Refractory Radiculopathy [Neurosurgery Wiki]

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====== Refractory Radiculopathy ======

===== Definition =====

Refractory [[radiculopathy]] refers to persistent or recurrent [[radicular pain]] that does not respond adequately to [[conservative treatment]], including [[medication]]s, [[physical therapy]], and [[injection]]s. It is often associated with [[nerve root compression]] or [[irritation]], leading to symptoms such as radiating pain, [[numbness]], [[tingling]], and weakness in the affected limb.

===== Common Causes =====

Herniated Disc – Persistent nerve root compression despite conservative or surgical treatment.
Spinal Stenosis – Narrowing of the spinal canal leading to chronic nerve compression.
Failed Back Surgery Syndrome (FBSS) – Persistent or recurrent radicular pain following spinal surgery.
Epidural Fibrosis – Scar tissue formation around the nerve roots after surgery.
Chronic Inflammation – Ongoing inflammatory response leading to nerve irritation.
Foraminal Stenosis – Narrowing of the foraminal space due to osteophytes or disc degeneration.
Peripheral Nerve Entrapment – Coexisting compression syndromes (e.g., piriformis syndrome, thoracic outlet syndrome).
Diagnostic Approach
Clinical Examination – Neurological assessment for weakness, sensory deficits, and reflex abnormalities.
Imaging Studies – MRI or CT myelography to assess nerve compression and surgical failures.
Electrodiagnostic Testing (EMG/NCS) – To differentiate radiculopathy from peripheral neuropathy.
Inflammatory Markers (if indicated) – To rule out autoimmune or infectious causes.
Management Strategies
Conservative Management
Medications: Neuropathic pain agents (gabapentinoids, TCAs, SNRIs), anti-inflammatory drugs, opioids (for severe cases).
Physical Therapy: Strengthening, posture correction, nerve mobilization techniques.
Epidural Steroid Injections (ESI): Temporary relief in cases with significant inflammation.
Transforaminal or Selective Nerve Root Blocks: Targeted pain relief for diagnostic and therapeutic purposes.
Interventional and Surgical Options
Spinal Cord Stimulation (SCS) – Neuromodulation therapy for persistent pain after failed surgery.
Radiofrequency Ablation (RFA) – For facet joint-related radiculopathy.
Reoperation (if indicated) – Microdiscectomy, decompression, or fusion in cases of recurrent disc herniation, instability, or foraminal stenosis.
Peripheral Nerve Stimulation (PNS) – Emerging therapy for chronic radicular pain.
Dorsal Root Ganglion Stimulation (DRGS) – More targeted neuromodulation therapy for localized radiculopathy.