Radiculopathy: Pinched Nerves in the Neck and Back with Dr. Dominic Pelle
Radiculopathy: Pinched Nerves in the Neck and Back with Dr. Dominic Pelle
Cassandra H.: Hi, thanks for joining us today. I'm your host, Cassandra Holloway and you're listening to Health Essentials Podcast by Cleveland Clinic. We're broadcasting from Cleveland Clinic's Main Campus in Cleveland, Ohio, and we're here today with Dr. Dominic Pelle. Thanks for being here.
Dominic Pelle: Thanks for having me.
Cassandra H.: Dr. Pelle is a spine surgeon at Cleveland Clinic Center for Spine Health. And today, we're going to be talking about pinched nerves in the neck and back. Before we begin, we want to remind our listeners that this is for informational purposes only. It should not replace your own doctor's advice.
Dr. Pelle, we know that there's a wide and complex variety of neck and back pain, but today we're specifically going to be talking about radiculopathy, also known as a pinched nerve in the neck and back. If someone is suffering from this, what is actually going on?
Dominic Pelle: Kind of, as you said, radiculopathy is the consequence of a pinched nerve, right? And so when we talk about what we're treating at times when these patients need surgery, we're treating the pain, the weakness, the dysfunction, or the numbness that's associated with a pinched nerve, in essence, the radiculopathy. And so what's happening is that nerve in the neck, thoracic spine or low back is being pinched and you get pain that's associated with the distribution of that nerve.
If it's sciatica, you get pain that radiates down the leg, usually in the buttock, down the side of the thigh, top of the leg into the top of the foot, would be like an L5 radiculopathy, or what most people would call sciatica. If it's a pinched nerve in the neck, oftentimes you get pain that begins in the neck, may radiate to different areas of the arm, sometimes all the way into the fingers. That can, again, be associated with numbness and it can be associated with weakness. Sometimes it's just a numbness, sometimes it's just a weakness. It just sort of depends on how your nerve responds to the pressure that it's experiencing.
Cassandra H.: You had said you could get it either in the lower spine or the upper spine.
Dominic Pelle: Correct, yeah.
Cassandra H.: Can you ever have it in both areas?
Dominic Pelle: Oh yeah. Yeah, you can. You can get things called tandem stenosis, where you have problems with the neck and the back at the same time. Most of this is your mobile spine segments. Your thoracic spine is protected by your rib cage. It doesn't move quite as much as your mobile spine does, like your lower lumbar spine or your cervical spine. And so those areas are a bit more prone to having a radiculopathy from either arthritic processes developing, disc herniation, so on and so forth, that may pinch those nerves. And yeah, sometimes you can have arm and leg pain.
Cassandra H.: You mentioned arm and leg pain, is there weakness ever involved in this, tingling sort of thing?
Dominic Pelle: Yeah. Again, the sort of trifecta, if you will, of radiculopathy is pain, numbness, and weakness. Most often it's not all three of those things at once. It certainly can be, but it's not all three. Usually, it's pain is the predominant symptom, which is good because that's the thing we're best at treating.
Cassandra H.: Got you. What causes this pinched nerve? What are some of the causes of this?
Dominic Pelle: Typically, it can be due to arthritic development or it can be due to a herniated disc, and I'll go through some of that. In the cervical spine specifically, what usually happens is you get some arthritic bone that grows around one of the small joints at the back of the disc space. Those are called your uncinate joints. They're little projections of bone in the cervical spine and you could get some osteophytes or abnormal growth of bone there. That mixes with a disc that begins to degenerate.
As it begins to degenerate, sometimes it kind of pushes backwards, okay. And some of the joints around the spine may even get bigger and some of the ligaments around the spine may get bigger. All of these things sort of combine to sort of pinch that nerve as it's trying to travel out into your arm. Usually, it gets it right when it's beginning to travel from the spinal canal into the arm. As it's exiting the spinal canal, oftentimes, it'll get it there in the cervical spine.
In the lumbar spine, it's sort of the same thing. You can get arthritic joints, arthritic ligaments, disc bulges or disc decussations. The disc loses water and it begins to collapse and push backwards a little bit that can pinch the nerve sometimes as the nerve exit, sometimes it's as the nerve is traveling down right before it exits, and those are things that we can see on MRI.
You can also have disc herniations. In your neck, let's say you have a nice, healthy, young spine, sometimes even in a nice, healthy spine, the disc herniate due to just bad luck in injury, so on and so forth. And that disc herniation can just press on the nerve. You may not have arthritis, you may not have any abnormal growth of bone, but you still have a nerve that's angry because it has pressure on it, right? Same thing can happen in the lumbar spine. You can get a disc herniation in an arthritic back, you can get a disc herniation in a perfectly healthy back.
Cassandra H.: Sure. You mentioned disc degeneration, can you explain a little bit more about what that is?
Dominic Pelle: Sure. Kind of as humans that walk on two feet, we're all sort of subjected to disc degeneration. If you look at our studies, most people over the age of 50 will begin to have disc degeneration. By the time people get to 80 years old, almost everybody will have some radiographic evidence of disc degeneration. Most of the time, we don't treat degeneration unto itself. We don't do fusions typically for degenerative disc for back pain.
The problem with this degeneration is that if it is part of a process that would begin to pinch on nerves, then it becomes a treatable issue and causes pain in the arms or legs. But in terms of, you want me to describe that? Typically what happens is when you're young, the disc is tall, it's healthy, it's filled with a gelatinous material that attracts water, okay. And so as you have pressure put on your spine, it's kind of a shock absorber. The outside the disc is like a ligament, like the ACL in your knee or any other ligament you've heard of in your body that sort of prevents the bone from translating. All of these things work together to sort of have your spine respond biomechanically as well as it can, okay. Over time that disc begins to lose some of that gelatinous material in the middle, it begins to lose some of it's water and it degenerates. It sort of collapses down. It doesn't have the same healthy appearance that it did before.
Cassandra H.: Are there certain risk factors? I know you said just aging in general, which unfortunately we cannot stop that. Are there other risk factors that put people more at risk for developing a pinched nerve?
Dominic Pelle: Yeah. I'll refer to this a few times, sometimes it's bad luck, okay. You're healthy, you exercise, you have good core strength, you have good weight and you still have a herniated disc and you end up with a pinched nerve, that can happen. And sometimes, I talk to people in the office, you didn't do anything wrong. This just happens to people sometimes. But other risk factors, certainly weight is a big contribution to that. I always say the spine sort of functions like a crane and it needs to use counterweight to lift a load in front. So the weight we have in our chest and our abdomen are sort of the weight the spine is trying to lift up, and our muscles and spine are the counterweight in the back trying to balance the crane, right? And so the more stress you put on that, the more you have disc degeneration or issues that on go with the spine. And the more you have arthritis developing the spine, the more risk you are for a pinched nerve.
Cassandra H.: Got you. That makes sense. What about spinal stenosis? Does that have anything to do with a pinched nerve?
Dominic Pelle: Yeah. Spinal stenosis is sort of a pinching of all the nurses that travel down. Not to get too technical, but as the nerves travel down the canal and the lumbar spine, they can get pinched right in the center, okay, as they travel down. And that's sort of a pinching of them all. So if you had a spine that had a canal that was this big, over time it kind of does this and squeezes everything off. Okay, that's spinal stenosis.
They can get pinched as they traveled down right before they exit, okay, in what's called the lateral recess. It's right next to the central canal. It's behind a joint. And that can cause a radiculopathy or pain that shoots down the leg. And they could get pinched as they're leaving the spine to exit into the leg or into the arm, that's called foraminal stenosis. That's the exit of the nerve where they can get pinched. That would also cause a radiculopathy or pain on the arm or the leg.
Cassandra H.: What about same thing but with bone spurs? How does that affect a pinched nerve?
Dominic Pelle: Bone spurs are a very relevant issue in the cervical spine. Again, we have these special joints in the back of our disc space in the cervical spine that are prone to bone spurs, that when they grow off them sort of gets into the area where the nerve is trying to exit. We have a lot of foraminal stenosis in the cervical spine, the exit of the nerve, okay. And bone spurs develop along with other forms of arthritis to really get those nerves as they're trying to leave the spine and cause arm pain, numbness or weakness.
Cassandra H.: Great. If you have a pinched nerve once, say either in the top of the cervical spine or the lumbar spine, are you more at risk for pinching a nerve again if you've already experienced it once?
Dominic Pelle: I would say in all likelihood, yes, depending on the reason for that. If you have sort of this process of arthritis building up in your back and you sort of look like you're going to have kind of at risk areas when you're looking at the MRI for the future, I would say it's a risk factor.
If you have a herniated disc, okay, sometimes people have a herniated disc, the pain goes away and they don't have a lifelong history of spine issues, okay. Yes and no, I can't really answer that directly. I have to equivocate just a little bit.
Cassandra H.: Great. If someone is listening to this podcast right now and they think that they're suffering from a pinched nerve, and they're trying to determine if they want to go in and see a doctor or if they want to try to baby it for a couple of weeks, what would be your recommendation for kind of that waiting period?
Dominic Pelle: Sure. Being a physician and surgeon, I don't think it's ever the wrong decision to go see a healthcare provider. If you're worried about something, that's why we exist. That's why we do what we do. Talk to somebody. It's okay. I don't know that if you have really bad pain that shoots down your arm, that you necessarily have to wait two weeks before you see anybody. Call, make an appointment. Sometimes you have to wait anyway, not always. But I think initiating the course of diagnosis and treatment or at least understanding what's going on, there's nothing wrong with that. I don't think there's any sort of merit to really having to tough it out. I don't think any listeners should be worried about wasting someone's time, okay. Even if it goes away on its own, at least you have an understanding of what happened, you know kind of what you had. You don't have to worry about it. And if it goes away, great, but that's at least you've initiated that contact, that treatment.
Cassandra H.: Absolutely. Let's talk about diagnosis then. If someone comes in to see you, what are the typical test or diagnosis options that happen to determine if they have this pinched nerve?
Dominic Pelle: Sure. Let's start with the cervical spine. The first thing we do is a history and the physical examination, and then we're going to look at the imaging. History is kind of all the things we've been talking about. "Doc, I was doing fine. Now I start to have this pain and numbness down my arm. It shoots into my thumb," so on so forth. That's a history that's very indicative of having a radiculopathy or pinched nerve in their neck.
During physical examination, they may have some weakness in that specific muscle group. There are certain special tests that we can do for them. One of them that we do frequently is called a Spurling's maneuver. That's where we take the head and rotate it towards the side that it hurts and laterally bend it towards that side. And so what that does is, if you can imagine my head, if I'm bending this side down like so, right. Where the nerves are all exiting out of my neck, it's sort of decreasing the space, oftentimes, that will reproduce the pain that shoots down the arm, okay. And these are all different than pressure on the spinal cord, which is a totally different phenomenon that involves kind of hand numbness and wobbly gait and things like that, which should prompt treatment from a medical standpoint. But from a specific pinched nerve, usually it's just pain that shoots down the arm.
Then we look at imaging. The first thing we do is we start with x-rays. The reason we like x-rays is because it shows me what your spine looks like when you have gravity acting upon it, right, whether that gravity is your head or your whole body. If you're talking your lumbar spine, it's the best way I understand what your spine is doing when you're standing up, okay, or you're rotating your head. Oftentimes, I have people flex their head down or extend their neck backwards and I shoot x-rays in those directions too to make sure the bones aren't abnormally moving. Sometimes x-ray can show us bone spurs where the nerves exit and the x-ray is really good for that. Other times, a x-ray is a little bit inconclusive.
What really shows the nerves well is an MRI scan. And typically when we're thinking about getting to the process of doing an injection or doing surgery, we always have an MRI scan ahead of time in that case. And so that tells us with fine detail where the nerves are and whether or not they're getting pinched. It shows the disc very well. It's not the best test for bone. That would be a CT scan. Most often, we only do that in special circumstances when we're really trying to decide how to do surgery, but it's a x-rays and MRIs is what we start with from an imaging standpoint.
Cassandra H.: Got you, and it starts with a physical exam first and foremost with your physician.
Dominic Pelle: History, physical exam, followed by the imaging. I would say there's three things that we look at when we're... And this is sort of jumping to talking about surgery. But when we're talking about surgery, number one is everything has to fit together. The history, the physical exam and the imaging, all the puzzle pieces have to coalesce into a picture, okay. The next is the severity of the pain and the length that you've had, the pain, which we'll we'll cover in a little bit, has to be there as well.
Cassandra H.: Great. Let's get into those treatment options now. Say someone presents to you and you do diagnose them with radiculopathy. What does treatment look like?
Dominic Pelle: It depends on how long you've had it for and what's going on. Most often radiculopathy, luckily, will get better on its own, okay. A lot of people have had bouts of arm and leg pain, I've had my own, that have gone away, okay, without any treatment whatsoever. If I see you and you're pretty early in your radiculopathy time course and you've had it for a few days or a week, I say give it time, okay. Time is usually the answer here.
Sometimes I pair that with physical therapy, and so physical therapy is a mainstay of treatment for that. Other things we do is give some medications, usually an anti-inflammatory or muscle relaxant or a medication to kind of relax the nerve a little bit. All sort of safe medications to take, non-addicting, not pain pills, but something that kind of help the symptoms ease down a little bit so you could kind of get onto your normal life and wait for this thing to resolve, okay.
Cassandra H.: Let's talk a little bit about, you said, physical therapy. What would that entail if you have radiculopathy? Kind of how long would you be in that? Kind of talk a little about that.
Dominic Pelle: Usually, we try to get people at least six weeks of conservative treatment. We start therapy usually a couple of weeks after this has gone on. The best known therapy at least for a pinched nerve in the low back would be a McKenzie program, which is really strengthening of the core, stretching of the low back and strengthening of the core. What that does is support your lumbar spine and give it added abdominal musculature to kind of help offload the pressure, and so we'll do that. Patients tend to feel better.
A lot of times therapy though too is, I feel like it's getting, people used to just moving, right? And so if people have a pinched nerve, they see me a couple of weeks after they've had it or even a month after they've had it. And they're like, "Doc, I haven't been able to do anything for a month." Well, I've got to get them used to moving again, right? I got to get them kind of back in the groove of it. And therapy is great for teaching people how to move in pain, how to move in safe ways, and to try and get them out of pain, and then using specific modalities to just try to get them better. Usually that paired with medication treatment is all you need.
Cassandra H.: You say medication, I know I've been reading a lot about gabapentin. Can you explain what they use for that is?
Dominic Pelle: Yeah, so gabapentin is that type of medication I talked about that relaxes the nerve, so it's a specific medication used to just ease nerve pain, okay. It's not a pain pill that necessarily functions on the brain like an opioid. It just relaxes the nerve, and so I use that usually in combination with something like an anti-inflammatory as well. Because let's say you have a herniated disc and this disc herniation is pressing on the nerve, you have all this inflammatory kind of milieu you around that nerve that's making it angry, right? The nerve, I always tell folks, if it's used to living in a colonial, now it lives in a ranch in it feels cramped, okay. And so the anti-inflammatory is to get that nerve used to its home a little bit better, okay, and it just kind of relaxes everything. That mixed with gabapentin is usually a fairly effective treatment.
Cassandra H.: And then I want to touch on spinal injections. Is that ever a treatment option for this?
Dominic Pelle: Absolutely, yeah. Yeah, spinal injections are a great treatment option. Sometimes those are diagnostic, sometimes those are therapeutic. Let's say we have an MRI. It has a lot of area of pinched nerves. Here's a common scenario. Someone comes in, they have a lot of disc degeneration in their back, a lot of arthritic change in their spine and they had a lot of different areas of pinched nerves. Well, I mean, let's say I'm thinking about surgery. I don't necessarily want to operate on the entire spine, right?
We want to very specifically, in a very precise way, do the smallest surgery that will give us the maximum results. And so sometimes I'll say, "I think this is coming from your L4 nerve." And so we'll send them for an injection specifically of their L4 nerve, and they go, "Doc, my pain got better." And then okay, we can just go after that nerve. Okay, we don't need to do a whole spine operation, right?
Other times injections are therapeutic, right? Somebody comes in with a disc herniation, a big disc herniation is pressing on the nerve. It's pretty early in the course. They're on a horrific amount of pain. We get them an injection to kind of get them over the hump to see if that disc herniation will get better, and then all of a sudden the pain goes away. The disc herniation may reabsorb over time and they never need surgery, and so in that case the injection was therapeutic.
Cassandra H.: Interesting. Now I want to touch on surgical options. I know that we try to stay away from surgery, especially in the spine if it's not needed. But if surgery is needed, what does that look like?
Dominic Pelle: It depends on where it is and what the cause it. Okay, so let's say we're talking the cervical spine and it's from some osteophytes or abnormal growths of bone and a pinched nerve from a narrowing of where the nerve exits. There are two mainstays of treatment there. One is an anterior cervical discectomy and fusion. That's where we go in through the anterior spine or the front of the neck, okay. We move some muscles out of the way to approach the spine and then we get rid of that pressure on the nerve by taking the disc out in front. Because we remove the disc in the front in its entirety, we have to do a fusion at that level. And so usually we put something in where the disc used to be to try to get that bone to grow and then some fixation on top of it.
If we want to try a smaller surgery with just a decompression without a fusion, we would do that from the back, where we drill a little hole out around where the nerve lives and just kind of release some of the pressure around it. We usually do that with a microscope and a small incision. Those are good treatment options for the neck.
For the low back, that depends on what's going on. If it's a herniated disc, oftentimes we can do a surgery called a microdiscectomy. That's a minimally invasive-type surgery where we make a small incision in the midline, use a microscope to approach the spine and then just drill out the bone over where the nerve sits, move the nerve off to the side and take the disc herniation out. And then usually just decompress the nerve or with the goal of decompressing the nerve, I should say. If it's from lumbar spinal stenosis, sometimes we do a full laminectomy, which is also a smaller spine procedure where we drill out the bone in the ligaments that's pressing on all the nerves as they travel down.
What we want to do is the smallest surgery that'll give the maximum results for the longest time that we can get those results. The goal of any spine surgery, most spine surgeries I should say, is to decompress the compressed structures. I always tell patients we're going to decompress the compressed structures. And if for some reason we need to stabilize the spine, if we're talking about a bigger surgery with a fusion, we're going to stabilize the spine. Usually, spine surgery is somewhat of an iteration of those things and a combination. And big surgery and even tiny little surgery like we're talking about now, it keeps the same goals in mind.
Cassandra H.: Sure. And so the last thing I want to touch on here is prevention. If someone is listening to this podcast and they're trying to be really mindful about preventing a pinched nerve, maybe it's hereditary, maybe they've had it, maybe they're just getting older, what would be your advice to them in terms of taking preventative measures to avoid this?
Dominic Pelle: Yeah, great question. The first thing I would say is if it happens, you just stop, don't blame yourself, okay. Some people just have bad luck. They're perfect, they've done everything right and they just end up with a pinched nerve. It's okay. It happens to everybody. Well, I shouldn't say everybody, to a lot of people.
From a preventative standpoint though, it's always good to understand weight control. That's a big issue in the spine, so managing that, keeping your core strong, doing a lot of core strengthening. Stretching exercises are good. Yoga's a great exercise, obviously, in consultation with your healthcare provider.
In terms of your neck, a lot of looking down, people that have to move their neck left and right often. Truck drivers sometimes are at increased risk for that. Just kind of being cognizant of sort of your neck posture and keeping yourself a good head alignment is important in your cervical spine as well.
Cassandra H.: That's great advice. Thank you.
That's all the time we have for today. Thank you Dr. Pelle for being here.
Dominic Pelle: Thanks for having me.
Cassandra H.: Thanks for listening to the podcast. If you're looking to learn more about pinched nerves and possible treatment options, visit clevelandclinic.org/spine. If you want to listen to additional Health Essentials podcast featuring Cleveland Clinic experts, visit clevelandclinic.org/agpodcasts or subscribe on iTunes. And don't forget, follow us on Facebook, Twitter, and Instagram at clevelandclinic, all one word to stay up to date on health tips, news and information. Thanks again for listening. We hope you enjoyed the podcast.
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