Painful Cervical Radiculopathy Research Articles

A randomised controlled trial of multimodal physiotherapy for recent onset painful cervical radiculopathy: The pacer trial

A randomised controlled trial of multimodal physiotherapy for recent onset painful cervical radiculopathy: The pacer trial

Synthetic Secoisolariciresinol Diglucoside Attenuates Established Pain, Oxidative Stress and Neuroinflammation in a Rodent Model of Painful Radiculopathy.

Painful cervical radiculopathy is characterized by chronic neuroinflammation that lowers endogenous antioxidant responses leading to the development of oxidative stress and pain after neural trauma. Therefore, antioxidants such as secoisolariciresinol diglucoside (SDG), that promote antioxidant signaling and reduce oxidative damage may also provide pain relief. This study investigated if repeated systemic administration of synthetic SDG after a painful root compression reduces the established pain, oxidative stress and spinal glial activation that are typically evident. SDG was administered on days 1–3 after compression and the extent of oxidative damage in the dorsal root ganglia (DRG) and spinal cord was measured at day 7 using the oxidative stress markers 8-hydroxguanosine (8-OHG) and nitrotyrosine. Spinal microglial and astrocytic activation were also separately evaluated at day 7 after compression. In addition to reducing pain, SDG treatment reduced both spinal 8-OHG and nitrotyrosine, as well as peripheral 8-OHG in the DRG. Moreover, SDG selectively reduced glial activation by decreasing the extent of astrocytic but not microglial activation. These findings suggest that synthetic SDG may attenuate existing radicular pain by suppressing the oxidative stress and astrocytic activation that develop after painful injury, possibly identifying it as a potent therapeutic for painful radiculopathies.

A randomised controlled trial of multimodal physiotherapy versus advice for recent onset, painful cervical radiculopathy \u2013 the PACeR trial protocol

BackgroundA research gap exists for optimal management of cervical radiculopathy in the first 12 weeks and short term natural history of the condition is somewhat unclear, although thought to be favourable. The primary aim of this assessor blinded, superiority, 2 parallel group randomised controlled trial is to investigate the effects of a 4 week physiotherapy programme (6–8 sessions) of manual therapy, exercise and upper limb neural unloading tape, compared to a control of weekly phone advice; on disability, pain and selected biopsychosocial measures, in acute and sub-acute cervical radiculopathy patients. A secondary aim is to identify whether any baseline variables, symptom duration or group allocation can predict outcome.MethodsParticipants are recruited from GP referrals in an urban setting, from a neurosurgery non-urgent waiting list and from self-referral through Facebook advertising. Eligible participants (n = 64) are diagnosed with radiculopathy based on a clinical prediction rule and must have symptoms of unilateral, single level, radiculopathy for between 2 and 12 weeks, without having yet received physiotherapy. Random 1:1 group allocation (using variable block sizes), allocation concealment, blinded assessment and intention to treat analysis are being employed. Treatment is provided by clinical specialist physiotherapists in primary and secondary care settings. Outcomes are measured at baseline, 4 (primary endpoint) and 12 weeks. Participants’ report of pain, disability and their rating of recovery is also recorded by telephone interview at 6 months. Statistical analysis of between group differences will be performed with ANOVAs and MANOVAs, and multivariable regression analysis will be undertaken to explore predictor variables. Ethical approval for this study has been received from the Beaumont Hospital and Irish College of General Practitioners Research Ethics Committees. The trial is registered at ClinicalTrials.gov (NCT02449200).DiscussionAn internal pilot study to test retention and recruitment strategies led to trial expansion and this is now a multi centre trial involving 5 clinical sites.Trial registrationNCT02449200. Registered 20/05/15.

Pre-treatment with Meloxicam Prevents the Spinal Inflammation and Oxidative Stress in DRG Neurons that Accompany Painful Cervical Radiculopathy

Painful neuropathic injuries are accompanied by robust inflammatory and oxidative stress responses that contribute to the development and maintenance of pain. After neural trauma the inflammatory enzyme cyclooxygenase-2 (COX-2) increases concurrent with pain onset. Although pre-treatment with the COX-2 inhibitor, meloxicam, before a painful nerve root compression prevents the development of pain, the pathophysiological mechanisms are unknown. This study evaluated if pre-treatment with meloxicam prior to painful root injury prevents pain by reducing spinal inflammation and peripheral oxidative stress. Glial activation and expression of the inflammatory mediator secreted phospholipase A2 (sPLA2) in the spinal cord were assessed at day 7 using immunohistochemistry. The extent of oxidative damage was measured using the oxidative stress marker, 8-hydroxyguanosine (8-OHG) and localization of 8-OHG with neurons, microglia and astrocytes in the spinal cord and peripherally in the dorsal root ganglion (DRG) at day 7. In addition to reducing pain, meloxicam reduced both spinal microglial and astrocytic activation at day 7 after nerve root compression. Spinal sPLA2 was also reduced with meloxicam treatment, with decreased production in neurons, microglia and astrocytes. Oxidative damage following nerve root compression was found predominantly in neurons rather than glial cells. The expression of 8-OHG in DRG neurons at day 7 was reduced with meloxicam. These findings suggest that meloxicam may prevent the onset of pain following nerve root compression by suppressing inflammation and oxidative stress both centrally in the spinal cord and peripherally in the DRG.

Serum Triamcinolone Levels following Cervical Interlaminar Epidural Injection.

Background Cervical interlaminar epidural steroid injections (ESIs) are commonly performed procedures to treat painful cervical radiculopathy, but little is known about the systemic absorption and serum levels of steroids following injection. The primary objective of this study was to investigate the pharmacokinetics of fluoroscopy-guided cervical epidural-administered triamcinolone acetonide in a cohort of patients with cervical radicular pain seeking treatment in a pain medicine clinic. Methods The study cohort included eight patients undergoing a fluoroscopically guided C7-T1 interlaminar ESI at a pain medicine specialty clinic. Blood was collected prior to the ESI and on days 1, 2, 4, 6, 8, 14, 21, 28, 35, and 42 following the injection. The sample extract was analyzed by tandem mass spectrometry. Results The terminal elimination half-life of cervical epidural-administered triamcinolone in a noncompartmental analysis was 219 hours. In the noncompartmental analysis, peak triamcinolone concentrations of 5.4 ng/mL were detected within 22.1 hours after administration. Conclusions The pharmacokinetics of cervical epidural-administered triamcinolone is consistent with our previous study of lumbar ESI, demonstrating that the elimination half-life is longer than that which has been reported following intravenous triamcinolone. The elimination half-life was shorter following cervical ESI than that which has been reported following lumbar ESI.

Effectiveness of Manual Traction and other Physiotherapy Treatment in the Management of Painful Cervical Radiculopathy

Background: Cervical radiculopathy, generally entitle as pinching of the nerves which causes severe shooting pain which mostly pass through the shoulder. Along with it causes muscle weakness and numbness into the arm and hand. In majority of the cases, cervical radiculopathy responds well to conservative mode of treatments which incorporate physical therapy with medical management. The aim of this study is to uncover the effective and evidence based conservative treatment of cervical radiculopathy.Method: Randomized controlled trial study conducted from January 2014 to December 2014. Participants were recruited from physiotherapy OPDs of tertiary care hospitals. A total number of, 100 subjects with a ratio of 50 men and 50 women were recruited between the ages of 25 and 55 years with unilateral cervical radiculopathy. Control group received combination of conventional AROM exercises and modalities including TENS and superficial thermotherapy as a treatment while experimental group received manual cervical traction and combination of conventional AROM exercises, modalities including TENS and superficial thermotherapy. For both groups, treatment was designed for two weeks (6 sessions/ week). Improvement in symptoms was assessed by evaluation of both groups on the basis of visual analogue scale (VAS).Results: After 2 weeks of treatment, patients with neck pain showed marked decreased in pain as compared with the control group (P<.001).For pre and post level a paired sample t-test was used and the results with p-value less than 0.05 were considered as significant. Mean difference of 0.94 (VAS) with a significant p-value (P<0.01) was obtained shows the respective improvements in thenumeric pain scale scores.Conclusion: Manual cervical traction when used with conventional AROM exercises and modalities were effective methods for decreasing pain in cervical radiculopathy. Recent literature supports such protocols involving multiple interventions. Results of this study also supported the treatment options in cervical radiculopathy in a multimodal approach.

Vertebral artery anatomical variations as they relate to cervical transforaminal epidural steroid injections.

To identify and categorize anatomical anomalies of the vertebral artery and determine the relationship of these unexpected variations to the site for cervical transforaminal epidural steroid injections (CTESI). The cervical region and course of the vertebral arteries was dissected in 10 cadavers. Anatomical anomalies of the vertebral arteries were identified and documented. Those that could increase the risk of intra-arterial injection during fluoroscopically guided procedures are detailed. Twenty percent of vertebral arteries were found to have anatomical variations including accessory vessels and lateral loops. These variations placed arterial segments in a portion of the posterior neural foramen where they could be at risk for cannulation during CETSI. In addition, 20% of the vertebral arteries entered the transverse foraminal column at a level other than C6. CTESI have become a mainstay in the treatment algorithm for painful cervical radiculopathy. Described techniques take extreme care to avoid cannulation of the vertebral artery during this procedure. Unexpected deviation of the artery, or an arterial segment, into the posterior neural foramen, the target zone for CTESI, increases the risk of intraarterial cannulation during injection. Accordingly, the practitioner must be aware of variant anatomy of the vertebral artery and take all precautions to avoid potential complications that may arise as a consequence.

Neuropathic Pain Components Are Common in Patients With Painful Cervical Radiculopathy, but Not in Patients With Nonspecific Neck-Arm Pain

The aim of this study was to investigate, using quantitative sensory testing (QST) parameters and the painDETECT (PD-Q) screening questionnaire, the presence of neuropathic pain (NeP) in patients with unilateral painful cervical radiculopathy (CxRAD) and in patients with unilateral nonspecific neck-arm pain associated with heightened nerve mechanosensitivity (NSNAP). All patients completed the PD-Q before QST. QST was performed bilaterally in the maximal pain area and the affected dermatome in 23 patients with painful C6 or C7 radiculopathy and in 8 patients with NSNAP following a C6/7 dermatomal pain distribution. Patients with CxRAD demonstrated a significant loss of sensory function in mechanical (P≤0.021) and vibration sense (P≤0.003) on the symptomatic side compared with the asymptomatic side in both tested body regions and in the dermatome reduced cold detection (P=0.021) and pressure pain sensitivity (P=0.005), findings consistent with nerve root damage. These sensory alterations in the maximal pain area/symptomatic side are confirmative for the presence of NeP. In contrast to these QST data, only 30% of patients with CxRAD demonstrated a NeP component according to the PD-Q score. In patients with NSNAP, a significant side-to-side difference was demonstrated for warm detection threshold in the dermatome (P=0.030). The PD-Q score indicated that NeP components were unlikely in this group. QST data suggest that NeP is likely to be observed in patients with painful CxRAD, but not in patients with NSNAP.

Self‐reported sensory descriptors are associated with quantitative sensory testing parameters in patients with cervical radiculopathy, but not in patients with fibromyalgia

The painDETECT questionnaire (PD-Q) has been used as a tool to characterize sensory abnormalities in patients with persistent pain. This study investigated whether the self-reported sensory descriptors of patients with painful cervical radiculopathy (CxRAD) and patients with fibromyalgia (FM), as characterized by responses to verbal sensory descriptors from PD-Q (sensitivity to light touch, cold, heat, slight pressure, feeling of numbness in the main area of pain), were associated with the corresponding sensory parameters as demonstrated by quantitative sensory testing (QST). Twenty-three patients with CxRAD (eight women, 46.3 ± 9.6 years) and 22 patients with FM (20 women, 46.1 ± 11.5 years) completed the PD-Q. Standardized QST of dynamic mechanical allodynia, cold and heat pain thresholds, pressure pain thresholds, mechanical and vibration detection thresholds, was recorded from the maximal pain area. Comparative QST data from 31 age-matched healthy controls (HCs; 15 women) were obtained. Patients with CxRAD demonstrated a match between their self-reported descriptors and QST parameters for all sensory parameters except for sensitivity to light touch, and these matches were statistically significant compared with HC data (p ≤ 0.006). The FM group demonstrated discrepancies between the PD-Q and QST sensory phenotypes for all sensory descriptors, indicating that the self-reported sensory descriptors did not consistently match the QST parameters (p = ≤0.017). Clinicians and researchers should be cautious about relying on PD-Q as a stand-alone screening tool to determine sensory abnormalities in patients with FM.

Uncommon presentations of neurocysticercosis

Neurocysticercosis commonly presents with seizures, raised intracranial tension and dementia. The unusual location of the cysts may result in uncommon manifestations mimicking a host of neurological disorders. Ten patients with neurocysticercosis with rare clinical presentations have been described in this series. These include dorsal midbrain syndrome, isolated bilateral ptosis, papillitis, cerebral hemorrhage, painful cervical radiculopathy, progressive swelling of arm, paraplegia due to intramedullary cyst, third ventricular cyst, dystonia and nominal aphasia masquerading as transient ischaemic attacks. The clinical details and possible mechanisms for these rare presentations are discussed.

Responses to mechanical stimulation of the upper limb in painful cervical radiculopathy

Clinical and electromyographic (EMG) responses to non-noxious mechanical stimuli were studied in four patients with painful cervical radiculopathy, and in two control subjects. In the symptomatic arm(s), palpation over one or more nerve trunks was painful and accompanied by EMG activity, whereas palpation of adjacent soft tissues was painless and unaccompanied by EMG activity. Electromyographic activity was widespread in three patients when myotatic reflexes were elicited in the symptomatic arm(s). In asymptomatic arms of patients and controls, EMG responses to the myotatic reflexes were more localised. Allodynic nerve trunks in cervical radiculopathy appear to be afferent correlates of central sensitisation; the accompanying EMG activity may represent a motor correlate of this same process.