NON SURGICAL TREATMENT OF PINCHED NERVE IN THE NECK (CERVICAL RADICULOPATHY)

 Cervical radiculopathy or pinched nerve in the neck is a common problem. Irritation or compression of the nerves coming out of the spine can cause severe pain travelling (radiating) to the shoulders and arms. The arm pain is often more severe although the root of the problem lies in the neck. This pain can be associated with tingling, numbness, weakness in the arm and hand.

To understand a bit more about these pains it is essential to have an understanding of the anatomy of the neck. The neck or the cervical region consists of seven bones (vertebrae) stacked one above the other. There are labelled as C1-C7, where C stands for cervical and 1-7 are the numbers to identify the level being referring to. These vertebrae are separated from one another by discs which are like cushions allowing the spine to move freely.

Each vertebra encloses a hollow space which lines up with the space of the vertebrae above and below, running along the entire length of the spine. This hollow space is called the spinal canal and houses the spinal cord which is a thick bundle of nerves connected to the brain. Between every two vertebrae there are openings on the sides called the foramina. A pair of spinal nerves (one on each side) exit through these foramina and supply a specific part of the body for example the nerves coming out of the neck would go to the arm and hands. When these nerves are irritated, either inside the spine or as they come out of the spine, it leads to the pain being felt in the area supplied by the neve and this explains when we get arm pain whereas the actual problem lies in the neck.

CAUSES

The main causes of pressure or irritation of the nerves in the neck include

• Disc problems such as bulging of discs can press on nearby nerves
• Age related wear and tear/degeneration. This can cause narrowing (stenosis) of the openings between the vertebrae  and pressure on the nerves as they exit the spine
• Instability of the neck. Loss of normal spinal alignment can cause compression of nerves 
• Other causes. Less common causes include infection, tumours and fractures

Cervical radiculopathy is seen more commonly in middle-aged people and injury, poor posture can further contribute to this.  In younger age groups this problem is majorly due to ruptured disc or injuries.   

SYMPTOMS

Pain from a pinched nerve may be felt in both the arm and the neck or may be limited to just the neck or arm. Although the root of the problem lies in the spine, the symptoms may be felt in the area where the nerve that is irritated travels such as the shoulder, the arm, or the hand. By looking at where the symptoms are, the pain specialist can usually tell which nerve is involved. Symptoms include: 

• Burning, sharp, squeezing, aching or electric shock like pain
• Tingling or pins and needles sensation in the arm or hand 
• Numbness or loss of feeling in arm or hand
• Shoulder, arm or hand weakness
• Increased pain travelling down the arm with neck movements such as looking up towards the ceiling (extension) or on turning the head

INVESTIGATIONS

MRI scans are the most useful investigation to confirm the diagnosis and assess severity. MRI is better than x-ray because in addition to the bones, it can also show the nerves and discs, giving a detailed picture of the spine. Other investigations such as Nerve conduction velocity (NCV), electromyography (EMG), x-rays and CT scans are sometimes requested.

TREATMENT

Most individuals with cervical radiculopathy get significantly better with 6-12 weeks, with good recovery in 4-6 months. For some however this can be a long-lasting problem. Ignoring persisting symptoms can aggravate the situation leading to chronic pain with reduced functionality. Treatment of this condition required multimodal approach with a combination of lifestyle changes, medications, physical therapy and injections. Surgical intervention is required in very few patients and there are specific indications for surgery. Presence of pain alone is not an indication for surgery.

Some of the pain management techniques include:

Lifestyle changes: These include activity modification, giving up smoking, being mindful of one’s posture and simple ergonomic changes. Incorrect posture while working on laptops, mobiles etc can cause excessive cervical spine strain with certain professions being more prone to develop neck pain. Simple measures such as adjustment of furniture height and computer position can go a long way in reliving symptoms. Taking regular breaks to walk around and stretch is a good practice.

Medications: Anti-inflammatory drugs, muscle relaxants, painkillers acting on the nerves (neuropathic agents) may all be used depending on the source of pain and severity of symptoms. Sometimes stronger painkillers may also be suggested by your doctor.

EPIDURAL INJECTION (Nerve Block)

The aim of this injection is to deliver the anti-inflammatory medicine in the epidural space, close to the affected nerve. Epidural space is a fat filled space present in the spine, between the bone and a protective sac around the spinal nerves. Epidural injections are effective procedures and may help in rapid recovery by reducing inflammation. These medicines may also help by reducing the sensitivity of the nerves carrying the pain signals. The relief from these injections may be short term or long term, lasting from days to years. In some cases it may even be permanent if the original problem responsible for pain heals. There is some evidence pointing to recurrence of symptoms in up to one-third of patients with cervical radiculopathy following initial treatment and repeated injections over one year may have a synergistic effect on pain relief. The goal of these injections is to reduce pain so that you can resume normal activities and engage in a physical therapy program.

The procedure involves the following steps

Step 1: Positioning and preparation

An IV drip is placed and patient is positioned on the x-ray table. Monitors for recoding the vital signs such as heart rate, blood pressure and oxygen levels are attached. The procedure area at the back of the neck is cleaned with antiseptics and drapes are placed around it to keep it clean. Local anaesthetic is used to numb the treatment area to reduce any procedural discomfort. The patient remains awake during the procedure as this helps to provide feedback to the physician performing the procedure and enhances the safety of the injection.

Step 2: Performing the injection

The problem area is localised using x-ray guidance. A needle is then slowly directed into the epidural space using real time x-ray guidance. These x-rays are visualised real time on a monitor attaches to the x-ray machine. Once the needle is correctly placed, a dye (contrast agent) is then used to verity needle position. A mixture of local anaesthetic and anti-inflammatory medicine (steroid) is then given. After the injection is complete the needle is removed and a small dressing is applied.

Step 3: Post procedure

After the procedure, monitoring is continued for some time.  Most people are discharged home after a few hours and are able to resume full activity from the next day. Simple painkillers such as paracetamol can be used for any discomfort around the injection site. The effect of injections can take some days to manifest and keeping a record of how your pain changes is advised. A post procedure follow up appointment is usually scheduled after a few days and it is important that you attend this appointment.

Tags >> cervical, cervical pain treatment, cervical radiculopathy, epidural injection, neck and arm pain, Neck Pain, Cervical Pain Treatment in India

Physiotherapy in Delhi provided by Best pain specialist in Delhi

 Tag: Physiotherapy in Delhi

Physiotherapy is an essential component of chronic pain management. Physiotherapy approach in chronic pain is different compared to that after an injury (acute pain). Longstanding pain results in altered biomechanics and changes in the way nerves transmit the pain sensations to the brain. Altered biomechanics leads to more stress on some body parts at the expense of protecting the painful areas. Over a period of time this can lead to the relative weakening of certain muscles and one needs to be re-educated on the basics such as correct posture, gait and, weight bearing.

We understand that getting started can be difficult. Your physiotherapist will help tailor the exercises to your current functional status.

An experienced physiotherapist can help you by:

• Setting realistic goals
• Dividing exercises into smaller achievable steps giving you a sense of achievement and enabling achievement of bigger goals which may seem impossible initially
• Giving you advice on posture and activity levels
• Educating you about your pain condition and the do’s and don’ts
• Explaining the concept of pacing of activities, activity cycle and helping you implement these. In simple words, this means avoiding over activity at one time and undertaking a predetermined amount of minimal physical activity every day irrespective of pain severity. The amount of physical activity is then increased gradually and maintained to let the body get accustomed to the new activity levels. Hence the focus is on gradual increase and maintaining the positive trend. Doing too much at one time can lead to increase pain and inactivity over the next few days. This is unhelpful as it promotes deconditioning of muscles and reinforced the negative thoughts such as increasing activity means more pain
• Aim to make you independent and self-reliant so that in the long run you can continue with the exercises on your own
• Keep you motivated and guide you through the difficult time, helping you progress towards your goals.

Arm Pain and Neck Pain Treatment In Delhi

 Neck Pain is a pain posteriorly anywhere between the skull base and thoracic spine. It is the largest cause of musculoskeletal disability after low back pain. Approximately two-thirds of the population will suffer from neck pain at some time in their life with high prevalence in middle ages. Fortunately for most people the acute pain resolves within days or weeks although in some it may reoccur or become chronic.

Neck pain may be a result of...

• Local pathology
• Whiplash (flexion-extension) injuries/ trauma
• Be a part of a more widespread systemic problem such as ankylosing spondylitis, rheumatoid arthritis, fibromyalgia etc.
• Be a result of referred pain from neighboring areas for example the shoulder joint

Neck pain usually has a multifactorial etiology -poor posture, neck strain/injuries, anxiety, depression and stress can play a role in magnifying the perceived pain. Quite often the diagnosis of simple or nonspecific neck pain is used implying postural and mechanical causes; this is contrary to other serious causes of neck pain such as fracture, tumour, infection etc.

Pain from upper neck can radiate towards the head leading to frequent headaches and that from the lower part of the neck can radiate to the shoulder, arm, chest wall and the scapula. Reduced neck movement along with localized areas of muscle tenderness known as trigger points are commonly observed along with pain.

Management

Like with other chronic pain conditions, multi-disciplinary management based on the biopsychosocial model of pain is the preferred approach. Please follow these links to find out how medication optimisation, physiotherapy, Psychology and complimentary therapies such as acupuncture TENS and meditation can help.

Read More Blog

Persisting Pain After Knee Replacement

Slipped Disc/ Sciatica Treatment: Non Surgical Pain Relief

Know about Meditation From Best Pain Specialist In Gurgaon

Central Nervous system plays an important role in regulating the signals being transmitted from other body parts. Meditation helps to relax body; mind and can help by reducing the amplification of these signals thus reducing the perceived pain. It can help in developing a positive outlook and getting rid of the negativity which exacerbates perceived pain. Whilst we may not have a choice in the diseases we acquire, we do have a choice in how manage them and meditation can help in this.

Effect of meditation on chronic pain conditions has been the subject of many research studies. In a recent systematic review on the effect of mindfulness on chronic pain the authors concluded that mindfulness meditation is associated with a small decrease in pain. They found statistically significant effects on depressive symptoms and quality of life. This systematic review analyzed 38 randomized controlled trials and the authors suggested that more large-scale studies should be conducted to decisively provide estimates of the efficacy of mindfulness. 

Tag:

• Pain Management in South Delhi
• Pain Specialist in Gurgaon
• Pain Management in Gurgaon

editation Meditation

Other Common Musculoskeletal Conditions

 Tag: Muscuoskeletal Conditions

Tennis/Golfer’s Elbow (Lateral/Medial Epicondylitis)

These are common problems involving staining/overuse of forearm tendons which attach to the bony prominences on the upper arm bone close to the elbow joint. Tennis elbow involves the tendons attaching to the outer side of elbow and repetitive activities involving gripping or twisting of forearm makes this pain worse. It may affect one or more tendons and it’s not uncommon for the pain to radiate down further into the forearm. Golfers elbow involves the tendons on the inner side of elbow.

Treatment involves activity modification, physiotherapy and painkillers. In clinic diagnostic ultrasound scan followed by PRP or steroid injection and physiotherapy can help effectively deal with the condition.

Achilles Tendinopathy

Achilles tendon attaches the calf muscles to the heel bone and is the biggest tendon in the body. It is located behind and above the heel. Overuse or underuse of the tendon can predispose to tendinopathy hence it may be seen in very active people or in those with a sedentary life style. Other predisposing factors include incorrect footwear, poor flexibility, being overweight and sudden increase in physical activities.

Most common symptom is pain behind or just above the ankle with associated stiffness and swelling. Diagnosis can be made with the help of an ultrasound scan. Conservative management involves rest, activity and footwear modification, weight management, medications and physical therapy. Tendon sheath PRP or steroids injections under ultrasound guidance, extracorporeal shockwave therapy are reserved for those not responding to conservative management.

Plantar Fasciitis

Plantar Fascia is a tissue band in the sole of foot which stretches from the front part of heel to the toes. It works like a shock absorber playing an important role in pushing the foot off from the ground during walking. Repeated stress/ injury to the fascia can lead to a condition called plantar fasciitis, which present as pain on the underside of heel worse on taking first few steps after a period of rest. Risk factors include using footwear with poor cushioning, being overweight, sudden change in activity levels, and calf muscle tightness.

The diagnosis is made by history, clinical examination and is aided by an ultrasound scan. Ultrasound can help in identifying any partial tears, fascia rupture and any foci of calcification or calcaneal spurs. An x-ray may be requested to rule out any bony spurs.

Conservative management involves

• Using correct footwear with shock absorbing sole and arch support
• Rest/ activity modification
• Physiotherapy involving stretching of plantar fascia and achilles tendon
• Night splints
• Painkillers
• Weight management and
• Ultrasound guided injections - Platelet Rich Plasma (PRP) or steroid are reserved for patients with a poor response to conservative management.

De Quervain’s tenosynovitis

This condition results from irritation of two tendons as they travel in close proximity to each other in their course from the wrist towards the thumb. Irritation results in inflammation, swelling and thickening of the tendons or their covering sheath impacting their ability to glide freely during wrist and thumb movements. It is seen more commonly in women and presents as pain, swelling at the base of thumb, wrist.

Treatment involves rest, splints, medications, physiotherapy and if not responding to conservative measures then steroid injection. Ultrasound scans can help in verifying the diagnosis and precise injection of steroid to reduce the pain.

Injections for proximal hamstring tendinopathy & ischial bursitis

Hamstrings are a group of muscles present at the back of thigh. They extend from the pelvis (ischial tuberosity) to the knee and play an important role is everyday activities such as bending or running. Muscles attach to the bones with the help of a special type of tissue called tendons. With overuse, misuse or injury, these tendons can get inflamed, torn leading to development of a condition called tendinopathy. Involvement of proximal part of hamstrings presents as buttock pain radiating down the back of knee. Pain may be worse on sitting on a firm seat. Sciatic nerve is present close by and its irritation can cause pain to radiate further down the leg.

Condition such as unequal leg length, core and pelvic muscle weakness, being overweight and repeated overloading with insufficient warm up predispose to development of hamstring tendinopathy. Higher incidence is seen in runners, football players, dancers and older adults who do a lot of walking.

Treatment options include rest, activity modification, physical therapy and medications. If these fail to produce desired results then injections with Platelet Rich Plasma (PRP), autologous blood (ABI) or steroids are considered. Percutaneous tenotomy is another option. Injections are performed under ultrasound guidance in the peritendinous region. Direct injection into the tendons is avoided. These are performed under local anaesthesia as an outpatient procedure or a day case.

Platelet Rich Plasma (PRP)

Platelets are one of the blood components. They help in clotting and contain growth factors which promote the healing process. PRP is a blood plasma with concentrated platelets. PRP therapy is an attempt to utilise body’s natural ability to heal itself. It is utilised for tendon or ligament injuries which have not responded to conservative measures such as tennis elbow, golfer’s elbow, plantar fasciitis, achilles tendinosis.

The procedure involves collecting a blood sample from the patient which is then placed in a spinning machine to separate different blood components. The component containing high platelets is separated and then injected at the intended site under ultrasound guidance. Most people require 1-3 injections at 4 weekly intervals depending on the response. Growth factors are released from the platelets influence the process and accelerate the repair of tendon or ligaments.

Trigger Point Injections

Muscles ability to contract and relax plays an important role in body functioning. When muscles fail to relax, they form knots or tight bands known as trigger points. In simple words trigger points are irritable areas/ bands of tightness in a muscle. Pressure over a trigger point produces local soreness and may refer pain to other body parts. Common causes include inflammation, injury of the muscle or the neighbouring structures. Poor posture and repetitive strain are other predisposing factors. Trigger points can limit the range of movement; affect posture predisposing other areas to unaccustomed strain. They are more commonly observed in head, neck, and shoulder muscles.

Trigger point injections are performed in an outpatient/ day-care setting and the procedure involves injecting local anaesthetic with or without a small dose of steroid into the painful muscle. The local anaesthetic blocks the pain sensations and the steroids help in reducing the inflammation, swelling. I prefer to perform these injections under ultrasound guidance as it improves the accuracy and reduces the chances of complications. Post injection physiotherapy is essential to prevent recurrence and maximise the benefits.

Read More Blog:

• Pain Treatment in Delhi
• Diabetic Pain Treatment in Delhi
• Cancer Pain Treatment In Gurgaon
• Back Pain Treatment In Gurgaon

Complex Regional Pain Syndrome (CRPS)

 Complex Regional Pain Syndrome (CRPS) is one of the causes of persisting limb pain. It can occur after surgery or injury and sometimes the injury is so trivial that you may not even remember it. In other cases the injury may be more severe with or without nerve damage. The pain however lasts much longer and is more severe than expected. It can range from mild self-limiting to chronic debilitating condition affecting activities of daily living and quality of life. The reason why CRPS develops is unclear and multiple mechanisms are thought to be involved. A combination of signs and symptoms is used to make the diagnosis as there is no specific diagnostic test. Investigations are helpful to exclude other conditions such as infection and rheumatologic conditions which may have similar presentation.

 

Pain in CRPS is accompanied by other signs and symptoms such as

• Hypersensitivity of the affected limb
• Swelling, abnormal sweating
• Involved limb may feel unusually cold or warm with or without colour changes
• Nail, skin and hair changes
• Stiffness, weakness, abnormal tone of muscles and jerky movements

Management

The aim in CRPS management is pain control and functional recovery. Early diagnosis and treatment using multi- disciplinary approach is preferred. Your pain management specialist may recommend interventions such as intravenous drug infusions, sympathetic blocks such as stellate ganglion block or lumbar sympathetic blocks and neuromodulation. These are used in combination with medications, physiotherapy and psychology input.  

Medications prescribed depend on the phase of disease and the predominant symptoms. A combination of anti inflammatory drugs, neuropathic medications and opioids is commonly utilised. Some other medications including bisphosphonates, free radical scavengers (topical 50% dimethylsulfoxide- DMSO), oral steroids etc. may also be used.

Your physiotherapist will teach you desensitisation techniques if the limb sensitivity is increased. It helps in preventing problems due to weakening and reduced usage of the affected limb. Strengthening exercises are incorporated as the pain is adequately controlled. He may consider specialist interventions such as mirror therapy or graded motor imagery if indicated.

Read Another Blog

Shoulder Pain Treament In Gurgaon

Cancer Pain Treament In Gurgaon

Elbowing the tennis elbow pain out of your life – Information Leaflet on Tennis Elbow

 Tags >> causes the tennis elbow, symptoms of tennis elbow,  Tennis Elbow Treatment in Delhi, Pain Management Centre in Delhi, pain specialist doctor in Delhi

This leaflet has been written to help you understand more about your elbow problem. It is not intended to be a substitute for professional medical advice and should be used in conjunction with the information provided by your treating doctor.

What is tennis elbow?

Tennis elbow or lateral epicondylitis is a common cause of elbow pain. It presents with pain along the bony bump on the outer side of the elbow. This bony bump provides attachment to the muscles on the back of the arm which play an important role in lifting of the wrist and fingers (extension).

What causes the tennis elbow?

Tendons can be viewed as springs that make muscle movement more efficient. Repeated sudden overloading of forearm tendons and muscles can lead to small tears & degenerative changes. Generally both overloading and under loading of tendons can be bad. When exposed to excessive stress they try to adapt but if the load is too excessive or too sudden, it can predispose to the beginning of the degenerative process. On the other side under loading of tendons can predispose them to becoming thinned out/ weak (atrophic).

More often tennis elbow is seen in people with sedentary life style when then begin overloading the tendons by undertaking new activities such as exercising at the gym, gardening, lifting a baby etc. Some of the risk factors include

• Age– most common between the ages of 30 to 50, although can affect all ages
• Occupation and certain sports – Now days it is more commonly caused by excessive computer usage and spending long hours at keyboard. Repetitive forearm actions such as using screwdrivers can predispose to developing the condition. Professionals such as plumbers, carpenters are hence more prone. Poor backhand technique in tennis can also predispose although one does not have to be a tennis player to develop the condition.

What are the symptoms of tennis elbow?

This condition generally presents with varying degree of pain on the outer side of elbow. The pain can radiate downwards towards the forearm & wrist. The outside of your elbow may be very tender to touch. As the pain increases it can interfere with routine activities such as turning a doorknob, holding a cup of tea or gripping objects.

How is tennis elbow diagnosed?

Your doctor will take a detailed history and examine your elbow, wrist, neck & shoulder. Examination may involve applying pressure to the affected area or asking you to move your elbow, wrist and fingers in different directions. In majority of cases the diagnosis can be made based on medical history and physical examination. Your doctor may request for other tests to confirm the diagnosis or rule out other conditions with similar presentation. These may include

• Ultrasound Scan– This can be used to confirm the diagnosis and if required an injection can also be performed at the same time.
• X-ray. This is used more often when there is history of injury or to rule out elbow arthritis.
• MRI scan– This can help your doctor to evaluate if a neck problem such as herniated disk or neck arthritis is responsible for your symptoms.

How is tennis elbow managed?

The treatment option will vary depending on multiple factors such as the duration of symptoms, severity & impact on your daily activities, previous treatments and their results.

Tennis elbow can be self-limiting and hence if the symptoms are mild your doctor may suggest conservative management to see if the condition gets better on its own. It may however take weeks or months for the pain to go away completely. Some studies report average duration of a typical episode is to be between six months and two years.

Treatments are aimed at reducing the load/stress on tendons; reducing the pain and preservation of movement, grip strength. Treatment options include-

• Rest. This includes avoidance of provoking activities and heavy work with the affected arm for several weeks. Gel wrist pads while working on computers can be helpful to reduce stress on the tendons.
• Ice pack – It can help to reduce the pain and swelling. Avoid applying the ice directly to the skin as this reduces the chances of frostbite. Ice can be wrapped in a towel and used for a few minutes (as tolerated), 3- 4 times in a day.
• Elbow brace – An elbow splint/brace can help provide support and limit the stress/movements, aiding the process of healing. Use the brace when the arm is being used and it can be taken off at night time.
• Medications – Pain killers can provide temporary relief and may include anti-inflammatory medications. It is important to use these medications as directed by your doctor.
• Physiotherapy – It is important to stretch the muscles of the hand and forearm, in order to prevent the development of stiffness and increase the flexibility. Physiotherapy can also help in the strengthening of these muscles. Exercises are best learned under supervision of an experienced therapist. Once you have learned the correct technique, you can continue these at home.
• Extracorporeal shock wave therapy (ESWT) – This uses energy of strong sound waves at specific frequencies to create microtrauma that promotes the body’s natural healing processes. It is a non invasive treatment which involves placing the wave generator on the overlying skin to deliver the treatment. Some studies show that it can be beneficial whereas others not shown significant difference. This option is more likely to be used if there are calcium deposits in the degenerated tendons.

In case the pain does not settle, then your doctor may consider injections in order to provide pain relief. These may include

• Dry needling — This is best performed under ultrasound guidance and involves piercing the damaged tendon with a needle to reinitiate the healing process.
• Platelet-rich plasma (PRP) injection. PRP is prepared from a patient’s own blood and contains high concentration of proteins called growth factors that play an important role in the healing. When tissue injury occurs, platelets collect at the site of injury and start the repair process. In PRP injection we collect a blood sample and spin it in a machine to separate the platelets with the growth factors. This concentrated preparation is then administered close to the injury site. It is a safe procedure which tried to emulate the natures healing process. Some studies have shown that this form of treatment is associated with more favourable long term results.
• Steroid injections Steroids are effective anti-inflammatory medicines. Your doctor may consider injection in the painful area around your lateral epicondyle with a steroid to relieve your symptoms. These injections can help in short term pain control.

Surgery– this is rarely required and is considered for persisting problems significantly impairing the quality of life.