Neck or Back Pain / Pinched Nerve
Neck pain: Neck pain is the sensation of discomfort in the neck area. Neck pain can result from disorders of any of the structures in the neck, including the cervical vertebrae and intervertebral discs, nerves, muscles, blood vessels, esophagus, larynx, trachea, lymphatic organs, thyroid gland, or parathyroid glands. Neck pain arises from numerous different conditions and is sometimes referred to as cervical pain.
Acute and Chronic Pain of All Kinds
Acute pain is pain that comes on quickly and usually lasts a short time. It serves as a warning of injury or illness. Acute pain can range from mild to severe and is often caused by an injury or sudden illness. Examples of things that may cause acute pain include:
A broken bone
Burns and cuts
Chronic pain is defined as pain that lasts longer than 3 months. Some experts define it as lasting longer than 6 months.
Chronic pain is different than acute pain in that it is not easy to find the cause. Diagnosis can reveal no injury in the body at all, and yet the patient can be experiencing very debilitating pain.
One way that chronic pain begins is from an injury. Scientists have found that repeated pain from an acute injury changes the way the brain lets you know you have pain. Even after the injury has healed, pain messages replay over and over again.
Injury Related Pain
Injury Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromyalgia. Pain is mediated by specific nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors.
Pain is also a term specifically used to denote a painful uterine contraction occurring in childbirth.
The word "pain" comes from the Latin "poena" meaning a fine, a penalty.
Arthritis / Joint Pain
Arthritis: Inflammation of a joint. When joints are inflamed they can develop stiffness, warmth, swelling, redness and pain. There are over 100 types of arthritis. (see osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, lupus, gout, pseudogout).
Migraine / Tension Headaches
Migraine headache: The most common type of vascular headache involving abnormal sensitivity of arteries in the brain to various triggers resulting in rapid changes in the artery size due to spasm (constriction). Other arteries in the brain and scalp then open (dilate), and throbbing pain is perceived in the head. The tendency to migraine is inherited and appears to involve serotonin, a chemical in the brain involved in the transmission of nerve impulses that trigger the release of substances in the blood vessels that in turn cause the pain of the migraine. These nerve impulses cause the flashing lights and other sensory phenomena known as an aura that may accompany a migraine. Not all severe headaches are migraines and not all migraines are severe.
Multiple sclerosis (MS) is a potentially debilitating disease in which your body's immune system eats away at the protective sheath that covers your nerves. This interferes with the communication between your brain and the rest of your body. Ultimately, this may result in deterioration of the nerves themselves, a process that's not reversible.
Symptoms vary widely, depending on the amount of damage and which nerves are affected. People with severe cases of multiple sclerosis may lose the ability to walk or speak. Multiple sclerosis can be difficult to diagnose early in the course of the disease because symptoms often come and go — sometimes disappearing for months.
There's no cure for multiple sclerosis. However treatments can help treat attacks, modify the course of the disease and treat symptoms.
Dizziness / Seizures / Stroke
Dizziness: As a disorder, dizziness is classified into three categories-vertigo, syncope, and nonsyncope nonvertigo. Each category has a characteristic set of symptoms, all related to the sense of balance. In general, syncope is defined by a brief loss of consciousness (fainting) or by dimmed vision and feeling uncoordinated, confused, and lightheaded. Many people experience a sensation like syncope when they stand up too fast. Vertigo is the feeling that either the individual or the surroundings are spinning. This sensation is like being on a spinning amusement park ride. Individuals with nonsyncope nonvertigo dizziness feel as though they cannot keep their balance. This feeling may become worse with movement.
Seizure: Uncontrolled electrical activity in the brain, which may produce a physical convulsion, minor physical signs, thought disturbances, or a combination of symptoms.
Stroke: The sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain. Sudden loss of speech, weakness, or paralysis of one side of the body can be symptoms. A suspected stroke can be confirmed by scanning the brain with special X-ray tests, such as CAT scans. The death rate and level of disability resulting from strokes can be dramatically reduced by immediate and appropriate medical care. Prevention involves minimizing risk factors, such as controlling high blood pressure and diabetes. Also known as cerebrovascular accident, abbreviated CVA.
Sleep Apnea / Other Sleep Disorders
Sleep apnea is a chronic medical condition where the affected person repeatedly stops breathing during sleep. These episodes last 10 seconds or more and cause oxygen levels in the blood to drop. It can be caused by obstruction of the upper airway, resulting in obstructive sleep apnea, or by a failure of the brain to initiate a breath, called central sleep apnea. It can cause and worsen other medical conditions, including hypertension, heart failure, and diabetes.
Carpal Tunnel Syndrome
Carpal tunnel syndrome: Compression and irritation of the median nerve as it passes under the transverse carpal ligament in the wrist. Abbreviated CTS. CTS can be due to trauma from repetitive work, such as that of retail checkers and cashiers, assembly line workers, meat packers, typists, writers, and accountants. Other factors that can cause CTS include obesity, pregnancy, hypothyroidism, arthritis, and diabetes. The symptoms of CTS include numbness, tingling, a 'pins and needles' feeling especially at night in the hand, particularly in the thumb, index, and middle fingers. CTS can also cause wrist pain, weakness in the grip, and a feeling of hand incoordination. In some cases the pain seems to migrate up from the wrist and into the arm, shoulder, and neck. The diagnosis is suspected based on symptoms, supported by signs on physical examination, and confirmed by nerve conduction testing. Treatment depends on the severity of symptoms and the underlying cause. Early CTS is usually treated by modification of activities, a removable wrist brace, exercises and/or manipulation (massage), and anti-inflammatory medicines. If detected early, CTS is reversible. If numbness and pain continue in the wrist and hand, cortisone injection into the carpal tunnel can help. Surgery is used only when other treatments have failed. In advanced CTS, particularly if there is profound weakness and muscle atrophy (wasting), surgery is done to avoid permanent nerve damage.
Dementia / Memory Loss
Dementia: Significant loss of intellectual abilities, such as memory capacity, that is severe enough to interfere with social or occupational functioning. Criteria for the diagnosis of dementia include impairment of attention, orientation, memory, judgment, language, motor and spatial skills, and function. By definition, dementia is not due to major depression or schizophrenia. Alzheimer's disease is the most common cause of dementia. Other causes include AIDS, alcoholism, brain injury, vascular dementia (damage to the blood vessels leading to the brain), dementia with Lewy bodies, brain tumors, drug toxicity, infection of brain, Creutzfeldt-Jakob disease, meningitis, Pick disease, syphilis, and hypothyroidism.
What is a Discogram?
Lumbar discography is an injection technique used to evaluate patients with back pain who have not responded to extensive conservative (nonsurgical) care regimens. The most common use of discography is for surgical planning prior to a lumbar fusion.
This diagnostic procedure – also called a discogram – is a controversial one.
- The protagonists of discography believe the information gleaned from this examination is unobtainable any other way.
- The procedure’s antagonists feel the responses evoked from disc pressurization are not useful in evaluating back pain patients.
This article does not extol the use of discography; rather it addresses some aspects of the procedure that may make a patient more at ease with what is an uncomfortable exam.
Indications for a Discogram
The indications for getting a discogram prior to a lumbar fusion surgery are extremely variable amongst spine surgeons. Ordering the procedure depends on access to a skilled discographer. A discogram is basically a very subjective test, and if there are no experienced discographers available, then the spine surgeon may forego the test since a poorly done discogram does not yield any useful information.
Lumbar discography is considered for patients who, despite extensive conservative treatment, have disabling lower back pain, groin pain, hip pain, and/or leg pain. When a variety of spinal diagnostic procedures have failed to elucidate the primary pain generator, these individuals may benefit from lumbar discography especially if spine surgery is contemplated.
Unique Aspects of Discography
It should be understood that the discogram is less about the anatomy of the disc (what the disc looks like) and more about its physiology (determining if the disc is painful). It is well known to discographers that a really abnormal looking disc may not be painful and a minimally disrupted disc may be associated with severe pain. It is impossible to definitively diagnose a painful disc without performing a discogram.
The Lumbar MRI and CT myelogram are very sensitive anatomic tests but are not very specific in defining actual pain generators. The lumbar discogram, if performed properly, is designed to induce pain in a sensitive disc. A spinal fusion procedure that is designed to obliterate an internally disrupted, painful disc (pain generator) would not be the procedure of choice if pressurization of the disc didn’t reproduce the patient’s clinical discomfort. The spine surgeon needs to be absolutely sure that the level or levels being fused are responsible for the patient’s pain.
If the fused levels were not initially painful, spine surgery will not help, and the patient will be left with a fused spine and probably still be in pain. Since a spine fusion procedure carries a significant level of risk and healing time, the more information that can be obtained prior to back surgery the better.
Radiofrequency ablation (or RFA) is a procedure used to reduce pain. An electrical current produced by a radio wave is used to heat up a small area of nerve tissue, thereby decreasing pain signals from that specific area.
Which Conditions Are Treated With Radiofrequency Ablation?
RFA can be used to help patients with chronic (long-lasting) low-back and neck pain and pain related to the degeneration of joints from arthritis.
How Long Does Pain Relief From Radiofrequency Ablation Last?
The degree of pain relief varies, depending on the cause and location of the pain. Pain relief from RFA can last from six to 12 months and in some cases, relief can last for years. More than 70% of patients treated with RFA experience pain relief.
Is Radiofrequency Ablation Safe?
RFA has proven to be a safe and effective way to treat some forms of pain. It also is generally well-tolerated, with very few associated complications. There is a slight risk of infection and bleeding at the insertion site. Your doctor can advise you about your particular risk.
What Are the Side Effects of Radiofrequency Ablation?
The main side effect of RFA is some discomfort, including swelling and bruising, at the site of the treatment, but this generally goes away after a few days.
Who Should Not Get Radiofrequency Ablation?
As with any medical procedure, RFA is not appropriate for everyone. For example, radiofrequency ablation is not recommended in people who have active infections or bleeding problems. Your doctor can tell you if you should not have RFA.
How Do I Prepare for Radiofrequency Ablation?
To prepare for radiofrequency ablation treatment, you should take a few precautions, including:
- Do not eat within six hours of your appointment. You may have clear liquids until two hours before the procedure.
- If you have diabetes and use insulin, you must adjust the dosage of insulin the day of the procedure. Your primary care doctor will help you with this adjustment. Bring your diabetes medication with you so you can take it after the procedure.
- Continue to take all other medications with a small sip of water. Bring all medication with you so you can take it after the procedure. Please note: Do not discontinue any medication without first consulting with your primary or referring doctor.
- You will need to bring someone with you to drive you home after the procedure. You should not drive or operate machinery for at least 24 hours after the procedure.
What Happens During Radiofrequency Ablation?
You will meet with a doctor for an evaluation. If radiofrequency ablation is recommended, a doctor will explain the procedure in detail, including possible complications and side effects.
The doctor will also answer any questions you may have.
An intravenous (IV) line may be placed in a vein in your arm before the procedure and a local anesthetic and mild sedative may be used to reduce any discomfort during RFA. You may be awake during the process to aid in properly assessing the procedure. Ask your doctor about specifics beforehand.
After the local anesthesia (you will be awake but will not feel any pain) has been given, the doctor will insert a small needle into the general area where you are experiencing pain. Using X-ray, your doctor will guide the needle to the exact target area. A microelectrode is then inserted through the needle to begin the stimulation process.
During the procedure, your doctor will ask if you are able to feel a tingling sensation. The object of the stimulation process is to help the doctor determine if the electrode is in the optimal area for treatment.
Once the needle and electrode placement are verified, a small radiofrequency current is sent through the electrode into the surrounding tissue, causing the tissue to heat. You should not feel discomfort during the heating portion of the procedure.
What Happens After Radiofrequency Ablation?
Following radiofrequency ablation:
- You will stay in a recovery room for observation, where a nurse will check your blood pressure and pulse.
- A bandage will be placed over the injection site.
- The nurse will give you a beverage and review your discharge instructions with you.
- Someone must drive you home.
Can I Resume My Normal Activities After Radiofrequency Ablation?
You will have a few restrictions immediately following radiofrequency ablation:
- Do not drive or operate machinery for at least 24 hours after the procedure.
- You may resume your normal diet.
- Do not engage in any strenuous activity for the first 24 hours after the procedure.
- Do not take a bath for one to two days after the procedure; you may shower.
- You may remove any bandages in the evening before going to bed.
What Side Effects May I Have After Radiofrequency Ablation?
You may experience the following effects after RFA:
- Leg numbness: If you have any leg numbness, walk only with assistance. This should only last a few hours and is due to the local anesthesia given during the procedure.
- Mild back discomfort: This may occur when the local anesthetic wears off and usually lasts two or three days, if it occurs. Apply ice to the area the day of the procedure and moist heat the day after the procedure if the discomfort persists. You may also use your usual pain medications.
Electromyogram (EMG) and Nerve Conduction Studies
An electromyogram (EMG) measures the electrical activity of muscles at rest and during contraction. Nerve conduction studies measure how well and how fast the nerves can send electrical signals.
Nerves control the muscles in the body with electrical signals called impulses. These impulses make the muscles react in specific ways. Nerve and muscle problems cause the muscles to react in abnormal ways.
If you have leg pain or numbness, you may have these tests to find out how much your nerves are being affected. These tests check how well your spinal cord, nerve roots, and nerves and muscles that control your legs are working.
Why It Is Done
An EMG is done to:
- Find diseases that damage muscle tissue, nerves, or the junctions between nerve and muscle. These problems may include a herniated disc, amyotrophic lateral sclerosis (ALS), or myasthenia gravis (MG).
- Find the cause of weakness, paralysis, or muscle twitching. Problems in a muscle, the nerves supplying a muscle, the spinal cord, or the area of the brain that controls a muscle can cause these symptoms. The EMG does not show brain or spinal cord diseases.
A nerve conduction study is done to:
- Find damage to the peripheral nervous system, which includes all the nerves that lead away from the brain and spinal cord and the smaller nerves that branch out from those nerves. This test is often used to help find nerve problems such as carpal tunnel syndrome or Guillain-Barr syndrome.
How To Prepare
Tell your doctor if you:
- Are taking any medicines. Certain medicines that affect the nervous system can change electromyogram (EMG) results. You may need to stop taking these medicines 3 to 6 days before the test.
- Have had bleeding problems or take blood thinners, such as warfarin or heparin. If you take blood thinners, your doctor will tell you when to stop taking them before the test.
- Have a pacemaker.
Do not smoke for 3 hours before the test.
Do not eat or drink foods that contain caffeine (such as coffee, tea, cola, and chocolate) for 2 to 3 hours before the test.
Wear loose-fitting clothing so your muscles and nerves can be tested. You may be given a hospital gown to wear.
For an EMG, you may be asked to sign a consent form. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean.
How It Is Done
An EMG is done in a hospital, clinic, or doctor's office. It may be done in a room that stops any outside electrical interference. The test may be done by an EMG technologist or a doctor.
You will be asked to lie on a table or bed or sit in a reclining chair so your muscles are relaxed.
The skin over the areas to be tested is cleaned. A needle electrode that is attached by wires to a recording machine is inserted into a muscle.
When the electrodes are in place, the electrical activity in that muscle is recorded while the muscle is at rest. Then the technologist or doctor asks you to tighten (contract) the muscle slowly and steadily. This electrical activity is recorded.
The electrode may be moved a number of times to record the activity in different areas of the muscle or in different muscles.
The electrical activity in the muscle is shown as wavy and spiky lines on a video monitor and may also be heard on a loudspeaker as machine gun-like popping sounds when you contract the muscle. The activity may also be recorded on video.
An EMG may take 30 to 60 minutes. When the test is done, the electrodes are removed and those areas of the skin where a needle was inserted are cleaned. You may be given pain medicine if any of the test areas are sore.
Nerve conduction studies
In this test, several flat metal disc electrodes are attached to your skin with tape or a paste. A shock-emitting electrode is placed directly over the nerve, and a recording electrode is placed over the muscles controlled by that nerve. Several quick electrical pulses are given to the nerve, and the time it takes for the muscle to contract in response to the electrical pulse is recorded. The speed of the response is called the conduction velocity.
The same nerves on the other side of the body may be studied for comparison. When the test is done, the electrodes are removed.
Nerve conduction studies are done before an EMG if both tests are being done. Nerve conduction tests may take from 15 minutes to 1 hour or more, depending on how many nerves and muscles are studied.
How It Feels
During an EMG test, you may feel a quick, sharp pain when the needle electrode is put into a muscle. After the test, you may be sore and have a tingling feeling in your muscles for 1 to 2 hours. If your pain gets worse or you have swelling, tenderness, or pus at any of the needle sites, call your doctor.
With the nerve conduction studies, you may feel a quick, burning pain, a tingling feeling, and a twitching of the muscle each time the electrical pulse is given. It feels like the kind of tingling you feel when you rub your feet on the carpet and then touch a metal object. The tests make some people anxious. Keep in mind that only a very low-voltage electrical current is used, and each electrical pulse is very quick (less than a split-second).
Epidural Steroid Injections
Epidural Steroid Injections (ESIs) are a common method of treating inflammation associated with low back related leg pain, or neck related arm pain. In both of these conditions, the spinal nerves become inflamed due to narrowing of the passages where the nerves travel as they pass down or out of the spine.
Why Get an Epidural Steroid Injection?
Narrowing of the spinal passages can occur from a variety of causes, including disc herniations, bone spurs, thickening of the ligaments in the spine, joint cysts, or even abnormal alignment of the vertebrae (‘slipped vertebrae’, also known as spondylolisthesis). The epidural space is a fat filled ‘sleeve’ that surrounds the spinal sac and provides cushioning for the nerves and spinal cord. Steroids (‘cortisone’) placed into the epidural space have a very potent anti-inflammatory action that can decrease pain and allow patients to improve function. Although steroids do not change the underlying condition, they can break the cycle of pain and inflammation and allow the body to compensate for the condition. In this way, the injections can provide benefits that outlast the effects of the steroid itself.
How Are Epidural Steroid Injections Performed?
There are three common methods for delivering steroid into the epidural space: the interlaminar, caudal, and transforaminal approaches. All three approaches entail placing a thin needle into position using fluoroscopic (x-ray) guidance. Prior to the injection of steroid, contrast dye is used to confirm that the medication is traveling into the desired area. Often, local anesthetic is added along with the steroid to provide temporary pain relief.
An interlaminar ESI, often referred to simply as an ‘epidural injection’, involves placing the needle into the back of the epidural space and delivering the steroid over a wider area. Similarly, the caudal approach uses the sacral hiatus (a small boney opening just above the tailbone) to allow for needle placement into the very bottom of the epidural space. With both approaches, the steroid will often spread over several spinal segments and cover both sides of the spinal canal. With a transforaminal ESI, often referred to as a ‘nerve block’, the needle is placed alongside the nerve as it exits the spine and medication is placed into the ‘nerve sleeve’. The medication then travels up the sleeve and into the epidural space from the side. This allows for a more concentrated delivery of steroid into one affected area (usually one segment and one side). Transforaminal ESIs can also be modified slightly to allow for more specific coverage of a single nerve and can provide diagnostic benefit, in addition to improved pain and function.
All three procedures are performed on an outpatient basis, and you can usually return to your pre-injection level of activities the following day. Some patients request mild sedation for the procedure, but many patients undergo the injection using only local anesthetic at the skin.
What Happens After the Injection?
The steroid will usually begin working within 1-3 days, but in some cases it can take up to a week to feel the benefits. Although uncommon, some patients will experience an increase in their usual pain for several days following the procedure. The steroids are generally very well tolerated, however, some patients may experience side effects, including a ‘steroid flush’ (flushing of the face and chest that can last several days and can be accompanied by a feeling of warmth or even a low grade increase in temperature), anxiety, trouble sleeping, changes in menstrual cycle, or temporary water retention. These side effects are usually mild and will often resolve within a few days. If you are diabetic, have an allergy to contrast dyes, or have other serious medical conditions, you should discuss these with your NASS doctor prior to the injection.
Epidural steroid injections have been performed for many decades, and are generally considered as a very safe and effective treatment for back and leg pain or neck and arm pain. Serious complications are rare, but could include allergic reaction, bleeding, infection, nerve damage, or paralysis. When performed by an experienced physician using fluoroscopic guidance, the risk of experiencing a serious complication is minimized. Overall, ESIs are usually very well tolerated and most patients do well.
Although not everyone obtains pain relief with ESIs, often the injections can provide you with improvement in pain and function that last several months or longer. If you get significant benefit, the injections can be safely repeated periodically to maintain the improvements. Injections are also commonly coupled with other treatments (medications, physical therapy, etc) in an attempt to either maximize the benefit or prolong the effects. You should consult with your NASS doctor to develop a comprehensive care plan.
Spinal Tap (Lumbar Puncture)
A lumbar puncture (also called a spinal tap) is a procedure to collect and look at the fluid (cerebrospinal fluid, or CSF) surrounding the brain and spinal cord.
During a lumbar puncture, a needle is carefully inserted into the spinal canal low in the back (lumbar area). Samples of CSF are collected. The samples are studied for color, blood cell counts, protein, glucose, and other substances. Some of the sample may be put into a special culture cup to see if any infection, such as bacteria or fungi, grows. The pressure of the CSF also is measured during the procedure.
Why It Is Done
A lumbar puncture is done to:
- Find a cause for symptoms possibly caused by an infection (such as meningitis), inflammation, cancer, or bleeding in the area around the brain or spinal cord (such as subarachnoid hemorrhage).
- Diagnose certain diseases of the brain and spinal cord, such as multiple sclerosis or Guillain-Barr� syndrome.
- Measure the pressure of cerebrospinal fluid (CSF) in the space surrounding the spinal cord. If the pressure is high, it may be causing certain symptoms.
A lumbar puncture may also be done to:
- Put anesthetics or medicines into the CSF. Medicines may be injected to treat leukemia and other types of cancer of the central nervous system.
- Put a dye in the CSF that makes the spinal cord and fluid clearer on X-ray pictures (myelogram). This may be done to see whether a disc or a cancer is bulging into the spinal canal.
In rare cases, a lumbar puncture may be used to lower the pressure in the brain caused by too much CSF.
How To Prepare
Before you have a lumbar puncture, tell your doctor if you:
- Are taking any medicines. If you take medicines every day, ask your doctor whether you should take these medicines on the day of the lumbar puncture.
- Are allergic to any medicines, such as those used to numb the skin (anesthetics).
- Have had bleeding problems or take blood-thinners, such as aspirin, warfarin (Coumadin), or clopidogrel (Plavix).
- Are or might be pregnant.
- Take any herbal remedies. Some of these remedies may thin the blood.
You will empty your bladder before the procedure.
For a lumbar puncture, you will be asked to sign a consent form. Talk to your doctor about any concerns you have regarding the need for the procedure, its risks, how it will be done, or what the results will mean. This procedure is often done in an emergency situation.
How It Is Done
A lumbar puncture may be done in your doctor's office, in an emergency room, or at your bedside in the hospital. It may also be done in the radiology department if fluoroscopy is used.
You will lie on a bed on your side with your knees drawn up toward your chest. Or you may sit on the edge of a chair or bed and lean forward over a table with your head and chest bent toward your knees. These positions help widen the spaces between the bones of the lower spine so that the needle can be inserted more easily. If fluoroscopy is used, you will lie on your stomach so the fluoroscopy machine can take pictures of your spine during the procedure.
Your doctor marks your lower back (lumbar area) with a pen where the puncture will occur. The area is cleaned with a special soap and draped with sterile towels. A numbing medicine (local anesthetic) is put in the skin.
Then a long, thin needle is put in the spinal canal. When the needle is in place, the solid central core of the needle (stylet) is removed. If the needle is in the right spot in the spinal canal, a small amount of cerebrospinal fluid (CSF) will drip from the end of the needle. If not, the stylet will be put back in and the needle will be moved in a little farther or at a different angle to get to the fluid. Your doctor may need to move to another area of your spine if it is hard to get to the spinal fluid.
When the needle is in the spinal canal, a device called a manometer is hooked to the needle to measure the pressure of the CSF. You may be asked to straighten your legs while you are lying down. Your doctor takes the pressure reading, called the opening pressure, and checks whether the fluid is clear, cloudy, or bloody. Several small samples of fluid are collected and sent to the lab for study.
A final pressure reading, called the closing pressure, may be taken after the fluid samples are done. The needle is taken out and the puncture site is cleaned and bandaged.
The entire procedure takes about 30 minutes.
To lower your chance of getting a headache following a lumbar puncture, you may be told to lie flat in bed or with your head slightly raised for 1 to 4 hours. Since your brain makes new CSF all the time and replaces it 2 to 3 times a day, the small amount of fluid that is removed will be quickly replaced. You may be told to drink extra fluids after the procedure to help prevent or to reduce the severity of a headache.
How It Feels
Some people find it uncomfortable to lie curled up on their side. The soap may feel cold on your back. You will probably feel a brief pinch or sting when the numbing medicine is given. You may feel a brief pain when the spinal needle is inserted or repositioned.
During the procedure, the needle may touch one of your spinal nerves and cause a tingling feeling, like a light electrical shock, running down one of your legs. The needle will not touch or damage the spinal cord.
Some people (10% to 25%) develop a headache after having a lumbar puncture. Of those who do get headaches, only about half report that they are severe. These headaches last 24 to 48 hours and go away on their own. Pain medicine does not help control the headache, but lying flat in bed for several hours after the procedure may help the headache.
You may feel tired and have a mild backache the day after the procedure. Some people have trouble sleeping for 1 to 2 days.
A lumbar puncture is generally a safe procedure. In some cases, a leak of cerebrospinal fluid (CSF) may develop after a lumbar puncture. Symptoms of this problem are a headache that does not go away after 1 to 2 days. A CSF leak can be treated with a blood "patch," in which the person's own blood is injected into the area where the leak is occurring in order to seal the leak.
About 1 in 1,000 people who have a lumbar puncture have a minor nerve injury. This heals on its own with time. There is also a small chance of infection of the CSF (meningitis), bleeding inside the spinal canal, or damage to the cartilage between the vertebrae. Your doctor will talk with you about these risks.
People who have bleeding problems and those who are taking blood-thinning medicine (such as warfarin or heparin) have a higher chance of bleeding after the procedure. A lumbar puncture may not be done unless it is needed for a life-threatening illness.
A lumbar puncture may cause serious problems for people who have high pressure in the brain caused by a tumor, a pocket of infection in the brain (abscess), or major bleeding inside the brain. Your doctor will check your nervous system, spinal cord and brain before doing a lumbar puncture. In some cases, a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan may be done before the lumbar puncture to know that it is safe to do the puncture.
After the procedure
Call your doctor immediately if you have:
- Chills or a fever.
- A stiff neck. This may be a sign of a developing infection.
- Any drainage or bleeding from the puncture site.
- A severe headache.
- Any numbness or loss of strength below the puncture site.
A lumbar puncture (also called a spinal tap) is a procedure to collect and look at the fluid (cerebrospinal fluid, or CSF) surrounding the brain and spinal cord. Many different tests can be done on the CSF. Some results will be ready right away, some will take a few hours after the procedure, and others will take several weeks.
The Basics of Osteoarthritis
Arthritis is a general term that means inflammation of the joints. Osteoarthritis, also called degenerative joint disease, is the most common type of arthritis. It is associated with a breakdown of cartilage in joints and can occur in almost any joint in the body. It most commonly occurs in the weight bearing joints of the hips, knees, and spine. It can also affect the fingers, thumb, neck, and large toe. Osteoarthritis -- also called OA -- usually does not affect other joints unless previous injury or excessive stress is involved.
Cartilage is a firm, rubbery material that covers the ends of bones in normal joints. Its main function is to reduce friction in the joints and serve as a "shock absorber." The shock-absorbing quality of normal cartilage comes from its ability to change shape when compressed (flattened or pressed together).
Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage. Over time, the cartilage may wear away in some areas, greatly decreasing its ability to act as a shock absorber. As the cartilage deteriorates, tendons and ligaments stretch, causing pain. If the condition worsens, the bones could rub against each other.
Who Gets Osteoarthritis?
Osteoarthritis affects nearly 21 million Americans. The chance of developing the disease increases with age. Most people over age 60 have osteoarthritis to some degree, but its severity varies. Even people in their 20s and 30s can get osteoarthritis. In people over 50, more women than men get osteoarthritis.
What Are the Symptoms of Osteoarthritis?
Symptoms of osteoarthritis most often develop gradually and include:
- Joint aching and soreness, especially with movement.
- Pain after overuse or after long periods of inactivity.
- Bony enlargements in the middle and end joints of the fingers (which may or may not be painful).
- Joint swelling and joint fluid accumulation.
What Causes Osteoarthritis?
There are several factors that increase a person's chances of developing osteoarthritis. These include:
- Heredity. Some people have an inherited defect in one of the genes responsible for making cartilage. This causes defective cartilage, which leads to more rapid deterioration of joints. People born with joint abnormalities are more likely to develop osteoarthritis, and those born with an abnormality of the spine (such as scoliosis or curvature of the spine) are more likely to develop osteoarthritis of the spine.
- Obesity. Obesity increases the risk for osteoarthritis of the knee and hip. Maintaining ideal weight or losing excess weight may help prevent osteoarthritis of the knee and hip or decrease the rate of progression once osteoarthritis is established.
- Injury. Injuries contribute to the development of osteoarthritis. For example, athletes who have knee-related injuries may be at higher risk of developing osteoarthritis of the knee. In addition, people who have had a severe back injury may be predisposed to develop osteoarthritis of the spine. People who have had a broken bone near a joint are prone to develop osteoarthritis in that joint.
- Joint Overuse. Overuse of certain joints increases the risk of developing osteoarthritis. For example, people in jobs requiring repeated bending of the knee are at increased risk for developing osteoarthritis of the knee.
How Is Osteoarthritis Diagnosed?
The diagnosis of osteoarthritis is based on a combination of the following factors:
- Your description of symptoms.
- The location and pattern of pain.
- Physical exam.
Your doctor may use X-rays to help confirm the diagnosis and make sure you don't have another type of arthritis. X-rays show how much joint damage has occurred.
Sometimes blood tests will be given to determine if you have a different type of arthritis.
If fluid has accumulated in the joints, your doctor may remove some of the fluid (called joint aspiration) for examination under a microscope to rule out other diseases.
How Is Osteoarthritis Treated?
Osteoarthritis usually is treated by physical therapy with muscle strengthening exercises, oral medications, hot and cold compresses to the painful joint, removal of joint fluid, injection of medications into the joint, use of supportive devices such as crutches or canes, and weight control. Surgery may be helpful to relieve pain when other treatment options have not been effective.
The type of treatment prescribed will depend on several factors including your age, activities and occupation, overall health, medical history, location of your osteoarthritis, and severity of the condition.
What Medications Are Used to Treat Osteoarthritis?
Medications may be prescribed to reduce pain caused by osteoarthritis. Pain-relieving drugs include acetaminophen (for example, Tylenol) and anti-inflammatory drugs (often called NSAIDs), such as aspirin, ibuprofen, or Celebrex. Some medications in the form of creams, rubs, or sprays may be applied over the skin of affected areas to relieve pain. For some people with persistent pain despite these pills or creams, steroids can be injected directly into the joint. These injections can be given several times a year though some feel it may ultimately accelerate joint damage.
The antidepressant Cymbalta (duloxetine) has been approved for osteoarthritis pain as well. It's a serotonin-norepinephrine reuptake inhibitor, or SNRI, that was first approved by the FDA in 2004.
Synvisc, Supartz, Euflexxa, Orthovisc, and Hyalgan are drugs given as a series of three to five weekly joint injections that can relieve pain in some people with osteoarthritis. Currently, these drugs are only approved for knee osteoarthritis.
When osteoarthritis pain is severe and other treatments are not working, some doctors will give stronger pain pills, such as narcotics.
Unfortunately, none of these will reverse or slow the progression of joint damage caused by osteoarthritis.
How Does Weight and Exercise Impact Osteoarthritis?
Staying at your recommended weight helps prevent osteoarthritis of the knees, reduces the stress on weight-bearing joints, and reduces pain in joints already affected. Once you have osteoarthritis, losing weight also can relieve the stress and pain in your knees.
Exercise is important to improve joint movement and to strengthen the muscles that surround the joints. Gentle exercises, such as swimming or walking on flat surfaces, are recommended because they are less stressful on your joints. Avoid activities that increase joint pain, such as jogging or high impact aerobics. Exercises that strengthen the quadriceps muscle reduce knee pain in patients with osteoarthritis.
Are There Alternative Treatments for Osteoarthritis?
Some medical research has shown that the supplements glucosamine and chondroitin may relieve pain in some people with osteoarthritis -- especially in the knee. There is no evidence that glucosamine can help rebuild cartilage.
Some people also use methylsulfonylmethane (MSM) and S-adenosylmethionine (SAM-e) for arthritis but there is questionable medical evidence showing their benefits. MSM is a naturally occurring compound that is taken as a dietary supplement.
Acupuncture and bioelectric therapy also may be useful at relieving pain.
What Supportive Devices Are Available to Help With Osteoarthritis?
Supportive or assistive devices may be helpful to decrease pressure on the joints with osteoarthritis. Knee supports may be helpful for some people to stabilize the ligaments and tendons and decrease pain. Canes or crutches may be helpful to take pressure off certain joints.
In addition to pain relief, assistive devices improve function and prevent falls. A licensed physical therapist or other health care professional is needed to recommend what devices are best for you.
Is There a Surgery for Osteoarthritis?
When osteoarthritis pain is not controlled with medications and the other mentioned treatments, or when the pain prevents you from participating in your normal activities, you may want to consider surgery.
There are several types of surgery for osteoarthritis. They include:
- Arthroscopy to clean out the damaged cartilage has not been proven in recent studies to be effective for osteoarthritis.
- Joint replacement surgery to replace the damaged joint with an artificial one. Joint replacement surgery should be considered when the severity of the joint pain significantly interferes with a person’s function and quality of life. Even under the best of circumstances, surgery cannot return the joint to its normal state (artificial joints do not have all of the motion of a normal joint). However, an artificial joint will diminish pain. The two joints most often replaced are the hip and the knee. Artificial joints are now also available to replace shoulders, fingers, elbows, ankles, and back joints to treat severe pain that has not responded to other treatments.
- Joint fusion removes the damaged joint and fuses the two bones on each side of the joint. This is done more often in areas in which joint replacement is not effective.