Podcast: You got nerve! A conversation about pinched nerves of the neck and low back

Podcast Transcript

Welcome to The Bone and Joint Playbook with Dr. John Urse. Today’s episode, You’ve Got Nerve, a conversation about pinched nerves in the neck and low back. Today, Dr. Urse talks with Dr. Brian Ceccarelli who is also a board-certified orthopedic surgeon. Let’s join the two doctors now and listen in.

Dr. Ceccarelli: So, Dr. Urse tell me specifically what exactly is a pinched nerve, how will I know I have a pinched nerve and then lastly, why should I care that I have one?

Dr. Urse: Well, we need to start with what nerves do and they are pretty important in our body. Most nerves look a little like a phone cable, they have different color fibers, some give us feeling and we get a sense of what is hot or cold, so we don’t touch a hot stove. Other nerves give us the ability to feel a very small pebble in our shoe. The other types of nerves then have purely movement functions, they make muscles contract, they control the strength in a muscle in an arm or leg. So, the nerve basically has two main functions, it gives us feeling and sensation, but it also controls movement or what’s called motor function. As nerves get compressed or pinched, some of those fibers that handle one or the other mentioned modalities that the nerve has, those get pinched, and they become the reason people have symptoms. Those symptoms can be weakness in a muscle, arm, or leg, they can be burning, tingling or painful prickly feeling. People just have pain from them because the nerves have a portion of pain bundles that help us make sure we don’t step on a nail or a thing that is going to cause a break in our skin or burn us. So, we have these pain fibers that are protective, but if they get over stimulated or pinched, they cause a burning pain, usually, a very eye-opening pain and for that reason most people want to know what they can do to relieve that.

Dr Ceccarelli: So, I can tell you from personal experience of having a pinched nerve in my neck. It was one of the worst pains I’ve ever had. It felt like I was constantly getting shocked. If you happen to have put your finger in a socket or just have an electrical shock, the pain was certainly one of the worst pains, I’ve ever had so I would urge you that if you have this kind of pain, you absolutely need to seek care. So, John in talking about that, how does one get a pinched nerve? What is the mechanism behind someone actually getting a pinched nerve in their neck or back?

Dr. Urse: Well, I’m glad you distinguished where we’re talking about pinched nerves because todays talk is going to stay away from things like carpal tunnel in your wrist, things around the knee or elbow. Those places can also have nerve entrapment but we’re going to focus today on the back and spine. So, the spine runs from the top of your head down to your tailbone and there are 24 different vertebrae. Vertebrae are simply square shaped blocks of bone that have a cushion between them, called a disc which is much like a sponge or even a more liquidy material much like the jelly in a donut. As we get older those sponges or jelly donuts tend to dry out as the water content in the disc just gets less water content. As that happens the disc spaces can narrow the bones can actually start to either flatten or they may develop spurs which are little bone prominences like a little icicle that comes off the edge of a bone. The nerves come off the back at each level of those vertebrae, so each little block has a nerve that goes to the right and to the left, the ones in your neck go to your arms and the back of your shoulder and shoulder blade, the ones in your low back go to your hip and down your legs and there are certainly a nerve at each level but also on each side. So, when we wonder why do we get these things in the first place, the main reason is we talked about 24 vertebrae, well the 12 in the middle called the thoracic or what’s called the middle in your back, they rarely have problems. We think the reason is our neck moves much more in one direction or the other, up and down, side to side, ear to ear, what is called side bending. So does the low back, we play golf, we play baseball, we twist, we lift, we do activities around the house and we garden. So, the low back and the neck both have much more twisting or what’s called torsional deformities or stresses put upon them and those lead to I believe some of the injuries to the low back or neck that contribute to nerve entrapment. We see very few problems in that whole middle portion of your back called the thoracic spine, so today’s talk is going to focus mostly on the neck and low back, and how we can recognize what the problem is but also come up with some simple and gradually work towards some more complex treatment options.

Dr. Ceccarelli: So, when you talk about how do you get it, you can get it from an acute injury, correct? Like if you’re in a car accident or if you lift something really heavy and twist the wrong way you can rupture a disc that presses on a nerve almost immediately, or you can develop a pinched nerve by the formation of spurs and narrowing of that space where the nerve runs through over a period of time correct?

Dr. Urse: That’s right, and most of the time people will say in their history, “boy I remember I fell off a horse April 4th two years ago and by back and right leg have been burning ever since.” That was a traumatic injury, same thing with people telling you about a neck problem that went down the shoulder blade and into the arm, those events with car accidents, traumatic injuries, falls are easy to put a timetable on. The other ones are a little harder because your low back takes an awful lot of force and because we have evolved from walking on all fours to standing. The force of the spinal column goes to the low back so the bottom of the low back is what’s called the L5 vertebrae, which is the lowest of the lumbar vertebra. They think the majority of the forces actually get transmitted from our upright posture by walking and as evolution has taken us down our method of locomotion. What we try to do though is realize that those are pretty sturdy vertebrae, and they don’t usually get a ruptured disc with one injury, its usually lots of multiple small micro traumas or repetitive injuries where you twist and turn and twist and turn and work in a factory or you play sports over time. Then one day you bend over and pick up a paper plate and rupture a disc doing that. Well, it didn’t happen from doing that, it happened from 20 other or 50 other micro injuries and then one little thing broke the camels back, and in the case of a disc would be the cushion between the bones where the lining is now stretched and finally lets that jelly come out of the space between the bones much like the jelly donut analogy.

Dr. Ceccarelli: So, if you were to see a patient in your office and you suspected them to have a pinched nerve what kind of physical exam would you do? Would there be certain signs that would be obvious to you, or would you have to get special imaging studies or other tests that might confirm that they have a pinched nerve?

Dr. Urse: Well, that is a good question and I want to hit every segment of that. I do want to say that in our history we would first want to know if anyone had any numbness to where they couldn’t feel their legs, they couldn’t control bowel or bladder function, they had more serious pressure on the spinal cord. Those are more worrisome involvement of the spinal column and where our nerves come from, so as long as those are eliminated as worrisome stories in the history, we then get to the exam and really start from the top and go to the bottom. We ask people if it involves their head and cranial nerves and most of the time the neck wont involve anything above that. So, we look at the patient have them move their arms, can they raise their arms overhead do they have movement, do they have strength, we check to see if they have feeling in certain areas, we ask them to point to where their problem is. As silly as that sounds someone taking their index finger and drawing a line from their shoulder down to the top of their index finger helps us see the pattern of a certain nerve and that nerve comes from a certain level and keys us in a little to that diagnosis. We also use a little hammer, you may have seen doctors use those little percussion hammers, called reflex hammers. So certain nerves when they get injured make one of those reflexes go away and by finding a normal one on one arm and the absence of one on the other arm can help localize or find where the certain level of the nerve injury may be. We do the same thing in the low back, we check your hip muscles, your leg muscles, straighten the knee, pull the toes up, push the foot down and we look at where numbness and burning are because those are the symptoms a nerve has when we talk about sensation or feeling. Most people can tell you where they hurt if it’s burning tingling or numb. I keep it pretty simple, I ask them if it goes below the knee, to the top of your foot, to the bottom of your foot, little toe side or big toe side. Most people can identify with where they’re feeling the problem. Then we do provocative tests where we turn their head, tilt their neck a little, straighten their leg out to check a low back problem, that’s a way to put tension on what’s called the sciatic nerve. The sciatic nerve is something people have heard of but it’s really more of a combination of nerves as they get into the leg and some of these branch off to different areas. Anything that puts more pressure on a nerve and aggravates a problem helps us pinpoint where that problem is. Then we get to the “I think you’ve got a problem” stage of the exam. We think it might be a nerve problem and what kind of tests would we do. Well, we always start with a basic x-ray and if your doctor doesn’t take an x-ray, number one, no insurance company will not allow you to do an MRI or CAT Scan or other tests. So, you start with simple things and make sure its not a fracture, make sure it’s not a slipped vertebra where one vertebra slides forward on another or as you do different views with the person bending their neck, straightening their chin back you can actually see if the vertebrae is moving on different views we take. So, we try to see as much as we can on a plain film, we look for calcium deposits, and bone spurs as we talked about. What you have to understand is that an x-ray does not show the nerves, it does not show the discs, it doesn’t show more of the details we need to see about a nerve. That leads us to CAT Scans that have more radiation, but can be safely done in a person with a pacemaker or an implantable electrical device. The test of choice by far is an MRI test. A MRI is a radio wave test that does not involve radiation to the patient and there are some that are open and others are a little more enclosed, so you will want to tell your doctor if you get claustrophobic and things like that, but they have open ones that are much like laying on a pool table for a half hour or forty five minutes. You get a great study, and it shows all the discs, all the nerves, it shows where those little pinched nerves maybe unhappy and they can maybe be unhappy in more than one place. They may have pressure from one of two things. We talked about this jelly as a disc between two bones, that’s considered a soft disc, but anything that pushes against the nerve is going to make it unhappy and cause compression or pinching. So, the other type of entrapment of a nerve whether its in the neck or low back is a hard disc. A hard disc is just a term for a bone spur or bony prominence, and you have to think of nerves as having a little exit tunnel out of each level of the back so when the nerves come off the spinal cord at, lets talk about the L5 level in the low back, they go out a little tunnel just like the Holland Tunnel in New York, but if something is pushing into the tunnel if there is a earthquake, a bone spur, something digging into the nerve then it doesn’t have any room to move and the nerve gets compressed or pinched and all of a sudden we have these symptoms that we have talked about.

Dr. Ceccarelli: Then finally John if you get an x-ray do your normally suggest they get an EMG or nerve conduction study to just assess the amount of damage to the nerve? Is that necessary?

Dr. Urse: It’s a good test, the problem with it is that it won’t show an abnormal nerve problem for about six weeks. So, if you fell asleep watching a movie last night, because there were no sports on and you have to realize your foot is numb and you think, “oh my goodness I’ve got a nerve entrapment” there isn’t a nerve test called an EMG that is going to pick that up for about six weeks until the nerve is actually conducting its electricity more slowly. The nerve test called an EMG does three things, number one is there a nerve problem or not, so if you’ve had this for a couple months and you need to know is it in my neck, in my arm, carpal tunnel or both. The EMG says is there a nerve problem first and second where is the problem? Is it in my neck, shoulder, or my wrist and three how bad is the problem? Is it mild, moderate, or severe? If the nerve has severe slowing in this test we used called to check the timing of electric impulses, then it’s not working very well. You can start to get nerve damage, muscles don’t work as well when they aren’t getting the stimulation from the nerve. I tell people the nerve looks like a black electric wire, we talked about the different layers and colors and if you have nerve damage it’s like the black coating on the wire has been taken away with one of your pair of pliers. You still have that copper inside to conduct electricity, but you’re now getting nerve damage. Those things are not as quick to recover as earlier nerve problems. So completely ignoring those symptoms is not always the right answer and that’s when I wanted to agree with you earlier about having someone take a look at it and say you know we better know how bad this is or how acute the problem needs to be addressed.

Dr. Ceccarelli: To summarize, it’s a combination of taking an accurate history, getting a really good physical examination and putting together those pieces and getting appropriate diagnostic testing such as an MRI or a possible EMG. That seems that it should fairly well localize if you do have a pinched nerve and what level it is, correct?

Dr. Urse: Yeah, I will tell you the way to summarize even further is we have to look at all that information and then look at you. So, if you have a ruptured disc at the lumbar 5th level on the right, but your left knee and leg hurt, those don’t match so we have lots of tests that show lots of things but were treating patients. So, if someone shows me an MRI and I’m staring at that and not examining you to see what your problem is, I want to see you first. I want to know what’s wrong, where your problem is and then I know where to look on that imaging study and say, why is that nerve unhappy? Well, it’s got a piece of bone digging into it or it’s got a little piece of toothpaste. So, I think it’s real important to try and find out a couple things before people go further. We are going to talk about why someone would want to do more than just find what’s wrong. Is there a reason to try simple things first, when would surgery be needed, and how would a surgeon or someone arrive at a reason to do something for someone.

Dr. Ceccarelli: So, going down that path John, you see a patient in your office, and you have kind of determined they have a pinched nerve. What can help a pinched nerve? What would you typically recommend initially for a patient that presents to you with a pinched nerve, or suspected pinched nerve?

Dr. Urse: This is going to solve the problem 90% of the time. We are going to tell people go to bed or if it’s your low back rest the injured area, alternate heat, and ice, put a pillow under your knee to take some pressure off the nerve. We talked about when nerves are more stretched, they’re more irritable, so bending your knee and bringing your knees up towards your chest, laying on your side can help. Just avoiding the activity, you may have said my wife wanted me to paint the ceiling and my neck has been bent back for two days painting a ceiling and I can’t even turn it now. Well, you’ve really aggravated some of those areas of the neck that weren’t a problem before but by the way you had your neck positioned, you’ve gotten yourself in trouble. So, we certainly try rest, some of the simple anti-inflammatories, people can take any of those things like Motrin or Aleve over the counter for a few days are pretty safe with some Tylenol for pain, and those two can be taken together. Most everyone is going to be recommended to see a physical therapist. The therapist will do two things, they will go over exercises that we will talk about later, but they will also talk about how to avoid things that will make it worse and having the right things to do and avoiding the wrong things to do together is what gets most people better 90% of the time.

Dr. Ceccarelli: So, you have seen this patient back in the office six weeks later and they’ve improved. Your recommendation to them would be, just be careful with the way you’re doing things and paying more attention to mechanics, lifting, and turning. Is that correct?

Dr. Urse: That’s correct. Occasionally is the nerve is still unhappy and people with nerve pain use the term neuritis and anytime your put “itis” at the end of anything it means inflammation of. So an anti-inflammatory may help, but there are also nerve medications. There is a medication called Gabapentin, its trade name is Neurontin, it’s a non-narcotic but it’s a nerve pill so to speak, and it can really quiet down nerve pain and it actually helps us diagnose some problems of arm and leg pain when other things aren’t helping. Sometimes we think maybe it’s a nerve and then we give them a nerve medication and that really helps their symptoms. That’s about all Gabapentin helps, it isn’t going to really make you feel funny it does have a little bit of drowsiness is about the main side effect. You can really start with very low dosing, and you can increase it and one of the best things about that medication is if its side effect is drowsiness, you can always take an extra pill or higher dose at nighttime to get some rest, because who cares if your drowsy right? So, I think when you ask what happens at the six weeks mark, we want to know are we getting better or not, do we still have muscle control and strength, are we loosing the ability to lift your arm, if you can’t put a dish on a shelf or lift your foot up, now you’re having a foot drop or significant weakness problem. You may not be having much pain but now you’re having worse function, that pushes us to getting more aggressive treating a problem or looking at other options besides watching and waiting.

Dr. Ceccarelli: So, surgery becomes more of a possibility with weakness being one of the predominate symptoms, correct?

Dr. Urse: It does, but there are three things you really need to consider with surgical intervention for a nerve problem. The first is, failed conservative therapy. Almost everyone would say six weeks if someone is working on you after three weeks, they probably have a boat payment, but that’s not giving the body time to heal something. So, failure of adequate conservative therapy which includes rest, therapy, mediations, avoidance of things that are making it bad. The second thing is a bonified neurological test. We talked about an MRI, CAT Scan, there is even a dye test in the spine called a myelogram, but if you have one of those along with an EMG those are solid tests, then if they match the patient’s symptoms so that L5 nerve on the right side is where the disc is ruptured and pushing on the nerve and that is where the persons pain is then that matches. So, if it doesn’t match it falls off as one of the three criteria to do something, because you’re not sure where their problem is. The third reason a person would consider having a surgery is if they have a progressive neurological deficit. Now that means all of a sudden you can’t lift your foot up, you’ve got a foot drop, you can hardly put a dish on a shelf, you’ve got severe weakness in your arm. You’re now involving function and loss of normal activities and that nerve is more than unhappy, it’s not able to stimulate the muscles to work and it maybe causing more pain and that pushes us to more aggressive treatment because people are not just waiting, they’re losing the ability to function normally. So that is where that surgical consult would be important. Most surgeons believe it or not, are fairly conservative and many of them would say, “I think I know what the problem is, it matches your symptoms and that takes us to a thing I would like to try before surgery is pain management.” Now pain management is a way an interventional doctor who is an anesthesiologist or a specialized pain doctor may use injections using cortisone that we have talked in the past about and even PRP or stem cells which are new and emerging areas for some of the spine problems. In fact Jack Nicklaus went to Munich, Germany for stem cell injections for his spine problem and those injections have helped him avoid surgery. Again, I think people who have most of these problems want to try as many modalities as they can before they have surgery. We all have friends that are good in the chiropractic field and some of the DO physicians, the osteopaths learn manual medicine techniques and many of those can help adjust or improve the mechanical problems that we see, sometimes from our repetitive injuries we encounter. One thing I caution people, we don’t do vigorous cracking of the neck or things like that could injury either the neck that already has a ruptured disc or some of the important arteries that run along the little openings on the side of the neck, because they can lead to injuries like a stroke and other things. So, we are not talking about cracking, popping and doing vigorous things to an injured neck or injured back. There are some very simple things that a therapist can show you. I may wrap this up with a couple simple things that will make most people better.

Dr. Ceccarelli: So just to summarize things in closing, would it be fair to say that most back and neck pain are not necessarily pinched nerves?

Dr. Urse: Thats correct.

Dr. Ceccarelli: So if you have back pain unaccompanied by sharp leg pain, you’re probably not a surgical candidate and one that can get better with physical therapy and other modalities, is that correct?

Dr. Urse: It would be correct in those instances. There are people who we talked about that have slipped vertebrae where one of the building blocks slides forward on the other, and that is just going to pull on the spinal nerves and just make your back really sore. In those cases you may not have the nerve involvement as extensively, but your back is really sore and that is a mechanical back issues where we actually fuse or stiffen the bone to keep it from wobbling so to speak. Your assessment is correct Brian because the majority of people will get back pain in their life. In Asia people don’t even see a doctor for back pain because they just assume everyone will get back pain at some point in their adult life and they tell you just to avoid what you’re doing that is causing it and to figure out a way to make it better. There are so many people over there that they do not have enough doctors to deal with all of the back problems. We certainly can probably deal with most of these ourselves.

Dr. Ceccarelli: So in closing John, is there anything you would like to tell your audience as far as what to do, when to do it and why to do it?

Dr. Urse: I would definitely embrace what your physical therapist tells you because you will be able to treat thyself for most of these problems. There are some simple exercises that help keep the back from being excessively swayed, some of the ones for the neck can help by turning the chin to the right or left and pushing the ear down toward the shoulder. Most of these are simple things and once you get those tracks to run on from your therapist that is going to allow the patient to treat themselves for the most part, and I think that will help them understand what they can do to make themselves better in the future.

Dr. Ceccarelli: Well, thank you Dr. Urse I think the conversation went along the lines that you wanted it to and certainly appreciate your information regarding this very important topic.

Dr. Urse: Thank you Brian, I appreciate that.

Thank you for joining us for this episode of The Bone and Joint Playbook with Dr. John Urse. Be sure to check back for additional episodes on important medical topics. This has been a production of Doctors Unmasked produced by Terry O’Brien.