Pain in the neck and arms can develop following injury to the spine or as a result of aging and disc degeneration. When this pain is severe it may be associated with the release by the body of certain chemicals which cause inflammation and swelling. This inflammation often can be decreased simply by rest and common medications such as aspirin or Advil. If the inflammation persists despite these treatments, cortisone may be recommended.

Cortisone (a type of steroid) is a very powerful anti-inflammatory medication. It can be administered as pills taken by mouth or with an injection. When administered by injection the cortisone is maximally concentrated at the site of inflammation and higher doses are possible with improved effectiveness.

An epidural injection places the cortisone in the space (epidural space) around the spinal nerves. Once injected the cortisone is slowly released into the surrounding tissues and decreases inflammation, swelling and pain. The cortisone does not cure the underlying cause of your pain. The goals of the injection are to decrease your pain to a tolerable level and to allow you to participate in rehabilitation and therapy while natural healing occurs. If you don’t notice an effect right away following the injection don’t become discouraged. It commonly takes 7-10 days for the cortisone to be fully effective. One injection may produce a dramatic relief of symptoms. Sometimes a second or third injection is required in order to obtain the maximum benefit. More than four injections in a year are not recommended.

Pain in the neck or back can develop following injury to the spine or as a result of aging, disc degeneration and arthritis. Herniation of a disc or bone spurs can compress the spinal nerves in the neck or lower back and cause pain to radiate into your arms or legs. This may be associated with numbness or weakness. Symptoms can often be improved simply by time, rest, and common medications such as aspirin or Advil. Exercises often under the supervision of a physical therapist may be started and hopefully allow you to return to full activity. If however routine treatments are unsuccessful and your symptoms are intolerable your doctor may recommend further testing to obtain a clear picture of what is causing the pain and to assist in planning further treatment. Routine X-Rays studies are able to produce pictures of the bones of the spine and are often the first test obtained. They may be helpful but are limited because they are not able to show the discs or spinal nerves. If more detailed information about the bones in a specific region is required a CT scan may be suggested. Sometimes it is important to visualize all of the bones in your body. If this is required a bone scan is indicated. The special test most commonly used to image the nerves of the the spine is a MRI scan. Often this is all that is required to understand the problem and plan treatment. Sometimes in more complex problems such as spinal stenosis and especially in people who have undergone previous surgery a myelogram combined with a CT scan is needed. A discogram is a test sometimes used in patients with long standing back or neck pain to identify which disc is the cause of your pain and to help plan possible surgery.

An electrodiagnostic study is a test that our physicians perform to help diagnose nerve and muscle disorders. It consists of two parts: NCS (nerve conduction study) and EMG (electromyography).

During the NCS portion of the exam, the physician uses a small amount of electricity to determine how well your nerves are functioning. You will feel brief tingles or small shocks each time the nerve is stimulated.

During the EMG portion of the exam, the physician will place a thin needle electrode into several muscles and examine their electrical properties on a screen. You will feel mild discomfort with the electrode.

Your physician will use the information obtained to treat your condition as effectively as possible. Some of the more common disorders diagnosed with an electrodiagnostic study include carpal tunnel syndrome, radiculopathy (pinched nerves in the neck and back), peripheral neuropathy, ulnar neuropathy and myopathy (muscle disease).

To prepare for the exam, the patient is asked to bathe or shower on the day of the study. A soap with little or no oil (such as Ivory soap) should be used. The patient should not apply any lotions to the skin on the day of the exam.

Please advise your physician if you are on any blood thinners or have had any surgery requiring the removal of lymph nodes (such as mastectomy).

If you have any questions prior to the exam, please fell free to call our office to discuss them with our staff. We have reserved a significant amount of time for your study. Each exam typically lasts 30-60 minutes. Please contact us well in advance if you cannot make that appointment so that we may schedule another patient in that time slot.

Numbness, tingling, pain, weakness, and loss of muscle bulk may indicate a nerve impingement or a nerve irritation. While x-rays, CT scans, and MRI scans are useful in producing a picture that you doctor can use to infer the possibility of a nerve impingement or a nerve irritation. These tests do not actually demonstrate what is actually going on with the nerve itself. In addition, x-rays, CT scans, and MRI scans are often non-specific and may demonstrate multiple abnormal findings, each of which may be capable of being the source of numbness, tingling, pain, weakness, and loss of muscle bulk. EMG/NCS is a useful test that can be used to complement the information obtained in a history, the physical examination, and tests. Conditions commonly diagnosed with the use of EMG/NCS include: carpal tunnel syndrome, cervical radiculopathy (nerve root impingement or irritation in the neck), and lumbar radiculopathy (nerve root impingement or irritation in the lower back).

What is an EMG/NCS?

Electromyography (EMG) involves a very thin needle or wire electrode that is placed into your muscle. By observing the activity on the screen as well as listening to the activity, this test is used to detect current or past irritation or impingement of the nerve, a problem with the nerve to muscle junction, or a problem with the muscle itself.

Nerve Conduction Study (NCS) involves small shocks using a stimulating electrode and measured by recording electrodes. This test measures how quickly your motor and sensory nerves are conducting messages from one point to another.

This procedure is performed by a physician trained in electro-diagnostic medicine.

Instructions

Your doctor has recommended that you undergo EMG/NCS. This will be performed as an outpatient procedure in an office setting. You may drive to and from the testing. There are no restrictions in regards to your eating before or after the testing.

Please give the physician performing your examination a list of medications you are currently taking. For the most part, you should not stop your medications in preparation for this test. If you are on pain medications, you should continue the pain medications prior to the test. A few medications, however, do have a small potential to alter the results of this test, and the physician performing the test needs to know.

Please take off your jewelry and watches and secure them in your clothing or bag.

Do not apply any lotion or ointments on to your skin on the day of the testing. If you use any types of lotion or ointment on any part of the body to be tested, please wipe it all off with soap and water and dry thoroughly. Lotions or ointments on the skin make the procedure difficult to perform and may invalidate results. If you are having you upper limbs studied, please take off your shirt and place the gown on with the back open. If you are having your lower limbs studied, please take off you pants or skirt, shoes, and socks or hosiery and place the gown on with the back open. Please keep your undergarments on. If you are not sure which part of your body we will study, take off everything except your undergarments and place the gown on with the back open.

If you have cold limbs, let your physician know. It is very important that your limbs are warm. Cold limbs may invalidate results. This test may take anywhere between 30 minutes to an hour or more. In some instances, it may be necessary to have you return at another time to complete the examination.

Relax. This test will provide useful information in regards to your condition. Your being relaxed will allow the test to be performed with greater ease, and we will be able to finish earlier. Following the testing, the physician performing the test will usually be able to give you the preliminary results of the testing.

Risks and Side Effects

There are no risks associated with nerve conduction studies. Nothing is inserted into the skin, so there is no risk of infection. The voltage of electrical pulses is not high enough to cause an injury or permanent damage. There is a theoretical risk that if you have a cardiac defibrillator, the shock from the nerve conduction study may activate it. If you have a cardiac defibrillator or a pacemaker, notify us before the examination.

Electromyography (EMG) is very safe. With the EMG, you may develop small bruises or swelling at some of the needle insertion sites. If you take blood thinners, such as Coumadin, the risk of bleeding and bruising may be greater. If you have a bleeding disorder, such as hemophilia, we may not be able to perform parts or the entire test. Please notify us if you are on a blood thinner or have a bleeding disorder. The skin is sterilized with alcohol pads, and sterile, single-use, prepackaged wire electrodes are used and discarded after each and every examination, so infections are extremely rare.

Post EMG/NCS Instructions

During the test, the physician will mark on your skin with a ballpoint pen to facilitate measurements. The ink wipes off easily with alcohol pads. You may ask the physician for some alcohol pads after conclusion of the examination.

Following the testing, the testing physician will be able to discuss the results of this test with you.

You may feel some mild soreness following the examination. Should this occur, the best way to address this is to use ice over the affected area for up to 10 minutes at a time. You may repeat this every hour. Do not do this, however, if you have diabetes or have peripheral blood vessel disease. Even if you do nothing, the soreness or bruising will resolve spontaneously and completely within a few days.

Remember, this test is meant to help you and to give you answers. If you have any questions, feel free to ask the physician performing the test.

Pain in the neck and back can develop following injury to the spine or as a result of aging, disc degeneration and arthritis. When this pain is severe it may be associated with the release by the body of certain chemicals which cause inflammation and swelling. This inflammation often can be decreased simply by rest and common medications such as aspirin and Advil, or with prescription anti-inflammatory drugs . If the inflammation persists despite these treatments, cortisone may be recommended.

Cortisone (a type of steroid) is a very powerful anti-inflammatory medication. It can be administered as pills taken by mouth or with an injection. When administered by injection the cortisone is maximally concentrated at the site of inflammation and higher doses are possible with improved effectiveness.

A facet joint or nerve injection places the cortisone into one of the joints in the spine or next to the nerve supplying the joint. Once injected the cortisone is slowly released into the surrounding tissues and decreases inflammation, swelling and pain. The cortisone does not cure the underlying cause of your pain. The goals of the injection are to decrease your pain to a tolerable level and to allow you to participate in rehabilitation and therapy while natural healing occurs. If you don’t notice an effect immediately following the injection don’t become discouraged. It commonly takes 7-10 days for the cortisone to be fully effective.

The spine has many facet joints in the neck, mid and lower back. Luckily the source of the pain is usually confined to only a few levels on one or both sides of your spine. Your doctor will discuss with you the number of joints or nerves for which injection is planned. Often, one set of injections will result in a decrease in symptoms. If successful however, it is difficult to predict how long the cortisone will continue to work. The injections can be repeated but not more than 3-4 times per year.

THE PROCEDURE

The injection is performed as an outpatient. You will need to arrive 15 minutes early unless notified otherwise. A nurse will greet you and answer any last minute questions. The injection takes about 15 minutes to perform. You will be positioned on your stomach. Your spine will then be washed with iodine. Then the skin at the injection site/s is numbed with local anesthetic. The needles are then inserted into the facet joint/s or next to the nerve/s to the joint. The position of the needles are checked using a special X-Ray machine. Once the needles are correctly positioned the cortisone is injected. Most patients experience very little pain either during or after the injection. After the injection you will be gradually mobilized up to sitting and walking. A nurse will review discharge instructions with you. A friend or relative should be with you or available to bring you home.

RISKS AND SIDE EFFECTS

Facet joint cortisone injections are very safe and usually have no side effects. There are however certain potential risks about which you should be familiar. Some patients experience a mild ache in the area of injection several hours after the procedure when the local anesthetic has worn off. This usually resolves rapidly and can be treated with an ice pack for 15 – 20 minutes and/or Tylenol. Allergic reaction to either cortisone, or local anesthetic (xylocaine) is very rare. If you think you may be allergic to any of these medications you must notify you doctor. The most common side effect following the injection is a small drop in your blood pressure if you get up too soon after the injection. This passes in a few minutes.

Complication from placement of the needle are rare. Infection, bleeding and nerve damage have been reported but are very, very, rare.

Facet joint cortisone injection should not be performed if you have active infection at the site of injection, a bleeding disorder, or uncontrolled diabetes or congestive heart failure.

Relax! Most patients find that undergoing facet joint injections is much easier than they had imagined. If you have additional questions please ask your doctor.

POST INJECTION INSTRUCTIONS

  1. If you have been provided with a pain diary, be sure to complete it with your activity level and level of pain. Make entries on an hourly basis for 4 – 6 hours after your procedure. Be sure to bring the diary with you to your follow-up appointment.
  2. Rest at home for the remainder of the day following the injection. Don’t tackle any big projects. If you do experience aching in you neck or back try an ice pack for 15 – 20 minutes or some of your usual pain medication such as Tylenol or Advil.
  3. The day after your injection you may resume normal activities. But remember not to push beyond your limits.
  4. A follow-up appointment should have been scheduled before your procedure. If it was not scheduled, be sure to do so at the time of your procedure.
  5. Contact your doctor or the emergency room if you develop signs of infection (fever or redness at the site of injection), or if you notice a change in the way the nerves in your arms or legs are working (increasing numbness or weakness) or a change in you bowel or bladder function.
  6. Call your doctor’s office to arrange follow-up as needed.

Problems in the spine can develop following injury or as a result of aging and disc degeneration. Small cracks or fissures may occur in the wall of the disc and cause pain centered in your neck or lower back. Large tears can result in herniation of the disc and pain radiating into your arms or legs.

Symptoms can often be improved simply with time, rest and common medicines such as aspirin or Advil. Sometimes more powerful treatment such as an epidural or facet joint cortisone injection is needed to obtain pain relief. Exercises often under the supervision of a physical therapist may be started and hopefully allow you to return to full activity. If however routine treatments are unsuccessful your doctor may recommend further testing to obtain a clear picture of what is causing the pain and to assist in planing further treatment. This could include X-rays, an MRI, a CT/myelogram, a bone scan and/or a discogram.

If your symptoms persist and the pain and limitations are intolerable surgery may be considered. Several types of spinal surgery are routinely recommended. Laminectomy and discectomy are commonly performed to treat disc herniation, pinched nerves and spinal stenosis. Spinal fusion is used to strengthen the spine or treat severely damaged or degenerated discs. IntraDiscal ElectroThermal Therapy (IDET) is a new procedure developed to treat small tears or fissures in the disc and some small disc herniations before they go on to severe degeneration.

THE PROCEDURE

(IDET) is a minimally invasive, out-patient procedure developed in 1998 that uses heat to treat certain types of disc injuries. An X-ray machine called a fluoroscope or C-Arm is used to place a specially designed catheter ( a thin tube) into the damaged portion of the disc thorough a needle. The tip of the catheter applies a carefully measured amount of heat to the disc which causes the collagen (a major protein in the disc) to thicken, shrink and strengthen. It also coagulates and desensitizes the pain sensors within the disc. 60-75% of patients in the initial studies have reported satisfactory pain relief one year after the procedure. The long term results are unknown. Not all disc problems can be treated with IDET. Patients with a large disc hernation, spinal stenois or advanced disc degeneration are not candidates for treatment. A complete diagnostic evaluation is required to determine if you will benefit from IDET.

You should not have anything to eat or drink for at least 8 hours prior to IDET, because you may be receiving intravenous sedation during the procedure. Please bring with you any X-ray studies you have at home. After registering, a nurse will complete preparations for the procedure. In the procedure room you will be positioned on the table on your stomach. After your skin is cleaned with iodine and is numbed with local anesthesia the needle and catheter will be inserted into the disc. The fluoroscope machine is used to guide exact placement. The disc is then slowly heated to the correct temperature. This usual takes about 17 minutes. While the disc is heating you may experience an increase in your typical pain. You will be given additional medication if needed. Often the entire disc can be treated through one needle. Sometimes a second needle inserted from the opposite side is needed to permit treatment of the entire disc. If two discs need to be treated the procedure is then repeated at the second level. At the completion of the procedure you will be monitored until stable. After the sedative medication has worn off, discharge instructions are reviewed. A friend or relative must be with you or available to bring you home. Driving is prohibited. If you have been fit with a spinal brace, bring it with you to the procedure so that you may wear it home.

After the Procedure

The discomfort generated when the disc is heated may take several days to subside. It can be treated with rest in bed, an ice pack and/or Tylenol or Advil. Your doctor may choose to give you a stronger pain medication or muscle relaxant if appropriate. Occasionally a short course of oral cortisone can be helpful to control post-procedure discomfort. A back support or brace is used at all times when out of bed after the procedure until sufficient healing has occurred ( usually about 6 weeks). Disc healing will continue for 3-4 months after IDET. You should not overexert yourself during this time, even if you experience a marked reduction in your usual pre-procedure pain.

During the first month after IDET you should restrict bending twisting or heavy lifting. No strenuous housework, gym workouts or sports activities such as running, biking, golfing, tennis, or skiing, etc. are allowed. Limit your sitting time to tolerance levels and limit long car rides or airplane flights to only what is absolutely necessary. You do not have to abstain from sexual activity, but be careful not to exert your back. Your should discuss with your doctor your plan to return to work. If your work is sedentary, you can typically return within one week after the procedure.

Rehabilitation exercises will begin in the second month after IDET. The physical therapist will instruct you in proper body mechanics and lifting technique and will begin an exercise program designed to improve your strength and flexibility. If you have been performing strenuous exercises before the procedure you will not return to that level of exercise but to a more moderate level that will be gradually increased as you improve. If you plan to return to strenuous work or sports special advanced training will probably help you achieve this goal. Improvements may continue for up to six months following the procedure.

RISKS and SIDE EFFECTS

There are a few potential risks and side effects which you should understand. Infection in the disc can occur. You will be given antibiotics prior to the procedure to minimize this risk. Bleeding and nerve damage have been reported but are very rare. Because you are awake during IDET your doctor can carefully monitor your neurologic status during needle placement and disc heating. Not all patients will find relief of their pain and symptoms may recur over time.

Post IDET Instructions

  1. In the first week after the procedure you may experience a moderate increase in your normal pain. Rest, ice, pain medications and anti-inflammatory medication will minimize discomfort during this time.
  2. Restrict your activities as described above. Use your brace when out of bed if advised.
  3. Any unusual or new symptoms (for example, fever, weakness, numbness, or a change in your bowel or bladder function) should be reported to your physician immediately, or you should contact the emergency room for further evaluation.
  4. Call your doctors office for a follow up appointment in several weeks.

Pain in the lower back and legs can develop following injury to the spine or as a result of aging and disc degeneration. When this pain is severe it may be associated with the release by the body of certain chemicals which cause inflammation and swelling. This inflammation often can be decreased simply by rest and common medications such as aspirin or Advil. If the inflammation persists despite these treatments, cortisone may be recommended.

Cortisone (a type of steroid) is a very powerful anti-inflammatory medication. It can be administered as pills taken by mouth or with an injection. When administered by injection the cortisone is maximally concentrated at the site of inflammation and higher doses are possible with improved effectiveness.

An epidural injection places the cortisone in the space (epidural space) around the spinal nerves. Once injected the cortisone is slowly released into the surrounding tissues and decreases inflammation, swelling and pain. The cortisone does not cure the underlying cause of your pain. The goals of the injection are to decrease your pain to a tolerable level and to allow you to participate in rehabilitation and therapy while natural healing occurs. If you don’t notice an effect right away following the injection don’t become discouraged. It commonly takes 7-10 days for the cortisone to be fully effective. One injection may produce a dramatic relief of symptoms. Sometimes a second or third injection is required in order to obtain the maximum benefit. More than four injections in a year are not recommended.

THE PROCEDURE

The injection is performed as an outpatient. You will need to arrive 15 minutes early unless notified otherwise. A nurse will greet you and answer any last minute questions. The injection takes about 15 minutes to perform. You will be either on your stomach or on your side. Your back will then be washed with iodine. Then the skin at the injection site is numbed with local anesthetic. A needle is then inserted into the epidural space. The position of the needle is checked using a special X-Ray machine, and by injecting a contrast agent into the epidural space. Once the needle is correctly positioned the cortisone is injected. Most patients experience very little pain either during or after the injection. After the injection you will be gradually mobilized up to standing and walking. The nurse will review discharge instructions with you. A friend or relative should be with you or available to bring you home.

RISKS AND SIDE EFFECTS

Epidural cortisone injections are very safe and usually have no side effects. There are however certain potential risks about which you should be familiar. Some patients experience a mild ache in their back several hours after the procedure when the local anesthetic has worn off. This usually resolves rapidly and can be treated with an ice pack for 15 – 20 minutes and/or Tylenol. Allergic reaction to either cortisone, contrast agent ( iodine), or local anesthetic (xylocaine) is very rare. If you think you may be allergic to any of these medications you must notify you doctor. The most common side effect following the injection is a small drop in your blood pressure if you sit up too soon after the injection. This passes in a few minutes. Less common side effects include transient headache, nausea, facial flushing, insomnia and low grade fever.

Complication from placement of the needle are rare. A small leak of spinal fluid can occur as the needle is placed into the epidural space. Usually the leak stops spontaneously and does not cause any problems. It can on occasion cause a headache which worsens when you sit up. Most often this can be treated at home with bed rest and fluids. On rare occasions more prolonged rest in the hospital or a procedure to stop the fluid leak is needed. Infection, bleeding and nerve damage have been reported but are very, very, rare.

Epidural cortisone injection should not be performed if you have active infection at the site of injection, a bleeding disorder, or uncontrolled diabetes or congestive heart failure.

Relax! Most patients find that undergoing an epidural cortisone injection is much easier than they had imagined. If you have additional questions please ask your doctor.

POST INJECTION INSTRUCTIONS

  1. Rest at home for the remainder of the day following the injection. Don’t tackle any big projects. If you do experience aching in your back try an ice pack for 15 – 20 minutes or some of your usual pain medication such as Tylenol. If you develop a headache you should rest in bed the next day and drink plenty of fluids. If it persists contact your doctor.
  2. The day after your injection you may resume normal activities. But remember not to push beyond your limits.
  3. Contact your doctor or the emergency room if you develop signs of infection (fever or redness at the site of injection), or if you notice a change in the way the nerves in your arms or legs are working (increasing numbness or weakness) or a change in you bowel or bladder function.

Myelogram with post-injection CT scan

Problems in the neck or back can develop following injury to the spine or as a result of aging, disc degeneration and arthritis. Herniation of a disc or bone spurs can compress the spinal nerves in the neck or lower back and cause pain to radiate into your arms or legs. This may be associated with numbness or weakness.

Symptoms can often be improved simply by time, rest, and common medications such as aspirin or Advil. Exercises often under the supervision of a physical therapist may be started and hopefully allow you to return to full activity. If however routine treatments are unsuccessful and your symptoms are intolerable your doctor may recommend further testing to obtain a clear picture of what is causing the pain and to assist in planning further treatment.

Routine X-Rays studies are able to produce pictures of the bones of the spine and are often the first test obtained. They may be helpful but are limited because they are not able to show the discs or spinal nerves. If more detailed information about the bones in a specific region is required a CT scan may be suggested. Sometimes it is important to visualize all of the bones in your body. If this is required a bone scan is indicated. The special test most commonly used to image the nerves of the the spine is a MRI scan. Often this is all that is required to understand the problem and plan treatment. Sometimes in more complex problems such as spinal stenosis and especially in people who have undergone previous surgery a myelogram combined with a CT scan is needed. A discogram is a test sometimes used in patients with long standing back or neck pain to confirm the site of the pain and plan surgery.

MYELOGRAMS

Sometimes a test called a myelogram is needed to visualize the nerves in your spine. A myelogram involves inserting a small needle into the sac that contains the spinal nerves and injecting an iodine containing contrast material called Omnipaque. The contrast coats and outlines the nerves and allows them to be seen . Most often the injection is made in your lower back. The contrast can then be moved into the area to be studied by tipping the special table upon which you are positioned in different directions. Often in addition to regular X-Rays a CT-scan is performed within a few hours of the myelogram before the contrast is absorbed. This gives the added benefit of high resolution and cross-sectional images.

THE PROCEDURE

In the morning prior to your myelogram you should increase your fluid intake. You may eat a light meal and take your regular medications. Plan to arrive one hour prior to the procedure. After registering, a nurse will complete preparations for the procedure. In the procedure room you will be positioned on the X-Ray table on your stomach. Your back will be washed and the skin numbed with a local anesthetic. The myelogram needle will be inserted and a small amount of spinal fluid will be removed for testing. Some patients feel a mild pressure in the back when the contrast is injected. This part of the test only takes a few minutes. Once the injection is complete the needle will be removed and X-Rays will be taken with the table in various positions.

Almost all patients will then be moved to the CT-Scan room where additional pictures are taken (see below). Following the CT-Scan you will be monitored until stable and then discharge instructions are reviewed. A friend or relative must be with you or available to bring you home. Driving is prohibited.

Most patients feel fine and are able to go home the same day. You will need someone to drive you home. If you are not ready to go home arrangements will be made to keep you in the hospital overnight.

RISKS and SIDE EFFECTS

There are a few potential risks and side effects which you should understand. Some patients experience a mild ache in their back several hours after the procedure when the local anesthetic has worn off. This usually resolves rapidly and can be treated with an ice pack for 15 – 20 minutes and/or Advil or Tylenol. Allergic reaction to either the contrast agent ( iodine) or local anesthetic (xylocaine) is very rare. If you think you may be allergic to either of these medications you must notify you doctor. Complication from placement of the needle are rare. Infection, bleeding and nerve damage have been reported but are very, very, rare.

Post Myelogram Instructions

The most common side effect is headache and nausea. About one out of five patients experience some headache. Usually it is mild and there are several things you can do to minimize the likelihood that this will develop. First, increase your fluid intake both before and after the myelogram. When you ride home you should either lie down in the back seat with your head on some pillows or recline the passenger seat all the way back. After you get home you should rest in bed or on a couch with your head elevated on two or more pillows through the night. The only activity you should engage in is going to the bathroom. You may eat your usual diet. In the event that you develop a headache, take Tylenol , aspirin or Advil every 4 hours. You may also take prescription pain medication that you may have at home as directed. Should you become nauseated and experience vomiting during the night, you should remain in bed in a flat position but keep your head elevated with two or three pillows. If you begin to vomit, it is best to remain in bed with your head elevated and try to drink as much clear liquid as you can tolerate. If uncontrollable vomiting or severe headache develop during the night, please contact the emergency room at Cooley Dickinson Hospital and ask for further advice.

Upon awakening in the morning after your myelogram, please do not jump out of bed immediately. Is is advisable that you initially sit up on the side of the bed for 3-5 minutes before you attempt to walk. If you develop a headache or dizziness or nausea or vomiting, then please lie back in bed with your head elevated. Continue to take pain medications and drink fluids. Once you are feeling better, then you can attempt to get out of bed for a short period of time. Gradually increase the time that you stay on your feet and rest if symptoms begin to return. If symptoms do not improve over the next day or two contact your doctor for further instructions.

Contact your doctor or the emergency room if you develop signs of infection ( fever or redness at the site of injection), or if you notice a change in the way the nerves in your legs are working (increasing numbness or weakness) or a change in you bowel or bladder function.

CT- SCANS

Computerized Tomography (CT) is a test which uses X-Rays to obtain cross sectional images of the spine or area being studied. It is excellent for showing small problems in bones and in addition can often image disc, nerve, and muscle problems. In the CT department you will be positioned on your back with a pillow under your knees. The table will slide into a short donut-shaped tube. You will be asked to lie still and hold your breathe each time an image is taken. The CT-scan should take approximately 30 minutes. No special preparation is needed.

Additional Instructions

Call your doctor’s office for a follow up appointment in 1-2 weeks.

Please remember to pick up the Myelogram and CT – Scan from the hospital and to bring it with you to that appointment so your doctor can review it with you.

Post-operative instructions vary widely due to the many different types of spinal surgeries performed. In addition, age and health status may influence specific instructions and activities. The following instructions are appropriate for most surgeries. Your doctor or their assistants may modify these instructions, if necessary, for your specific circumstance. If you have any questions, please do not hesitate to ask the hospital or office clinic staff.

ACTIVITIES

All patients undergoing spinal surgery will need to limit their activities for a period of time during their recovery. The specific limitations vary greatly depending upon the type of surgery. Your doctor will discuss these limitations with you and your physical therapist, prior to your discharge.

In general, avoid strenuous activities until told otherwise.

  • LIFTING—It is usually safe to lift up to ten pounds initially (about the weight of a half-gallon of milk). Gradually, you will be allowed to lift more as muscle strength returns. Always remember to use proper lifting technique.
  • SITTING – Sitting for brief periods is usually tolerated. Prolonged sitting should be avoided.
  • DRIVING – You should not drive if you are taking narcotic pain medications and your driving ability is impaired. Muscle weakness or numbness in your arms or legs will also impair your driving ability. A neck brace restricts your ability to turn and may make such activities as changing lanes, turning in traffic or parking unsafe. Prolonged driving also places stress on the lower back and may results in increased pain or prevent normal healing. In general, you should avoid driving for 4 – 6 weeks unless you have specifically discussed this with your physician.
  • WALKING – Walking is an excellent exercise and may be started immediately after most spinal surgeries. If your balance is unsteady, you should use a support such as a cane or walker initially. Begin by walking short distances and gradually build up your endurance. Start on flat, level ground, and as your recovery progresses, you may tackle more challenging terrain. Always be careful on slippery surfaces, especially during winter when ice or snow may make walking unsafe. If you live close to a shopping mall, supermarket or public building, these may provide locations in which you can walk during poor weather. Many patients find pushing a shopping cart excellent early exercise.
  • STAIRS—After most spinal surgeries, you may use stairs if your balance is satisfactory. If you have any questions, please discuss this with your physical therapist. Sturdy handrails are important on you staircase at home.
  • BENDING, TWISTING AND TURNING – These activities should be avoided early after all spinal fusions, these activities are usually avoided several months following surgery.
  • SEX – You may resume sexual activity in most cases as soon as you feel comfortable. You should avoid activities or positions that place stress on the operated area. You may need to consider new methods of obtaining and giving pleasure during the early post-operative period. Don’t be frustrated if it takes some time before your sexual desire returns. Post-operative pain, general anesthesia, and medications you are taking can all cause temporary impairments in sexual functions.
  • BATHING—You may shower four days after your surgery. You should not soak in the tub for two weeks.

BRACE / NECK COLLAR

Depending upon the type of procedure you undergo, you may need a brace following surgery. In general, patients undergoing discectomy or laminectomy do not need a brace following surgery. Patients undergoing a cervical or lumbar fusion will usually use a neck collar or a lumbar spine brace following surgery. Usually these are worn when out of bed and may be removed when resting in bed. In certain cases, such as spinal fractures, you may need to use your brace at all times until instructed otherwise.

EXTERNAL BONE GROWTH STIMULATOR

Depending on the type of fusion you undergo, your doctor might order an external bone growth stimulator. This unit helps the bones fuse after the surgery. Start wearing the unit approximately 3 weeks after surgery. The unit is to be worn as instructed.

DIET

Gradually resume your normal diet after surgery. You do not need to take specific supplements as long as you follow a balanced diet. If you have undergone an abdominal approach for anterior surgery on the lumbar spine, it may take several days for your normal intestinal function to return, and you may need to return to your regular diet at a slower rate. If you develop abdominal pain or distention, you should contact your healthcare provider.

BOWEL FUNCTION

Constipation may develop following surgery due to medications. Increase your fluid intake, especially water. If necessary, varieties of food or over-the-counter medications are available and should be considered. These include:

Prune juice, Multigrain cereal, High fiber foods (raw fruits )
Colace
Metamucil

HOME SUPPLIES / EQUIPMENT

  • BED – In most cases a normal bed is all that is required. If your surgery has been extensive or your mobility is markedly impaired a hospital bed may facilitate positioning and assist in moving in and out of bed. You should discuss this with your therapist.
  • WALKER – A walking may be helpful after surgery to improve balance and decrease stress on your lower back.
  • CANE / CRUTCHES – Used for balance.
  • BEDSIDE COMMODE – A bedside commode may be helpful following surgery if your bathroom is far from your bedroom or your mobility is impaired.
  • GRASPER – For picking up objects from the floor if you are unable to bend. Discuss this with your therapist.

DENTIST

Routine dental appointment should be avoided for six weeks following spine surgery. If an emergency procedure is required within that time, it is recommended that you receive antibiotic coverage for that procedure. After six weeks, antibiotics are not necessary unless prescribed by your dentist.

MEDICATIONS

In general, you should resume any medications prescribed by you primary care physician upon returning home unless instructed otherwise. In addition, you may also receive a number of other medications to help with post-operative pain and muscle spasm, These include pain medications, muscle relaxants and anti-inflammatory medications.

REHABILITATION CENTER AFTER SURGERY

After discharge from the hospital most patients will be able to return home. On occasion, if your medical condition requires additional treatment or if there is not sufficient support at home a stay in a rehabilitation center can be considered. This can allow additional time for you to regain strength, improve mobility, and prepare for a safe return home. If you believe this is needed, discuss this with your doctor or with the case management nurse assigned to you while in the hospital.

HOME SERVICES

Some patients are able to go immediately home from the hospital but will benefit from additional support until they feel stronger and are more independent. These support services can include, nursing visits, physical therapy, and home assistance with activities such as shopping and meal preparation. If you believe this is needed, discuss this with your doctor or with the case management nurse assigned to you while in the hospital.

  1. Visiting Nurse Association
  2. Home Physical Therapy
  3. Home Health Aide
  4. Meals on Wheels

SUTURES

Your surgical incision, in most cases, is closed with either metal staples or dissolvable sutures.

  1. METAL STAPLES – Do not need to be covered after four days. Typically they are removed approximately 10 – 14 days after the surgery. This can be arranged wither through Dr. Papazoglou’s or Dr. Mick’s office. If you live a long distance from either office, in some cases your primary care physician may be willing to remove the sutures.
  2. DISSOLVABLE SUTURES – The incision is also covered with pieces of tape called Steri-Strips. They’re giving the healing wound more strength and improve the cosmetic appearance. Leave them in place until they fall off, (usually between two and three weeks).

WOUND CARE

Following surgery, your incision will either be left open or covered with a dressing. The dressing is usually left in place for 3 – 4 days. If there is drainage on the dressing, it will be changed before you leave the hospital. After four days, the dressing can be removed and the wound does not need to be covered. If there is drainage, the wound should be covered with a piece of sterile gauze. If the drainage persists, contact your physician.

Infection is unusual, and may take several weeks after surgery to develop. If you notice increasing redness of the wound, drainage and fever, consult your physician’s office.

TRAVELING

Almost all patients can travel home in a normal automobile. For lower back surgery, initially you should travel lying down in either the back seat or the front seat with the back fully reclined. It may help to bring along several pillows to cushion sensitive areas or an ice pack.. As long as you are comfortable, there is no limit to how long you can ride in the car, but you will probably need to stop periodically to move and stretch.

In rare circumstances, ambulance transportation home may be required. Public transportation should be avoided. If you need to travel by airline, discuss this with your physician. Some of the metal implants used in spinal surgery may set off metal detectors. Relax! This is a common occurrence for the millions of people who have had metal screws, plates, rods or artificial joints implanted. The security guards are very familiar with this occurrence. You do not need a special card or doctor’s note. Simply follow the guard’s instructions.

X-RAYS

Some types of spinal surgery require periodic x-rays to assess healing. The first x-ray is usually obtained during surgery. Repeat x-rays may be obtained 4-6 weeks following surgery and then again every few months as needed.

FOLLOW-UP APPOINTMENTS

If you have sutures in place that need to be removed, your initial follow-up appointment is usually 10-14 days following surgery. If dissolvable sutures have been placed, your initial follow-up appointment is usually 4-6 weeks following surgery.

WORK

A return-to-work date is quite variable following spinal surgery. If you have had a discectomy or laminectomy, in some cases, many patients return to work within 6-12 weeks. This is dependent upon your overall physical condition and the requirements of your job.

More complex surgeries such as spinal fusions will have greater limitations and typically require months of healing and therapy before you are able to return to work.

PHYSICAL THERAPY

In most cases, you will see a physical therapist during your hospital stay. They will review with you basic self-care activities as well as an initial exercise program. Formal physical therapy may be instituted following surgery when sufficient healing has occurred.

In general, if you have had a discectomy or laminectomy, therapy will begin within 1-2 months after surgery.

If you have had a spinal fusion, upon returning home, you should begin exercising by walking each day. Gradually increase your walking as you feel stronger. For most people by six weeks after surgery the goal is to walk one mile each day. In several months, when the fusion strengthens, a formal physical therapy and exercise program will be prescribed. Your physician will discuss the specifics of your exercise program.

QUESTIONS

Questions can be answered in the hospital by the nursing staff, physical therapists, your physicians or their assistants. After discharge, you may contact the clinical staff:

Andrew Britten (Dr. Papazoglou’s office) (413) 734-2540
Donna Egan (Dr. Mick’s office) – (413) 582- 0330

If there is any change in your overall health that develops after spinal surgery, you may also need to discuss this with your primary care practitioner. Should any life-threatening emergency, such as chest pain or difficulty breathing develop, contact your local hospital emergency room immediately.

Radio Frequency Neurotomy is a technique for applying heat very precisely to the region of a specific nerve while avoiding heat injury to other nerves and structures in the area. While many people refer to this technique as “burning” the nerve or “cutting” the nerve, or “killing” the nerve, that is not precisely what happens. The nerve is heated enough to damage some of its signal transmission components. After the neurotomy, the nerve will go about repairing itself, a process that takes 6-18 months. During that time period, pain being transmitted by those nerves is relieved.

The technique can be used on some nerves in the body which transmit pain signals but are not crucial for proper functioning. Examples include nerves to the sacroiliac joint, the facet joints in the spine, and some neck pain and pain from some internal organs.

Typically before doing radiofrequency neurotomy, your doctor will do a series of diagnostic anesthetic blocks to the nerves in question, to prove that they are transmitting the pain signals that are bothering you.

How is it Done?

Conscious sedation is utilized to make the procedure more comfortable. This means you will have an IV placed before the procedure is done and through that IV you will be administered sedative medication during the procedure. It will be enough to relax you but you will still be awake so you can answer the doctor’s questions during the procedure. Because of the sedation you will not be able to have any food on the day of the procedure until after the procedure is completed.

For the procedure you will be placed on your stomach on the procedure table. In the procedure room there will be monitoring devices checking our heart rate, blood pressure and blood oxygen level and there will be a fluoroscopic X-ray machine which the doctor will use to guide the needles used during the procedure. The procedure will start with the doctor cleaning off your skin with an antiseptic soap. Then the fluoroscope will be used to find the needle entry sites in the skin. These will be marked with a pen and then the doctor will anesthetize the skin and muscles with an anesthetic injection similar to the Novocain a dentist uses. At the same time you will be getting some sedative through the IV to relax you.

Using a fluoroscope the doctor will then place the needles, called RF canula, near the nerves to be heated. This part can be a little uncomfortable and that is why you get the IV sedative. Once the canula are near the nerves, the doctor will stimulate the nerves with a little electricity to make sure the canula are right next to the nerves we want to heat and far away from any nerves we do not want to injure. There are two types of electrical stimulation, a high frequency and a low frequency. The high frequency fells like a buzzing, tingling, or pressure and the doctor will ask you to identify the moment you start to feel it. The low frequency actually makes the muscles near your spine contract. The doctor will turn the stimulus up to a certain threshold level and if there are no strong contractions in muscles other than the paraspinals, the canula is in a perfect position. If other muscles are contracting strongly then the canula will be repositioned until those contractions go away. Once the canula is in the optimal position, the doctor will inject lots of anesthetic and wait 3 minutes. Each nerve will be heated for 60-120 seconds and heating should not be uncomfortable. If it is uncomfortable, the procedure will be interrupted and a little more anesthetics will need to be injected before proceeding. At the end a little corticosteroid will be injected to reduce any post-procedure inflammation around the nerve.

After the procedure you will be observed by the procedure nurses for about ½ hour to make sure the sedative is wearing off appropriately. They may also ice your back to reduce any muscular soreness post procedure.

Risks and Side Effects

When the procedure is done as described, the risks are minimal. To date we have never had an instance of unintentional damage to a nerve that wasn’t the target of the procedure. Every patient experiences some local muscle tenderness for a few days. Approximately 1/15 patients undergoing lumbar radiofrequency neurotomy for facet pain experience a significant increase in their usual pain, which can last 3-12 days and which ends abruptly. There is a small risk of infection with any needle procedure. There is a very small risk of being left with a dysesthetic sensation on the skin above the procedure area. The feeling is similar to the feeling three days after a minor sunburn.

When Radiofrequency is done to treat facet pain in the neck the side effect profile is a little different. When the C4-C7 nerves are treated 50% of the patients should expect increase pain for up to two weeks. You may have numbness on the skin of the neck that persists for several months. When the C3 nerve is treated one additional side effect can be expected. Most patients will experience “ataxia” a non-disabling feeling of unsteadiness that can last for two weeks.

In rare instances such as severe cancer pain, nerves critical to function might be lesioned intentionally and in that case specific more severe side effects would be expected. Ask your doctor what those expected side effects would likely be.

Post Radio Frequency Neurotomy Instructions

Normal activity can be resumed the day after the procedure. Due to the conscious sedation, no driving or operating dangerous machinery on the day of the procedure. For local muscle tenderness ice the procedure area 15 minutes 3-4 times per day. If you experience an amplification of your usual pain post procedure, contact your doctor and ask if you can use a little higher dose of your usual pain medication for 3-10 days.

Osteoporosis is a common disorder that causes bone loss and may lead to fractures. It occurs with normal aging or may be associated with certain diseases such as diabetes or hyperthyroidism. Chronic steroid usage, smoking, or calcium and vitamin-D deficiency may also cause osteoporosis. It affects 25 million Americans of whom 80% are women. Thin women of northern European heritage are at high risk especially if they have experienced an early menopause. Bone mass is lost each year and gradually all bones become weak and at risk for fracture even with minor trauma. The hip, spine, and wrist are common sites of fracture in osteoporotic bones.

The best approach to osteoporosis is prevention. This must begin in youth and early adulthood by maximizing bone mass through exercise and adequate calcium and vitamin-D dietary intake and the maintenance of normal menstrual cycles. There are several drugs in addition to calcium and vitamin D, which are now utilized to slow bone loss. They include estrogen replacement, biphosphonates (Fosamax, Actonel), serum estrogen receptor modifiers (Evista), Calcitonin (Miacalcin nasal spray) and parathyroid hormone (Forteo).

Many men and women never realized they have osteoporosis until they sustain a fracture. Osteoporotic fractures will heal with appropriate treatment (cast, brace, or surgery). People with one fracture are likely to sustain additional fractures and should be evaluated and receive osteoporosis treatment to minimize this risk. Treatment should include drug therapy, exercise and fall prevention.

Vertebral compression fractures are common in people with osteoporosis. In 1996 700,000 vertebral fractures occurred in the United States. In some cases the fracture causes only minimal pain and heals in 6-12 weeks with rest, medication and a brace. In other cases the pain is severe and significantly limits function despite medical intervention. Approximately 150,000 patients are hospitalized each year for severe compression fractures. Some patients may develop persistant pain and progressive spinal deformity, impairment of respiratory and gastrointestinal function and a sleep disturbance. Patients with severe symptoms may benefit from a new treatment (vertebroplasty or kyphoplasty) which may reduce the pain and disability from vertebral compression fractures.

INSTRUCTIONS

You should not have anything to eat or drink for at least eight hours prior to your procedure because you will be receiving intravenous sedation during the procedure. A friend or relative must be with you or available to bring your home. Driving is prohibited. The procedure is described in greater detail below. If you have more questions please do not hesitate to ask the day surgery staff or your doctor at the time of the procedure.

Vertebroplasty

Vertebroplasty is a minimally invasive, outpatient procedure for treating painful vertebral compression fractures. An x-ray machine called fluoroscope or C-arm is used to guide a needle into the fractured vertebrae. A special bone cement (methylmethacrylate) is injected and hardens within the bone providing pain relief and stability. 80-90% of patients report satisfactory pain relief after the procedure. Before undergoing vertebroplasty you must have a thorough evaluation of your osteoporosis and be receiving appropriate drug therapy.

Kyphoplasty

Kyphoplasty is a more recent modification of vertebroplasty. It contains an additional step which inserts a balloon into the fractured vertebrae which is then inflated to attempt to reduce the collapse before the bone cement is injected. 80-90% of patients also report satisfactory pain relief after the procedure.

THE PROCEDURE

You should not have anything to eat or drink for at least 8 hours prior to the procedure, because you may be receiving intravenous sedation during the procedure. Please bring with you any X-ray studies you have at home. After registering, a nurse will complete preparations for the procedure. In the procedure room you will be positioned on the table on your side or stomach. After the skin is cleaned with iodine and is numbed with local anesthesia a needle will be inserted into the vertebrae. The fluoroscope is used to guide exact placement. When the needle is correctly positioned the bone cement is injected and allowed to harden. The procedure usually takes about 60 minutes depending upon the number of vertebrae which will be treated. You will be given additional medication to help you relax and remain still during the procedure. At the completion of the procedure you will be returned to the Day Surgery Unit. After the sedative medication has worn off, discharge instructions are reviewed and someone can bring your home. . A friend or relative must be with you or available to bring you home. Driving is prohibited.

After the procedure

The discomfort produced during insertion of the needle may take several days to subside. It can be treated with rest, an ice pack and/or Tylenol or Advil. Your doctor may choose to give you a stronger pain medication if appropriate. A back support can be used if it helps you to feel comfortable but is not necessary. You can resume your regular activity gradually as tolerated. There are no special restrictions but you should not overexert yourself. Use care when walking to prevent a fall. If you feel unstable ask your doctor for a referral to physical therapy to work on balance.

RISKS and SIDE EFFECTS

There are a few potential risks and side effects, which you should understand. Infection in the bone can occur. You will be given antibiotics prior to the procedure to minimize this risk. Bleeding and nerve damage have been reported but are very rare. Because you are awake during the vertebroplasty or kyphoplasty your doctor can carefully monitor your neurologic status during needle placement. If your fracture is in the thoracic region of the spine the needle used for injection must pass close to the lung. Sometimes an air leak from the lung can occur. If the leak is large a tube may need to be inserted until the leak seals. If too much cement is injected it could spread outside of the bone and cause problems with neurologic function or breathing. The amount and location of the cement injected is carefully measured and monitored using the fluoroscope to minimize this risk. Not all patients will find relief of their pain and fractures can occur at other sites in your spine.

Post Vertebroplasty Instructions

  1. You may experience discomfort for several days following the procedure. Rest, ice, pain medications and anti-inflammatories will minimize discomfort during this time.
  2. Restrict your activities as necessary but don’t remain in bed all the time.
  3. You may use a brace if you have one if it makes you feel more comfortable but it is not necessary.
  4. The dressing may be removed in the day after the procedure.
  5. Any unusual or new symptoms (for example fever, weakness, numbness or a change in your bowel or bladder function) should be reported to your physician immediately or you should contact emergency room for further evaluation.
  6. Call your doctor’s office tomorrow and arrange a follow-up appointment in (4-6) weeks.