All posts by Legacy Neurosurgery

Asymptomatic Cervical Stenosis

Your condition involves narrowing of the cervical spinal canal discovered on imaging that appears to have no current symptoms nor findings on exam and therefore surgery is not indicated at this point even though there is pressure to some degree on your spinal cord.  Neck pain without other red flag symptoms does not warrant surgical recommendations. 

 

            Normal Canal           Cervical Stenosis


 

 

 

 

Why one person with cervical spinal stenosis is having major symptoms and another with the same MRI findings has none is unknown but very commonly seen.


In the normal spinal canal the spinal cord floats freely in the cerebrospinal fluid, CSF or spinal fluid, which serves as a protective shock absorber.  In patients with Cervical Spinal Stenosis the amount of CSF around the spinal cord is markedly diminished reducing the ability to protect the spinal cord from normal impacts or stronger forces.   This increases the risk of injury to the spinal cord from various normally tolerated forces.  You have seen this in football games when a player gets a sudden hard impact to the head and neck and suddenly goes paralyzed.   Most of these patients had this impact injury develop due to having such a blow in the setting of previously asymptomatic cervical spinal stenosis that was likely present since birth but never known to exist until the injury.   Fortunately the NCAA and NFL have focused on these “targeting” incidents in recent years. 

 

Most of the time if the patient has no symptoms neurosurgeons will suggest non surgical follow up observation only with recommendations to avoid high risk activities unless:

  • The cervical spinal stenosis is particularly severe in degree
  • There is associated with spinal cord edema
  • The patient’s career has unavoidable risk of high impact injuries
  • The patient has no symptoms yet does have positive findings on   neurological examination of spinal cord dysfunction
  • The cervical spinal stenosis is progressively worsening on follow up MRI scans

 

   Many patients ask why do we not go ahead and do surgery if there is cervical spinal stenosis even without symptoms or exam findings?

The answer:

  • The risk of surgery for cervical spinal stenosis must be weighed against the risk of observation. In most patients who are without symptoms the risk benefit ratio favors observation only.
  • Most people who have asymptomatic cervical spinal stenosis do not ever develop the need for surgery by never becoming symptomatic nor showing exam findings of spinal cord dysfunction nor significant MRI worsening during follow up over time.
  • Most asymptomatic patients that ultimately become symptomatic and need surgery for cervical spinal stenosis will develop warning or red flag minor symptoms early enough that they usually have no long term side effects from not having surgery done prior to symptoms.
  • Most patients with asymptomatic cervical spinal stenosis do not suddenly go paralyzed from their condition, unless there is a major impact injury that would likely injure even a patient without cervical spinal stenosis, but rather develop slowly progressive red flag symptoms
  • Medical studies on asymptomatic cervical spinal stenosis consistently support the role of observation vs prophylactic surgery.

 

When non-surgical observation only is the plan it is recommended that you avoid:

  • Sports and non sports axial load injuries
  • High-energy impact sports such as skydiving, downhill skiing, cliff climbing, football etc
  • Falls
  • Car, bike and motorcycle accidents whenever possible
  • Forceful Manipulation of the head and neck including physical therapist or chiropractic neck manipulation

 

The above is recommended in order to mitigate the increased risk of spinal cord injury in patients with cervical stenosis as compared to someone with a normal spinal canal.    Again people without cervical spinal stenosis have risks of spinal cord injury and paralysis with the above but those with cervical spinal stenosis have a statically increased risk of injury with the same force applied as compared to a person with a normal spinal canal.  Nevertheless, the same applies to breaking a leg or an arm from a fall in patients with osteoporosis versus normal bone.  We would not recommend putting casts on all the limbs of osteoporotic patients to prevent fractures from a fall!

 

Typically if non surgical treatment is the plan you will be followed up after a period of time with a clinical follow up visit +/- a follow up MRI at variable intervals for years to come and be advised to contact your neurosurgeon sooner if you develop any concerning red flag symptoms listed below.

 

 

 

 

 

 

 

 

 

 

Once patients develop symptoms and/or findings on exam then the condition is called “cervical myelopathy”.    Typically the MRI will show abnormal signal changes like the images above due to edema of the spinal cord in patients that are symptomatic from the cervical spinal stenosis.    This term is used to describe dysfunction of the spinal cord from many causes but in this case it is due to cervical spinal stenosis and the damage from the pressure on the actual spinal cord. 

MANY PATIENTS WITH SYMPTOMATIC CERVICAL SPINAL STENOSIS, MYELOPATHY, WILL HAVE LITTLE TO NO NECK OR ARM PAIN BUT RATHER ONE OR MORE OF THE NON PAINFUL RED FLAGS BELOW.

 

 Red flag symptoms to be aware of that might be indicative of cervical stenosis becoming symptomatic include any of the following:

 

  • Development of numbness and tingling in the arms and/or hands
  • Development of electric shock sensations that run down the spine or through the extremities with such activities as movement of the neck or coughing, sneezing or bowel movements etc. (Lhermitte’s phenomenon)
  • Development of pain running from the neck down one arm of the other or both.
  • Development of clumsiness or loss of dexterity with loss of fine motor movement of the fingers and of the hands. This may evidenced as problems buttoning ones shirt or developing problems writing with a pen or clumsiness typing with a keyboard.
  • Development of unsteadiness and clumsiness of gait while walking. This may present as stumbling when walking for no apparent reason. This is particularly noticeable when present during attempts to perform field sobriety testing, tandem gait testing or walking placing one foot immediately in front of the other while trying to walk a straight line
  • Development of significant weakness of the arms and hands that may present with inability and to normally use one’s hands and arms in the normal course of work and or play activities
  • Development of clumsiness and dysfunction and stiffness of the muscles of the upper or lower extremities (spasticity)
  • Development of urinary &/or bowel incontinence particularly associated with symptoms above is a typically a very late symptom. Isolated urinary problems would be uncommon due to cervical spinal stenosis and more likely related to urological/GI disorders. 

 

If symptoms develop or MRI findings worsen or findings on neurological exam appear then surgery will likely be needed. 

When needed surgery can be either an anterior cervical decompression and fusion surgery or a posterior cervical decompression with or without fusion or both depending on your anatomy.    

 

Hopefully your cervical spinal stenosis will never need treatment but please carefully read the warnings above and be mindful of the red flag symptoms discussed.  Please report to your neurosurgeon development of any concerning symptoms when they develop.  Do not wait for the follow up visit if these symptoms develop sooner.   Regardless, keep your scheduled follow up plan even if you have zero symptoms and are pain free!    

Any questions or concerns visit legacyneuro.com

Scott Schlesinger MD

Legacy Spine and Neurological Specialists

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Selective Nerve Root Block

WHAT IS A SELECTIVE NERVE ROOT BLOCK?

A selective nerve root block (SNRB) is a test performed to determine if a specific spinal nerve is the source of your arm or leg or radiating chest pain. Often patients with spine issues have multilevel MRI abnormalities often close together.   If we treat your problem with conservative care and it fails to respond, then surgery for your radiating pain may be an option. However, due to the above issue identifying which abnormality on the MRI is the cause of the actual radiating pain can be a challenge.   In most cases pain that radiates in a radicular fashion as above is caused by just one nerve root regardless of the number of abnormalities on the MRI. Therefore, we are trying, like an electrician would do in your house to find the short circuit, to isolate the responsible nerve that is the source of the pain.

A SNRB is performed to diagnose the specific nerve root of origin of your cervical (neck), thoracic (mid back) or lumbar (low back) radiculopathy (pain in the distribution of a particular nerve root off the spine due to compression, irritation and/or inflammation of a nerve root). A selective nerve root block is an injection of a local anesthetic that lasts hours to a few days very close to a specific nerve root. Along the spine, there are several exit “holes” or “foramina” through which nerve roots emerge. If these foramina are partially closed due to either bony overgrowth from degenerative changes, bulging disks, misalignment of vertebrae, etc., the nerve root can also be pinched. This typically causes a shooting or radiating pain along that nerve root. In a selective nerve root block, a small needle is placed in the foramen alongside the nerve root, and the medication is injected. The goal of a diagnostic injection is twofold. 1. We want to see if the needle adjacent to the nerve creates radiating pain that closely replicates your typical radiating pain for which you are seeking relief. 2. To see if, while the nerve that we injected adjacent to is “asleep” or effectively blocked by the local anesthetic, your normal radiating pain is gone or improved during any period of time while the block is effective. Your feedback helps to identify the cause of radiating pain.

 

WHY IS IT DONE?

When the nerves in the foramina are irritated or pinched, the resulting inflammation can cause pain, numbness, or tingling. If the local anesthetic is acting on the correct nerve that is causing the pain, then the temporary resolution of pain will provide diagnostic information to your doctor.

 

 

 

HOW LONG DOES IT TAKE TO DO?

The actual injection takes only a few minutes. Please allow about an hour for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.

WHAT MEDICINES ARE INJECTED?

The injection consists of local anesthetic that can last for a few hours to days (e.g., bupivacaine).

 

WILL IT HURT?

All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. The actual placement of the needle is not painful. However, keep in mind the nerve root is pinched and irritated. If the needle tip brushes against the nerve during placement, you may feel a “zing” down the nerve root, similar to striking your “funny bone”. During the injection of the local anesthetic, there may be a temporary shooting pain along the nerve root’s normal distribution until the local anesthetic sets in, usually in about 15 seconds. These sensations are normal and if they are very similar or identical to the pain that you normally experience then this information is very helpful in confirming the diagnosis of the “pain generator” in your case. It is very important that you let the doctor know doing the injection if you feel the typical shooting pain or not as the needle is nearing your nerve!   If the radiating pain you feel during the procedure is not in the normal distribution that you feel this is helpful information as well.   If you do not feel any radiating pain, then the needle may not have gotten close enough to the nerve. The medicine could still reach the nerve through diffusion so the block may still give diagnostic information, but we prefer to get the needle as close to a nerve as possible without injuring the nerve.

 

 

HOW IS IT DONE?

It is typically done with you lying on your stomach for thoracic or lumbar and on your back for cervical blocks. Your vital signs will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin on the back or neck is cleansed with antiseptic solution, and then the procedure is performed.

 

 

 

WHAT SHOULD I EXPECT AFTER THE INJECTION?

Immediately after the injection, you may feel your legs or arms, along that specific nerve root, becoming heavy, numb or weak. You may notice that your pain may be gone or considerably less. This is due to the effect of the local anesthetic. Your pain may return, and you may have some soreness at the injection site for a day or so. It is very important to be careful for several hours afterwards to avoid falling due to weakness if done on the lumbar or thoracic spine or dropping or mishandling things with your hand or arm if done on the cervical spine. This should resolve with the passage of hours but if it persists beyond 8 or so hours please notify our team.

 

HOW LONG DOES IT LAST?

The immediate effect is from the local anesthetic injected. This wears off at varying time intervals. It may last only 30 minutes, or it may last up to several weeks or months. The length of time that you experience relief is not as important as how much relief you experienced. Please document carefully even hourly for the first day or so.   If lucky some even get long term relief of the pain from the nerve block. Of course, that would not only be of diagnostic but therapeutic benefit!

Risks vs Benefits:

Like all procedures or tests there are risks and benefits. The benefit as above is to localize a potential target for surgery when patients have multiple possible causes. The goal here is limiting surgery to the least invasive option possible by treating only the cause of the pain not all the abnormalities on an MRI.   The risks include nerve injury, bleeding, post procedure increased pain, allergic reactions, spinal headache, infection and very rarely major neurological complications including the very rare risk of paralysis. Complications are very unlikely and most if they occur can be resolved with treatment. Nevertheless, all procedures and tests have risks.

Conclusion

Selective nerve root blocks are important to help identify the nerve root of origin of your radiating nerve pain. Although the procedure may be uncomfortable, our staff is dedicated to making you as comfortable as possible during the procedure.

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Seizure First Aid

Do I call 911?

Seizures do not usually require emergency medical attention. Only call 911 if one or more of these are true:

  • The person has never had a seizure before.
  • The person has difficulty breathing or waking after the seizure.
  • The seizure lasts longer than 5 minutes.
  • The person has another seizure soon after the first one.
  • The person is hurt during the seizure.
  • The seizure happens in water.
  • The person has a health condition like diabetes, heart disease, or is pregnant.

These are general steps to help someone who is having any type seizure:

  • Stay with the person until the seizure ends and he or she is fully awake. After it ends, help the person sit in a safe place. Once they are alert and able to communicate, tell them what happened in very simple terms.
  • Comfort the person and speak calmly.
  • Check to see if the person is wearing a medical bracelet or other emergency information.
  • Keep yourself and other people calm.
  • Offer to call a taxi or another person to make sure the person gets home safely.

First aid for generalized tonic-clonic (grand mal) seizures

When most people think of a seizure, they think of a generalized tonic-clonic seizure, also called a grand mal seizure. In this type of seizure, the person may cry out, fall, shake or jerk, and become unaware of what’s going on around them.

Here are things you can do to help someone who is having this type of seizure:

  • Ease the person to the floor.
  • Turn the person gently onto one side. This will help the person breathe.
  • Clear the area around the person of anything hard or sharp. This can prevent injury.
  • Put something soft and flat, like a folded jacket, under his or her head.
  • Remove eyeglasses.
  • Loosen ties or anything around the neck that may make it hard to breathe.
  • Time the seizure. Call 911 if the seizure lasts longer than 5 minutes.

Stop!

Knowing what NOT to do is important for keeping a person safe during or after a seizure.

stop sign with hand

Never do any of the following things:

  • Do not hold the person down or try to stop his or her movements.
  • Do not put anything in the person’s mouth. This can injure teeth or the jaw. A person having a seizure cannot swallow his or her tongue.
  • Do not try to give mouth-to-mouth breaths (like CPR). People usually start breathing again on their own after a seizure.
  • Do not offer the person water or food until he or she is fully alert.
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Too Much, Too Little, Just Right

All too often a patient will come into clinic that has been very diligent with a fitness regime for years but despite preemptive health measures the patient will develop low back pain. It is described as a deep ache that is worse in the morning and/or night begins to interfere with the normal activities of his/her day. Seems like such a waste of time to put all the effort into staying fit then still having pain, right?

Often there is no specific injury and very little diagnostic grounds other than “facet hypertrophy” (described normally as arthritis in the low back) to support the claim of this pain. Chances are with most of these patients, arthritis did not develop in the last week or month. It is an accumulation of years of repetitive weightbearing and compressive forces to the spine that have brought about this change. The question remains, what can be done to improve this pain when you already believed you were doing all the right things to stay healthy?

In terms of treatment with patients that present with the history that I have outlined above; moderation becomes a recurrent phrase of emphasis. Other useful tools are variation and observation. Mixing up the cardio routine with a variation of biking (indoor or outdoor), swimming, and walking. If you have a gym routine for lifting weights or resistance exercises, try mixing things up by doing body weight activities or group aerobics. It may also be a nice change of pace to do a beginner’s class of yoga or Pilates. Moderation and observation are key parts to avoiding overuse injuries that cause setbacks.

There is current research to suggest that indeed there is a “happy medium” to activity. Too much activity can have as much of a negative impact on the body as doing nothing at all. Take home points:

  1. Use Variation in exercise choice
  2. Practice moderation with strenuous activities
  3. Observe how your body responds to activity and modify if necessary

If you are having setbacks due to low back/neck pain from too much activity or you find yourself sedentary and have no idea where to start, give us a call at 501-661-0077 for a consultation and evaluation at Legacy Spine and Neurological Specialists so that we can get you Back to Life!

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Happy Veteran’s Day

Thank YOU for all that you do for America and our citizens.

We are one of the only neurospine clinics that accepts Tricare and Triwest. Let us return the favor, in helping you, with a better life.

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How the Brain Shapes Pain and Links Ouch with Emotion

The ouch part of pain begins when something—heat, certain chemicals or a mechanical force—activates special nerve endings called nociceptors. Once they are activated, they trigger a cascade of events with a representation of that signal going through your nerves and into your spinal cord and then to the brain.  And that’s when things get really complex.

Pain signals interact with many different brain areas, including those involved in physical sensation, thinking and emotion.  That leads to all the complexities of what we feel associated that initial hurt.

Having an emotional component linked to the sensory experience is a great memory enhancer. If you touch a hot stove your brain remembers, and you will never do that again.

The link between pain and emotion is a good thing, but sometimes it can also be destructive. Mental health disorders amplify pain. They engage regions of the brain that associate with pain processing, and they can also facilitate rumination and fearful focus on the pain. And when pain doesn’t go away it can cause disabling changes in the brain.  Pain is a danger signal, but once pain becomes chronic these pain signals no longer serve a useful purpose. Over time, these signals can lead to problems like depression, anxiety and stress, but it’s often possible to break that cycle by learning techniques that help pain patients gain some control of the way their brains are processing pain signals. For example, a state of relaxation is an antidote to the hard-wired pain responses that are automatically triggered by the experience of pain.

For some patient techniques like these can provide an alternative to pain drugs, including opioids. And for pain patients who rely on medications, psychological therapies can often help the drugs work better.

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Peripheral Neuropathy

Peripheral neuropathy is a disorder caused from damage to the endings of the nerves. Patients frequently report burning, itching, or shooting pain that often begins in the feet and gradually progresses to other areas. Peripheral neuropathy is a symptom of an underlying disease or process and tested to find out the underlying cause. EMG and nerve conduction testing performed by a trained physician can help rule out other causes of these symptoms and help plan for the best course of treatment. Our neurologists are trained in advanced EMG and nerve conduction testing and are well-versed in diagnosing and managing peripheral neuropathy.

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Eat to live….or live to Eat?

“What can I do to reduce my chance of Alzheimer’s?”  As a neurologist, this is one of the most common questions I am asked.  My reply was typically “select different parents, get better genes” as little was known beyond that as far as a risk factors for many diseases of the nervous system.  We still do not know exactly why people get ALS, Parkinson’s disease, amongst others, but it seems to be more and more clear that while nutrition is not the only factor, it is an extremely important one.  More and more studies are being completed that show healthy people get less chronic disease including diseases of the nervous system. There is an abundance of information that comes at us from all directions which can be conflicting and confusing.  I have now discovered a resource that I feel confident enough to guide my own and my family’s nutrition and a resource I refer patients to.  

Nutritionfacts.org  is a nonprofit organization founded by Michael Greger, MD, FACLM to provide science behind nutrition recommendations.  He has videos discussing the science behind ketogenetic diets, artificial sweeteners, which plans to eat to combat certain diseases, amongst 100s of other topics.  And, it is an invaluable FREE resource.  Of note, I have no relationship with this site nor Dr Greger. I am just a very happy recipient of the information given by his nonprofit organization.

If a more healthy diet seems out of reach financially, here are a few additional resources to consider:

Find a Food Program near You

Fair Food Network: fairfoodnetwork.org; 734-213-3999

Based in Michigan, this initiative has a national Double Up Food Bucks program that doubles the value of federal Supplemental Nutrition Assistance Program (SNAP, or food stamps) benefits at farmers’ markets and grocery stores.

Fresh Prescription: ecocenter.org; 734-761-3186, 313-881-2263

This Detroit-based program caters to low-income patients with chronic diseases, caregivers of young children, and pregnant women who are referred by their primary care physicians. Patients receive a prescription for produce that’s filled at partnering farm stands or markets.

Wholesome Wave: wholesomewave.org; 203-226-1112

This national organization can help people start a produce prescription program in their own area. Contact them for a tool kit that includes fundraising strategies and step-by-step instructions.

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Top Doctors 2020

” Do you know a doctor who deserves recognition? We want to know who you think are the top doctors in the state.

Tell us your favorite doctor in the 25 categories below. Doctors with the most nominations will appear in our Top Doctors list in the Winter issue of Arkansas Life.

Please click on the ‘Top Doctors 2020‘ to be taken to the correct website.

https://arkansaslife.com/doctors/

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Short Game Seminar From Former PGA Professional

Legacy Spine and Neurological Specialists proudly hosts former PGA professional and one of the top PGA instructors in the nation Stan Utley to Chenal CC in Little Rock last week.  Stan presented a short game seminar to participants in the Oak Leaf Classic.   Then see how I actually somehow caught on and carried out a great surgical removal of the ball from the deep rough almost holing out!   

To Learn more about his short game expertise visit stanutley.com

Stan’s principles of the golf swing is to utilize the dead weight of the clubhead to do the work.   Using the momentum of the dead weight of the clubhead and wrists to direct such certainly allows one to swing the clubhead faster with much less effort.   Swing fast not hard he explains.   Accelerate the clubhead not the grip!   

Swinging hard and/or incorrect posture can lead to sports spine issues just as incorrect posture and ergonomics can lead to work and activities of daily life spine injuries.  Injury prevention not only can improve your game but your life more importantly (if anything is more important than golf?)!

To learn more about how to best prepare your spine for life’s sports and daily activities or to see treatment please visit our website LegacyNeuro.com or make an appointment to see our physical therapist Jessica Beggs who has vast expertise in spine physical therapy treatment and prevention of injuries.   Incidentally if you suffer from Golfer’s or Tennis’ Elbow issues reach out to Jessica as well.   She has done wonders with mine!

https://legacyneuro.com/?p=4775&preview=true

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