopathy is described as irritation of a single nerve root that can be caused by a variety of musculoskeletal and immune factors. This is different from Myelopathy which is narrowing of the vertebra causing compression of the spinal cord.

Radiculopathy can be caused at any level of the spine however it is most common in the cervical spine (neck) and lumbar spine (low back). Radiculopathy of the neck is most common over 40 years of age however radiculopathy into your legs is generally more common irrespective of age. It can result in muscular atrophy and weakness.

What is it caused by?

Radiculopathy can be caused at the level of the spine or along the nerve pathway.

Compression of the nerve root can be caused by disc herniation (disc bulge), trauma resulting in narrowing or displacement of the spine, bone or tumour growth, diabetes, and immune disease.

A peripheral cause may be Deep Gluteal Pain Syndrome. It presents with pain on sitting, burning/cramping in the buttock and posterior thigh, radiculopathy in the lower limb and can be caused by a history of trauma.

What are the conservative treatments:

Conservative treatment includes manual therapy, such as Osteopathy, pharmaceutical pain therapy and the use of corticosteroid injections. This treatment aims to decrease inflammation around the nerve and as a result reduce pain. Results vary and some patients may have a decrease in pain and increase in function however it is only a short-term solution (Chou et. al., 2015).

What is involved in surgery:

Surgery in the case of a disc bulge includes a discectomy – that is the removal of excess disc tissue that is compressing the nerve and causing radicular symptoms. This procedure is performed as a minimally invasive surgery and typically the patient will be discharged the same or next day. Risks include recurrent disc herniation – a bulging disc at a different level of the spine, infection and bleeding. The success rate for this surgery is between 70% – 90% (Cluett, 2023)

What can we do as osteopaths?

Osteopathic treatment commonly consists of de-loading and decompressing the area. This can be done using traction, mobilisation, soft tissue and nerve flossing (Kuligowski et. al., 2021). Mobilisation was found to be effective at improving functional ability and range of motion when applied in both a rhythmic or static position (Hassan et. al., 2020).

Practitioners may decide to use manipulation in the thoracic in the treatment of cervical radiculopathy. A study by young et. al. (2019) revealed that thoracic manipulation improved pain, disability, cervical rom and deep neck flexor endurance.

A study by Langevin et. al. revealed that when combined with exercise manual therapy is effective in reducing neck radiculopathy pain and increasing functionality. This included mobilisation and facet gliding as well as strengthening of the deep stabilising muscles, muscles of the spine and muscles that would help increase range of motion that were specific to the patient (Langevin et. al., 2015).  Strengthening exercise can include press ups, flexion rotation stretches, lumbar glides and pelvic tilts (Sears, 2023)

Addition of neurodynamic exercises such as sciatic nerve flossing can result in reduced nerve symptoms and mechanical sensitivity however do not appear to assist in decreasing pain (Plaza-Manzano et. al., 2020).

 

Sciatic Nerve Flossing Instructions:

  • Begin in a seated position and straighten your knee on the effected leg.
  • Pull your toes towards your head.
  • Look to the floor.
  • Reverse those steps until you are again in a normal seated position.
  • Repeat ten times.

 

References:

Chou, R., Hashimoto, R., Friedly, J., Fu, R., Bougatsos, C., Dana, T., Sullivan, S.D., Jarvik, J. (2015). Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis. Annals of Interna; Medicine 162, 373-381. https://doi.org/10.7326/M15-0934

Cluett, J. (20 September, 2023). Lumbar Discectomy for a Herniated Disc. Very Well Health. Lumbar Discectomy – Spine Surgery to a Herniated Disc (verywellhealth.com)

Healthline. (23 April, 2018). Nerve Flossing Exercises to Try. Nerve Flossing: How it Works for Sciatica and Other Conditions (healthline.com)

Kuligowski, T., Skrzek, A., Cieslik, B. (2021). Manual Therapy in Cervical and Lumbar Radiculopathy: A Systematic Review of the Literature. International Journal of Environmental Research and Public Health 18. https://doi.org/10.3390/ijerph18116176

Langevin, P., Desmeules, F., Lamothe, M., Robitaille, S., Roy, J.S. (2015). Comparison of 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy: A Randomised Clinical Trial Evaluating Short-Term Effects. Journal of Orthopaedic and Sports Physical Therapy 45, 1-17. https://doi.org/10.2519/jospt.2015.5211

Plaza-Manzano, G., Cancela-Cilleruelo, I., Fernández-de-Las-Peñas, C., Cleland, J.A., Arias-Buria, J.L., Thoomes-de-Graaf, M., Ortega-Santiago, R. (2020). Effects of Adding a Neurodynamic Mobilization to Motor Control Training in Patients With Lumbar Radiculopathy Due to Disc Herniation: A Randomized Clinical Trial. American Journal of Physical Medicine and Rehabilitation 99 (2), 124-132. https://doi.org/10.1097/PHM.0000000000001295.

Sears, B. (27 May, 2023). Epidural Corticosteroid Injections for Sciatica: Epidural for nerve pain in the lower back, buttocks, and thigh. Very Well Health. Epidural Corticosteroid Injections for Sciatica (verywellhealth.com)

Young, I.A., Pozzi, F., Dunning, J., Linkonis, R., Michener, L.A. (2019). Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients With Cervical Radiculopathy: A Randomized Controlled Trial. Journal of Orthopaedic and Sports Physical Therapy 49 (5), 299-309. https://www.jospt.org/doi/10.2519/jospt.2019.8150

 

 

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Nerve Impingement

Lymphatic system

What is Nerve Impingement?

Nerve impingement or entrapment occurs when nearby bone – whether it be vertebrae or otherwise, impinge on the pathway of the nerve or the nerve itself resulting in neurological symptoms.

Nerve impingement typically only occurs on a single side unless it presents in the spine when caused by a disc or narrowing of the spinal foramen (gaps where the nerves exit the spinal cord). In the extremities it can occur at the elbow, knee, fibular, hips, wrists and shoulders.

It is more common if the patient has experiences trauma in the past. There can be feelings of the joint “Giving out”, decreased sensation of hot/cold, fine touch, sharp and dull as well as tingling, numbness or weakness. 

In the legs the most common nerve impingement is of the peroneal/fibular nerve which runs on the outside of your shin. When this nerve is impinged it can cause a foot drop where the food cannot lift the ball of their feet or toes. They may have pain in the knee or below, weakness in the movement of pulling the toes to the ceiling and a burning/tingling pain on the top of the foot.

The most common form of nerve impingement in the upper limb is of the median nerve. This is commonly known as carpal tunnel and affects 3% of the adult population, mostly female and between the age of 40 and 60 years old. Like nerve entrapment of the lower limb patients will experience neurological symptoms and weakness. Repetitive movements found in occupations such as admin (office work) and trades can increase the risk of carpal tunnel syndrome.

 

Assessment:

Firstly, your osteopath will look at the area of symptoms and the associated chain. For example, if it is the foot they will look at the foot, knee, hip and low back. They will assess range of motion, the nerve pathway and possibly perform a Tinel tap (taping the nerve to reproduce neural symptoms). They may refer you to a radiographer for imaging such as an x-ray if this was after an acute trauma, ultrasound to identify soft tissue lesions or scar tissue build up. In addition, general practitioners (GP’s) can perform motor conduction studies where they test musculature innervated by nerves in the same chain to identify what nerve may be impinged.

Lower limb neurological assessments will also be performed that identify reflexes, strength of muscles/nerves, light touch sensation of nerves, sharp and cold sensation of nerves. These tests will be performed on both sides to make sure it is an issue with the peripheral nervous system and not the central nervous system (spinal cord). 

 

Treatment:

Osteopathically your practitioner will work on decreasing tissue tension in the area – this includes muscles and ligaments. They will work on the joint itself as well to increase space and range of motion.

As the nerves begin in the spinal cord you may find your practitioner works on the entire chain (Neck, shoulder, elbow wrist or low back, pelvis/hip, knee and ankle). This can be done using a variety of techniques such as soft tissue, mobilisation, manipulation (if deemed appropriate) as well as more indirect techniques such as balance ligamentous tension, osteopathy in the cranial field and functional techniques. In addition, we may prescribe stretching, strengthening and nerve gliding exercises.

As we are a holistic therapy, we will also ask about your lifestyle factors such as sleeping position, work, exercise and more. We may suggest changes to the positions or activities you are doing to see if it makes an improvement of the symptoms.

Surgically, nerve blocks using a lidocaine solution may be used or a local corticosteroid injection. If there is a build-up of scar tissue in the area the practitioner may work on that or refer you to a specialist for a procedure called neurolysis for nerve decompression – this has been seen to be effective in patients with nerve injured less than or equal to 8 cm in length. There is a healing time of 3-4 months however healing can take up to 12 months depending on a range of factors.

 

References

Carpal tunnel syndrome: MedlinePlus Genetics. (n.d.). Medlineplus.gov. https://medlineplus.gov/genetics/condition/carpal-tunnel-syndrome/

Fortier, L.M., Markel, M., Thomas, B.G., Sherman, W.F., Thomas, B.H., Kaye, A.D. (2021). An update on

peroneal nerve entrapment and neuropathy. Orthopaedic reviews, 13(2). Pp 24937. https://doi.org/10.52965/001c.24937

Klifto, K.M., Azoury, S.C., Gurno, C.F., Card, E.B., Levin, L.S., Kovach, S.J. (2022). Treatment approach

to isolated common peroneal nerve palsy by mechanism of injury: systemic review and meta-analysis of individual participatnts’ data. Journal of plastic, reconstructive and aesthetic surgery, 75(2). Pp 683-702. https://doi.org/10.1016/j.bjps.2021.09.040

LaPrade, R. (2022). Peroneal Nerve Entrapment.

Peroneal Nerve Entrapment (drrobertlaprademd.com)

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Occipital Neuralgia

What is Occipital Neuralgia?

Occipital neuralgia is an irritation and/or damage to the greater or lesser occipital nerve. In 90% of cases the greater occipital is the primary nerve irritated, and only 10% of cases had the lesser occipital nerve as the cause.

When these structures are damaged it can result in a bilateral (on both sides) ache, throbbing or burning pain that begins at the base of the skull and comes over the scalp. This can sometimes occur in a ram’s horn pattern going from the base of the neck in a circle to in front of the ear and near the eye. It is likely to occur after there is a trauma to the area such as a bend and twist of the neck.

In addition to the symptoms above there can be pain in the upper neck that can be associated with nausea and sensitivity to light. There can be a positive tunnel’s sign – reproduction of neurological tingling and numbness, after there is palpation o f these nerves. Other symptoms can include tinnitus (ringing of the ears), dizziness and blurred vision, scalp tenderness and headaches.

Assessment:

When you see an osteopath physical examination will include examination of the neck to identify tight muscles at the mase of the skull, range of motion, neurological testing and identification of referral pain. Tests that identify any possible ligament damage, facet irritation and nerve irritation will also be performed. These tests may aggravate your symptoms however that is necessary in order to pinpoint what is going on.

To rule out any damage to the nerves of the skull and those that innervate the arms neurological strength and sensation testing will be performed. Outcome measures such as the neck disability index may be performed and a referral to the patient’s general practitioner for an MRI/CT and possible nerve block may also be required.

Treatment:

Conservative treatment includes manual therapy such as osteopathy, massage and physiotherapy that focuses on decreasing tight muscle, neuropathic pain and referral.

Our osteopathic practitioners can use a variety of techniques including inhibition, soft tissue, mobilisation, manipulation as well as techniques from osteopathy in the cranial field – something which we specialise in and is performed by no other modality. It is common after treatment to experience some aggravated symptoms however this should subsite within one to two days.

The application of heat and steroids can be used to temporarily manage pain levels and medication is typically prescribed by your doctor. Over the counter anti-inflammatory medications can also have an effect. It is advised that these methods are used regularly and over a shorter period of time.

Other conservative interventions include nerve blocks which last a period of three to four months can also be affective as they contain anaesthetic and anti-inflammatory medications.

Pulsed radiofrequency uses a radiology machine as a treatment mechanism. The theory is that by exposing the nerve to many high voltage short duration pulses can decrease the nerve sensation and pain. Stimulation of the nerve using a neurostimulator can also block nerve sensation and decrease pain.

If none of these methods are effective, then occipital release surgery is recommended. This surgery takes 2-3 hours while the patient is under general anaesthesia with a recovery period of two to three weeks. However, risks of this surgery include permanent numbness of the scalp.

If you are experiencing any of these symptoms and wish to see an osteopath for conservative treatment you’re welcome to book an appointment at eclipse health and osteopathy today. Call 5613 3505 or book through our website.

References

Dougherty, C. (2014, April 16). Occipital Neuralgia. Current Pain and Headache Reports 18, 411. https://doi.org/10.1007/s11916-014-0411-x

Hammond, S.R. and Danta, G. (1978). Occipital Neuralgia. Clinical and Experimental Neurology, 15. Pp 258-270. Occipital neuralgia – PubMed (nih.gov)

John Hopkins Medicine, (2022). Occipital Neuralgia. John Hopkins Medicine. Occipital Neuralgia | Johns Hopkins Medicine

London Pain Clinic, (2022). Nerve Pain – Occipital Neuralgia. London Pain Clinic. Nerve Pain – Occipital Neuralgia – London Pain Clinic

London Pain Clinic, (2022). Occipital Neuralgia. London Pain Clinic Occipital Neuralgia – London Pain Clinic

Marks, H., (2020, July 23). Occipital Neuralgia. WebMD. Occipital Neuralgia: Symptoms, Causes, Diagnosis, Treatments, and More (webmd.com)

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