Cervical Radiculopathy

 

Cervical radiculopathy or a “pinched nerve” is often results from from inflammation, mechanical compression, or both.  Cervical discogenic pain often begins with localized symptoms and progresses into radicular complaints.  Lesions without mechanical compression may produce only local discomfort and pain or sensory disturbances that radiate into the head, neck, shoulders, or interscapular area. Neck pain may be worse with prolonged workstation use or prolonged flexion. The distribution of non-radicular, cervical discogenic pain is well documented.

“Disc lesion” refers to a disruption of the material inside your disc. Annular disruption is accompanied by an inflammatory reaction capable of producing local symptoms or in more severe cares, a “chemical radiculopathy.” Significant annular disruption can lead to disc bulging or herniation, resulting in mechanical compression of adjacent nerve roots or a “pinched nerve”. Most radicular complaints are thought to arise from a combination of mechanical and chemical factors.  It can also be caused by stenosis, a nerve stretch injury (“stinger” or “burner”) Ensuing symptoms may include pain, paresthesia, numbness, or weakness in the distribution of the affected nerve root(s).

Disc lesions are rarely the result of a single traumatic event, but rather, the undesirable mid-point on a continuum of problems, beginning with repetitive disc sprain, leading to herniation, ending in degeneration. The age-related loss of the normal viscoelastic properties of the disc coupled with repetitive mechanical stressors like compressive loading, sheer stress, and vibration weaken annular fibers. This process eventually leads to annular disruption via fissures and avulsion of annular fibers from their vertebral body attachments.  Constant cervical motion and awkward postures combined with compressive loading allow for hydrostatic migration of nuclear material through the weakened annular fibers.  Diffuse annular fiber weakening can lead to broad-based or circumferential bulging, while more concentrated fiber disruption allows focal protrusions or extrusions.

Cervical disc lesion is the second most common cause of cervical radiculopathy behind degenerative stenosis.  Cervical disc herniation is most likely to affect adults below the age of 55 with a peak incidence in the fourth decade.  Cervical disc herniations are slightly more common in males. Activities that are thought to predispose patients to cervical disc problems include repetitive stressful workstation postures (i.e. maintaining a prolonged forward head posture), repetitive cervical flexion, improper sleep postures, trauma, frequent heavy lifting, cigarette smoking, and driving or operating vibrating equipment- including motor vehicles.

In addition to cervical degeneration, the differential diagnosis for cervical disc lesion includes, facet syndrome, sprain/strain, brachial neuritis, peripheral nerve entrapment, Pancoast tumor, infection, neoplasm, Parsonage-Turner syndrome, TOS, herpes zoster, sympathetic mediated syndromes, Brown Sequard syndrome, chronic regional pain syndrome/ RSD, rotator cuff injury, and viscerosomatic referred pain.

The goal of conservative management should be to reduce pain and inflammation, decrease mechanical compression, and improve functional stability. Conservative management of cervical disc herniation with radiculopathy has been shown to result in regression of herniated material with subsequent reduction in local and radicular complaints.  The relatively avascular anatomy of the intervertebral disc may prolong recovery times.

A study by Croft  found that 93% of chiropractors utilize manipulation in cases of cervical disc herniation. While sometimes controversial, the judicious application of spinal manipulation has been shown to be safe, appropriate, and effective for the management of cervical disc herniation and/or radiculopathy.  One study of 50 patients undergoing HVLA manipulation at the level of cervical disc herniation demonstrated significant improvement after two weeks of care with none worsening and 85.7% reporting significant improvement at three months. Another study of 104 MRI-confirmed disc herniations demonstrated that patients treated with SMT were significantly more likely to report relevant “improvement” compared to those treated with cervical nerve root injection blocks.

Supportive therapies that research has been show to be beneficial include cervical traction, myofascial release and manual therapies and therapeutic exercises.

NSAIDs may help relieve inflammation. Medical co-management of acute cases with short-term tapering oral steroids is a potent anti-inflammatory adjunct. Recalcitrant cases may require pain management and/or neurosurgical consult. Cervical epidural injections or selective nerve root blocks may be helpful.  The addition of spinal manipulation post-epidural injection has been shown to improve outcomes. Surgical alternatives, including discectomy, or discectomy with fusion, should be considered only after a failed trial of conservative therapy, or in the presence of progressive neurologic deficit.

If you think you may be experiencing these symptoms, gives us a call today (434)293-3800. We would be happy to see if we can help.

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