What To Expect

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Evaluation

All new patients are required to fill out forms prior to their initial visit. We try to send these forms to you so you can complete them at home prior to coming in. However, if you do not receive the paperwork in time, please arrive at least 20 minutes early to fill them out. You may also download the forms from our website prior to your appointment. A complete list of your current medications should be included. After the paperwork is completed, you will meet with one of our staff doctors for a thorough consultation, health history and physical examination to determine the nature of your problem and what the best course of treatment would be. Additional diagnostic testing may be recommended if necessary. The initial consultation will take between 30 to 60 minutes depending on the complexity of your condition.


EMG

What to Expect During Your EMG Test:

Electrodiagnostic medicine is the study of diseases of your nerves and muscles. Your doctor has recommended an EMG test to see if your muscles and nerves are working right. The results of the tests will help your doctor decide what is wrong and how it can be treated.

Why am I being sent to the EMG lab for tests?

You are being sent to the electromyography (EMG) lab because you have numbness, tingling, pain, weakness or muscle cramping. Some of the tests that the EMG doctor may use to diagnose your symptoms are nerve conductions studies (NCS) and needle EMG. The EMG doctor will examine you to decide which tests do.

What type of testing will be performed?

Nerve conduction studies – NCSs show how well the body’s electrical signals are traveling to a nerve. This is done by applying small electrical shocks to the nerve and recording how the nerve works. These shocks cause a quick, mild, tingling feeling. The doctor may test several nerves.

Needle EMG – For this part of the test, a small, thin needle is put in several muscles to see if there are any problems. It is used once for each patient and is thrown away after the test. There may be a small amount of pain during this part of the examination. The doctor tests only the muscles necessary to decide what is wrong. During the EMG test the doctor will be able to hear and see how your muscles and nerves are working by the electrical signals made by your muscles. The doctor then uses his medical knowledge to figure out what could be causing your problem.

How long will these tests take?

The tests usually take 20 to 90 minutes. You can do any of your normal activities, like eating, driving and exercising, before the tests. There are no lasting side effects. You can also do your normal activities after the tests.

How should I prepare for the tests?

Tell the EMG doctor if you are taking Aspirin, blood thinners (like Coumadin or Plavix), have a pacemaker, or have hemophilia. Take a bath or shower to remove oil from your skin. Do not use body lotion on the day of the test. If you have myasthenia gravis, ask EMG doctor if you should take any medications before the test.

When will I know the test results?

The EMG doctor will discuss your test results with you or send them to your regular doctor. After the exam, check with the doctor who sent you to the lab for the next step in your care.

What kind of medical training do doctors who do EMGs have?

Doctors who do EMGs go to 4 years of medical school then have 3 or 4 more years of training in a residency program. Most work as neurologists or physical medicine and rehabilitation doctors. Medical training helps the doctor decide which tests to perform based on your symptoms. It teaches doctors what can go wrong with the human body and how to tell the difference between these problems.

Who does the testing?

The American Association of Neuromuscular and Electrodiagnostic Medicine’s policy is that an appropriately trained doctor should do all needle EMG testing. A trained assistant or technologist under a doctor’s supervision can do nerve conduction studies. However, at Redding Spine and Sports Medicine the entire test is performed by a physician.

How is Dr. Purcell especially qualified to perform EMG tests?

Dr. Joseph Purcell has achieved board certification in electrodiagnostic medicine from the American Board of Electrodiagnostic Medicine (ABEM) and is an ABEM Diplomate. The designation of ABEM Diplomate demonstrates that Dr. Purcell has obtained specific training and passed a comprehensive written and oral examination to demonstrate competency in electrodiagnostic evaluation of disorders of the neuromuscular system. Physicians who practice electrodiagnostic medicine diagnose and manage individuals who have medical problems related to muscle and nerve disorders such as carpal tunnel syndrome and neuropathies, just to name a few. The most common electrodiagnostic tests include EMG and nerve conduction studies. The American Board of Electrodiagnostic Medicine is the national certifying body for physicians specializing in electrodiagnostic medicine. It was established in 1989 to maintain the high standards required for electrodiagnostic certification and promote high quality patient care. Dr. Purcell is a member of the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) and as a Diplomate of the ABEM is granted Fellow status with AANEM, the international association dedicated to advancing neuromuscular, musculoskeletal and electrodiagnostic medicine.


Musculoskeletal Ultrasound

Using ultrasound guidance, we can now precisely place injections in the exact location where they are needed and avoid structures such as blood vessels and nerves. The more precise the placement of the needle, the more effective the medication will be in healing and pain relief. Ultrasound guided injections have been shown to improve the outcome in treatment when used in various areas such as in the shoulder for a bursal injection. We have used ultrasound to guide injections into a variety of structures which include the shoulder, knee, hip joint and carpal tunnel.


Interventional Spine Procedures

Learn more below about the following Interventional Spine Procedures:

– Epidural Steroid Injections
– Medial Branch Blocks
– Radiofrequency Neurolysis

 

Epidural Steroid Injections
General Overview:

Epidural injections can provide diagnostic information and pain relief by delivering two medications (local anesthetics and corticosteroids) into the spinal canal. These injections are done under x-ray guidance for safety and to better enable your doctor to target the direct source of your pain.
An epidural injection may be ordered by your provider as a way to confirm a specific diagnosis and/or to decrease pain and inflammation. Epidural injections are recommended to provide pain relief and allow patients to progress with their rehabilitation. They may be an effective nonsurgical option to treat common conditions such as lumbar disc herniations, lumbar spinal stenosis and degenerative disc disease.

Steroids:

Medically used steroids are strong anti-inflammatory agents which are used in epidural steroid injections. They are useful in treating patients with low back and leg pain caused by local inflammation due to disc injury or degenerative changes.

Steroids do have possible risks associated with them, although most adverse effects are associated with long-term use. When steroids are used locally as they are in epidural steroid injections, the associated risks are much less.

What To Expect During and After Your Procedure:

The typical procedure for an epidural steroid injection involves having an appointment at an outpatient surgery center. You may be given the option of receiving light conscious sedation intravenously, which should help you relax and be more comfortable during the procedure. If sedation is used, you will be monitored closely with an EKG monitor, blood pressure cuff and blood oxygen monitoring device. Local anesthetic will be used prior to the actual injection to decrease discomfort. Your doctor will then locate the area to be injected under x-ray guidance. Contrast is usually injected to confirm proper placement of the needle prior to injection of the medications (typically local anesthetic and steroid).
You will typically be at the surgery center for one to two hours. You are required to arrive prior to the procedure and be monitored for a short time following the procedure. The actual procedure time is usually around fifteen minutes. You will then be taken to the recovery room for a short time prior to being discharged.

Because the procedure involves an injection, you may feel some discomfort. You may also experience reproduction of your typical pain. Most patients tolerate the procedure without difficulty and complications are rare.

You may experience numbness and relief from your typical pain for up to six hours after the injection. This is due to the local anesthetic injected. Your usual symptoms may then return and may possibly increase for the next few days. The beneficial effects of the steroid part of the injection usually begin two to three days after the injection and may take as long as a week.

It is difficult to determine if additional injections would be recommended. If the first injection provided a certain amount of pain relief, a second injection may be offered to provide additional benefit. If the pain resolves completely but returns at a later date, additional injections may be an option.

Risks of the Procedure:

These procedures are generally very safe and complications are rare. However, as with any procedure, there are potential risks of side effects and complications. Some people experience a transient increase in pain for a few days after the procedure. Risks also include infection, nerve injury or reactions to the medications which may cause breathing difficulties and/or cardiac difficulties. However, serious risks or complications are extremely rare.

The Different Types of Epidural Steroid Injections:

Transforaminal Epidural Steroid Injection – This procedure is performed for both diagnostic and therapeutic purposes for pain, numbness, tingling or weakness. In this procedure, a needle is directed under x-ray guidance through the opening where the spinal nerve exits. The level chosen is usually where a disc and/or nerve injury is suspected to have occurred. Contrast is usually used to confirm proper needle placement. The medications (anesthetic and steroid) are delivered between the disc and nerve interface along the course of the nerve which seems to be causing the majority of the symptoms.

Caudal Epidural Steroid Injection – For this procedure, the spinal needle is introduced through a portion of the sacrum (near the tailbone) at a small bony opening called the sacral hiatus. This area is entered with a spinal needle under x-ray guidance. This is a relatively safe, easy procedure to perform and can provide significant anatomical coverage of the injected medications. It is not one of the more specific, localizable procedures.

Interlaminar Epidural Steroid Injection – The approach in this procedure involves a needle being advanced to a site specific to the level of injury. The level of injury is viewed under fluoroscopy, and the needle is advanced between two vertebrae to a depth that allows it to reach the epidural space. Contrast is usually injected to confirm placement in the epidural space prior to the injection of medication.

Selective Nerve Root Block – This procedure is performed for diagnostic and sometimes therapeutic purposes. In this procedure, a needle is directed under x-ray guidance to a spot overlying the nerve root in the spine where nerve injury is suspected to have occurred. Contrast is usually used to confirm proper placement. A small amount of local anesthetic, and sometimes steroid, is then administered to bathe the nerve root which seems to be causing the majority of the symptoms. A pain log will usually be given in which you should record your pain level before and immediately following the procedure.

Medial Branch Blocks

General Overview:

Medial branch blocks are part of a procedure used to diagnose pain coming from the facet joints of the spine. Medial branch nerves are located on the back of the spine on each side next to the facet joints. They send sensory signals to the brain from the facet joints, which can be a source of spinal pain. Medial branch blocks stop these sensory signals by injecting local anesthetic around the nerves. Medial branch blocks are performed to help diagnose and treat pain related to disease or injury to the posterior joints of the spine (facet joints). Injecting local anesthetic around these medial branch nerves is an accurate way of diagnosing facet joint pain because certain joints may appear abnormal but not cause pain and problem joints may appear normal.

Facet Joint Syndrome:

Facet joint syndrome is a group of symptoms which result in diffuse pain which does not fit a clear nerve root pattern. Pain from facet joint syndrome is typically worse with movement of the spine such as standing, walking and turning in bed. The pain does not typically radiate into the extremities and is located in the spine.

What To Expect During and After Your Procedure:

The typical procedure for medial branch blocks involves having an appointment at an outpatient surgery center. You will be asked to lie flat on your stomach for the procedure. X-ray guidance will be used during the procedure. Local anesthetic will be used prior to the actual injections. A small needle will be positioned along the medial branch nerves. Injection of dye may be used to check positioning. Anesthetic medication is then injected. Multiple levels on either one or both sides of the spine may be performed in the same session depending on your symptoms. The entire procedure usually takes around 15 minutes although you will be at the surgery center for one to two hours including the check-in and post-procedure monitoring. During the procedure you may feel some slight pressure or discomfort. You may experience numbness and relief from your usual spinal pain for several hours after the injection. Your usual symptoms may then return, although this is not always the case. A pain log will be given to you at the procedure to record your pain levels prior to the procedure, immediately after and for several hours during the rest of the day of the procedure. If the injection blocked your pain effectively, but only for a short time, your provider may suggest additional injections including a procedure which offers more permanent relief, such as radiofrequency neurolysis. This option will be discussed at your follow up appointment.

Risks of the Procedure:

There are some inherent risks from medial branch blocks, as with any procedure, but most of these are minimal. Common risks include, but are not limited to, bruising, bleeding, headaches, irritation of a nerve or nerve injury, numbness and weakness. Risks also include infection or reactions to the medications which may cause breathing difficulties and/or cardiac difficulties. However, serious risks or complications are extremely rare.

Radiofrequency Neurolysis
General Overview:

Radiofrequency neurolysis is a safe and proven technique to interrupt pain signals from the spine. In this procedure, special radiofrequency needles are directed under x-ray guidance to the location of specific nerves (medial branch nerves) which supply joints in the spine. A radiofrequency current is then used to heat up a small volume of nerve tissue, therby interrupting pain signals from traveling from painful joints to the brain. The procedures can be performed with little discomfort using local anesthesia and IV conscious sedation if necessary. Some common medical conditions which respond to radiofrequency techniques include chronic low back pain, thoracic pain, cervical pain and sacroiliac joint dysfunction.

What To Expect During and After Your Procedure:

The radiofrequency neurolysis procedure involves having an appointment at an outpatient surgery center. For the procedure you will be asked to lie flat on your stomach. After the local anesthetic and IV medication for sedation (if used) are administered, the doctor will insert a small needle into the area where you experience pain. Local anesthetic will be used prior to insertion of the procedure needle. The doctor will first administer a local anesthetic to minimize discomfort. Then, radiofrequency needles will be advanced under x-ray guidance to the target sites. A microelectrode then will be inserted through the needle to begin the stimulation process. During this process the doctor will ask you if and where you feel the stimulation. The object of the stimulation is to help the doctor ensure that the electrode is in the optimal area for treatment. Local anesthetic is applied to the area before the treatment begins. Once the needle electrode placement is verified, treatment can begin. A small radiofrequency current will then travel through the electrode into the surrounding tissue, causing the local tissue to heat and eliminate pain pathways. You should alert the doctor if at any time during the procedure you experience discomfort, especially in the extremities.

Risks of the Procedure:

Although there are inherent risks with this procedure, as with any procedure, they are minimal. Common risks include, but are not limited to bruising, bleeding, headaches, nerve irritation or nerve injury, numbness and weakness. Risks also include infection or allergic reactions to the medications which may cause breathing difficulties and cardiac difficulties. Serious risks and complicates are extremely rare.