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the disc, facet or ligament. This enables different forms of therapy to be utilized, preventing further worsening of each condition. At times symptoms are not clear, they may be multi-dermatomal, diffuse, not correspond to anatomical findings or be associated with multiple changes on radiographic studies. Radiographic studies only show changes in anatomy, they do not necessarily demonstrate pain. MRI demonstrates multiple changes and many times there are multiples areas of radiographic pathology that do not correspond to symptoms or signs.
In these cases an electromyogram (EMG) of both extremities can often help distinguish between specific radicular findings and peripheral neuropathies. An EMG of both sides of the same extremity can be extra helpful because sometimes the findings are in the normal range but dramatically different from the other side, suggesting a problem. EMG may help diagnose muscle spasms but can be affected consciously by the patient. If a spinal cord abnormality is anticipated e.g. contusion, demyelination, stenotic compression or intrinsic mass, then a somatic sensory evoked potential (SSEP) should be ordered. These tests comprise almost all tests necessary to diagnose the common problems.
However, there are times when the symptoms still do not coincide with the clinical findings or imaging studies. In these limited instances provocative pain tests may be administered. An invasive discogram can tell if a disk is symptomatic. This test should be performed by an experienced physician and include the nature, extent, distribution of pain, the ability of the disk to accept the dye, as well as morphology of the disk on x-ray or CT-scan. The discogram must also show areas of no reproducible pain, unless chemical irritation is wide spread.
A selective nerve root block (SNRB) is an invasive procedure that can both diagnose and treat. The SNRB, like the epidural steroid injection (ESI) and facet injection contains a mixture of numbing xylocaine and the strong anti-inflammatory steroid. The xylocaine or its related medication acts almost instantly to produce numbness or other paresthesia in the nerve root distribution thereby covering the pain if the correct level has been selected. Then approximately two days later, the steroid starts to relieve the inflammation and therefore pain, reaching a maximum at 2 weeks. Unlike the ESI, the SNRB is very specific, placing the treating medication exactly at the problem. ESI are beneficial also for stenosis or when multiple areas of coverage are needed without multiple injections. ESI can also be injected in front of the dural sac to help treat painful annular tears. However, the typical ESI may not reach the intended nerve root and thus fail to help in the management of the symptoms. Facet injections can tell the clinician if the joints are responsible for the back pain and rarely leg or groin pain. If the patient responds to the facet injections, even temporarily, and there was no spillage then the patient may benefit from a facet rhizotomy. This procedure deadens the nerve in the joint, not the nerve root responsible for movement or sensation. This procedure may only be temporary lasting as little as 6-18 months. However, injected medication leading to the dramatic improvement of pain, combined with back and abdominal strengthening exercises, may be a good treatment for some.
TREATMENT NON-OPERATIVE
With all disease processes improving the over all health of the body should be paramount. In the treatment of the spine, one should attempt weight loss, cessation of (Continued on page 17)
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