Radicular Pain and Sciatica

What is it?

Radicular pain is pain related to an irritated spinal nerve. "Radiculopathy" refers to damage or disturbance of nerves into the arms or legs from irritation and/or compression of nerve roots in the spine. This is most commonly due to a herniated disc. The disc itself does not often cause pain; rather, an irritated or pinched nerve is the source of pain.

Other common causes of pinched nerves include spinal stenosis and bone spurs from spinal arthritis.

Nerve roots in the low back (lumbar) area can cause pain, loss of sensation and weakness in the lower extremities, including the buttock, hip, thigh, calf and foot.

Nerve roots in the neck (cervical) area can cause pain, loss of sensation and weakness in the upper extremities, including the shoulders, arms, and hand.

What causes it?

The causes of radicular pain are quite varied. Some cases occur suddenly due to a specific incident while others have no exact inciting event and the symptoms start more gradually.

The type and degree of pain can be quite varied. For example, some people may feel just a slight ache in the shoulder blade and forearm with tingling in the fingers, while others will have intense burning all the way down the arm that keeps them from sleeping.

How is it diagnosed?

Radicular pain and radiculopathy are typically diagnosed by careful history and physical examination.

X-ray may be helpful but is not always necessary.

MRI is generally not necessary unless the symptoms are not responding to usual treatments. MRI is considered the gold standard to evaluate for compressed nerves, and to determine if injections or surgery are indicated.

Occasionally, a CT scan or other imaging modalities may be helpful.

What are the treatment options?

Nonsurgical (physical therapy, medication management) – nonsurgical treatment is the first step for radicular pain unless there are significant neurologic symptoms. Initial treatment is aimed at decreasing pain and neurologic symptoms.

As long as there is no evidence of severe or worsening nerve damage, most patients with radiculopathy do not require surgery.

Treatment typically involves physical therapy, activity modifications and tailored medication management.

If these usual measures are not adequate, epidural steroid injections may be a good treatment option to treat the radicular pain.

Surgery is an option for those who continue to have painful nerve symptoms or have persistent or progressing weakness or numbness.

• Activity modification: For very acute pain, a temporary decrease in activity without too much restriction may be indicated. However, it is recommended to remain as active as possible, and bed rest for more than a few days has been shown to make disc conditions worse.
• Physical therapy: There are many different types of physical therapy. Our team will decide which approach is best for you. In general an active approach in which you are given exercises and stretches is recommended. There is no way to predict how many sessions you will need, though you should feel that there is clear progress within a few visits and many people only need 6 to 8 visits.
• Manual medicine: At times, there are restricted areas in your body that either lead to pain or cause increased strain in another region. There are numerous techniques employed in manual medicine, and the treatment choice is individualized for the patient. Our team will guide your treatment for your specific needs. It is difficult to predict how many sessions are necessary, but there should be clear progress within a few visits. Activity modification: For very acute pain, a temporary decrease in activity without too much restriction may be indicated. However, it is recommended to remain as active as possible.
• Medications: Analgesic medications such as acetaminophen or an anti-inflammatory such as ibuprofen can be helpful temporarily. Our team will tailor your medications to help you stay active. This may include prescription anti-inflammatories, medications that target nerve pain and muscle relaxers. For very acute and severe pain, narcotics may be used for a short period.
• Injections: Epidural steroid injections can be quite effective for radicular pain. There are several different approaches and a few different types of steroid medication. The specific type of injection is individualized after careful history and physical, and personal review of the imaging. There is no need for a routine "series" of injections. Your response to the injection will be monitored and further treatment will be recommended depending on your personal results. Injections are typically part of a comprehensive treatment plan.

Surgical (injection/minimally invasive/surgical) – spine surgery for radiculopathy is indicated if one has not responded to other treatments or if there is progression of neurologic symptoms such as weakness or numbness.

The exact type of surgery will depend on multiple factors, though most are done with minimally invasive techniques to provide patients with the quickest recovery and minimize post-surgical pain.