Pinched Nerve / Impingement

Pinched Nerve / Impingement

by | Apr 1, 2022 | Back problems, other, pain

Pinched Nerve Sign

Pinched Nerve/Impingement

A pinched nerve is a common complaint in people seeking medical care. Also known as nerve impingement, a pinched nerve can occur at nerve roots coming from the spine, or in other areas like the wrist and ankle. In either case, it often results in pain and/or numbness and tingling in an arm or leg. Luckily, symptoms are usually treatable with conservative care and don’t require surgery. It’s important to know what to look for, however, because the symptoms aren’t always what you might expect.

What is a Pinched Nerve?

A pinched nerve, or nerve impingement, goes by different names when occurring in different areas of the body. When a nerve root is compressed at the spine, it’s called radiculopathy and is usually caused by degenerating bone or disc. When a nerve is impinged in the arm or leg, it’s called entrapment or compression. To better understand how nerve impingement affects the body, let’s examine the function of nerves.

How Do Nerves Work?

Nerves are our master communicators. They take information from the brain and send it to the rest of the body, and vice versa. The ultimate goal is to maintain a state of balance in the body called homeostasis. Nerves communicate in various ways, triggering sensory and motor reactions to protect the body. For instance, when you touch a hot stove, the nerves in your skin send signals to your brain at lightning speed that danger is present. Your brain responds by sending a burning pain to sensory nerves in your hand, while simultaneously sending a message to your motor nerves to pull your hand away. Nerves, in a nutshell, keep us alive and well. Unfortunately, they are the primary source of pain, too. Peripheral nerves, or nerves that connect our brain to our body, originate as nerve roots exiting the vertebrae from the spinal cord. From here, they branch out and supply, or innervate, muscles to help us move, sensory areas to help us feel, and autonomic areas to activate our fight-or-flight and rest-and-digest responses. When something puts pressure on a nerve root, it affects everything the nerve branches out into. Compression of a nerve root can cause weakness, numbness, tingling, and dull, nagging pain. Irritation of a nerve root can cause sharp, shooting pain, burning, and hypersensitivity.

Types of Nerve Impingement

Nerve root impingement at the spine (radiculopathy), can occur at any of the 3 main spinal sections: cervical, thoracic, and lumbar. Nerve roots in the neck, or cervical spine, primarily affect the arms (upper extremities). Nerve roots in the midback, or thoracic spine, affect the trunk and ribcage. Nerve roots in the low back, or lumbar spine, affect the low back and legs (lower extremities). Pinched nerves can also occur in other areas of the body. Think about when you wear tight shoes to a wedding and feel a tingly sensation in your feet by the time dinner is served. You end up kicking your shoes off to dance after dinner because a nerve in your foot was being compressed. Common areas of nerve entrapment are the carpal tunnel at the wrist and tarsal tunnel in the ankle.

Cervical Impingement

man touching sore shoulder
Nerve impingement in the neck is most common among adults ages 50-54 and is often mistaken for a shoulder or arm injury. Many times, the person feels arm pain or numbness but never has any neck pain. A basic understanding of cervical impingement can help direct proper treatment.

How Does it Happen?

A pinched nerve in the neck, or cervical radiculopathy, occurs when a nerve root is compressed by herniated disc material, a degenerating disc, or aging bone. The body activates the inflammatory response, which causes swelling around the nerve root. This ultimately leads to pain and changes in nerve function.

While internal changes in the neck are the culprit for a pinched nerve, there are often external events that trigger the symptoms to follow. These inciting factors can contribute to the onset of pain with cervical radiculopathy:

  • Poor posture
  • Trauma (such as car accident)
  • Sleeping in uncomfortable positions

What are the Symptoms?

A person with cervical radiculopathy may have symptoms in one or both arms and feel pain and/or numbness and tingling. Symptoms may go all the way into the fingers and follow a dermatome, or sensory nerve root pattern. Neck movements may be painful, the affected arm might feel weak, and the muscles around the neck may be tight. A clinician will likely do in-office testing to rule in the diagnosis, but unless trauma has occurred, further testing is not usually needed. If conservative treatment fails, an X-Ray or MRI may be considered.

How is it Treated?

Most cases of cervical radiculopathy resolve with conservative (nonoperative) management. In fact, in a five year follow up study of patients who had conservative treatment, 90% of patients were symptom-free or only had mild symptoms. Conservative treatment starts with medication, which can include nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxers, opioids for acute pain, and antidepressants for chronic pain. Physical therapy may be prescribed to stretch the neck muscles and strengthen the postural muscles. The physical therapist may also use manual therapy or spinal manipulation to help reduce muscle tightness, joint stiffness and pain. Mechanical traction may be used, where the neck is intermittently placed in decompressive positions. If symptoms persist, an epidural injection may be considered. Only if all these fail is surgery considered. The most common procedure for relieving a pinched nerve is an anterior cervical diskectomy and fusion.

Thoracic Impingement

woman holding lower back
Nerve impingement in the thoracic spine, where the ribs attach, is much less common than in the neck or low back, at least according to reports. It can get missed for months, or even years, however, since it mimics many other potentially life-threatening diseases. Thus, skilled evaluation is imperative with diagnosing thoracic radiculopathy.

How Does it Happen?

Thoracic radiculopathy, or nerve impingement in the thoracic spine, can be caused by degenerative disc disease, rib dysfunction, diabetes mellitus, and placement of spinal cord stimulator. Since it is more rare in the thoracic spine than in the cervical and lumbar spine, thoracic radiculopathy can get overlooked among clinicians. In addition, symptoms of thoracic radiculopathy can mimic heart attack, lung problems, cancer, or other visceral organ dysfunction, making it important for doctors to rule out those conditions first.

What are the Symptoms?

People usually report radiating pain around the ribcage and in the trunk region. Pain may be present in the back near the shoulder blade (scapula) or in the lower abdominal region. Numbness and tingling may also occur, and it can feel painful to take a deep breath.

Treatment

Like nerve impingement in the neck, thoracic radiculopathy typically resolves with conservative management; medications to reduce pain and inflammation, physical therapy to stretch muscles and correct postural imbalances, and activity modification are the first lines of defense. If these methods don’t improve a person’s symptoms, then a procedure called percutaneous vertebroplasty may be considered. In cases of progressive symptoms and neurologic compromise, surgery is necessary.

Lumbar Impingement

It goes by many names—sciatica, lumbar radiculopathy, lumbosacral radiculitis, radicular pain, and pinched nerve, to name a few. This literal “pain in the rear” can be a nuisance, and in some cases debilitating. Spinal nerves are tricky, and a pinched nerve in your back may feel like pain in your foot. Let’s examine why this happens.

How Does it Happen?

Dysfunction of a spinal nerve root in the lumbar spine (low back) is the cause of lumbar radiculopathy. When one is compressed or irritated, a person will develop symptoms of a pinched nerve. Depending on the severity of the compression, the nerve may be affected along its entire course through the body, which is sometimes down to the feet. Here are some common causes of lumbar radiculopathy:

  • Bulging disc
  • Herniated disc
  • Lumbar facet overgrowth (hypertrophy)
  • Spondylolisthesis

People can develop this condition from direct trauma or chemical irritation to the nerve root, inactivity, staying in certain positions too long, using poor body mechanics with lifting, or having weak core musculature. Regardless of the cause, it is important to get an accurate diagnosis in order to treat it correctly. Lumbar radiculopathy, like thoracic radiculopathy, can mimic other conditions, which require different treatments. In rare cases, lumbar radiculopathy can be caused by infection, cancer, vascular disease, or congenital abnormalities. Therefore, quality evaluation and diagnosis from a physician is vital.

What are the Symptoms?

The classic symptoms of lumbar radiculopathy are pain and/or numbness and tingling extending down the leg, with or without accompanying back pain. The compromised spinal nerve root results in pain, weakness, and/or impairment of sensory regions associated with the affected nerve root. The muscles of the back, hip, thigh, and calf may be tight or feel like they are in spasm. This is more likely a result of irritated nerve rather than actual muscle tightness. Typically, the symptoms worsen with certain positions or activities, such as sitting or standing for long periods. Sometimes even lying flat to rest can increase symptoms. When the bones in the spine undergo the aging process, the spaces for nerves and the spinal cord to run through may narrow (spinal stenosis) and impinge nerves on both sides. In these cases, people can experience pain, heaviness, and/or numbness and tingling in both legs while standing upright or walking, which is called neurogenic claudication. The most commonly affected nerve with lumbar radiculopathy is the sciatic nerve, which is where sciatica gets its name. Symptoms specific to impingement of nerve roots of the sciatic nerve are pain and/or numbness and tingling starting in the low back, then radiating into the buttocks, and shooting down the back of the leg into the foot. This can be confused with piriformis syndrome or hamstring syndrome, which also affect the sciatic nerve, but not at the nerve roots. Often people with lumbar radiculopathy experience no back pain but have numbness and tingling in their legs and feet, which explains why people might not initially consider the low back as the source of their pain. It can feel like peripheral neuropathy, diabetic neuropathy, or Tarsal Tunnel Syndrome. However, these conditions are distinct from lumbar radiculopathy and should be treated as such. Neuropathy describes damage to or disease of peripheral nerves, which are outside the spine. Tarsal Tunnel Syndrome, as discussed later, is caused by compressed nerve in the foot. Other more serious conditions should also be ruled out in cases of numbness and tingling in the feet, such as Guillain-Barre Syndrome, autoimmune disease, and infection.

Treatment

Treatment for lumbar radiculopathy, like in the rest of the spine, is symptom-based. In the early stages, the primary goals are to reduce pain and restore any loss of sensation. This can be accomplished through medications, epidural injections, application of topical analgesics, and education on staying active/exercise. Physical therapy can help with reducing neural tension (pain caused by nerve irritation), releasing muscle tightness, and improving strength in core muscles. Research has shown that core musculature weakens during episodes of low back pain, which increases vulnerability to future episodes of radiculopathy. Mechanical traction and spinal manipulation may be used by physical therapists or chiropractors and can relieve symptoms in the short-term. Surgery may be used to decompress a nerve or fuse an unstable spinal segment. While statistics show that lumbar surgery is safe and effective in short-term, it has shown no long-term benefits for pain and function.

Other Types of Impingement

holding wrist

Carpal Tunnel Syndrome

Carpal tunnel syndrome is nerve compression at the wrist. Here, the median nerve passes through bones and tendons and can become entrapped. Sitting at a computer for extended periods increases the risk, which may explain why it is the most reported nerve entrapment syndrome. It is also the most expensive upper extremity disorder in the United States, costing over $2 billion annually. In addition to desk job workers, others at increased risk are industrial workers and elderly. Symptoms include numbness and tingling in one or both hands, weakness of the hands and fingers, and wrist stiffness. Treatment includes activity modification, splinting, ergonomic modifications, occupational therapy, injections, and in serious cases, surgery. When evaluating, clinicians should rule out neck problems, as they can mimic carpal tunnel syndrome.

Tarsal Tunnel Syndrome

Though much less reported than carpal tunnel syndrome, tarsal tunnel syndrome is a nerve entrapment syndrome that often goes undiagnosed because it gets missed. The posterior tibial nerve travels behind the inner ankle bone, where three other ankle muscle tendons also pass through. In anatomical terms, this is called the tarsal tunnel. In the tunnel, the nerve branches into three segments. When compressed, it can cause pain and/or numbness and tingling in any or all three segments, which affect the ankle and foot. Treatment includes physical therapy for stretching tight structures that may be compressing the nerve, strengthening weak muscles to avoid compensations, injection, and surgical release if necessary. Perhaps most important in treating this issue is getting an accurate diagnosis, as it may be assumed to be a pinched nerve in the back.

If you are experiencing pain that you want to discuss further, please make an appointment with Dr. Connor.

What is Degenerative Disc Disease and What Can You do About it?

What is Degenerative Disc Disease and What Can You do About it?

by | Mar 1, 2022 | Back problems, other

What is Degenerative Disc Disease

What is Degenerative Disc Disease and What Can You do About it?

Back pain is so common it’s almost inevitable. Like sprouting a gray hair, most people deal with at least one episode of low back pain by middle age. A major cause of back pain can be degenerative disc disease. Various factors, including what’s happening both inside and outside your cells, contribute to getting degenerative disc disease. A combination of wear and tear, poor nutrition in the discs, and neural changes over time lead to degenerative disc disease. In this article, we’ll get into what degenerative disc disease is and how you can treat it.

What is Degenerative Disc Disease?

To better understand degenerative disc disease, let’s discuss the umbrella term under which it lies: low back pain. Low back pain is the fifth most common reason people go to the doctor in the United States. Whether people are extremely active or relatively sedentary, healthy or unhealthy, back pain affects most people at some point in their lives. Of the many causes of back pain, degenerative disc disease is the leading cause of lower back pain and disability. One reason may be because our discs start degenerating much earlier than our bones and muscles, which we’ll go into more detail on later. Let’s start by looking at the spine.

Degenerative Disc Disease

A Brief Look at Spine Anatomy

Most people are born with a spine comprised of 33 bones called vertebrae stacked on top of one another like puzzle pieces. By adulthood we typically have 24 vertebrae because the bones at the bottom of the spine fuse together. The vertebrae differ based on their location in the spine and have different functions in the neck (cervical), mid back (thoracic) and low back (lumbar) regions. While degenerative disc disease can occur in any part of the spine, we’ll focus on the most prevalent, the lumbar spine.

Each lumbar vertebra is comprised of a prominent, round body in front, a pointy spinous process in back, a transverse process on either side, the spinal canal, which houses the spinal cord, and facet joints, which articulate with the vertebra above it. When stacked together, they create the spinal column. The spinal column has 4 main functions: to support the weight of the body above the pelvis, to protect the spinal cord, to act as the central axis of the body, and to control posture and movement.

Degenerative Disc Disease

Where do Discs Come into Play?

In between the bodies of the vertebrae lie intervertebral discs, which act like soft pillows and provide flexibility and cushion to the spine. They also allow for the spine’s natural curvature, or lordosis, to absorb shock, provide stability, and carry heavier loads. Each disc is made up of three parts:

  • Nucleus pulposus: The center of the disc containing the “filling”
  • Annulus fibrosus: Inner and outer rings surrounding the nucleus pulposus
  • Terminal endplates: Cartilage and fibrous tissue

How Discs Degenerate

The nucleus pulposus plays the largest role in disc degeneration. A healthy nucleus pulposus is gel-like, well hydrated, and rich in proteins called proteoglycans. It creates pressure in the disc to separate the vertebra, puts tension on the surrounding rings (annulus fibrosus) to hold the disc shape, and helps evenly distribute pressure over the end plates. As we age, the nucleus pulposus loses proteoglycans, which causes the disc to become firmer, dehydrated, and more vulnerable to damage. These changes cause the disc to lose its height and pressure, which sets off a sequence of events that changes the biomechanics of the spine.

Nucleus Pulposus Over Time

 AGE  FILLING CONSISTENCY
 Young  Jelly
 Middle-aged  Toothpaste
 Older  Chalk

 

Disc degeneration over time is inevitable. But many people going through it never even know it’s happening. Discs begin the degeneration process as early as adolescence, with 20% of young people showing mild symptoms. It’s when these changes cause painful and debilitating symptoms that we refer to it as degenerative disc disease, or intervertebral disc disease.

What Causes Degenerative Disc Disease?

Degenerative Disc Disease

Like many other chronic conditions, such as heart disease and diabetes, no one specific event causes degenerative disc disease. Degenerative disc disease results from a complex interaction of genetics, age, structural changes, biochemical changes, environment, trauma, and activity level over time. Three main factors lead to the progression of degenerative disc disease: wear and tear, decreased nutrition in the discs, and neural changes.

Wear and Tear

Natural disc degeneration can start as early as ages 11-16, but most people begin showing symptoms in middle age, after they have put their spines through some wear and tear. Age-related changes cause an imbalance between building tissue (anabolism) and breaking tissue down (catabolism). This changes the composition of the nucleus pulposus, leaving it dehydrated and firmer. As disc height falls, the dynamics of the extracellular matrix (area surrounding disc cells) change, causing the once perfectly functioning spine to use altered movement patterns.

Decreased Nutrition in the Discs

With age, fewer nutrients are supplied to the discs, causing terminal end plates to harden and calcify. Nutrient loss also causes discs to be less capable of load distribution. As one disc degenerates, it causes surrounding segments to work harder to distribute load and maintain postural stability, which accelerates degeneration of the surrounding discs. This in turn affects other structures, such as joints, ligaments and muscle.

Neural Changes

The discs in the spine are aneural (without nerves) and avascular (without blood vessels). So how do they generate so much pain? When the disc degeneration cycle progresses, a series of reactions are stimulated in which cytokines, the immune responses’ signaling cells, are secreted. An inflammatory response follows, which can cause tears in the annulus fibrosis (fissures), push the disc into nerve tissue (bulge), or even cause the nucleus pulposus to rupture and leak out (herniate). Over time, the spinal canal becomes too narrow (spinal stenosis) and compresses nerve tissue (radiculopathy), which causes pain.

Am I at risk?

Degenerative Disc Disease
If you are getting older by the day (hint: we all are!), then you are at risk of disc degeneration. Since discs begin degenerating much earlier than muscles and bones, many people who experience low back pain associated with degenerative disc disease are of working age. This may explain why degenerative disc disease is the leading cause of work-related disability. Some factors may put you at higher risk for developing degenerative disc disease. Here are a few to keep in mind:

  • Age: The older the individual, the higher the risk
  • Genetics: If one or more family members have been affected, you are more likely to be affected
  • Gender: Men are at higher risk
  • Joint laxity: Imbalances in muscle dynamics can create spinal instability
  • Repetitive loading over time: Healthcare workers, foundry and forest workers, production operators, cabinet makers, truck drivers, locksmiths, bricklayers, and workers who lift, rotate, and/or bend are more at risk
  • Environmental factors: Smoking, obesity, and diabetes mellitus increase the risk
  • Psychosocial factors: Low socioeconomic status and depression increase the risk
  • Nutritional deficiency: Poor disc nutrition accelerates degeneration

How do I know if I have Degenerative Disc Disease?

Degenerative disc disease may be present in 90% of people over age 70. So why don’t 90% of people over age 70 have severe low back pain? Many people with degenerative disc disease are asymptomatic and will never need treatment. Others have episodic bouts of pain that are treatable with conservative interventions, which is why your physician usually won’t jump right to ordering an MRI. Chances are, if you have back pain, an MRI will show some degeneration of your discs. But that won’t necessarily change the course of treatment. Managing symptoms is the priority.

Symptoms

Besides the most obvious symptom of low back pain, the next most common symptom is sciatica, or nerve type pain running down the leg. This type of pain is usually sharp and shooting and may feel numb and tingly radiating down the leg and foot. It can be on one or both sides, and can follow what are called dermatomal patterns, or areas of the leg innervated by certain nerves. Specifying the location of your symptoms can help your clinician determine what level of the spine he or she suspects is involved.

Your symptoms may be aggravated with bending, sitting, turning, coughing, sneezing, and occasionally standing. Typically, if sitting aggravates your symptoms, then standing or laying will alleviate them, and vice versa. However, in an acute case of a disc herniation, it may be painful to be in any position.

Things to Report Immediately

While degenerative disc disease symptoms may be painful, they aren’t usually dangerous. However, there are a few symptoms that require immediate evaluation by a medical professional. These can lead to rare, but potentially life-threatening complications:

  • Change in bowels or bladder accompanying back pain
  • Saddle anesthesia (loss of sensation in the buttocks, perineum, and inner thighs)
  • Fever
  • Drug abuse
  • Recent trauma (car accident, fall, sports injury, etc.)
  • Unrelenting pain

Diagnosis

Degenerative Disc Disease

When seeking evaluation for degenerative disc disease, you must first choose where to begin for proper medical evaluation. Your primary care physician can diagnose your condition, provide recommendations, and possibly medications to help temporarily, and this physician can provide referrals for therapy, whether this be physical therapy or occupational therapy, depending on your condition. Your primary care physician can also help you to find the most appropriate specialist for your condition — and make this referral for you. This physician may be an orthopedic physician, a physiatrist (PM&R physician), a neurologist, or a neurosurgeon. They all specialize in differing capacities in spinal dysfunction. No matter who you choose, it’s always a good idea to know what to expect.

Your physician will ask a series of questions about your medical history, current symptoms, aggravating factors, and alleviating factors, and any medications you’ve taken for this condition. You will be asked specific questions about your pain, such as location, quality, intensity, and frequency. They may test your strength, flexibility, and range of motion. During this time, it is important to be honest: lay it all out there. Don’t be embarrassed to say you fell off the wagon with your diet, or that you haven’t left your couch since Covid-19 began. It’s important for the physician to know what’s going on in your life so you can be diagnosed accurately.

While an MRI is the main imaging technique for degenerative disc disease, it is just one of many diagnostic tools a clinician may use. Remember that more likely than not, you have disc generation if you have low back pain. Since the results of an MRI often don’t change the treatment plan for the individual, physicians typically only order them if conservative treatment fails.

What to do About it

Treatment typically starts with conservative management, which includes physical therapy, oral medications, injections, and education about understanding pain and coping mechanisms. Statistically, 80% of patients respond to physical therapy within four to six weeks.

For those who still suffer from symptoms after trying conservative care, some promising prospects are less invasive than surgery but still being studied. Restorative therapies include molecular therapy, growth factor therapy, cell therapy and gene therapy. Reconstructive methods include percutaneous IVD techniques, mechanical decompression, and biomaterial injection.

The more invasive treatments and typically last resort for symptom relief are decompression surgery, total disc replacement, and rigid fusion. While fusion protects the integrity of the segment, it may compromise other levels of the spine. It also addresses symptoms, not causes of the condition.

If you want to decrease your risk of getting degenerative disc disease, you can start by exercising. Exercise, especially when done in moderate to high volume, with low repetition and frequency, can decrease your risk of having symptoms. Along with a multitude of other health benefits, exercise will keep your postural muscles strong, spine stable, and cardiovascular system healthy.

What Not to Do

If you suffer from degenerative disc disease, don’t lay around hoping it will go away. Bedrest can make low back pain worse. After 1-2 days of rest per new episode, it is important to move your body. Your clinician will direct you on what kind of activities are safe and effective for your case.

Conclusion

Degenerating discs are about as common as getting wrinkles with age. When they become painful and debilitating, however, we call it degenerative disc disease. It is the result of a complex interplay of actions happening both inside and outside of cells, environmental factors, genes, and change over time. If you have an episode of low back pain, you may have degenerative disc disease, but don’t schedule your surgery just yet. Make an appointment with Dr. Connor to discuss your back issues so you can get back to being you!

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