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Point/Counterpoint

Guest Discussants: Sayed E Wahezi, MD, Andrew Lederman, MD, Eric H Elowitz, MD Feature Editor: Jaspal Ricky Singh, MD

Conservative Treatment Versus Surgery for Lumbosacral Radiculopathy with Muscle Weakness and Loss of Reflexes

What is radiculopathy?

A compressed or irritated nerve in the spine can cause pain, numbness, tingling, or weakness along the path of the nerve. This condition is called radiculopathy. It can occur in any part of the spine, but it is most common in the low back (lumbosacral radiculopathy, sometimes called sciatica) and neck (cervical radiculopathy). Patients involved in heavy labor or contact sports are more prone to develop radiculopathy than those with a more sedentary lifestyle.

What causes radiculopathy?

Spinal disks are located between each vertebra of the spine, acting as shock absorbers when the body moves. A disk is made up of a tough fibrous outer surface with a soft, gel-like inner substance. A forceful movement can injure the lumbar spinal disks, or repetitive straining can gradually damage them over time.

With a mild injury, the disk can be stretched or pinched. With a more severe injury, the outer surface can be weakened, allowing the substance inside to push towards the outside. This is known as a bulging or herniated disk. Disk herniation reduces the amount of space in the spinal canal and compresses the exiting nerve. This is called “mechanical radiculopathy.”

With further damage, the outer surface can tear, and the disk fluid inside might leak out. This is known as a complete herniation or extrusion. The disk material may then irritate nearby nerves as they exit the spinal cord. This is called “chemical radiculopathy.”

How is radiculopathy diagnosed?

A physician will begin by asking the patient his or her medical history and performing a physical examination. During the medical history, the doctor asks questions about the type and location of symptoms, how long they have been present, and what makes them better and worse.

By knowing the exact location of the patient’s symptoms, the doctor tries to determine the nerve that is responsible for the pain. Neurological tests are performed to determine loss of sensation and motor function. Abnormal reflexes and muscle weakness may indicate a source of the radiculopathy.

Imaging may also be useful for diagnosis. Plain X-rays can often see the presence of trauma or osteoarthritis and early signs of tumor or infection. A magnetic resonance imaging (MRI) or computed axial tomography (CAT) scan looks at the soft tissues (nerves, muscles, etc.) around the spine to determine possible compression of the nerves. In some cases, the doctor may order an electromyogram (EMG) which can show if there is damage to the nerve.

How is radiculopathy treated?

Most radiculopathy symptoms go away with conservative treatment such as anti-inflammatory medications, physical therapy, chiropractic treatment, and avoiding activity that strains the neck or back. Symptoms often improve within 6 weeks to 3 months. If radiculopathy symptoms do not improve with conservative treatments, patients may benefit from an epidural steroid injection (ESI), which reduces the inflammation and irritation of the nerve. Read more about ESIs.

If the symptoms continue despite all the above treatment options, surgery may be an option. The goal of the surgery is to remove the compression from the affected nerve. Depending on the cause of the radiculopathy, this can be done by a diskectomy or microdiskectomy.

A diskectomy removes the part of the disk that has herniated out and is compressing a nerve. In microdiskectomy (or microdecompression) spine surgery, a small portion of the disk and disk material impinging the nerve root is removed to provide more room for the nerve to heal.

In the June 2015 issue of Pain Management and Rehabilitation Journal, three physicians shared differing opinions about treatment for lumbosacral radiculopathy with muscular weakness and loss of reflexes. A patient’s case is presented here, followed by a debate as to the best treatment plan. Drs Sayed Wahezi and Andrew Lederman will argue that a conservative treatment plan will help the patient regain full function. Dr Eric H Elowitz suggests that surgery will provide the best outcome.

Sayed E Wahezi, MD, and Andrew Lederman, MD, respond

Logan’s treatment plan is up for debate because current literature supports both nonsurgical and surgical intervention.

Logan has persistent weakness, and his pain is going away. We recommend an ESI because Logan likely has chemical radiculitis. The painful symptoms already have subsided, and motor recovery will likely follow. If a compressed nerve were the cause, the pain would likely persist.

Logan’s case is an example of a complete herniated disk. The herniated disk is the cause of Logan’s muscle weakness. Understanding the composition of the extruded disk material is critical to understanding our case.

Herniated disk material is primarily the gel-like substance that cushions the vertebrae. Due to its chemical composition, this material promotes inflammation. When it comes into contact with the nerve root, nerve pain occurs. We will demonstrate that Logan’s symptoms indicate chemical radiculitis as the cause of his radiculopathy.

As in Logan’s case, radiculopathy with muscle weakness is likely caused by nerve damage. Chemical radiculopathy causes nerve damage due to the direct contact of the thick disk material with the nerves, causing inflammation and decreasing normal neural transmission [1,2]. The nerve heals as the disk herniation recedes from the nerve and the chemical irritants go away. Chemical radiculopathy usually responds well to conservative treatment, while mechanical radiculopathy may not.

A complete disk herniation, as in Logan’s case, often improves without

surgery because of the absorption of the disk material back into the body. In clinical practice, most disk herniations with muscle weakness are caused by inflamed nerves rather than compression. This is substantiated by most patients whose symptoms improve with conservative treatment alone.

Epidural steroid injections (ESIs), physical therapy, and oral anti-inflammatory medicine are important in treating chemical radiculopathy because they all help reduce inflammation [13]. ESIs decrease the chemical irritation to neighboring nerve roots.

Some investigators have even demonstrated the effectiveness of ESIs without steroids, which supports the theory that diluting or “washing away” inflammation-inducing material adjacent to a nerve also could reduce symptoms [6]. Physical therapy may improve spinal blood flow as well as cerebrospinal flow, adding to the washout concept [7]. Finally, oral anti-inflammatory medicine improves the local inflammation [8].

The decision to perform surgery is a clinical one; we must consider the type of herniation, partial or complete herniation, as well as the patient’s pain state. I believe that current evidence and research suggests that physicians should use conservative therapy in cases of mild weakness before considering surgery.

In Logan’s case, he has chemical radiculitis with mild muscle weakness.

His MRI, which depicts a disk extrusion, and his pain that went away on its own, both support this diagnosis. An ESI may reduce local inflammation, ultimately leading to resolution of his chemical radiculopathy.

We must also consider the cost of the services we offer our patients. A head-to-head cost analysis favors conservative, non-surgical treatments, including ESI, physical therapy, and potentially oral medications, for this patient.

Disk extrusions often improve on their own. A trial of ESI has a better chance of improving short-term outcomes than worsening long-term outcomes [5,9]. Furthermore, Logan’s other factors support conservative therapy; his young age, new symptoms, mild muscle weakness, and the limited number of muscles involved all favor a good prognosis without surgery [3,4].

If we were treating this patient, we would closely monitor Logan’s weakness and schedule Logan for an ESI. At this point, we are comfortable watching Logan’s neurologic function, and if there is no return of strength or even progression of weakness in the ensuing 4-6 weeks, we would then consider surgery.

References

  1. Saal JS, Franson RC, Dobrow R, Saal JA, White AH, Goldthwaite N. High levels of inflammatory phospholipase A2 activity in lumbar disc herniations. Spine (Phila Pa 1976) 1990;15: 674-678.
  2. Mulleman M, Mammou S, Griffoul I, Watier H, Goupille P. Pathophysiology of disk-related sciatica. Evidence supporting a chemical component. Joint Bone Spine 2006;73:151-158.
  3. Aono H, Iwasaki M, Ohwada T, et al. Surgical outcome of drop foot caused by degenerative lumbar diseases. Spine (Phila Pa 1976) 2007;32:E262-E266.
  4. Matsui H, Kanamori M, Kawaguchi Y, Kitagawa H, Nakamura H, Tsuji H. Clinical and electrophysiologic characteristics of compressed lumbar nerve roots. Spine 1997;22:2100-2105.
  5. Dubourg G, Rozenberg S, Fautrel B, et al. A pilot study on the recovery from paresis after lumbar disc herniation. Spine (Phila Pa 1976) 2002;27:1426-1431.
  6. Manchikanti L, Singh V, Cash KA, Pampati V, Falco FJ. The role of fluoroscopic interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: A randomized, double-blind trial. Pain Pract 2013;13:547-558.
  7. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome study. Spine 1989;14:431-437.
  8. Vane J. The evolution of non-steroidal anti-inflammatory drugs and their mechanisms of action. Drugs 1987;33(Suppl 1): 18-27.
  9. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: A systematic review. Clin Rehabil 2015;29:184-195.
Eric H Elowitz, MD, responds

The management of Logan’s condition can be quite controversial. Although his muscle weakness can sometimes appear trivial to the examiner, it can have an adverse impact on function and self-image in active patients. Herniated lumbar disks, one of the most common problems seen by physicians, can produce back pain and other symptoms, including lower extremity pain, numbness, and weakness.

The treatment recommendations for a patient with a herniated disk are based on the initial physical examination, as well as MRI images. Therapeutic options include physical therapy, EPIs, oral steroidal and nonsteroidal anti-inflammatory medications, and surgery [1,2]. Although herniated lumbar disks are common, there is no standard for the timing and order of these therapeutic options [3,4].

Logan is a young, active man with radiculopathy. He is unable to perform a single-leg heel raise, and his MRI scan indicates an extruded disk herniation with S1 nerve root compression. Patients with muscle weakness are clearly more of a treatment concern than those who present with pain alone. In fact, Logan no longer has pain.

Although most patients with herniated disks should initially be treated nonsurgically [5], early surgical intervention can be beneficial for select patients [6]. I believe that, in Logan’s case, a minimally invasive microdiskectomy would be the best treatment.

The Spine Patient Outcomes Research Trial (SPORT) assessed the efficacy of surgery in patients with herniated lumbar disks [5]. Eligible patients were assigned to either the surgery or nonsurgical treatment groups; however, patients could crossover between groups. Patients in both the nonsurgical as well as in the surgery groups achieved substantial improvement over 2 years. A follow-up study of patients at 4 years found that those who underwent surgery achieved greater improvement than patients who did not undergo surgery [7].

Logan has muscle weakness caused by extruded disk herniation. Few studies specifically address the timing of surgery in such patients. Studies by Aono et al [8] and Postacchini et al [9] evaluated the recovery of motor function after a microdiskectomy. Overall, there was a full recovery in muscle strength in 84% of patients with mild muscle weakness and 61% with severe muscle weakness. Regarding the timing of surgery, all patients with a severe deficit undergoing surgery within 1 month of the onset of weakness had a complete recovery in contrast to those undergoing surgery after 70 days, where most had an incomplete recovery of

muscle strength. This finding would argue for early surgery in patients with a severe deficit.

A review of patients with muscle weakness who underwent surgery showed a significant improvement in strength [10]. Maximal recovery occurred within 6 weeks in most the patients.

In evaluating patients with radiculopathy and muscle weakness, I take several factors into consideration. Clearly, the degree of weakness as well its functional impact on Logan must be weighed. One can assume that Logan is a high-level functioning young man who would find even a mild residual muscular weakness and loss of reflexes to be unsatisfactory. In such a patient, I would be much more inclined to recommend surgery earlier rather than later to decompress the nerve root.

Another factor is the MRI findings. I would lean more toward early surgery in patients with a disk herniation or an extruded fragment that is causing significant nerve root compression. In patients with smaller herniations or less-obvious nerve root compression, I would feel more comfortable in nonsurgical measures initially.

Another factor arguing for surgery in Logan’s case is the safe and minimally invasive nature of modern-day microdiskectomies [11,12]. This surgery is provided on an outpatient basis, and most patients can return to work within a week. The recurrence rates are low, generally in the 3-5% range, and the

complication rate is extremely acceptable.

Treating a herniated lumbar disk must be customized to the patient and have a clear goal in mind. For Logan, the goal would be an improvement in his motor strength to prevent permanent disability. As such, I recommend an early microdiskectomy rather than nonsurgical treatment to maximize his chance of a complete recovery.

With this approach, the nerve root would have an opportunity to heal and subsequent treatment, such as a physical therapy, may have a better chance of success in regaining his strength. Ultimately, the decision would have to be one shared between the physicians involved and Logan with a clear understanding of the treatment goals.

References

  1. Gregory DS, Seto CK, Wortley GC, Shugart CM. Acute lumbar disk pain: Navigating evaluation and treatment choices. Am Fam Physician 2008;78:835-842.
  2. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine 1989;14:431-437.
  3. Legrand E, Bouvard B, Audran M, Fournier D, Valat JP. Spine Sec tion of the French Society for Rheumatology. Sciatica from disk herniation: Medical treatment or surgery? Joint Bone Spine 2007; 74:530-535.
  4. Sharma H, Lee SWJ, Cole AA. The management of weakness caused by lumbar and lumbosacral nerve root compression. J Bone Joint Surg Br 2012;94-B:1442-1447.
  5. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonopera tive treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA 2006; 296:2441-2450.
  6. Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW; Leiden-The Hague Spine Intervention Prognostic Study Group. Prolonged conservative care versus early surgery in patient with sciatica caused by lumbar disc herniation: Two year results of a randomized controlled trial. BMJ 2008;336:1355-1358.
  7. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar disc herniation: Four-year results for the spine patient outcomes research trial (SPORT). Spine (Phila Pa 1976) 2008;33:2789-2800.
  8. Aono H, Iwasaki M, Ohwada T, et al. Surgical outcome of drop foot caused by degenerative lumbar diseases. Spine (Phila Pa 1976) 2007;32:262-266.
  9. Postacchini F, Giannicola G, Cinotti G. Recovery of motor deficits after microdiscectomy for lumbar disc herniation. J Bone Joint Surg Br 2002;84-B:1040-1045.
  10. Ghahreman A, Ferch RD, Rao P, Chandran N, Shadbolt B. Recovery of ankle dorsiflexion weakness following lumbar decompressive surgery. J Clin Neurosci 2009;8:1024-1027.
  11. Dasenbrock HH, Juraschek SP, Schultz LR, et al. The efficacy of minimally invasive discectomy compared with open discectomy: A meta-analysis of prospective randomized controlled trials. J Neu rosurg Spine 2012;452-462.
  12. Parikh K, Tomasino A, Knopman J, Boockvar J, Ha¨rtl R. Operative results and learning curve: Microscope-assisted tubular microsurgery for 1- and 2- level discectomies and laminectomies. Neuro surg Focus 2008;25:E14.
Keywords

Chemical radiculopathy: With a complete disk herniation, the outer surface can tear, and the disk fluid inside leaks out; this disk fluid irritates the nearby nerves as they exit the spinal cord.

Compressed nerve: Sometimes called a pinched nerve, this condition is caused when if a spinal disk weakens or tears and puts pressure on a spinal nerve.

Mechanical radiculopathy: When disk herniation reduces the amount of space in the spinal canal and compresses the exiting nerve.

Motor function: The ability of the nerves to convey sensory and motor impulses to the body.

Radiculitis: Terminology used to describe the neurological symptoms felt as a nerve is pinched, compressed, irritated, or inflamed.

Radiculopathy: A set of conditions in which one or more nerves do not work properly, resulting in pain, weakness, numbness, or difficulty controlling specific muscles.

Spinal nerve: A nerve that carries motor, sensory, and autonomic signals between the spinal cord and the body. There are 31 pairs of spinal nerves, one on each side of the vertebral column.

Vertebrae: The bones that make up the spinal column. In between each vertebra lies a disk.

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