Spine and Nerve Disorders

Overview

Radiculopathy occurs when a spinal nerve root is injured or inflamed. It can cause radiating pain, numbness, tingling, weakness, and reflex change in a characteristic arm, trunk, or leg distribution. “Pinched nerve” is a useful everyday phrase, but compression is not the only mechanism; chemical inflammation from a disc herniation can produce severe symptoms even without dramatic mechanical pressure.

Cervical radiculopathy affects nerves from the neck into an arm. Lumbar or lumbosacral radiculopathy affects nerves from the lower back into a leg and is often called sciatica. Thoracic radiculopathy is less common and can cause band-like chest or abdominal pain.

The most important evidence messages in 2026 are:

• Most uncomplicated cases improve without surgery. Time, continued activity within tolerance, targeted rehabilitation, and symptom control are first-line when there is no progressive deficit or emergency feature.⁵⁶
• Immediate MRI is not necessary for every episode. Imaging is guided by red flags, neurological deficits, duration, and whether an intervention or surgery is being considered.¹²
• EMG and nerve-conduction studies complement MRI. They can localize and characterize nerve-root injury and exclude peripheral neuropathy or entrapment, but may be normal early or in purely sensory radicular pain.⁴
• Epidural steroid injections provide limited, mainly short-term benefit. The 2025 AAN review found probable short-term reductions in pain and disability for radiculopathy, with insufficient evidence for long-term pain benefit.³
• Progressive weakness, spinal-cord signs, or cauda equina symptoms require urgent action.

Evidence cutoff: This article reflects publicly available evidence through July 10, 2026. New bowel/bladder dysfunction, saddle numbness, major weakness, or spinal-cord symptoms require emergency evaluation.

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Symptoms and Common Patterns

Radicular pain often travels farther down the limb than ordinary neck or back pain. Symptoms can include:

• Electric, burning, shooting, or aching pain
• Tingling or numbness in a dermatomal pattern
• Weakness in muscles supplied by the affected root
• Reduced reflexes
• Worsening with cough, sneeze, strain, neck position, or sitting

Real patients do not always follow textbook maps. Root overlap, multilevel disease, pain referral, and coexisting entrapment neuropathy can blur the pattern.

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Causes

• Disc herniation: common in acute cervical and lumbar radiculopathy
• Foraminal narrowing: bone spurs, disc-height loss, and facet enlargement
• Spinal stenosis or spondylolisthesis
• Inflammation, infection, tumor, fracture, or vascular lesion: less common but important
• Diabetes or herpes zoster: can cause painful radiculoplexus or radicular syndromes without ordinary disc compression

Many adults have disc bulges or narrowing on MRI without symptoms. The diagnosis requires a clinically meaningful match among history, examination, and tests.

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Emergency and Urgent Red Flags

Cauda equina or conus medullaris syndrome

Emergency symptoms include new urinary retention or incontinence, loss of bowel control, saddle or genital numbness, rapidly progressive bilateral leg weakness, or severe back pain with these findings.

Spinal cord compression or myelopathy

Neck pain with hand clumsiness, gait imbalance, leg stiffness, falls, hyperreflexia, or bowel/bladder change can indicate cervical myelopathy. A root problem affects a nerve leaving the cord; myelopathy affects the cord itself and often requires more urgent specialist assessment.

Other red flags

• Progressive motor weakness or foot drop
• Fever, immune suppression, injection-drug use, or recent infection
• Cancer history, unexplained weight loss, or severe night pain
• Major trauma or osteoporosis-related fracture risk
• New symptoms after spinal procedure or anticoagulation

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Diagnosis

Neurological examination

Strength, sensation, reflexes, gait, long-tract signs, and provocative maneuvers help localize the problem and distinguish root disease from shoulder, hip, joint, plexus, peripheral nerve, spinal cord, or central nervous-system disorders.

MRI and other imaging

For uncomplicated acute low-back pain with radicular symptoms and no red flags, early imaging usually does not improve outcomes. Lumbar MRI becomes more appropriate when symptoms persist despite a reasonable conservative trial and surgery or an injection is being considered, or when there is progressive deficit or another red flag.²

Cervical imaging recommendations differ by scenario. MRI without contrast is generally the key test for persistent radiculopathy or neurological deficit; contrast is used for selected postoperative, infection, tumor, or inflammatory questions.¹

EMG and nerve-conduction studies

Electrodiagnostic testing evaluates physiological nerve function. It can:

• Support root localization and severity
• Distinguish radiculopathy from carpal tunnel syndrome, ulnar neuropathy, plexopathy, or polyneuropathy
• Show active denervation or chronic reinnervation

Sensory nerve-conduction studies are often normal in radiculopathy because the lesion is proximal to the dorsal-root ganglion. Needle EMG abnormalities take time to develop, and a normal study does not fully exclude early, mild, intermittent, or sensory-only radiculopathy.⁴

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Treatment

Activity and rehabilitation

Prolonged bed rest is discouraged. Most patients benefit from maintaining ordinary movement within tolerance, then progressing through physical therapy focused on mobility, nerve mechanics, strength, posture, and function. A program should be adjusted if weakness or neurological symptoms worsen.

Medication

Short-term acetaminophen or NSAIDs may help some patients when medically safe. Oral corticosteroids are sometimes used, but average benefit is limited and risks include glucose elevation, mood or sleep change, infection, and bone effects. Gabapentinoids, SNRIs, or tricyclic antidepressants may be considered when neuropathic pain persists, although benefit is variable and sedation or dizziness can be limiting. Routine opioids are discouraged.

Epidural steroid injections

An epidural steroid injection may reduce inflammation and create a window for activity or rehabilitation. The 2025 AAN review concluded that ESIs probably reduce short-term pain and disability in cervical and lumbar radiculopathy and may reduce longer-term disability, but evidence is insufficient for long-term pain reduction. Results were driven mainly by lumbar studies.³

Risks include bleeding, infection, dural puncture, transient worsening, steroid effects, and rare catastrophic neurological injury. Image guidance, medication choice, approach, anticoagulant management, and operator expertise matter.

Surgery

Surgery is considered for cauda equina syndrome, spinal-cord compression, progressive or substantial weakness, or persistent disabling symptoms with a clear structural target after conservative care. Procedures include discectomy, foraminotomy, decompression, and fusion when instability or other anatomy requires it. Surgery can relieve root compression; it does not guarantee elimination of every neck/back symptom.

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Common Diagnostic Pitfalls

• Calling every radiating pain “sciatica” without examining strength, reflexes, and sensory pattern
• Assuming an MRI abnormality is causal simply because it is present
• Using a normal EMG to dismiss early or sensory-only symptoms
• Missing hip, shoulder, plexus, peripheral nerve, spinal-cord, or vascular disease
• Delaying urgent care when weakness, saddle anesthesia, or bladder symptoms emerge

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A Practical Treatment Framework

1. Screen for emergencies and myelopathy.
2. Localize the neurological pattern.
3. Use imaging and EMG to answer specific questions.
4. Begin active conservative care when safe.
5. Escalate based on function and neurological deficit—not MRI appearance alone.

Bottom line: most radiculopathy improves without surgery, but progressive neurological loss changes the urgency. The best decisions integrate symptoms, examination, imaging, and electrodiagnostic evidence.

At Los Altos Neurology, evaluation includes neurological localization, review of imaging, electrodiagnostic testing when useful, conservative treatment planning, and timely spine or pain referral.

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References

1. American College of Radiology. Revised 2024. ACR Appropriateness Criteria: Cervical pain or cervical radiculopathy.
2. American College of Radiology. Evidence-based imaging guidance. ACR Appropriateness Criteria: Low back pain.
3. American Academy of Neurology. 2025. AAN systematic review: Epidural steroids for cervical and lumbar radicular pain.
4. AAPM&R KnowledgeNow. Updated 2023. Electrodiagnosis of cervical, thoracic, and lumbar radiculopathies.
5. AAPM&R KnowledgeNow. Updated 2024. Cervical radiculopathy: assessment and management.
6. AAPM&R KnowledgeNow. Updated 2023. Lumbar radiculopathy: assessment and management.

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