Pinched Nerve Treatment
Once a pinched nerve is diagnosed through history, physical exam, and imaging studies, a treatment plan is created. Treatment generally begins with addressing symptoms through conservative, non-invasive options and may include a combination of options. These options include alternative therapy, medication, physical therapy, injections, and lifestyle modifications.
The traditional way to perform a spine surgery is also called an open spinal surgery, which uses a large incision with a great amount of tissue and muscle disruption. Minimally invasive surgeries are performed through a small incision with minimal disruption of the surround muscle tissues, to allow for faster healing and return to normal activities. There are several different surgical options available to address pinched nerves. Surgical options will vary by location and the cause of the pinched nerve. Both decompressive and stabilization procedures may be performed, but it depends on the area of the spine and the causative factor of the pinched nerve. Conservative therapy is typically initiated before surgical therapy, in the majority of patients.
Certain lifestyle factors may increase the incidence of a pinched nerve, such as smoking and increased weight. Smoking decreases blood flow throughout the body which is needed to repair damaged tissues, including those around a compressed nerve. Cessation may restore blood flow, allowing the tissues to access proper nutrition. Added weight may increase the risk for disc herniation which may pinch the nerve, or the acceleration of the aging process, leading to pinched nerves. Reducing weight through a low-calorie diet and exercise can reduce pressure on the spine, decreasing the symptoms of a pinched nerve.
Repetitive leisure or work-related motions such as excessive bending, lifting, and twisting, along with any activity that may be high impact on the spine, such as running or riding ATVs, can also lead to pinched nerves. Some of these repetitive task activities may be due to leisure and others due to demands of a job. For people with full labor or heavy-duty jobs, you may need to change jobs or support your work with proper lifting technique, relaxed breaks, and equipment such as a back brace to avoid worsening symptoms. You may also need to alter or avoid high impact activities, such as running to reduce the symptoms of a pinched nerve.
Alternative therapies include massages, chiropractic care, and acupuncture. These may also be referred to as manual therapies since they address the spine with hands on technique. Massage relieves tension in muscles surrounding the spine and in arm and leg muscles experiencing radiating symptoms. These muscles may be under tension due abnormalities with walking and changes in posture due to pain from a pinched nerve. Chiropractic care may use specific techniques, such as adjusting the spine or application of traction on the spine. Acupuncture may also provide pain relief as muscles are stimulated electrically.
Physical therapy focuses on changing body mechanics to improve posture and walking as well as to strengthen and retrain muscles, particularly those in the core. The initial step is meeting with a Physical Therapist for a consultation to assess posture, gait, and muscle weakness and to design a personalized exercise program. Other techniques that physical therapists may use are manual treatments such as massage, ultrasound, and electro-stimulation through a TENS (transcutaneous electrical nerve stimulation) unit. A combination of these methods can provide symptom relief.
A home exercise program may be used in conjunction with or instead of a formal physical therapy regimen. A daily low impact exercise regimen is important for strengthening muscles, especially those in the core. Low impact cardiovascular activities such as walking, swimming, elliptical, and biking are also important for increasing blood flow and strengthening muscles without adding stress on the spine. Home exercise can also lead to weight loss which may reduce pressure on the spine and reduce symptoms. Home exercise routines should be paired with stretches and physician supervision to avoid harm.
There are multiple types of prescribed and over the counter medications that may be used to treat the symptoms of a pinched nerve. Some of these medications include Tylenol (acetaminophen), NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, nerve membrane stabilizers, topical medications, and off label medications.
Common over the counter medications are acetaminophen and NSAIDs. Acetaminophen is considered an analgesic, meaning it relieves pain but does not reduce inflammation. NSAIDs are effective at both relieving pain and reducing inflammation; they can be found in brand and generic forms over the counter. These medications are best taken with food to avoid an upset stomach. They can be taken for longer durations, as long as there is no history of kidney disease. The mechanism of both NSAIDs and Acetaminophen differ, so they are taken together often to combat pain.
Topical medications may also relieve pain and are available in over the counter and prescription variations. Common over the counter formulations are Salonpas, Icy Hot, Bengay, and Aspercream, which bring localized pain relief to the location where they are applied. Prescription topical medications also provide localized relief and include lidocaine, a numbing medication, and Diclofenac (Voltaren), an anti-inflammatory medication. Topical medications are good options for those that want to avoid or are unable to take oral medications.
Muscle relaxants are used to provide relief from muscle spasms and increase range of motion; they are best used in combination with physical therapy or an exercise/stretching regimen. Drowsiness is a common side effect of muscle relaxants and they are not recommended while driving or working. Common muscle relaxants include Flexeril, Soma, Baclofen, Robaxin, and Tizanidine.
Nerve membrane stabilizers are another class of medications often used to treat the numbness, tingling, shooting, stabbing, or radiating pain associated with a pinched nerve. Gabapentin (Neurontin) and Lyrica (Pregabalin) are commonly prescribed nerve membrane stabilizers and work by reducing pain signals released by nerves. Both medications, Gabapentin especially, can be taken in higher dosages multiple times per day, but this class of medication may cause dizziness and drowsiness. Nerve membrane stabilizers are typically started on a low and infrequent dose; the dosage is gradually increased until the pain is controlled and then gradually decreased prior to discontinuation.
There are other medications that may be used ‘off-label,’ meaning not for the use listed on the label. Some common medications used off label for pain are anti-depressants, such as Cymbalta and Amitriptyline. Similar to the nerve membrane stabilizers, these medications are slowly increased in dosage and they also target nerve-type pain, such as burning, numbness, and tingling associated with nerve pain. They may also cause drowsiness and are usually used at night for pain control.
Epidural Steroid Injections
Epidural steroid injections reduce pain by injecting steroid, or anti-inflammatory, medication at a specific level/levels in the spine. As the herniation places pressure on a nerve, this causes inflammation of the nerve and surrounding tissue which causes pain. A specialized needle is used to deliver medication to the correct area, past the muscles of the back and as close to the spinal nerves as possible. As steroids are a natural anti-inflammatory, this may reduce the inflammation around the nerve, diminishing pain caused by the disc herniation. Steroid injections have the ability to provide pain relief for up to several months, and provide better pain relief for radiating symptoms, such as leg pain, than treatments designed for back pain alone. Steroid injections are only safe to have completed 3 times in one year and must be at least one month apart between sequential injections. This is due to the muscle and tendon breakdown with exposure to the steroid medication too often or too soon.
A foraminotomy is a minimally invasive surgical decompression procedure that is performed in the cervical spine to alleviate the compression on a cervical spinal nerve from a pinched nerve. This may be due to bone spur formation or a disc herniation. This procedure is performed through a small midline incision on the back of the neck. A small amount of bone from the back of the vertebrae is removed, called the laminae, so opening for the spinal nerve, the foramen, is reached. The compression is alleviated either by removing disc material or bone spurs that are pinching the nerve. Once the nerve is decompressed, the incision is closed and the procedure is completed.
An ACDF is a minimally invasive surgical stabilization procedure. This is performed through a small incision on the front of the neck. The surgeon tunnels between the thin neck muscles until the spinal column is reached. The old disc is removed and once removed, any contents can be removed around the nerve roots to relieve the pinched nerve. A special implant with bone graft will then be placed in the disc space with screws to secure placement. Once the procedure is completed, the disc level is fused.
A cervical disc replacement is a minimally invasive surgical stabilization procedure that is performed similarly to the ACDF, however the implant is slightly different, as it preserves some motion of the cervical spine instead of creating a fusion in the ACDF. The pinched nerves are alleviated through the removal of the disc material.
Lumbar (and Thoracic)
A microdiscectomy is a minimally invasive surgical decompression procedure that is typically performed on both the thoracic and lumbar spine to address disc herniations, which cause pinched nerves. A small incision is made in the midline of the back until the backside of the vertebrae, laminae, is reached. At this point, a small amount of the laminae is removed until the pinched spinal nerve is well visualized. The compression on the nerve is removed and once completed, the incision is closed.
Endoscopic discectomy is a minimally invasive surgical decompression procedure that uses specialized instrumentation to remove a disc herniation, which is a source or pinched nerves. A small incision is made on the midline of the back and the use of specialized imaging, called a fluoroscope is used. After the incision is made a thin wire, called the guide wire, is placed until it hits bone. A series of small cylindrical tubes are then placed over the guide wire to dilate the tissue and a retractor is placed over the cylinders and the cylinders are removed. A light source is place down the retractor and instruments are placed down through the retractor to remove the disc fragments pushing on the nerve. The retractor is then repositioned, so that the compression can be removed around the nerve on the opposite side of the body. The instruments are removed and the surgery is completed.
A transverse lumbar interbody fusion (TLIF) is a minimally invasive stabilization procedure that uses a specialized implant to fix the appropriate disc level. This procedure is performed through a small incision on the midline of the lumbar spine. Once the spine is reached, the backside portion of the vertebrae is removed, the laminae, until the nerve is reached and the compression on the nerve is removed. The disc material is removed from the disc space and a special implant with bone graft is placed into the disc space with screws placed into the vertebral body above and below the disc space, that are connected via rods. Once the procedure is complete the spinal level is fused.
An extreme lateral lumbar interbody fusion, or XLIF, is a minimally invasive surgery that is performed on the lumbar spine. A small incision is made on the left side, between the hip and the ribs. A thin wire, called a guide wire, is placed and sequentially cylindrical tubes, called dilators are placed through the psoas muscle to reach the left side of the spine. Once the spine is reached, the disc is then completely removed. A special implant is sized, filled with bone graft and placed in the empty disc space. The implant is then screwed in place, with screws placed into the upper and lower vertebral body to provide structure. This will fuse and stabilize the level to prevent any further motion. The XLIF can only be performed on certain levels in the lumbar spine, as the space between the hip and lowest rib is limited, even with specialized positioning of the body on the surgical table.
All procedures used to alleviate the symptoms and structural problems from pinched nerves are minimally invasive decompressive and stabilization procedures. The spinal nerve roots are decompressed properly any mal-aligned vertebral body is stabilized to prevent further motion. Multiple factors are taken into consideration to plan an appropriate surgical option to treat the structural problems associated with a pinched nerve.
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