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SP14 Surgery, nerve root block or no intervention for radicular pain?
  1. Michal But


Galen Medycyna Bólu Anestezjologia SPL, Koszalin, Poland

The most common origin of lumbar radiculopathy is nerve root compression. It commonly results from either disc herniation, spondylosis, and spinal canal stenosis . A disc herniation can be either due to an acute injury or secondary to chronic degeneration of the spine. Spondylosis results in a narrowing of the spinal canal, neural foramen, or the lateral recess. The most common cause of canal narrowing is degenerative arthritis of the lumbar spine. More rarely, the cause of lumbar radiculopathy is a compression fracture, tumour pressure, which may be located in the spinal canal or in the paraspinal region.5 Other etiologies include inflammation, infection, trauma and vascular disease.2

Treatment of radicular pain depends on etiology and symptoms. If non-invasive causal treatment of radiculopathy is possible, it should be used. For example discitis should be treated with antibiotics.1 There are three categories of radicular symptoms and signs.2 Mild radiculopathy is considered a sensory loss and pain without motor deficits, moderate radiculopathy is the sensory loss or pain with mild motor deficits, and severe radiculopathy is considered sensory loss and pain with marked motor deficits. The primary treatment for lumbar radiculopathy will include conservative management such as nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, manual therapy and exercises. Most cases of lumbosacral radiculopathy are self-limited. Counselling is essential for patients with radicular symptoms since most cases are mild and will resolve within six weeks after the onset of symptoms. It is vital to encourage patient to weight loss reduction considering that in most cases elevated body mass index is observed. Spontaneous improvement following a disc herniation or lumbar spinal stenosis is very high.4 However minimal invasive treatment if there are no contraindications, should be considered at any level of symptoms. On the one hand, minimally invasive procedures modulate inflammation within the compressed root.6–8 On the other hand, they prevent peripheral and central sensitization. The minimally invasive methods of treating radicular pain include steroid epidural blockade, pulsed RF of dorsal root ganglion (DRG), transforaminal epidural ozone (O3) injection. In properly qualified patients intradiscal injection of gelified ethanol (Discogel) is effective. For radiculopathy in patients after multiple surgeries and peri-root scar confirmed in MRI epidural adhesiolysis should be considered.3 if there is no improvement and muscle strength deficits persist after non-invasive and minimal invasive treatment, neurosurgical intervention should be considered .

Treatment depends on patient condition and needs. Although most radicular symptoms resolve spontaneously, effective treatment should not be delayed.4

References 1. Muscara JD, Blazar E. Diskitis. [Updated 2021 Aug 5]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022 Jan.

2. Dydyk AM, Khan MZ, Singh P. Radicular Back Pain. [Updated 2021 Nov 2]. In: StatPearls . Treasure Island (FL): StatPearls Publishing; 2022 Jan

3. Lee F, Jamison DE, Hurley RW, Cohen SP. Epidural lysis of adhesions. Korean J Pain. 2014;27(1):3–15. doi:10.3344/kjp.2014.27.1.3

4. Kreiner DS, Hwang SW, Easa JE, et al. North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014

5. Hsu, Hui-Ching et al. ‘differences in pain intensity of tumors spread to the anterior versus anterolateral/lateral portions of the vertebral body based on CT scans.’ Pain research & management 2019; 2019: 9387941. doi:10.1155/2019/9387941

6. Helm Ii S, Harmon PC, Noe C, et al. Transforaminal Epidural Steroid Injections: A Systematic Review and Meta-Analysis of Efficacy and Safety. Pain Physician 2021;24(S1):S209-S232. PMID: 33492919.

7. Hagiwara S, Iwasaka H, Takeshima N, Noguchi T. Mechanisms of analgesic action of pulsed radiofrequency on adjuvant-induced pain in the rat: roles of descending adrenergic and serotonergic systems. Eur J Pain 2009;13:249–252.

8. Bonetti M., Fontana A., Cotticelli B., et al. Intraforaminal (O)2-(O)3 versus periradicular steroidal infiltrations in lower back pain: Randomized controlled study. AJNR Am. J. Neuroradiol.

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