Tag: neck pain

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!!!

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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……….

 

Mind-body interventions: applications in neurology

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A comprehensive review  on mind-body interventions and its application in various neurological disorders was recently published in Neurology. The authors Wahbeh, Elas and Oken searched Medline and PsychoInfo databases to identify clinical trials, reviews and published evidence on mind-body therapies and neurological diseases.

Meditation, relaxation, breathing exercises, yoga, tai-chi, qigong, hypnosis and biofeedback are some of the mind-body interventions that have been used in various neurological conditions like general pain, back and neck pain, carpel tunnel syndrome, headaches (migraine and tension), fibromyalgia, multiple sclerosis, epilepsy, neuromuscular diseases, stroke, falls with aging, Parkinson disease, stroke and attention deficit hyperactivity disorder (ADHD).

The authors do a good job in shifting through all the data to try to identify the effectiveness of mind-body interventions. As they point out in their discussion , many patients as many as 62% use complementary and alternative medicine therapies (CAM). Some with and many without the knowledge of their physicians. One of the reason why CAM therapies are popular is that they are relatively easy to implement, cheap (though many patients have to pay out of their pocket. Some insurance companies shall reimburse if you have a letter from your doctor) and more importantly as the authors point out it makes the patients feel empowered. They feel that they are in control of some of the decision making in their disease process and treatment. Moreover it gives a sense of general well being.

The authors righly point out that is difficult to scientifically judge whether these interventions are all effective. The reason for this is that many of the studies included small number of subjects and some of them did not have a control group. Moreover it is hard to blind these studies so as to avoid a placebo effect. Like suppose I want to study whether acupuncture is effective for lower back pain. One group I give acupuncture. Ideally I should have a control, a group which receives sham acupuncture so as to null the placebo effect. Now this is difficult to implement.

Th authors in their review conclude that there are several neurological conditions where the evidence in favor of mind-body therapies is quite strong such as migraine headaches. In other conditions the evidence is limited due to small clincial trials and inadequate control group.

It is reasonable to conclude that CAM therapies like yoga, tai-chi and qigong improve balance in the elderly and decrease the incidence of falls. Moreover they give a sense of well being and happiness. Meditation exercises whether it is mindfulness meditation, transcendental meditation or concentration meditation with the repetition of a word like Om or a mantra

“Hare Krishna Hare Krishna

Krishna Krishna Hare Hare 

Hare Rama Hare Rama

Rama Rama Hare Hare”

all help in relaxation and reducing stress. This may decrease blood pressure and reduce the incidence of strokes and heart attacks. Brain changes have been observes during meditation in EEG and imaging studies and there is evidence that these exercises have wide spread effects on the endocrine and immune systems as well neurotransmitters. Hatha yoga may help in improving mobility and balance and thus decreasing fall risk. As the authors point out righly Bikram yoga  which is carried out in very hot temperatures is likely not good for patients with MS, as it may worsen their weakness. This is called Uhthoff phenomena.

There is also some evidence to suggest benefits of these interventions in patients who have chronic lower back and neck pain, those with fibromyalgia, osteoarthritis as well as carpel tunnel syndrome (some studies suggest benefit while others do not).

My advise to patients who want to try out CAM therapies for various neurological conditions is to take their doctors into confidence. It is likely that some of these therapies when used along with allopathic medicines shall give added benefits and likely make you feel better. Like with any other therapy one must find a knowledgeable practitioner who knows what he or she is doing.

Then one can truly reap the benefits of these ancient therapies.

Personal Regards,

Nitin Sethi, MD