Thoracic Radiculopathy is thoracic spinal nerve irritation caused by mechanical, or chemical, irritation of the spinal nerve. The term radiculopathy refers to the whole complex of symptoms that can be caused by a nerve root pathology. Thoracic spine has 24 nerve roots. 12 on each side. Symptoms typically correlate to the path of that specific nerve (see chart). Can be anywhere from upper back pain, rib pain, chest pain and abdominal pain (1).
Thoracic radiculopathy can be caused by any of the multiple structures surrounding the exiting nerve root. For example, thoracic disc herniation or disc tears which can create mechanical compression or chemical irritation of the exiting nerve root. Rib attachments can become unstable creating excessive movement and in effect irritation to the exiting nerve root and degenerative conditions such as osteoarthritis of the facet joints can create excessive bone spurs that can narrow the opening where the nerve exist (foramen).
WHAT ARE THE SYMPTOMS OF THORACIC SPINE NERVE DAMAGE?
Paresthesia – an abnormal sensation, typically tingling, pricking (“pins and needles”) or even burning sensation along the path of the nerve
Hypoesthesia – (abnormally decreased sensitivity, particularly to touch)
Anesthesia – (insensitivity to pain)
motor loss, pain and stiffness.
CAN RADICULOPATHY BE CURED – OR – HOW TO RELIEVE THORACIC NERVE PAIN
Traditional spine physicians treat thoracic radiculopathy with high dose corticosteroid epidurals to attempt to reduce inflammation around the nerve root.
Why Epidural Steroids Are A Bad Idea!
While corticosteroids do have a potent anti-inflammatory effect when placed around the nerves, this can reduce symptoms. The bad news, corticosteroids are extremely toxic to the local stem cells around that maintain the health of local tissue (1,2). In addition to local toxicity they have systemic effects. Epidural steroid injections have been associated with a 29% increase in spinal fracture risk, for each epidural shot, in middle-aged and older women due to bone loss (3,4). Another risk women assume with epidural steroid injections is vaginal bleeding after the procedure and studies showing these shots can cause poor blood-sugar control in diabetics (5, 6).
Can Steroid Affect Your Hormones?
Epidural steroid injections have been shown to suppress the hypothalamus-pituitary-adrenal (HPA) axis, the brain loop that allows you to respond to stress and inflammation. The effect lasting as much as three weeks after just one injection. These hormones affect the function of almost every tissue type in your body (7)! This suppression effect can create problems with energy reserves, hormonal regulation, the nervous system, immune function, and increase susceptibility to illnesses. A similar effect was also found with steroids injected into knees, with a resulting 60% of subjects showing adrenal problems two months after their steroid injections (8).
Steroid injections into knees are also associated with significant cartilage loss \with no clinically significant improvement in pain (9). If all of this isn’t enough, we’ve seen many studies simply showing these epidural steroid injections are providing less relief than the anesthetic alone (10).
Why did one steroid help but the additional ones help minimally if at all?
• First epidural: Knocks down the inflammatory process but also kills off the important local stemcells that maintain the tissue.
• Second epidural: Continues to reduce inflammation but again taking out the most local maintenance cells
• Third epidural: Most of the inflammation is gone but all the local cells that keep the tissue healthy no longer present and pain starts to build because tissue continues to break down
CAN SURGERY HELP THORACIC RADICULOPATHY?
Should corticosteroid epidurals and conservative treatments fail to give any relief then the only option is surgery. While surgery is an option if all else fails, the biggest problem with surgery, is the complications! The complication rate is as high as 35%! Given the unique aspects of the thoracic spine, rib attachments, lungs nearby, many large blood vessels, spinal cord and other vital structures, the complications from surgery can be severe and life threatening. These complications can be infections, re-herniation of disc, persistent pain, further degeneration of the disc, and spinal cord or nerve injury. Some complications do not show up until after surgery. Some show up quickly and some may take months to become evident (11).
Is there an alternative to corticosteroids that can help prevent the need for surgery?
In 2017 we published the world’s first clinical research article outlining a better way to treat radiculopathy compared to steroid injections.
We have been utilizing these advanced injections for the past 15 years and seeing excellent results. Here is a quick video outlining the use of platelet rich plasma called platelet lysate in spine treatment.
We have been treating thoracic radiculopathies for over a decade with excellent results that are safer and more effective when compared to traditional corticosteroid epidurals. If you have been diagnosed or have symptoms that fit this diagnosis, feel free to contact our office to get set up for an evaluation where we can further discuss these treatment options and discuss your candidacy for these procedures.
1.Zhang AZ, Ficklscherer A, Gülecyüz MF, et al. Cell Toxicity in Fibroblasts, Tenocytes, and Human Mesenchymal Stem Cells-A Comparison of Necrosis and Apoptosis-Inducing Ability in Ropivacaine, Bupivacaine, and Triamcinolone. Arthroscopy. 2017;33(4):840-8. https://www.ncbi.nlm.nih.gov/pubmed/28089496
2. Wyles CC, Houdek MT, Wyles SP, et al. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clin Orthop Relat Res. 2015;473(3):1155-64. https://www.ncbi.nlm.nih.gov/pubmed/25187334
3. Carreon LY, Ong KL, Lau E, et al. Risk of Osteoporotic Fracture After Steroid Injections in Patients With Medicare. Am J Orthop. 1976;46(5):E293-E300. https://www.ncbi.nlm.nih.gov/pubmed/29099886
4.Nah SY, Lee JH, Lee JH, et al. Effects of Epidural Steroid Injections on Bone Mineral Density and Bone Turnover Markers in Patients Taking Anti-Osteoporotic Medications. Pain Physician. 2018;21(4):E435-E447. https://www.ncbi.nlm.nih.gov/pubmed/30045610
5. Even JL, Crosby CG, Song Y, et al. Effects of epidural steroid injections on blood glucose levels in patients with diabetes mellitus. Spine. 2012;37(1):E46-50. https://www.ncbi.nlm.nih.gov/pubmed/21540770
6. Shanthanna H, Busse JW, Goudsmit EM, et al. Abnormal vaginal bleeding after epidural steroid injection: is there a cause for concern. Evid Based Med. 2014;19(2):e16. https://www.ncbi.nlm.nih.gov/pubmed/24282169
7. Habib G, Jabbour A, Salman J, et al. The effect of epidural methylprednisolone acetate injection on the hypothalamic-pituitary-adrenal axis. J Clin Anesth. 2013;25(8):629-33. https://www.ncbi.nlm.nih.gov/pubmed/23988802
8. Johnston PC, Lansang MC, Chatterjee S, et al. Intra-articular glucocorticoid injections and their effect on hypothalamic-pituitary-adrenal (HPA)-axis function. Endocrine. 2015;48(2):410-6. https://www.ncbi.nlm.nih.gov/pubmed/25182149
9. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017;317(19):1967-75. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815012/
10. Felson DT, Anderson JJ, Goudsmit EM, et al. Across-study evaluation of association between steroid dose and bolus steroids and avascular necrosis of bone. Lancet. 1987;1(8538):902-6. https://www.ncbi.nlm.nih.gov/pubmed/2882300
11. Manchikanti L, Knezevic NN, Boswell MV, et al. Epidural Injections for Lumbar Radiculopathy and Spinal Stenosis: A Comparative Systematic Review and Meta-Analysis. Pain Physician. 2016;19(3):E365-410. https://www.ncbi.nlm.nih.gov/pubmed/27008296
12. McCormick WE, Will SF, Benzel EC. Surgery for thoracic disc disease. Complication avoidance: overview and management. Neurosurg Focus. 2000;9(4):e13. https://www.ncbi.nlm.nih.gov/pubmed/29225115
13. O’Connor RC, Andary MT, Russo RB, et al. Thoracic radiculopathy. Phys Med Rehabil Clin N Am. 2002;13(3):623-44, viii. https://www.ncbi.nlm.nih.gov/pubmed/12380552