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.