MAIN LINE SPINE

EMG                                                        Electromyography and Nerve Conduction Tests are ordered to tell us more about the peripheral nerves. These tests can determine if a nerve is pinched, and give an indication of the location and severity of damage. The test lasts anywhere from a half an hour to an hour.

During the Nerve Conduction portion of the test, electrodes like EKG patches are placed along the known course of the nerve. The nerve is stimulated with a small electrical current at one point. The nerve should then transmit the signal along its course, and an electrode placed further down the arm or leg will capture the signal as it passes it. A healthy nerve will transmit the signal faster and stronger than a damaged nerve.

The EMG portion of the test will measure the electrical activity in muscles. Muscles normally receive constant electrical signals from healthy nerves, and then send out their own electrical signals. During the EMG portion of the test, the doctor places acupuncture like needles into the muscles to record the electrical signal from the different muscles in the arm or leg. If a muscle does not receive adequate signals from a damaged nerve, it will not be able to respond properly.

From the Nerve Conduction Test and the EMG's, we can determine which nerves are pinched and how serious the condition is. This information can then be used to plan treatment.

Trigger Point Injections
Myofascial trigger points are areas in muscles and fascia that are hyperirritable and have taut muscle bands. A trigger point is found by palpating the muscle which produces a local twitch response causing referred pain distal to the site of muscle irritability. Trigger points cannot be diagnosed when a patient is having acute low back pain because muscle spasm and inflammation are present. Initially, trigger points respond to stretching exercises and correction of poor posture with or without using superficial heat or cold. Trigger point injections should be used for patients who do not respond in the first four to six weeks to initial treatment measures.

The trigger point injection is done under antiseptic technique after the patient is informed of potential adverse effects. There are no reported benefits of adding a corticosteroid to the injection. 

Injecting multiple trigger points at once is not advisable. Some trigger points may need more than one injection, but generally a trigger point does not require more than three injections. If a trigger point is injected repeatedly there may be local muscle damage and scarring, which can possibly lead to a poor functional outcome. Trigger point injections should be done in conjunction with a directed exercise program. After the procedure, it is necessary to follow the patient's response to the injection and to progress the rehabilitation program.

Epidural Corticosteroid Injections
Epidural corticosteroid injections are used because there is an inflammatory basis of radicular pain from disc herniation. Epidural steroids are effective in pain reduction in patients with radicular pain and the efficacy is increased if used in the first weeks following onset. The goal of these injections is to enable the patient to facilitate an active exercise program and progress through the pain and inflammation stage of recovery as quickly as possible.

The procedure is done under fluoroscopic guidance to ensure proper needle placement of corticosteroids.  Some patients may need more than one injection. The decision to repeat an injection should be based on the pre-treatment goals and therapeutic response of the initial injection.  All patients should be seen for follow up 10-14 days after the injection to assess their therapeutic response.   

Facet Injections

Facet injections can often aid in diagnosing the etiology of back pain. Facet injections should be used for patients who have failed a non-operative treatment program which incorporated various manipulation/mobilization techniques. They are not indicated in the first four to six weeks of treatment.  The injections are done under fluoroscopic guidance using contrast medium to assure proper placement.  Facet injections help verify the diagnosis and perhaps assist with pain reduction in order to facilitate an active physical therapy program. If prior injections were helpful and pain recurs the injection can be repeated.

Sacroiliac Joint Injection
The sacroiliac joint is a common area of referred pain. Pain is typically referred to an area around the posterior superior iliac spine.  A sacroiliac joint injection can be helpful for both diagnostic and therapeutic purposes in patients who have failed a four to six week comprehensive treatment program that included anti-inflammatories, exercise, icing and mobilization/manipulation techniques.

Sacroiliac joint injections are performed with fluoroscopic guidance using contrast medium to ensure proper needle and medication placement. If helpful, they may be repeated along with a comprehensive exercise program.

Discography or Discogram         Discography is a diagnostic tool used to determine the structural integrity of an intervertebral disc (or discs) and can tell us if a particular disc is responsible for the patient's back pain. Provocative Discography is a form of discography that replicates the patient's pain. 

The test is performed on an outpatient basis in a hospital, surgery center or medical facility. A local anesthetic is used to numb the target area. Fluoroscopy is used to guide the spinal needle into the suspect intervertebral disc and dye is then injected through the spinal needle into the nucleus (center) of the disc. During the test, the dye pattern is evaluated for any 'leaking' outside the intervertebral disc walls. At this time, the patient's symptoms may be replicated due to the pressure created by the dye injection.

Plain Radiographs (X-Rays)
The main purpose of plain x-rays is to detect serious underlying structural and/or pathologic conditions. The typical types of x-rays we order are AP, lateral and flexion/extension films to help us determine if there is a fracture, malalignment or motion between vertebral levels (instability).. 

Bone Scan
Bone scans are rarely needed to evaluate acute low back pain. They can be helpful in cases where a tumor, infection, or fracture is suspected.  A positive bone scan finding should generally be followed by confirmatory imaging such as MRI or CT, which help provide better anatomic detail of the spine.

Magnetic Resonance Imaging (MRI)
MRI has demonstrated excellent sensitivity in diagnosing lumbar disc herniation and is considered the imaging study of choice. The speciifc indications for a patient to have an immediate MRI include progressive neurologic deficits, bowel/bladder dysfunction and patients with a possible malignancy or inflammatory condition.

MRI may be helpful in patients with neurogenic claudication due to suspected central or foraminal stenosis. MRI's can also be useful to help determine the level of pathology in patients when physical examination and electrodiagnostic findings are otherwise not definitive.  Some clinicians reserve MRI for those patients not responding to treatment as expected. 

Computer Tomography (CT)
CT imaging of the lumbar spine provides superior anatomic imaging of the bones in the spine and good resolution for disc herniation. It is less sensitivity for detecting disc herniation when used without myelography than an MRI.  CT imaging is best used when there is a suspected fracture, but can also be used to detect a disc injury in patients who cannot undergo MRI scanning.