From the Guidelines
Management of thoracolumbar nerve root impingement should begin with conservative measures, including 6 weeks of pharmacologic and nonpharmacologic therapy, before considering imaging or surgical intervention. This approach is supported by the American College of Radiology's 2021 update on low back pain, which emphasizes the importance of initial conservative therapy 1.
Initial Treatment
Initial treatment should focus on pain control with medications such as NSAIDs and muscle relaxants, combined with physical therapy, including core strengthening exercises, stretching, and proper body mechanics training. Activity modification to avoid positions that exacerbate symptoms is crucial during the acute phase.
Imaging
For patients who have failed 6 weeks of conservative therapy, imaging should be considered to identify potential actionable pain generators that could be targeted for intervention or surgery 1. MRI of the lumbar spine is the initial imaging modality of choice, due to its excellent soft-tissue contrast and ability to accurately depict lumbar pathology, including disc degeneration and neural structures 1.
Surgical Intervention
Surgical intervention should be considered for patients with progressive neurological deficits, cauda equina syndrome, or failure of conservative treatment after 6-12 weeks. The specific surgical approach depends on the location and nature of the impingement, with options including decompression procedures like laminectomy or minimally invasive techniques.
Key Considerations
- Patients presenting with subacute or chronic low back pain, with or without radiculopathy, who have failed 6 weeks of conservative therapy should be imaged if they are believed to be candidates for surgery or intervention 1.
- CT myelography of the lumbar spine can be useful in assessing the patency of the spinal canal/thecal sac and of the subarticular recesses and neural foramen, particularly in patients with implanted medical devices that are not MRI safe or conditional 1.
- Upright radiographs provide useful functional information about axial loading, and the ability to incorporate flexion and extension radiographs is essential to identify segmental motion, which is important in the surgical management of spondylolisthesis 1.
From the Research
Management of Thoracolumbar Nerve Root Impingement
The management of thoracolumbar nerve root impingement involves a combination of non-interventional and interventional techniques.
- Non-interventional diagnosis involves physical examination and clinical assessment, with a level of evidence II and strong strength of recommendation 2.
- Imaging techniques such as fluoroscopy or computed tomography (CT) are recommended for diagnostic and therapeutic facet joint interventions, with a level of evidence I and strong strength of recommendation 2.
- Interventional diagnosis and treatment options include:
- Lumbar diagnostic facet joint nerve blocks, with a level of evidence I to II and moderate to strong strength of recommendation 2.
- Thoracic diagnostic facet joint nerve blocks, with a level of evidence II and moderate strength of recommendation 2.
- Therapeutic facet joint nerve blocks, with a level of evidence II and moderate strength of recommendation for both lumbar and thoracic spine 2.
- Radiofrequency ablation, with a level of evidence II and moderate strength of recommendation for lumbar and cervical spine, and emerging evidence for thoracic spine 2.
Non-Operative Treatment
Non-operative treatment is a viable option for certain types of thoracolumbar spine injuries, including:
- Stable fractures without neurological deficits 3.
- Patients with intact posterior ligament complex and no significant spine deformity 3.
- Patients who are suitable for conservative management based on fracture type and stability, absence of neurological deficits, and patient-specific factors 3.
Evidence-Based Diagnosis and Management
Evidence-based diagnosis and management of thoracolumbar spine injuries involve:
- Imaging as a necessary diagnostic tool 4.
- Consideration of operative management for unstable fractures, decompression, and deformity 4.
- Patient quality of life and burden following injury 4.
- A comprehensive approach to management, including non-interventional and interventional techniques, as well as consideration of patient-specific factors and fracture characteristics 2, 5, 6, 3, 4.