Melanie Cole, MS (Host): Welcome to Back to Health, the latest in health, wellness, and medical care. Keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And today, we're talking about chronic radiculopathy. Joining me is Dr. Erik Wang. He's an Assistant Attending Anesthesiologist at New York-Presbyterian Hospital Weill Cornell Medical Center, and an Assistant Professor of Clinical Anesthesiology at Weill Cornell Medical College, Cornell University.

Dr. Wang, thank you so much for being with us today. Now, radiculopathy, that's not even easy to say and a lot of people certainly don't know what that is. So, why don't you tell us what it is? We hear about it. And we think about this as something that causes pain, which is what it sounds like it is, pinched nerves, sciatica, all of these kinds of things, can you tell us a little bit about it, what it is, and how it differs from those?

Erik Wang, MD: Sure. Well, thanks for having me, Melanie, first of all. I would just say just in terms of like radiculopathy as a term in general, I think thinking about it in a way of like pinched nerves or sciatica is a pretty good way for somebody to think about, just from like a broad sense. Very broadly, basically pain related to narrowing or irritation where nerve roots are coming off along the spine, so it can really come off or originate anywhere along the spine, whether it's like around your neck in the cervical region, or very commonly in like the low back and the lumbar region as well. So, any kind of thing that can cause basically narrowing where those nerves are coming out, whether it's something anatomical like developing arthritis over time that kind of narrows those spaces where the nerves are coming out, potentially like a disc herniation that also decreases space where those nerves are coming out. And then, people with that tend to get pain eventually just because of the way the nerves get irritated.

Melanie Cole, MS: Yeah, we're certainly learning more and more about nerve pain, chronic pain, and the field of pain management. And anesthesiology is really such a burgeoning field now, and we're going to talk about that a little bit. But are there risk factors, Dr. Wang? Are there certain lifestyle behaviors, genetics that predispose us to this happening?

Erik Wang, MD: Sure. I think from like a very broad sense, you can think about pain being an issue related to radiculopathy in the sense of developing inflammation. So in terms of risk factors, I think about it as lifestyle or medical issues that can potentially increase inflammation throughout your body. So for example, chronic smokers are more likely, I guess I would say, to have potentially issues with radiculopathy. Diabetic patients, the changes that you can have over time from the course of diabetes can also predispose you to things like that. I think a lot of people get concerned in terms of potentially if there's activities or specific things that you may do that could potentially cause things to happen.

In a vacuum, you know, it's possible to have like an injury where you get a slipped disc or something that may in itself anatomically lead to radiculopathy symptoms. But I wouldn't necessarily say that there is like specific exercises or anything like that, that you should really be fearful of that could potentially cause this to happen.

Melanie Cole, MS: That's interesting. Now, Dr. Wang, are you seeing this in younger and more middle-aged patients? You mentioned before arthritis and stenosis and the things that we know happen to our back that are going to cause some of this nerve compression that leads to that pain. But are you seeing it in younger people?

Erik Wang, MD: I do see it sometimes. And kind of like what I was getting to, usually in younger patients, what I tend to see are you have like a healthy young patient who's pretty athletic, likes to stay fit and work out, and maybe they weren't careful when they were lifting something heavy or something like that, those are patients that tend to get referred to us, because maybe they had an ED visit and they got some imaging done that it showed maybe like an acute slipped disc. And if your disc is bulging out and really narrowing that space where some of those nerve roots are coming out, you can definitely be in potentially for a lot of discomfort there.

But overall, I would say the patient population that I'd see more commonly is probably older patients, sometimes in the middle age range as well, just with degenerative changes over time in their spine that causes narrowing for those nerves.

Melanie Cole, MS: So, Dr. Wang, as an exercise physiologist, I've been seeing people with back pain for 37 years. And it comes in so many forms, right? And pain is somewhat subjective. So, how we tell how much pain somebody's in is always an interesting thing to look at. But when we think of back pain, are there some telltale signs that this is a radiculopathy? What are those? Tell us a little bit about when somebody comes to you with this kind of pain, whether it's chronic or new, what do you do and how do you tell?

Erik Wang, MD: So, when we started things off, you were talking about like pinched nerves and sciatica and things like that. I would say, in general, using that term sciatica is like a pretty easy way to kind of describe or like ask questions with a patient who may not be super familiar with a lot of more like medical language, things like that, because everybody has some kind of familiarity with that.

So, I would say almost the textbook thing that you may see with radiculopathy is like a shooting pain that's associated with a nerve distribution, and it depends in which area along the spine as well. I would say lumbar, so like the low back is what I tend to see more commonly in my clinic, and then also cervical spine, like in the neck area. So following the distribution where the nerves are coming off from your spine, you may get pain that kind of courses along that. So, shooting pain down the buttock, down the leg, originating from the back. Sometimes one-sided, sometimes both sides. You may potentially have sort of like a numbness or tingling sensation as well. And sometimes people feel a little bit weaker in that area as well.

Melanie Cole, MS: Well, I've always said that unless you're someone who's really ever experienced back pain. And that pain of sciatica, that shooting pain or the weakness that you were just describing, or really the debilitating pain that knocks you out, you can't really get it. You don't really understand the limitations and the quality of life that's so effective.

So, speak a little bit about, first of all, some of the non-surgical management techniques. What do you do when someone comes to you, Dr. Wang? What are some of the more conservative measures that you might try?

Erik Wang, MD: Sure. So, there's a lot of ways to go about things. And in my mind, what I tell patients is kind of like the three kind of main areas that we try to address. So, one would be potentially medications that may help with pain during that situation where they're having pain now. Potentially procedures or like injections that may help with pain. And then, also physical therapy as a more long-term thing that will be helpful. Maybe not necessarily fully in the acute setting, if you're having like a new serious pain.

But just to elaborate on that, in terms of medications, a lot of people can start with over-the-counter stuff like Tylenol and NSAIDs, like ibuprofen, naproxen, things like that. There are also longer acting versions of those medications that we can prescribe that can be quite helpful in the short period. And then, as far as medications, it may help with like nerve-related pain, which this really is because there's irritation around the nerve. There's medications like gabapentin or pregabalin, which kind of help calm those nerves down, is how I like to describe it for patients. I would say those are like the more common things. Sometimes you may have other concurrent pains that aren't necessarily just because of the nerve irritation or nerve pain. Muscle relaxants may be helpful for that as well.

And then, as far as procedures go, I would say almost like the bread and butter for us is considering epidural steroid injections, if it looks appropriate based off patient symptoms and what imaging looks like. And there's a couple ways that you can go about that, which I can get into a little bit more if you'd like.

But also, I think physical therapy is very key. I really like to emphasize that a lot for patients. As somebody who had done a lot of years of like weight training and likes to stay active myself, one of the ways I kind of frame it for patients that are maybe not so enthusiastic about considering PT, especially if there are like younger patients who are pretty active and exercising themselves, is that it's very helpful to work with somebody who specializes in that and working on specific exercises for those kind of like smaller core-stabilizing muscles, and also potentially for like your posture and the way that you move around, like economy of motion. And those are not necessarily things that you get better at by like lifting heavy in the gym or like doing a lot of cardio. So, I think, for anybody, there is a lot of benefit you can get from working closely with a physical therapist.

And the way I frame things often is I want to do things right now to try to get your pain feeling better, but I also want you to feel better so you can stay active and get stronger, and then prevent this from being more of an issue in the future.

Melanie Cole, MS: That's so true, Dr. Wang. And physical therapy does give you that little extra edge of exercises that you're not going to get really in the gym. And working on those small muscle groups and the protective muscle groups that can help protect and quiet those nerves.

So, that's a great point. Now, I would like you to expand a little on injections because there are so many now, right? You have so many tools in your toolbox, and people don't always understand, they don't know how many you can get. They hear about all these different kinds of things, not only steroids, but blocks. And give us a little injection lesson here today, because it's a really big field right now.

Erik Wang, MD: Yeah. We don't have to get too like pedantic about like the fine details. But in my mind, if I'm looking at something where it's like a very clear lumbar radiculopathy, the patient is giving me like textbook description of their symptoms, like maybe I noticed this like six weeks ago, it's been getting worse. It's in my low back, but it's going down my right buttock down the back and the side of my leg all the way down into my foot. And let's say we get like an MRI and we see that there's very significant narrowing at one of the lumbar levels on the right side. So, a lot of that kind of corresponds and tells me, "Yes, I see irritation of the nerve. And it makes sense with the distribution of pain that you're having."

For those kinds of patients, epidural steroid injection is like the quick and easy way that a lot of pain physicians will try to help with managing the pain. And a lot of people are familiar with the term epidural from the sense of like OB anesthesia, like having an epidural catheter placed for labor and delivery. That is the name of the space that the medication is going in, or where the catheter is going in for if you're getting a labor epidural. So, that's just all that it means. I get that question a lot. The concept is still getting something into that space. So in this case, we typically use steroid to help with inflammation, tying back to what we were talking about earlier. So, the idea is kind of a more directed delivery of a strong anti-inflammatory medication directly at the source where there seems to be a problem.

And there's a few ways you can go about doing an epidural approach. I would say the two most common ways that we discuss them are like an interlaminar or translaminar, which is right down the middle, and then transforaminal, which is coming in more obliquely to the sides where you're getting the nerves as they're coming out of the area on the side of the spine there.

Melanie Cole, MS: You explained that very well. Now, Dr. Wang, I'd like to briefly touch on the field of interventional pain management because that's what you do. And as we said, you know, it's not a new or field, but it's not been around that long. And it's very exciting time in your field. And as we look at opioid stewardship and what used to be mainly the standard of care for pain management, but now is looking towards not only these interventional procedures, but a multimodal pain management, looking at that patient. So as talking about physical therapy and all of those things, tell us a little bit about your field itself and why it's so exciting and what's going on.

Erik Wang, MD: I think what's really exciting about interventional pain as a field is that it's very multidisciplinary. And there's so many ways that you can approach trying to help with somebody. And a lot of ways too, I really like to try to emphasize like patient function as well. Like, I want to help get your pain feeling better, but I also want you to be more functional and be able to do the things that you like to do. Because at the end of the day, the important thing is like being able to live your life and enjoy yourself.

So as far as like the things that we can offer, multimodal pain regimens is definitely a big thing. I think since the '90s, there's been this whole issue where people are getting more and more concerned about opioid use and opioid prescriptions. I think it goes without saying that there are a lot of downsides to opioid use, especially chronically. So, one important aspect of medication management, I think, is finding regimens that can address pain in like multiple angles and try to reduce your need for opioid medication specifically for pain.

When I talk to patients about it from like a multimodal perspective, what I like to describe it as is kind of we try to address pain in multiple different ways. Like, every medication that we pick works a different way. It works on different receptors, it works potentially in different parts of the body, and it's multiple parts coming together to be greater than the sum of its parts in terms of helping with your pain.

And what I think is great is that you can combine this with physical therapy, other types of therapy, interventional procedures, which there are almost like infinite possibilities of things you can do as well. And even considering like more holistic things, like I'm a big fan of acupuncture, potentially considering massage if it helps for some patients. There actually is some decent literature for some like nutritional supplementation. Although I think people should, in general, be a little bit careful about where they're sourcing products from. But I think those are all things that are also worth discussing with your doctor if you see them regarding your pain. There's a lot of options out there. It's not just opioids anymore.

Melanie Cole, MS: Well, thank you for saying that. And what I find interesting is I like that you mentioned acupuncture and massage. There's yoga and mindfulness. There are all these new ways that are-- well, they're not new, but they're coming together and I like that sort of Eastern and Western medicine is coming together to help people with some of this chronic back pain and just general pain, and working together because we're finding more and more, right, that all of these things work well together and in conjunction. And if you had to talk to people and say, looking at exercise, weight management, good nutrition, keeping calcium levels up, those kinds of things that we were touching on, yoga, exercise, physical therapy, posture, we're all sitting at our computers all day now, and posture is a big thing, right? I'm trying to sit up for this right now, but that also contributes to our back pain. So, what's your best advice, if you had to think of your best advice to keeping that healthy back and hopefully not even getting that nerve pain in the first place?

Erik Wang, MD: And you know, now I'm thinking about how I'm probably not sitting in the best posture. It almost feels like kind of a cop out answer, but all the things that you would do in general to try to stay healthy are going to be things that are helpful for preventing pain or at least optimizing pain that you may be already having.

So, maintaining physical fitness, like being at a healthy weight level, I think there's a lot of benefit to doing cardio exercise and also resistance training, especially for patients as they get older, like having adequate muscle mass that's actually supporting all those structures in their body, maintaining a good diet. There is some decent evidence for like anti-inflammatory diets or like Mediterranean diets, as some people say. But honestly, just in general, living a healthy lifestyle is going to be one of the things that really helps prevent things from happening in the first place, or getting worse if you're already starting to deal with some issues.

Melanie Cole, MS: And Dr. Wang, I mean, you've been such a really educational and informative guest. If somebody is struggling with this chronic pain and they're not sure if it's nerve related, what would you like them to know about when they should see a physician and the hope that's out there. Because as we said before, it affects your quality of life. It is some of the most debilitating, painful conditions that you can have. And so, what would you like them to know about when it's good to see a doctor and look into some of these things we've been discussing today?

Erik Wang, MD: I think if things are bothering you and it's affecting your lifestyle, it's probably a good time to just see somebody like, don't put it off. I know being from the side of being like a healthcare professional, there are things that we navigate through in terms of like timing with like insurance and all of those things. But if you, as a patient, if you're being affected by your pain, I think it's worth seeing somebody, because at the very least they can probably discuss with you some options that maybe you didn't consider. I think some people get worried about, "I have new back pain right now. Should I stop doing any kind of activity?" which is usually not good. Or I'm worried that if I go see somebody for medication, they're going to just recommend opioids and I'm not interested in that. But there are so many options. There's so many things we can do even just from the start that are conservative. And if things continue to be an issue, there's so many more options that are available. All of these things are there to help you. It just takes you seeing somebody first.

Melanie Cole, MS: Thank you so much, Dr. Wang, for joining us today and sharing your incredible expertise with us. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review back to Health on Apple Podcast, Spotify, iHeart, and Pandora. And for more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole.

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