Dr. Steve...Another Question [Archive]

Kathi49

04-01-2007, 01:01 PM

I am still in the process of sorting out this shoulder, arm and hand pain. According to my OS shoulder tendonitis shouldn't cause pain past the elbow. But when my PM did the injection into the shoulder joint, I could feel the numbing medicine go clear down my arm and back towards the shoulder blade which felt great. I know I need to give the injection a longer time to work. But I am still concerned about the tremors in my arms. I don't know if it is from the weakness in the upper body or not.

Anyway, I mentioned to you before that the C4/C5 is lying right up against the thecal sac...almost nudging it (slight, slight indentation). And I think you said that that wouldn't cause the arm pain.

Soooo...

What else should I be looking at besides the C4/C5? The C5 nerve root itself or possibly the C6/C7? I am just trying to get some ideas of what might be disturbed. The MRI reports says no exiting nerve root impingment so I am confused. Oops, I know you mentioned finding the pain generators and I agree. I am just trying to determine what level should be looked at first.

Any thoughts? Thank you.

lobelsteve

04-01-2007, 04:58 PM

I'm not your doc, so this does not apply to you. Besides- your messed up anyways from an anatomical standpoint given prior neck surgery.

Pain into an arm can be from a nerve in the arm, shoulder, or neck. It can be from a muscle, tendon, bone, ligament, joint, skin, nailbed. Hair and nails themselves are dead tissue and do not cause pain.

Locating the pain generator requires taking a detailed H&P, getting appropriate imaging studies, EMG if needed.

Pain in the arm can be from the arm, a nerve in the arm, or referred pain from another source (a heart attack can radiate pain down the left arm).

Nerve fibers running down the arm are from C5-T1. An injection into the shoulder that radiates relief/pain down the scapula may not be a shoulder injection at all. It could have been a suprascapular nerve block.

I'd pick the Ortho, PMR, or Neurologist to help diagnose rather than an Anesthesiologist.

Kathi49

04-01-2007, 05:29 PM

Thanks Steve,

I AM messed up! :eek:

Okay, my next step will probably be with the Neurologist since I have already seen the NS, PM and OS...all saying shoulder/neck for right now; mechanics I suppose. And probably came to their conclusions based upon manipulation of the right shoulder.

And, I agree, could be the levels you mentioned. I was looking more specifically at C4/C5.

But thank you again.

slipnslide

04-01-2007, 05:36 PM

Pardon my ignorance, what is a PMR????

BrokenBladder

04-01-2007, 07:01 PM

I think it's a pain management radiologist. Someone please correct me if I'm wrong!!

Kathi49

04-01-2007, 07:09 PM

I think he means a pain management specialist that does rehab but I am not sure either. ;)

lobelsteve

04-01-2007, 07:14 PM

PMR- Physical Medicine and Rehabilitation = Physiatrist.

www.aapmr.org
www.abpmr.org

GJZH

04-02-2007, 03:06 AM

Kathi,

Hi! I just wanted to put up a picture of the dermatomes thinking it might help pinpoint some of your pain coming possibly from C4 and C5. If you look at the diagram, you can see that C5 could certainly be a cause of arm pain. I just want to say too that just because degeneration does not look severe on the MRI does not mean that it is not worse than it is. After I had my surgery at Hopkins my surgeon said the degeneration was a lot worse once they actually got in there to do the surgery. The other thing I wanted to mention and emphasize from my terrific top doc, Kathi...No PT for your shoulder until you are absolutely certain about what is going on...They are now certain that if you have a rotator cuff tear and you exercise your shoulder,you will make it worse. I have a tear now and the only thing they want me to do is to keep it mobile so that it does not freeze up, but no rigorous execises at all....I hope this helps!

http://mywebpages.comcast.net/epollak/PSY255_pix/dermatomes-netter2.JPG

Kathi49

04-02-2007, 09:29 AM

Thank you GJZH,

If it is not the C4/C5 is may very well be C6/C7. My PM DID mention the C5 nerve root as a potential culprit. I know SlipnSlide is going through this as well and I believe she said she has some procedures scheduled to identify the pain generators. I think I am following right behind her. :( Something similar happened after the C3/C4 fusion and after a couple of injections; the pain was gone.

But I am with you. I am not doing any PT until the problem is identified. It really makes no sense to do so....not if there is inflammation going on.

So, in the meantime I will stick with what my spinal PM is recommending and he may even send me to the Neurologist to have an EMG done and maybe even an MRI; but not sure about that yet. I just have to wait and see if this injection will be helpful or not. :) Or maybe he has some other ideas. I just don't know for sure at this point.

I do want to add that the left shoulder is feeling a little better; still a wee bit of pain but not like it was and he didn't even touch that one.

slipnslide

04-02-2007, 11:01 AM

Kathi,

As you know, I had PT ordered for me after the ACDF to increase my range of motion and build strenght in the areas I had been guarding for so long. I didn't make it through any of the range of motion or resistance exercises without being laid up for the days following with increased pain.

My OSS checked my shoulders with moving my arms in all different directions which didn't illicit any sharp pains, plus my pain was bilateral so he didn't believe it to be shoulder related.

In the past, I have had issues with my shoulders and calcium deposits, along with inflamation and I know that kind of pain to where just sitting or standing in a natural position brings tears to your eyes....ugh.

The pains in my arms and shoulders that I have seem to be in the C5, C6, and C8 dermatomes. Why the C8?...I don't know....all I know is that my deltoids, biceps and triceps burn and ache, and I get stabbing pains in my deltoids and biceps. My PM mentioned the C5/6 also during my last visit. I have an appointment with him next tues. regarding the transforaminal injections and hopefully will know more about what is to be done next.

Being that they think it has to do with your C5/6, I doubt that the MRI or the EMG will help you any more than it helped me, unless the MRI is done on your shoulder...lol...we're fused at those levels so there is no reason to have pain in those dermatomes!:rolleyes: Kinda makes ya think you're crazy, eh?...LOL;) :D

Kathi49

04-02-2007, 11:24 AM

Kim,

Precisely why I don't think PT is a good idea at all right now! :eek: I'd probably flunk out anyway LOL!

We have some slight differences though; I have that C4/C5 wedged in between the two fusions. And my PM DID say something about the C5 nerve root being right there. I am no doctor but maybe the pressure or the force of the two fusions have something to do with this even though it says no exiting nerve root impingement. But you are right, it does make one crazy. And God only knows if it is the C6/C7. Like I said, I think I am right behind you in this adventure. :)

Somehow or another SOMETHING is aggravated for both of us. And getting to what that is is tough. But in no way, shape or form am I going to have someone tugging, pulling, stretching, reaching...whatever...until the pain generator is found...if ever LOL! For all I know it may be a form of neuropathy. And if that is the case, then the whole ballgame changes....I think.

What I really think he might do is a Selective Nerve Root injection. But again, I am not positive. Or he may proceed as your docs are doing. I wish I knew more at this point but I simply don't.

I did want to say that the right shoulder is feeling better this morning and there is no pain in my forearm. But that is TODAY! Tomorrow I might be slam dunked again. :eek:

Kathi49

04-02-2007, 11:26 AM

Kim,

NOTE TO SELF: Stay away from the PC as much as possible LOL! But I am not good at that. :eek:

GJZH

04-02-2007, 11:28 AM

I am going to be real honest about my opinion about EMG's....I think they are useless and painful...I am going to refuse to allow them from now on...My cervical spinal surgeon told me he never uses them becasue they are too subjective. He said that the results are in the measurements. He said that one doctor can get one set of results and you can go to another doctor and then get another set of results. This in fact happened to me last year with a cervical EMG. One doctor said nothing was wrong with the cervical spine and then I had to have a lumbar EMG and the examiner said she would retest the cervical spine if I wanted her to...well she said she found a problem in the one nerve...She wanted to redo the entire EMG. My doc rewrote the script for her to redo the upper extremity EMG...She did not find the problem with the nerve that she originally did ....so I thought...never again...It is voodoo and I am not subjecting myself to it...

I am curious...when they fiddle around with your shoulders, do they hear a clunking sound? Are you taking an anti-inflammatory?

My shoulders clunk...but today I woke with pain that I know is different...It is definitely cervical...It is a different kind of pain...and it prevents me from doing many things...

SlipNSlide
It might be that you are having problems too because you do not have a solid fusion :confused:

Wish I could be of more help!

lobelsteve

04-02-2007, 11:43 AM

Kathi49

04-02-2007, 11:47 AM

Gloria,

I agree with you about the EMGs and I wasn't going to say anything. But even my PM said...wouldn't be worth my time as they would probably come back normal. Actually what he said was that whether I had tendonitis or bursitis the treatment is the same. I know I mentioned it in previous posts, but I was really seriously doubting whether it would show anything anyway And I think he is right because the two I have had done in the lumbar have always come back normal. Yet, I still had the radiculopathy! :eek:

Okay, I can't take anti-inflammatories very well. I have the GERD/gastritis/IBS going on. But I could up the Nexium to help with that. I have been prescribed Celebrex by my OS and will be honest and tell you I have not taken it yet. Because it was shortly after that that the injection was done. I have taken all kinds in the past and the docs told me I would just have to take them every other day. But they really tore me up...worse than the injections. Plus I ALWAYS get that ringing going on in my ears when I take them and dizziness. What that is I don't know. Anyway, just name the anti-inflammatories and I can tell you I have tried them all. I even thought Arthrotec or Mobic would be easier. Actually, they were the worst of any!
This is why I stick with ice most of the time or go with the injections. Call me crazy I guess. But again, I could probably up the Nexium. Now Voltaren alone will not bother me as much but if taken every day; then there are problems. The Celebrex is for 200mg. once a day. But I am wondering if Vicoprofen wouldn't be too bad. I am just not sure. That is one I have NOT tried.

And no, no clunking at all in my shoulders. It was only when he bent my elbow back and sort of manipulated the shoulder backwards that I really felt it.

Kathi49

04-02-2007, 12:17 PM

Steve,

All I can say is that my Neurologist performed two EMGs on my lumbar and the test results were negative. I do feel they are subjective based on what she said as well as what the Cleveland Clinic Neuros have said on the Neurology Forum. I tend to think a person CAN get variable results depending. I don't think GJZH was being reckless. In some cases I even think they are unncessary.

GJZH

04-02-2007, 03:43 PM

Steve,

My EMG's were done by Neurologists and a Physiatrist....One Neurologist said I had neuropathy in the lumbar and the other seemed to want to contradict his findings so she said I had radiculopathy...He said I had no problems in the upper extremities and she said I had carpel tunnel syndrome. My Physiatrist just did a lower extremity EMG two weeks ago and he said there is neuropathy...I say it is just all hog wash and am not showing the results to anyone..My surgeons did not order it so I will just file it away with the other four or five I had done, but I will not ever allow another EMG. They are painful and useless. I will tell the docs to order an MRI since my problems always show up on an MRI anyway...

slipnslide

04-02-2007, 04:07 PM

GJZH,

No clunking in my shoulders either. As far as the solid fusion, I'm not sure, but my OSS did say I was fusing just fine back in October. I've had a couple sets of xrays done on my c-spine since then and he's said that everything looks fine with them.

Lobelsteve,

I had an EMG/NCS done where the Physiatrist who did it said in the report, that there was global sensory slowing and problems with the ulnar nerves bilaterally. My PM and OSS don't seem to think that the slowing or ulnar nerve results are too big of a deal, and if I remember correctly, neither did you when I sent you the wave forms. I guess my point would be that EMG's and NCS's are subjective. Whereas you, my OSS and PM didn't feel the results shed any light on why I am still having all this neck, shoulder/arm/hand pain, but yet the physiatrist who performed the test felt it was sginificant enough to mention!?!? I guess my question would be, just how significant of a change has to show on an EMG/NCS for the results to be considered?....and how much pain must a person have to be in in order for it to actually show up as a tiny blip on the waveforms?

GJZH

04-02-2007, 04:21 PM

SlipnSlide,

I guess that is my point as well....My EMG's never really showed anything, yet I was falling down before surgery and had considerable weakness. I also had an MRI to prove considerable degeneration....I had numbness and cramping yet very little showed on the EMG, so I put little faith into an EMG and think the tester can make it show whatever he/ she wants or does not want to show...I personally think my neurologists hated each other and wanted to contradict each other...so the results were completely opposite..It was idiotic and I was a pawn at their expense ...

My surgeon was telling me everything was looking good with my fusion as well too, until I kept saying I was not doing well...Then they admitted there was too much arcing on the x-rays and they wanted a CT Scan, but they cannot read the CT Scan. The radiologist said he could not read the films because of arcing, but my surgeon said he could and said I was fusing....so why do I still have pain?

Kathi49

04-02-2007, 04:34 PM

Gloria,

Ditto that! I don't know why my lumbar radiculopathy wasn't picked up on EMG??!! Not once but twice! And my Neurologist is one of the top docs in the city. So, it's not like she didn't know what she was doing. The neuropathy was picked up by a QSART and I STILL wonder if I truly have PN? But we are speaking of large fibers vs. the smaller C fibers. In any case, neither one gave me too much information. I'd much rather go with an MRI and symptoms than to have an EMG etc. OR, have my spinal anesthesiologist PM give me injections to determine where the pain generators are! It is easy enough to tell. If the injection works and the pain calms down and I have significant relief, there's the problem. :) Come to think of it, I am thinking of my past PM's and I don't recall one time where they told me to get an EMG. If anything, it was injections, CT Scans, and MRIs. It was the Neurologist that mentioned the EMG and QSART when I was having the "burning" sensations.

GJZH

04-02-2007, 04:44 PM

The surgeon I see for upper extremities can make my shoulders make a clunking sound. I also have arthritis in the bones in my shoulders. They talk about shaving down the bones when they fix the rotator cuff and then putting a stitch into the cuff. Both shoulders are arthritic.

Kathi49

04-02-2007, 04:52 PM

Gloria,

Ouch, ouch, ouch!!!

The OS took an xray and didn't see any arthritis but that doesn't mean it isn't there; probably hidden somewhere LOL! But I DO feel a "snapping" in the trapezius I guess...sort of near the right shoulder blade. It doesn't hurt..it just snaps like a rubber band. Now, this is weird, if I lift my legs as in walking upstairs is normally when I feel it. Go figure!!!

GJZH

04-02-2007, 09:35 PM

Kathi,

I read what you said about the anti-inflammatories and tinnitus...I woke up the other night and thought our fire alarm was going off in the house...As I laid there, I thought no it is the air going out of a balloon....I thought geez it is my ear....The tinnitus is just getting worse and worse...I do not know if I should just stop the pills or tolerate it. I did try to stop them once, but the tinnitus did not go away...I like you have tried many of them...Celebrex,Ectodolac, Mobic, Bextra, Vioxx, etc

Kathi49

04-02-2007, 10:17 PM

Gloria,

I have my list somewhere of all the ones I have tried. :) And they all seem to cause the tinnitus. I do not know why that is! Originally, I thought it might be coming from the C3/C4 before I had it fused. I was taking all kinds of meds at that time so it is hard to tell. But even now, I can take one 75mg of Voltaren and I will have the tinnitus again. I don't have it at all if I stay clear of the oral anti-inflammatories. And with our stomach issues I just don't know what to tell you. :(

lobelsteve

04-02-2007, 10:31 PM

I'd like to explain the EMG/NCV a little better. The test is only subjective in the acquisition of the amplitudes and latencies for nerve studies. There are fairly rigid criteria for the needle portion of the test.

EMG measures the electrical activity of a nerve and can define if a nerve is damaged. An MRI is only a picture and tells nothing about the function of the nerve.

EMG's are objective. THeir application to your symptoms is where art meets science. The tests are over utilized because reimbursement for diagnostic testing is quite good.

The test is purly meant as anextension of the history and physcial and is worthless without this information. For a doctor to look at you and send you to a tech for the study and not know how the test was done or what the EMG looked and sounded like compromises the sensiticity and specificity of the test. Dr's should only order the tests from other doctors they have good working relationships with as the report can stand on its own but the phone call to discuss the findings is much more important.

Of course if the test is showing carpal tunnel and you have weakness in your bicep, a depressed reflex at the elbow, and decreased sensation on the outside of your elbow- well it is nice that the test picked up carpal tunnel, but you are more likely to have a C5-6 radiculopathy. I find neruologists overread tests like a radiologist overreads a mammogram.

THe importance of the test needs to be weighed against the imaging and the clinical correlate- the patients symptoms and H&P. Otherwise- I'll agree the test becomes nearly useless. It is a shame that few doctors make the connecion between the EMG/NCV and the patients symptoms.

Kathi49

04-02-2007, 10:56 PM

Okay Steve,

You just said a "damaged" nerve. What about "compression" of a spinal nerve root? I just wonder why the lumbar radiculopathy was not picked up on. I know my NS, PM and Neuro are all on the same sheet of music so that isn't an issue. But as Kim stated how significant does it have to be before it is picked up on? Maybe I am not wording this correctly but I am speaking more of deficits than actual damage.

My lumbar/sacral EMG was fine as an example, but the pain, radiculopathy or PN was still there. So, really, I found both EMG's to useless in that regard.

And I am going to slightly disgree about the MRI. Mine were obvious; the arthritis compressing the nerve roots and encroachment on the spinal cord were plain as day. But I am strictly speaking of the cervical spine now. And yes, the symptoms (neurological deficits) correlated to the MRI.

And I wonder about the QSART as well. My neurologist used that to diagnose the PN but told me later it was very minute; almost didn't show up. So, maybe this is all simply radiculopathy. But again, I really wonder why the EMG didn't pick that up.

GJZH

04-03-2007, 12:14 AM

Kathi, Steve, and SlipnSlide,

My EMG's were done by Neurologists, not techs....I think the errors are in the measuring...and possibly needle placement or needle depth...I do not place any faith in the tests and would not allow them again unless it was done at a prestigious learning center...U of Penna, Hopkins, etc...My EMG's were done weeks apart and had very, very different results...and now another result was given after my surgery...which may be, but I still have numbness,pain, sciatica, and cramping in my legs...so I think there must be compression of nerves somewhere. If there is degeneration and hypertrophic changes of the facets than there is probably stenosis...causing my pain in the feet, legs and back...He did not have the MRI report to use as a guide though so he did not know what to look for...He asked me to bring it along with me to the next appointment...I do think though that he did not want to hurt me so maybe he was being especially careful...

Kathi49

04-03-2007, 08:25 AM

Same here Gloria; done by a Neurologist not a tech.

My lumbar issues are mainly with the facets; a Rhizotomy took care of SOME of the pain. I still have pain, cramping, etc., down the left leg. And there is a disc bulge at L4/L5. And, well, throw in some female problems and it is all just painful period. Oh, and you mentioned stenosis. That is one thing I DON'T have in the lumbar; I have already asked about it when I asked about the XStop.

I think you are right though. I know my Neuro seemed to be careful when placing the needles and/or the electrodes both. And my legs flopped like fish! It didn't really hurt at all...it was just weird to see my legs do that. And she said, "If only ALL my patients had nerves as good as yours." I was like...WHAT???!!! What was really strange is after she had electrocuted me so to speak, my left leg actually felt better! :) I still want to know why the radiculopathy was not picked up on though.

Anyway, what is the test called where they actually place those much longer needles into you and then have you flex? I have never had that done but my husband has. And he said that hurt pretty darn bad. The needles my Neuro used were more like acupuncture needles if I had to guess. But I didn't look they just felt like it because I have had acupuncture done before.

Oh, and one more thing about EMGs. My sister was diagnosed with carpal tunnel. But the first thing the Hand Surgeon did was to order an MRI of her neck. When that came back okay, they did the EMGs. When they did the first one, NOTHING showed up. So, they thought something was wrong with the machine. They went and got another one...same thing! Her arms were in horrible shape and like rocks according to them. And even prior to all of that she went into PT. The PT told her that her arms were so terribly bad there was no way they could fix them with PT alone. Anyway, she ended up with carpal tunnel surgery and is much better but not 100% yet. I asked her why she hadn't gone a long time ago. And what she told me is that it never bothered her, never really knew how bad her arms were until it just hit out of the blue and was severely painful.

slipnslide

04-03-2007, 10:07 AM

Not the same here:D ...lol....Both of my EMG/NCS's were done by the same Physiatrist in my OSS'S group. The first one was done months before my surgery, and the second was after the ACDF and it showed things to have slightly declined since the first one.

slipnslide

04-03-2007, 10:25 AM

I'd like to explain the EMG/NCV a little better. The test is only subjective in the acquisition of the amplitudes and latencies for nerve studies. There are fairly rigid criteria for the needle portion of the test.

EMG measures the electrical activity of a nerve and can define if a nerve is damaged. An MRI is only a picture and tells nothing about the function of the nerve. How much of a latency has to show for the nerve to be considered damaged? And, even if a nerve does show damage, can it repair itself over time and that is how different results are recorded from one EMG to another?

EMG's are objective. THeir application to your symptoms is where art meets science. The tests are over utilized because reimbursement for diagnostic testing is quite good. So it's just a money maker for some doctors!?!?!....I'm really not surprised!;)

Of course if the test is showing carpal tunnel and you have weakness in your bicep, a depressed reflex at the elbow, and decreased sensation on the outside of your elbow- well it is nice that the test picked up carpal tunnel, but you are more likely to have a C5-6 radiculopathy. I find neruologists overread tests like a radiologist overreads a mammogram.
How does one know if they actually do have weakness in the bicep, or if they just feel weak? What would show bicep weakness on an EMG/NCS?

Sorry for asking so many questions, I'm just trying to understand.:o :)

Kira

04-03-2007, 05:41 PM

I'm with Steve on this one... not only as an MD but also as a pt who has had 4 EMGs.

EMGs give you objective data (waveforms, etc), but that data has to be interpreted in the context of the patient.

It is not like a blood test, where you will get back one number and it is clear whether or not that number is abnormal (like if my calcium comes back at 7.3, and the low end of normal is 8.2, then my calcium is clearly low). It is more like imaging studies (X-rays, MRIs, etc), where you will get an objective picture of what is going on, but that picture still needs to be interpreted by human beings (docs). Just like with imaging studies, different docs will interpret the EMGs slightly differently. Have you ever had one person say they saw something on your MRI, but then the next person saw something completely different? It's like that.

Kathi49

04-03-2007, 06:24 PM

Thanks Kira,

Don't you think too that maybe certain meds can skew the results? I only ask that now because a friend of mine just called; must be the week for neck, shoulder, arm pain. :( She just had nerve conduction test done today; she didn't say it if was an EMG or not darn it. But she did say the Neurologist asked her if she was taking Neurontin, Lyrica, etc. When she said no. The Neuro said, good because it could skew the results. I mean I don't really know because I have never heard that. But I suppose it is possible. And again, she didn't say SPECIFCALLY what TYPE of test. Only that the Neuro found exactly where the nerve was pinched.

And I am still wondering after two EMG's why my Radiculopathy was not picked up on? I will have to ask my Neurologist about this.

debhun

04-03-2007, 07:14 PM

GJZH

04-03-2007, 07:40 PM

I guess we could beat this topic to death, but I just do not believe this to be an accurate test....I do not have any faith in the EMG because my surgeons do not...My surgeons happen to be from the best hospitals in the country. The only reason my lumbar surgeon ordered it last year before my big lumbar surgery was for insurance purposes, but he too told me the test is unreliable. These are top docs...the best in the country....I only go to the best surgeons..so you are not going to sway my opinion on this..An MRI is an actual picture of my spine. The EMG is a test where they measure with a measuring tape and a pen and then the examiner places needles into the skin.. If the needles are not placed at just the right place or the same place as the last examiner then the results are skewed..It is not a reliable test. I will simply refuse another, if one is ordered. I was told I have carpel tunnel in my left hand...I show no signs of it...I do have numbness in my pinky and the fingers next to it...but that is cervical spine, not carpel tunnel.

Kathi49

04-03-2007, 08:37 PM

Gloria,

Come to think of it neither my NS nor my PM ever ordered an EMG. The only reason I had the two EMGs done were both for the lumbar and my Neurologist offered them up. And I consider my NS to be top notch as well. You would think if they thought an EMG was important they would have ordered several through the years, but they never have. I do remember telling my PM a couple of years ago that I was about to be tested for PN. But he said, "They probably won't find a thing." And sure enough...he was right!

And, again, my MRI's have always shown what was going on...and pointed out to me. It is just a shame that the first group of PM's I was going to looked off of the MRI REPORT and NOT the actual MRI because the PM I have now saw the problem in seconds with the actual films!

Anyway, yes, we could beat this topic to death. But I will just say in my experience they have not been reliable at least not in my opinion.

curiousforever

04-03-2007, 09:50 PM

I guess we could beat this topic to death, but I just do not believe this to be an accurate test..I think it is barbaric...I do not have any faith in the EMG because my surgeons do not...My surgeons happen to be from the best hospitals in the country. The only reason my lumbar surgeon ordered it last year before my big lumbar surgery was for insurance purposes, but he too told me the test is unreliable. These are top docs...the best in the country....I only go to the best surgeons..so you are not going to sway my opinion on this..An MRI is an actual picture of my spine. The EMG is a test where they measure with a measuring tape and a pen and then the examiner places needles into the skin.. If the needles are not placed at just the right place or the same place as the last examiner then the results are skewed..It is not a reliable test. I will simply refuse another, if one is ordered. I was told I have carpel tunnel in my left hand...I show no signs of it...I do have numbness in my pinky and the fingers next to it...but that is cervical spine, not carpel tunnel.

I agree. Besides that, one doc couldn't find a nerve in my arm. I guess the nerve migrated somewhere it shouldn't be....

Kira

04-03-2007, 10:06 PM

GJZH,

That's fine, and you can have your own opinion. I think we may be saying a version of the same thing... that it is only a good test if the person who is doing it and interpreting it is good at it. And that it has to be read in the context of what is going on with the patient.

I only go to doctors I trust are good, too :)

I know it isn't an actual picture like an MRI... but I was making a comparison to the way MRIs and such are interpreted.

Believe me, I know how EMGs are done... remember that I said I have had 4 of them?

Kira

04-03-2007, 10:09 PM

And, again, my MRI's have always shown what was going on...and pointed out to me. It is just a shame that the first group of PM's I was going to looked off of the MRI REPORT and NOT the actual MRI because the PM I have now saw the problem in seconds with the actual films!

This is similar to what I was saying about the EMGs. The person who is reading/interpreting it has to know what they're doing, or else it may get misinterpreted. So... if the person who does the test writes it up wrong in the report, then yeah, it's going to be a useless test. But in the hands of someone who knows what they are doing (like the PM you had look at your films), an EMG can be really useful. But you have to 1) know how to do the test correctly and 2) know what you're looking for. Otherwise it is a crapshoot, just like anything else.

GJZH

04-03-2007, 11:09 PM

Kira,

I have had (5) EMG's...Three of the lumbar and two of the upper extremities...and none of them read the same....My MRI's read just about the same with a little more degeneration depending on the length of time in between. The only time my MRI has changed is after surgery and the radiologist notes the surgery. I will admit I probably have not had the greatest doctors doing the EMG's, but there should be some similarities about the test and there wasn't. I find it odd too that the surgeons tell us that they are not going to find anything wrong....when we are experiencing numbness, cramping, burning, and tingling...something should show up on these tests...I think too that the EMG was developed in Transylvania...Now what does that tell you? My Romanian Neurologist told me that ....I was not surprised since the test is just so dog gone painful...especially the upper extremities...I have had the test done too where I had no pain and then the Romanian Neurologist had me crying from the pain and she was telling me I could curse if I wanted to...I did not want to curse...I wanted her to stop. The other two Neurologists that did the test did not cause me to cry, so why was it so different with her? She did by the way find problems and the other two did not...so maybe you really have to turn up the juice to get some results...:eek: Just kidding! I thought I would make us laugh a little!:D This Neurologist told me she did not want to be a doctor, but was forced...and I wondered if that is why she made me cry...She was pleasant enough, but geez was that test painful....OUCH!:

Bobbi

04-03-2007, 11:13 PM

Thank you, Kira :).

I've had two EMGs (C-spine & L-spine) - and each was done in tandem with NCV (along with a plethora of x-rays, MRIs, and CTs); also tested were my arms, hands, legs and feet.

BTW: It was my neurosurgeon who referred me for the EMG/NCV of my L-spine - and he ain't chopped liver. He's the best - in my opinion.

Editing to also say: Though the testing was far from pleasant, it also wasn't the worst I've felt. Bone scans, by far, feel like torture - to my body. But that's as subjective as saying an EMG is "barbaric."

I thought this site was interesting, IMHO, and it's not by anyone I've "seen" as a patient (or anyone, whom I know, has seen):

http://www.cordingleyneurology.com/emg.html

As others have said, more pointed than I may: An EMG is but one tool that doctors may draw upon for a more complete understanding and making a differential diagnosis.

Kathi49

04-04-2007, 07:08 AM

Well, I guess we all have different viewpoints and opinions and that is okay. :) I suppose we could debate the pros and cons forever.

I am laughing at the "Transylvania" remark...the EMGs and what not can be downright painful (heard from others) or simply unpleasant (experienced by me). And, well, my Neurologist is tops; of course my NS, nurses and a whole host of other docs have said the same regarding her. My point is...it's not like she didn't know what she was doing in regards to the EMGs. I know when in the ER they always ask me who my Neurologist is. When I tell them, it is always, "...she's the best!"

Bobbi, could you explain about the bone scan? I am honestly very curious. I had a bone density scan and it was not painful at all. But maybe you are speaking of something else. And I ask since I have had a hysterectomy and have had 2 density scans over 7 years. And I am certain I will have more coming.

Anyway, maybe part of the troubles are the nature of our illnesses or disorders. I was sitting here thinking last night do I have a form of CIDP? Do I have polyneuropathies? I mean all kinds of things go through my mind. What I really mean is for instance, small fiber PN is difficult to test for. Of course the EMG did NOT pick up on that at all. It is or was the "C" fibers giving me fits. So, of course a more sensitive test was done; QSART along with all kinds of tests for toxins, heavy metals, vitamin deficiencies...you name it. And all negative! All I know is that she said if I were to worsen, to get back to her. And she DID say, "The small fiber PN almost did NOT show up; it was very minute." But these aches and pains are all over the place and I have been told I have inflammation everywhere from more than one doctor. Even the Rheumatologist ran his tests and again...negative. And no, I don't have all the trigger points for FMS.

And then I had to go to the Podiatrist to check on the orthotics one day. I didn't say a word about all of my conditions and after testing my feet, he asked, "Do you have problems with your lumbar?" Well, yep!!! Then he did some kind of sensory test and came back with radiculopathy!

So, it is no wonder we or I should say I, get confused. One minute it is PN and the next it is Radiculopathy. Again, even though my Neurologist is great and all of that. I still maintain the EMG's are not reliable and don't pick up on everything. I do have a call into my Neurologist to talk to her about some other things. It will be interesting if she mentions having an EMG on my arms. I think if she does, I will just have her do it since I have never had one done on my arms. I mean if she recommends it, I will go forth. But I can lay down $100 that nothing will be found. I WOULD like her to do some more blood tests since the PN ordeal was a couple of years ago.

And once again, when I read what the Neuros write on the Cleveland Clinic site, I see over and over again where they say EMG's are subjective even though they do them. So, I tend to lean more towards what they say as well as my own Neuro simply because that is what they do!

UGH, I almost feel like asking for an IVIG LOL! Yes, I know...not a good thing to insist upon. I saw my niece go through that with GBS. But sometimes I wonder. And maybe it is just from having so many surgeries that my body took a hit...who knows.

lobelsteve

04-04-2007, 09:45 AM

Kathi49

04-04-2007, 11:08 AM

As taken from SpineHealth.com in regards to an L5 herniated disc causing compression:

"A CT scan can provide an image of the vertrebral disc if it is sizeable, but does not give quite as DETAILED an image of an MRI. Likewise, an EMG study (electromyography) of the leg can indicate if a muscle group is affected, but the test is NON-SPECIFIC and typically does NOT detect herniated discs. The BEST test to evaluate nerve compression is an MRI scan."

So, there is the answer to my original question which was probably why the lumbar radiculopathy was not picked up on. And also answers why on the MRI it was plain as day (L4/L5 disc bulge and facet arthritis). AND probably why my NS never even recommended an EMG prior to the cervical fusions. And why my PM didn't recommend one for the lumbar. It was all in plain sight on the MRI's.

Never said it wasn't a useful diagnostic tool...depending on WHAT the problem is. Like I said in another post, my sister had carpal tunnel. But the very FIRST thing they did was to rule out anything going on in her cervical spine with an MRI and THEN did the EMG right after. I still maintain the results can be variable and this was per my Neurologist as well!

I don't have a problem using any diagnostic tool including injections. But an EMG is only a small part of the puzzle.

Anyway, there are all kinds of websites that lists the pros and cons. So, for now I will stick with what the docs recommend and if my Neurologist recommends one, then I will do as she suggests. So, let's just say she finds a slowing so to speak or something abnormal and let's say she believes it is coming from my cervical spine. Well, then, it is right back to the spine PM to determine exactly which nerve root it is because my Neurologist does not work on or with the spine. This is where my frustration comes in. An EMG may be diagnostic at that point. But it was one extra step that could have been avoided in that the spinal PM could have given me an injection and truly determined what specific nerve root it was. On the other hand, if it is carpal tunnel then it would be off to the Hand Surgeon.

My whole point is...it MAY just be one more step that was not needed to begin with and it really depends on WHAT conditions you are looking for.

jena1225

04-04-2007, 11:39 AM

Kathi - Nothing to do with "EMG's", but my MRI's picked up my bulge, yet a simple X-ray picked up my tear, DDD and arthritus. Well, they did not TELL me about the others after my MRI, so either they missed them, or the MRI did not pick them up. What are your thoughts on that?

Kathi49

04-04-2007, 12:08 PM

Jena,

I am not sure what you mean by "others". Do you mean the arthritis and such? I am not sure why they would miss them. I asked that once myself when my first PMs either missed it or just didn't tell me. All they told me was that I would eventually need a fusion and proceeded with injections and meds. Yet, when I got those SAME films in hand and took them to my newer group, the PM there caught it right away and pointed it out to me. I asked him then, why in the heck didn't the other group see that or even tell me???!! And he asked me if they ever had my films in front of them. I told him no because I never saw them with my films they always had the typed report. (Heck, this was in the very early stages and I was clueless). Then he said they were probably reading the MRI Report and Radiologists can't always detect the subtleties. This very same thing happened this last year with another doctor totally unrelated to spinal issues and the Radiologist reported something wrong. Yet the films showed otherwise to my benefit. So, really, I don't know what to tell you. At least the xray picked up on it. :) I don't know maybe it was the MRI film itself, the doctor reading it, the radiologist reporting it...hard to say.

jena1225

04-04-2007, 12:35 PM

Yes Kathi, I was talking about the DDD, tear, etc... sorry. That does make sense, as my PCP was the one who informed me of the bulge only. Yet she was only reading the report.

But I did bring those films to the OS, and when they told me about all the other problems, I honestly cannot say whether she got that info only from the x-rays or if she also saw them in the films :confused: Just now thought about that.

I am going to dig the report out again because I do remember it saying a couple of things that caught my attention, yet noone else's. Like hypertrophy and something else... Thanks!

Bobbi

04-04-2007, 12:57 PM

Kathi,

The following links explain what a bone scan is:

Site one (http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/23953.html) (and not by my insurance ;)).

Site two (http://arthritisinsight.com/medical/tests/bonescan.html).

Even before ending up with a (wheel)chair, I couldn't walk following the bone scans, and an imaging center tech wheeled me to my friend's car. I'd prefer a CT any day; it's faster and, in my opinion, seems to offer way more detailed imaging.

The bone density (DEXA) scan was also painful for me. After having my legs elevated on the "block," it was a killer on my spine and legs. Though the technician tried assuring that I was too young to have osteoporosis, I do have it - along with my constant companion: Ankylosing Spondylitis (AS).

Of all the tests available to doctors, the one I wish that my rheumatologist had ordered - but didn't - several years ago is the HLA-B27 test. It was Dr. W. (whom posts at the SD forum) who told me about the test and suggested it. I went to my PM doc, and he ordered the test; not positive re: the results, (though my body was evidencing tell-tale or hallmark indicators), he ordered a repeat on the test. Both times? Positive. My PCP then asked the lab to go back and run more tests - to rule out any possibility of a false positive.

I thought the third test was over-kill, but... it assured my doctors of the diagnosis before making it "formal." What may not seem essential to me panned out to be an important aspect of the diagnostic process, and ended up giving my physicians leverage when confronting my insurance company over its coverage of, i.e., medications my doctors prescribe and DME.

oh_snap

04-04-2007, 12:59 PM

meaning...to see so many different "opinions" about electrodiagnostic testing.

My own: I would never act upon or take a surgical option based soley on what was found on MRI or other film study (unless I was perhaps paralysed or about to become paralysed).

The benefit of emg/ncv is that it may help correlate film diagnostics, patient symptoms, and physician findings. There are other kinds of electrodiagnostics like SSEP (Somatosensory Evoked Potential) which can also help the physician zero in on problems going on in the spine. http://www.allaboutbackpain.com/html/spine_diagnostics/spine_diagnostics_ssep.html

I have, over the years had a total of (7) EMG/NCV diagnostics as well as (2) SSEPs, one of which was done before my last spinal reconstruction/cord decompression. The information they supplied to the treating doc(s) was valuable, and their results have all been consistent (and progressive).

There is an "interpretation" factor, but, in my own experience, if nerve function is gone (the brachial plexus/lower trunk problem), there's not much to interpret. More subtle or developing problems can also be tracked with follow up studies (that was also good in my case). In the case of the spinal radiculopathy, these studies help to verify that the levels we thought were causing trouble, were indeed involved.

Now, I do agree that sometimes an emg/ncv isn't going to or doesn't pick up some kinds of nerve irritation/compression, but that may also be due to the depth of the nerve.

Anyways, I have had both a long time positive experience in results via electrodiagnostic studies, and probably one very frustrating experience when dealing with post-hysto sciatic like symptoms. A nerve study of the lower spine turned up nothing, when in actuality, a very large (off the scale) inguinal hernia cut off the nerves in its vicinity (thus the sciatic like symptoms). It only looked at the peripheral nerves, and I had a clean bill of health. I couldn't sit, walk, drive a car. I endured seven months of hell, and no answers. Everything (symptoms) pointed to a lumbar problem, but the data didn't support it. After the hernia (found on ultrasound) was fixed, the symptoms, most of them resolved, although I still have numbess in half of me "private" area, down the inner thigh, and part of the lower abdomen as well as some weakness in the hip. I'll take numb over pain any day though.

So, electrodiagnostic testing, IMHO, can help tie a case together, track progressive nerve problems, or be no good at all, depending on what is at play.

The human body is idiotic that way it tries to tell us what is wrong. I am a pretty good "problem solver" and I can say with complete certainty that unless I have a bone sticking out, or am utterly dead, I still have trouble sorting out what the hell is going on. I have to admit that I have very overlapping problems, and am definitely a doctors' diagnostic nightmare.

best of luck to all...