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 nerve 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 within 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 the patient is positioned on the x-ray table. Monitors for recording 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 anesthetic 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.

Tag = Cervical Pain Treatment in India

What are the latest treatment options for hip joint pain treatment in India?

 

What is hip osteoarthritis (OA) and why does it hurt?

Osteoarthritis is the commonest form of arthritis and is a common cause of hip pain, especially amongst older people. It affects about 7% of men and 10% of women over the age of 45 years.

The main problem in this condition is the degeneration of the cartilage covering the ends of the bones. The loss of cartilage and its shock absorbing, cushioning effect leads to the bones coming closer to each other and their thickening in an attempt to protect the joint. Bony growth called osteophytes form around the joint edges. The joints and the surrounding ligaments, tissues may also develop swelling (inflammation).

Pain in arthritis may result from

• Inflammation (swelling) of joints
• Damage of joint tissues
• Overloading of surrounding structures such as the muscles and ligaments
• fatigue and extra effort required in mobilisation

Many people are not able to able to identify the symptoms of hip arthritis and often ignore it as a minor injury which would heal in a few days. They are unable to appreciate that the arthritis pain is not the same and cannot be treated like any other injury pain. Some of the other causes of hip pain include

• Rheumatoid arthritis. This is an inflammatory condition which can involve the hip join, although is less common compared to OA. It is seen more in middle aged or elderly women.
• Avascular necrosis (AVN) – In this condition the bone forming head of the thigh bone (femur) dies leading to bone collapse and severe hip damage.

What all are at risk of developing hip arthritis?

There are several factors that contribute to one’s chances of is developing this condition. These can be classified as those related to an individual and those related to the joint.

Individual factors include

• Age over 50 years
• Being overweight
• Gender. Below the age of 50 years hip OA is more prevalence in men in, whereas above the age of 50 years it is more prevalent in women
• Genetic predisposition
• Occupation. Certain occupations such as farming which involve hard repetitive tasks, heavy lifting or standing for long periods are more at risk

Joint related factors such as

• Joint shape. Abnormal shape predisposes the joint to more stress
• Previous injury or surgery of the hip
• Illness and infection – joint infection and conditions such as gout can contribute to the development of arthritis
• Muscle function

Often the pain originating from neighbouring structures such as the lower part of spine is felt in the hip and the correct diagnosis is essential for successful treatment.

What are the symptoms of hip arthritis?

Common symptoms include

• Pain. This may be felt over the hip, groin or buttock and is described as a poorly localised, dull, aching sensation. It can radiate along the thigh towards the knee. Initially the pain is present only on movement or when the joint is loaded. As the condition progresses pain becomes more frequent and persists even during periods of rest. Some individuals find their arthritis pain increases in the winter months and rainy season.
• Stiffness. This is worse in the morning and after periods of rest.
• Reduced range of hip movements can make simple tasks such as walking or bending a challenge. Hip movements may be accompanied by a creaking or clicking noise/ sensation.

How is hip arthritis diagnosed?

Your doctor can often diagnose osteoarthritis on the basis of your symptoms and examination findings. Tests such as x-rays are commonly requested to confirm the diagnosis. Other tests such as blood tests, CT scan or MRI may also be requested for further evaluation.

What are the non-surgical pain relief options in hip arthritis?

The treatment of hip OA begins with education and self-management. The self-management options for hip arthritis include:

• Weight loss
• Balancing rest with activities (pacing) and avoiding high impact activities.  Sitting crossed leg or on low height chairs should also be avoided if it increases your pain
• Use of hot/ cold compression
• Staying active. Regular gentle exercises such as walking, yoga, pilates, swimming can improve function, reduce pain, protect the joints and maintain muscle strength. Inactivity can worsen the arthritis symptoms
• Wearing supportive footwear to cushion the impact on the hip joint and use of aids such as a walking stick

Your pain specialist can help with

• Medications such as anti-inflammatories. These should be used medical supervision in the lowest dose and for the shortest duration possible, as long-term use is associated with risks. There are other painkillers which work through different mechanisms and can be prescribed by your pain specialist.
• Joint injections
  Steroid injections are the most commonly used injection option. As hip joint is a deep joint it is recommended that these injections are performed using ultrasound or x-ray guidance. Ultrasound guidance is preferred as it can be easily performed in the clinic and does not involve radiation exposure. Ultrasound helps to improve accuracy and reduce chances of complications. Most often a mixture of local anaesthetic and steroid is used for the injection. Local anaesthetics help to relax the muscle and steroids aid in reducing inflammation thus prolonging the effect of the injection. These injections also have a diagnostic role in confirming the source of pain.

PRP injections. The use of platelet-rich plasma for hip OA is under investigation in clinical trials with limited guidance available on their clinical role.

Treatments that are NOT recommended include

• Supplements such as Glucosamine/Chondroitin, vitamin D and antioxidants are not recommended for hip arthritis
• Hyaluronic acid injections. There is no strong to support their use. As per current evidence these injections are no better that placebo in improving function, stiffness and pain in hip OA.

What are the latest treatment options for hip joint pain?

When it comes to managing hip pain, there is a large lacuna in the treatment options as medications often offer limited relief or are limited by side effects and surgery is not always the answer as many are unwilling or unfit to have one. Some in their 40s and 50s are considered to be too young to undergo a joint replacement. Besides 5 to 15% of patients have persisting pain even after having a hip replacement.

For all these subgroups the new options including radiofrequency ablation, cooled radiofrequency and cryoablation offer a ray of hope. These options have been used most often for hip arthritis pain (as it is more common) although they work equally well for other hip joint pain conditions such as avascular necrosis (AVN). The primary aim in these treatments remains the interruption or reduction of the pain signals travelling from the hip joint to the brain. This is achieved by deactivating or stunning the nerves responsible for transmitting the pain signals from these joints. The method used for achieving deactivation is where these treatments differ.

These options can be considered for anyone with hip joint pain who has not responded well to non-surgical or surgical options. Typical indications include someone who

• Is not fit for hip replacement
• Doesn’t want to have surgery or is old and doesn’t want to go through extensive recovery and rehabilitation
• Is young and wants to delay the surgery as worries about wearing out of hip joint and need for repeat surgery are not unfounded
• Has persisting pain after hip replacement surgery
• Has chronic hip pain with inadequate response to other treatment options

All the above mentioned treatment options share some common advantages such as

• Minimally invasive pain management alternative for those not keen on surgery
• Safe procedures without the increased risk of complications
• Can provide quick, lasting pain relief.
•  Less pain can translate into improve functional ability  and reduced painkiller requirements, disability
• Day care procedure with no requirement for overnight hospital stay
• No cuts or incisions involved in the procedure
• No requirement for general anaesthesia
• Quick return to routine activities with no downtime and no requirement of prolonged rehabilitation

Diagnostic test injections are often performed prior to the radiofrequency procedure. This involves using small amount of local anaesthetic to numb the nerves in order to gauge the chances of success of the subsequent treatment. 50% or more reduction in pain after the test injection is considered a positive response and an indication to proceed with the treatment.

These new treatment options are discussed further in the section below

Radiofrequency ablation (RFA)

This procedure uses heat generated by radio waves to target specific nerves carrying pain from the hip joint. Specialised needles are used for controlled, targeted application of heat to these nerves, impairing their ability to send pain signals from hip to brain thereby resulting in pain relief.

The procedure involves placement of needles at specific locations under x ray and ultrasound guidance. For hip pain, branches of two specific nerves are targeted. These nerves are very small to be actually seen under ultrasound but are located in a specific area which is targeted using x-ray and ultrasound guidance. Once the needles are correctly placed they are connected to the radiofrequency machine. As a safety precaution testing is done to ensure there is no other nerve close to the needle location. This is followed by the actual treatment involving the application of heat generated by radio waves.

Post procedure, pain relief usually begins within one to two weeks and may last up to 24 months. Like most medical treatments, individual responses to RFA treatment will vary with different levels of pain reduction. Those with a successful test injection have more chances of responding to the RFA treatment. Over time the nerves regenerate, at which point the treatment can be repeated if required. RFA is safe to administer repeatedly in patients with consistent pain reduction.

Cooled radiofrequency ablation (c-RFA)

This procedure involves placement of needles at the same location as described previously in the radiofrequency procedure. However the needles and the radiofrequency equipment used is different. Cooled Radiofrequency has water circulating through the device and the needle tip. cRFA is able to deliver more energy to the surrounding tissues, thereby creating a larger treatment area and increasing the chances of achieving effective pain relief.

Cryoablation

Cryoablation refers to the technique of inactivation or blocking the nerves for a long time by freezing the nerves sending pain signals to the brain. The procedure is performed using a special probe called cryoprobe, which is a hollow needle through which the super-cooled gas such as nitrous oxide or carbon dioxide is delivered directly to the treatment area. The extremely low temperatures achieved in the area being treated can inactivate the nerves thereby reducing the pain.

The probe is guided to the correct location using ultrasound and x-rays. Prior to cryoablation the nerve is identified with the help of a stimulation tests. Gas is delivered once the probe is in the correct place. An ice ball is created by a rapid decrease in the temperature at the tip of the probe and this can be visualised using ultrasound. Once the procedure is finished, the cryoprobe is removed and the procedure site covered with a small bandage.

Tag = Back Pain Treatment in India, Joint Pain Specialists in Delhi, hip joint pain treatment in delhi, hip osteoarthritis, Hip Pain

Knee Pain Treatment in India - Removemypain

How Common Is Persisting Pain After Knee Replacement And Why Is It Important ?

Pain is the most important indication for joint replacement surgery and although surgery is successful in a vast majority of patients, some continue to have persisting pain. As per research evidence, approximately 9% after hip and 20% after knee replacement have an unfavourable pain outcome. 20% implies 1 in 5 patients, a significant number. Despite the high prevalence, the condition remains under acknowledged and can be rightly addressed as a silent epidemic.

Persistent pain not only has an adverse impact on the quality of life but often leaves patients confused or blaming themselves for the pain or the decision to go ahead with surgery. It can have an impact on mobility, general health, mood, sleep and lead to functional limitation with social isolation. When no obvious cause is found, the problem may be downplayed leading to the dissatisfaction, frustration, anger, tension or breakdown of the doctor–patient relationship, promoting doctor shopping. Somewhat ironically, persisting pain can sometimes be a consequence of surgery that was performed to alleviate pain.

Risk Factors for Persisting Pain after Knee Replacement

Persisting pain may have more than one reason, with a wide range of factors influencing the outcomes. It is important to know about these as some of them are modifiable. 

Some of the known risk factors include

• Poor mental Health including major depression, anxiety
• Catastrophization (Constant worrying and exaggerated negative orientation towards pain experience)
• Presence of other chronic pain conditions
• Surgical factors include infection, instability, implant loosening or failure, alignment problems with the implant (misalignment), soft-tissue impingement, nerve injury and extensor mechanism problems (patellar malt racking and non-resurfaced patella) 
• Severe preoperative pain. Some studies have linked poorly controlled pain after the operation to increased chance of developing chronic pain whereas other studies have found insufficient evidence. 
• High number of comorbidities (other medical problems). Pre-existing heart disease has been found to be an independent risk factor for pain at 5 years after knee replacement. The peripheral edema (swelling), sedentary lifestyle/ reduced engagement with physical therapy may contribute to increased pain levels. 
• Young age and female gender 

Pain Assessment

Most patients with persisting pain after the replacement surgery would return to the operating surgeon for a reassessment. Sometimes a second opinion from another surgeon is sought. Careful assessment in required to identify the problem and this involves detailed history, clinical examination (including the spine, hip and knee), psychological exploration, review of preoperative images & operative records, new investigations (serological, radiological and microbiological), assessing response to treatments and joint aspiration/ diagnostic injections if indicated. Sometimes despite extensive evaluation and best attempts using all modern technology at our disposal, the cause of pain cannot be identified. In such cases a trial of conservative therapy including pain relieving medications and physical therapy is often suggested. 

Management Of Persisting Knee Pain After Knee Replacement Surgery

Treatment of chronic pain after knee replacement is challenging. It requires a multidisciplinary team approach with input from orthopaedic surgeon, pain physician, physiotherapist, psychologist and many others. The aim is generally improvement in function and quality of life. Once the cause of persisting pain is known the treatment can be directed accordingly. 

Anatomically the cause of pain may be located 

• Extra articular (outside the knee joint at a distant site such as spine)
• Peri articular (around the joint) such as tendinitis (ten on problem), bursitis (inflammation of bursa) 
• Intra articular (inside the joint) such as joint instability, loosening of implant, issues related to size/type of implant, infection, osteolysis (loss of bone), kneecap problems 

How Can A Pain Physician Help ?

A pain specialist plays an important role in management of persistent pain and this includes

• Identifying the type /source of pain. This is especially relevant when issues with implant have been excluded and surgery is not required/not possible. Diagnostic joint injections can help differentiate whether the pain is coming from inside the joint or from an external source. If required, some joint fluid can be aspirated (removed) at the same time to evaluate for infection. Similar injections can be used to identify pain sources around the joint by trigger point injections, nerve blocks etc.
• Regulating pain medications. This is an essential component of overall management, best performed by professionals who are aware of all options and their limitations. Pain physicians are more familiar with use of stronger pain killers and some options such as capsaicin & Lidocaine patches as they use it more often. Sometimes small changes in medications can make a huge difference in the pain levels.
• Treating nerve pain. Nerve pain after knee replacement often goes unrecognized and may be responsible for persisting pain in approximately 6%-13% of patients. Typically, it presents with electrical shock like or burning sensation, numbness or altered sensitivity, although it can also present as an aching sensation associated with stiffness. Sometimes thickening of the nerve (neuromas) can be a source of persistent pain. 

Infrapatellar branch of the saphenous nerve. This is a small nerve running from the inner to the outer side of the knee below the kneecap. An injury to this nerve or a neuroma can be a common cause of persistent knee pain. Pain physicians can treat this successfully in an overwhelming majority of patients with nerve blocks, radiofrequency or cryoablation procedures. 

• Nerve blocks are offered if nerves are suspected to be the pain generator. A simple OPD performed procedure can often help identify the pain source and provide prolonged relief. 
• Pulsed Radiofrequency can be performed as a day case in an attempt to prolong the pain relief, in case the effect of the nerve block is short lasting. This is similar to nerve block but uses special needles and a radiofrequency machine to interfere with the pain signals being transmitted to the brain. 
• Cryoablation. This specialised technique involves application of cold to cause temporary disruption of the nerves ability to transmit pain signals without causing permanent nerve damage. 

• Other specialist interventions used to provide pain relief include

• Radiofrequency Ablation of Genicular nerves. Knee joint is supplied by many nerves and these are collectively addressed as genicular nerves. This procedure involves an initial diagnostic test whereby a small amount of local anaesthetic is injected close to these nerves. If this produces effective pain relief then one proceeds with the radiofrequency ablation. In radiofrequency ablation special types of radio waves are used to create a heat lesion around the nerves interrupting the transmission of pain signals to the brain. These nerves are approached with help of needles placed under x-ray and ultrasound guidance with no requirement for any surgical incisions. This is a safe, non-surgical procedure performed as a day case under local anaesthesia.
• Cooled Radiofrequency Ablation. Cooled Radiofrequency treatment is a minimally invasive treatment performed on a day care basis under local anaesthesia. The treatment aims to deactivate the nerves responsible for transmitting pain signals from the painful knee. It involves placing needles close to these nerves under x-ray or ultrasound guidance followed by heating of nerves to reduce the pain signals being transmitted. It differs from conventional Radiofrequency (described earlier) as it has water circulating through the device and can create a larger treatment area increasing the chances of success. Normal activities can generally be resumed soon after the procedure. 

• Spinal Injections – All nerves supplying the knee joint originate from the spine and interventions targeted on these (such as pulsed radio frequency of dorsal root ganglion) can help reduce the pain.
• Identifying your needs and directing you to other experienced professionals (such as physiotherapists, occupational therapists, psychologists) as required. 

Tag = Knee Pain Treatment in India, Knee Pain Treatment in Delhi, Pain Specialist in Delhi