Jeffrey R. Carlson, MD, MBA, CPE, FAAOS
Pinched nerves in the neck and lower back can produce significant anxiety in patients as they concurrently deal with worrisome symptoms while seeking the best treatment. The spinal nerves carry information to and from the brain to allow us to use our limbs effectively. Interruption of the signals to the arm or leg can cause pain, numbness and weakness. Although pain and numbness are significant disruptors in a patient’s life, weakness in the arm or leg can be the most serious symptom, leading to the inability to walk or use an arm for daily tasks. Sometimes, the patient may only have weakness and not pain or numbness. They’ll tell me about symptoms, such as dropping things suddenly, the feeling of dragging their leg or getting their foot caught on the stairs (foot drop).
My clinical evaluation for these symptoms includes a history and physical exam as well as x-rays. X-rays show the alignment of the spinal vertebrae and can be done with flexion and extension (having the patient bend forward and backward while standing) views to give a dynamic component to the boney anatomy. I also will have the patient complete a series of physical tests in the exam room with me, which are specifically designed to show any weakness or loss of function. If these tests show deficits in the arm or leg that correlates with one of the spinal nerves, I’ll then order an MRI. MRI scans look more specifically at the nerves, the spinal canal and for degeneration or leakage of the spinal disc material (the discs that are between the spinal vertebrae). These MRI images are then reviewed to determine if any of the spinal nerves are compressed that correlate to the patient’s physical exam.
The symptoms of pain, numbness and tingling can be treated with oral medications, epidural steroid injections at the site of the affected spinal nerve and physical therapy to decompress the nerve. Weakness, however, tells us that the spinal nerve is severely compressed and may become permanently damaged.
The European Spine Journal (2022 Mar; 31(3):551-560) recently published an analysis of some of the most relevant literature related to the treatment of foot drop. In reviewing six studies including 312 patients with foot weakness as noted by their surgeon, they found significant differences in neurological improvement in patients who had surgery within a month of their symptoms as compared to those patients that had surgery after a month. Their recommendation was to get the pressure off the nerve root as quickly as possible. However, weakness is not an emergent need for surgery in foot drop. The Journal of Clinical Neuroscience (2020 Feb; 72:39-42) evaluated patients that had surgery within 72 hours of the foot drop symptoms and found no real difference compared to those the had surgery after 72 hours.
Weakness caused by a disc herniation (when the jelly-like material inside of a spinal disc leaks out) compressing a nerve should be taken seriously, as the nerve can recover when surgery is done as soon as it can be safely arranged. The nerve becomes damaged by pressure over time, so my recommendation is that patients seek treatment as quickly as they can.
Sometimes, the insurance company may require additional conservative treatment, clinical information or peer-to-peer review before authorizing coverage of an MRI. This process can be tedious and may burn several weeks of precious time prior to getting the pressure off of the compromised spinal nerve through treatment.
To make an appointment with Dr. Jeffrey Carlson, call Orthopaedic & Spine Center at 757-596-1900, or use our online scheduling tool.