Spine specialists and neurosurgeons often see patients who have complaints related to radiculopathy and/or neuropathy. There are some overlapping symptoms between the two entities, and for that reason it's important to differentiate between the two because treatment patterns are different. In patients with radiculopathy, the problem occurs at or near the root of the nerve along the spine, while a neuropathy is a deranged function of the specific peripheral nerves — caused by an entrapment of the nerve, a vitamin or nutritional deficiency, diabetes or other metabolic problems — and it isn't necessarily treated with surgery, as a radiculopathy might be.
In addition to finding the right treatment, identifying the causes of the patients' symptoms also allows the surgeon to create appropriate postoperative expectations for the patient. Leonel P. Limonte, MD, chief of neurology and rehabilitation services at The Bonati Spine Institute in Hudson, Fla., discusses some important points to keep in mind while evaluating patients suspected to have any of these conditions and to effectively treat each one.
1. Take a good patient history. Recording a detailed patient history is extremely important when differentiating between radiculopathy and neuropathy, Dr. Limonte says. Neuropathies may be hereditary, caused by alcohol abuse or nutritional deficiencies, exposure to certain drugs and toxins, or even have an infectious etiology. For that reason, it is important to look at the patients' family history, daily habits and recent travel history.
It is also important to establish the onset of the symptoms and the presence of any other associated factors: Was the onset of the symptoms abrupt? Is there a history of trauma? Does the pain radiate from the neck or back into any of the extremities? In those instances, root entrapment or radiculopathy may be the cause.
On the other hand, if the symptoms began slowly and have been persisting for a long period of time, if they are symmetric and bilateral, or if they are coupled with comorbidities such as diabetes, the patient may be suffering from peripheral nerve damage as a result of an underlying neuropathy.
2. Detail symptom differences. Symptoms sometimes appear to involve a specific nerve radiating to a specific part of the body, such as the extremities. "Experiencing 'numbness' doesn't just mean the root is compressed or that there is a problem with the spinal cord; it could also be a peripheral nerve problem," says Dr. Limonte. "You don't treat peripheral neuropathy with surgery. However, if you have compression of a nerve, or if you have a spinal root problem, treatment may involve surgery."
Some patients have symptoms of both conditions. For example, patients may have a problem affecting the cervical root (C6-C7) and they might have carpal tunnel syndrome, which comes from damage of the peripheral nerves, an indication that the median nerve is compressed at the wrist. If the patient has numbness of an index or middle finger, it could be the result of carpal tunnel or it could be compression of the cervical spine, or both.
"If both conditions co-exist, they aren't going to resolve 100 percent with just one form of treatment," says Dr. Limonte. "You may be able to relieve the cervical compression, but the nerves are still compressed distally, so there is still a residual numbness. If you perform a carpal tunnel release, the cervical condition isn't fixed, so some symptoms will still persist."
3. Imaging tests and exams. Surgeons can order studies, such as electromyography or imaging studies of the spine. In specific cases, it may be beneficial to perform a myelogram to look at the specific level of the spine when an MRI isn't clear.
"In addition, in some unusual cases of peripheral neuropathy, you may need to perform a lumbar puncture to examine the spinal fluid to see if there is a more severe problem," says Dr. Limonte. "All these exams help confirm your diagnosis. When you suspect that multiple problems are present, performing electromyography and nerve conduction studies helps to distinguish a peripheral nerve from a root problem. Within the studies, look at velocity and the responses of the peripheral nerve to make sure the impulses are conducted properly. Slowing of the conduction velocities and decreased amplitude of the responses are signs of neuropathy. Further testing can also help you localize a particular root in the cervical spine to see which muscles are being affected."
4. Create appropriate patient expectations. If patients have two coexisting conditions, one solution won't fix the entire problem and patients need to know what to expect after surgery. Patients who have comorbidities, such as diabetes, may need similar expectation coaching. Diabetic patients may experience numbness in their feet as well as back pain. If they have a lumbar spine compression affecting a particular root that causes pain in that area and triggers shooting pain in the extremities, they may also be suffering from neuropathic pain as a result of their diabetes.
"If we perform surgery on these patients, we can take care of the radicular pain, but patients will still have another type of pain — neuropathic pain affecting their extremities," says Dr. Limonte. "Neuropathy may be associated with diabetes and it is important to make the distinction from radiculopathy and offer the appropriate treatment."
When patients know that the symptoms associated with the neuropathy will remain, they are more likely to feel satisfied with their surgical outcome and control those symptoms with alternative methods and with specific medical treatment.
Related Articles on Spine Surgery:
Endoscopic Spine Surgery: 6 Things to Know About the Present and Future
10 Spine Surgeon Investigators of Artificial Discs
Where Infuse Stands: 6 Points on the Controversial Spinal Fusion Product
In addition to finding the right treatment, identifying the causes of the patients' symptoms also allows the surgeon to create appropriate postoperative expectations for the patient. Leonel P. Limonte, MD, chief of neurology and rehabilitation services at The Bonati Spine Institute in Hudson, Fla., discusses some important points to keep in mind while evaluating patients suspected to have any of these conditions and to effectively treat each one.
1. Take a good patient history. Recording a detailed patient history is extremely important when differentiating between radiculopathy and neuropathy, Dr. Limonte says. Neuropathies may be hereditary, caused by alcohol abuse or nutritional deficiencies, exposure to certain drugs and toxins, or even have an infectious etiology. For that reason, it is important to look at the patients' family history, daily habits and recent travel history.
It is also important to establish the onset of the symptoms and the presence of any other associated factors: Was the onset of the symptoms abrupt? Is there a history of trauma? Does the pain radiate from the neck or back into any of the extremities? In those instances, root entrapment or radiculopathy may be the cause.
On the other hand, if the symptoms began slowly and have been persisting for a long period of time, if they are symmetric and bilateral, or if they are coupled with comorbidities such as diabetes, the patient may be suffering from peripheral nerve damage as a result of an underlying neuropathy.
2. Detail symptom differences. Symptoms sometimes appear to involve a specific nerve radiating to a specific part of the body, such as the extremities. "Experiencing 'numbness' doesn't just mean the root is compressed or that there is a problem with the spinal cord; it could also be a peripheral nerve problem," says Dr. Limonte. "You don't treat peripheral neuropathy with surgery. However, if you have compression of a nerve, or if you have a spinal root problem, treatment may involve surgery."
Some patients have symptoms of both conditions. For example, patients may have a problem affecting the cervical root (C6-C7) and they might have carpal tunnel syndrome, which comes from damage of the peripheral nerves, an indication that the median nerve is compressed at the wrist. If the patient has numbness of an index or middle finger, it could be the result of carpal tunnel or it could be compression of the cervical spine, or both.
"If both conditions co-exist, they aren't going to resolve 100 percent with just one form of treatment," says Dr. Limonte. "You may be able to relieve the cervical compression, but the nerves are still compressed distally, so there is still a residual numbness. If you perform a carpal tunnel release, the cervical condition isn't fixed, so some symptoms will still persist."
3. Imaging tests and exams. Surgeons can order studies, such as electromyography or imaging studies of the spine. In specific cases, it may be beneficial to perform a myelogram to look at the specific level of the spine when an MRI isn't clear.
"In addition, in some unusual cases of peripheral neuropathy, you may need to perform a lumbar puncture to examine the spinal fluid to see if there is a more severe problem," says Dr. Limonte. "All these exams help confirm your diagnosis. When you suspect that multiple problems are present, performing electromyography and nerve conduction studies helps to distinguish a peripheral nerve from a root problem. Within the studies, look at velocity and the responses of the peripheral nerve to make sure the impulses are conducted properly. Slowing of the conduction velocities and decreased amplitude of the responses are signs of neuropathy. Further testing can also help you localize a particular root in the cervical spine to see which muscles are being affected."
4. Create appropriate patient expectations. If patients have two coexisting conditions, one solution won't fix the entire problem and patients need to know what to expect after surgery. Patients who have comorbidities, such as diabetes, may need similar expectation coaching. Diabetic patients may experience numbness in their feet as well as back pain. If they have a lumbar spine compression affecting a particular root that causes pain in that area and triggers shooting pain in the extremities, they may also be suffering from neuropathic pain as a result of their diabetes.
"If we perform surgery on these patients, we can take care of the radicular pain, but patients will still have another type of pain — neuropathic pain affecting their extremities," says Dr. Limonte. "Neuropathy may be associated with diabetes and it is important to make the distinction from radiculopathy and offer the appropriate treatment."
When patients know that the symptoms associated with the neuropathy will remain, they are more likely to feel satisfied with their surgical outcome and control those symptoms with alternative methods and with specific medical treatment.
Related Articles on Spine Surgery:
Endoscopic Spine Surgery: 6 Things to Know About the Present and Future
10 Spine Surgeon Investigators of Artificial Discs
Where Infuse Stands: 6 Points on the Controversial Spinal Fusion Product