Tag: herniated disk

About pinched nerves and herniated disks—The final saga!!!

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About pinched nerves and herniated disks—The final saga!!!

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

The last post ended with our patient officially getting the diagnosis of a pinched nerve due to a herniated disk.  He was in excruciating pain and the doctor had referred him for a MRI scan of the lower back (we call this MRI LS spine (lumbo-sacral spine) or MRI C spine (of the cervical spine) as the case may be).  I want to emphasize that the diagnosis of a herniated disk is usually a clinical one and hence a MRI scan is not warranted in each and every case. I usually refer a patient for a MRI scan only if the clinical presentation is atypical or if there are signs of pressure on the spinal cord itself and lastly if the patient does not respond to treatment.

Well enough of my views, let us get back to our patient, who at this moment finds himself saddled inside a MRI scanner. The magnet starts moving, making a thunderous noise with the patient inside wondering what he has got himself into (many people feel claustophobic inside a MRI machine and for many the scan itself can be quite unnerving!!!).

After seeing the MRI pictures, the doctor decides to treat our patient symptomatically. A few days rest, some pain killers to keep the pain in check and a referral to physical therapy is prescribed. For the majority of patients with herniated disks and pinched nerves, this conservative therapy usually is effective. Traditional pain killers such as Motrin and Advil may not be very effective for neuropathic pain (pain due to the pinched nerves).  Hence medications like gabapentin (Neurontin) and carbamazepine (Tegretol) are at times prescribed. These work well for neuropathic pain though have their own side-effects which patients at times cannot tolerate. 

In patients who do not respond to the above conservative therapy more aggressive and usually invasive treatment options may be pursued. These include epidural steroid injections (these are injections of steroids (anti-inflammatory agents)  and pain-killers administered in the epidural space. The jury is still out whether these injections are truly beneficial. They have their own risks and should be administered only a qualified pain specialist. Relief if any is short lived and I personally do not refer my patients for epidural steroid injections. Surgery to remove the herniated disk (the procedure is called discectomy) is the last option. It is usually reserved for patients who have a large central disk herniation with compression of the spinal cord.

Thankfully our patient responds well to conservative therapy with gradual resolution of pain and discomfort. Soon he is back to his usual state of good health and cheerfully lifting heavy office supplies.  Herniated disks, pinched nerves and other things that make him go ouch and ah are but a distant memory….. A happy ending indeed.

 

 

About pinched nerves and herniated disks—oh how that hurts!!!

braindiseases3 Comments

About pinched nerves and herniated disks—oh how that hurts!!!

 

 

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

 

Recently I have seen many patients in my office with complaint of pain, numbness and tingling radiating down either the arms or legs. Most of these patients have pinched nerves due to herniated disks. They have ranged from ages of 25 to 65 and all of them have sought a neurological consultation primarily due to discomfort and pain from the pinched nerves.

I have written about pinched nerves before (we refer to this condition as radiculopathy. If the pinched nerve occurs in the neck i.e. the cervical vertebrae are involved it is called cervical radiculopathy and if it occurs in the lower back and involves the lumbar vertebrae it is called lumbar radiculopathy) but thought this might be a good time to again discuss this relatively common but frequently disabling condition. So what does a pinched nerve actually mean?

Well as you know our spinal cord is enclosed and protected by a rigid structure called the spinal column (commonly we refer to this as the spine. The spinal column is made of small bones called vertebra which are stacked one on top of each other and interconnected to one another by ligaments and other soft tissues. It is the tail (spine) of the vertebra which you can feel when you touch someone’s back. Now this bony spinal column encloses and protects the delicate spinal cord (the spinal cord starts from the base of the brain and contains all the nerve tracts which carry signals from the brain to the periphery of the body and vice versa. As it descends down into the neck, it gives off nerves which supply all the muscles of the arms and in the lower back (lumbar area) nerves to the legs come out from the spinal cord).

SO LET’S GO OVER THIS AGAIN. YOU HAVE THE SPINAL CORD; IT IS ENCLOSED BY A STRUCTURE (we are calling this the spinal column) WHICH IS MADE OF SMALL BONES CALLED VERTEBRA STACKED ONE ON TOP OF OTHER. FROM THE SPINAL CORD THE NERVES COMING OUT AND SUPPLY THE MUSCLES OF THE ARMS AND LEGS.

HOLD ON WE FORGOT ABOUT THE DISKS!!! So what is a disk or more correctly called the INTERVERTEBRAL DISK? As the name suggests the disk is a small cartilaginous tissue which lies in-between two vertebrae (think of it as a cushion between two bones which is what it actually is!!!). As compared to the vertebrae which are bones, the disk is a cartilage and fibrous tissue which is prone to degeneration and rupture.

Now imagine a scenario.  You are lifting a heavy weight. You bend down, squat and strain to lift that heavy box of office supplies. You hear a “pop” in the back and feel “something give”. Well what do you think has happened? One of the cartilaginous disks in the lower back (most common is either the one between the 4th and 5th lumbar vertebrae or between the 5th lumbar and 1st sacral vertebrae. In the neck it is between the 5th and 6th or between the 6th and 7th cervical vertebrae) has herniated (POPPED OUT) and is now compressing (PINCHING) the nerve coming out of the spinal cord and going into the leg (may be the arm if it occurs in the neck). What is the end result of this disk herniation?

Well the next day you are in terrible pain and can barely get out of bed. You make an appointment to see your doctor. You have shooting pain (the pain radiates down your leg or in the case of a cervical disk herniation into your arm). You complain of feeling pins and needles and electric shocks radiating into your leg (or the arm as the case may be). Some people have more “negative” symptoms and complain of numb feeling rather than pain. The doctor examines you and orders a MRI of the lumbar spine (or the neck as the case may be). He gives you some pain medications and asks to take it easy!!!.

Voila you now officially have a herniated disk with a pinched nerve. It sure hurts like crazy. Will this story have a happy ending?

The story continues in the next post……….

 

I have a pinched nerve-now what do I do?

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I get a lot of patients who say thay have a pinched nerve either in their backs or in their necks. They are invariably on pain-killers and some of them even have had surgery for their pinched nerves. As there is a lot of confusion and misperception in the minds of patients when it comes to “pinched nerves” I thought this might be a good time to discuss this topic.

So what exactly is a “pinched nerve”? When patients say they have a pinched nerve, they are referring to what we as neurologists call “radiculopathy”. Let me try to explain this in simple terms. The nerves that supply the muscles of the arms and legs come out from the spinal cord. These nerves exit as small nerve rootlets (radicles) from inbetween the bones that make the vertebral column (spine). At times these nerve rootlets (radicles) may be compressed (pinched) by either a bony spur of the vertebral column or a disk might herniate out and compress the nerve rootlet. This compression of the nerve (radicle) leads to pain which characteristically radiates down along the length of the nerve. So for example if you have a pinched nerve in the neck, the pain shall radiate down your arm and if you have a pinched nerve in the back, the pain shall radiate down your leg. This is what is called RADICULOPATHY.

The pain of radiculopathy can be excrutiating causing much discomfort and distress. In the acute stage, patient may find it so painful that they cannot move. They complain of “current” running down their arm or leg.

So how do we treat a pinched nerve? Well in the acute stage (when the nerve is inflammed), bed-rest is prescribed. This may vary anywhere from 3 days to a week. The acute pain of a radiculopathy is treated with painkillers–these may range from simple analgesics like Tylenol to anti-inflammatory drugs like Motrin, Advil and even corticosteroids for a short duration. Other medications used include medications effective against neuropathic pain such as gabapentin (Neurontin) and carbamazepine (Tegretol).

Recent studies have shown than most radiculopathies shall settle down over time with the above conservative measures. At times a disectomy is carried out (removal of the herniated disk) for pain relief. Epidural steroid injections may provide temporary relief.

BUT AS I STATED EARLIER MOST RADICULOPATHIES (PINCHED NERVES) SHALL SETTLE  DOWN WITH CONSERVATIVE MANAGEMENT.

Nitin Sethi, MD