Brief Answer:
I am a neurologist and therefore, very agreeable to NCV tests!

Detailed Answer:
Good morning from where I am in XXXXXXX Ohio, USA. My name is Dr. Saghafi and I have read your question as well as the similar questions you have posed to my colleagues earlier about this situation with your wife in the month of July.

I think that in the first place- you will want to have a conversation with the doctor who gave your wife the injections. You'll want to know what kind of injections these were to begin with. Were these FACET INJECTIONS? NERVE BLOCKS? EPIDURALS? In other words you should first define the type of injection your wife received. There are different purposes and different locations that each of these types of injections are done and there are different expected outcomes.

I hope these answers satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?

Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?

Please direct more comments or inquiries to me in the future at:

bit.ly/drdariushsaghafi

I would be honored to answer you quickly and comprehensively.

Please keep me informed as to the outcome of your situation.

The query has required a total of 46 minutes of physician specific time to read, research, and compile a return envoy to the patient.

For example, a FACET INJECTION is typically done for the purpose of testing a patient to see if a more definitive or fuller block would be of benefit...therefore, the longevity of the procedure is much shorter and not expected to be of the same degree of "pain relief" as either a nerve block or epidural injection/infusion.

The 2nd parameter that you should investigate is what medication was she given through that injection protocol she received? If for example, she was being given a simple facet injection just for the purpose of seeing whether or not a fuller more definitive nerve block would be of benefit then, it is likely that she would've received a simple anesthetic such as lidocaine, marcaine, or something similar. It would not have necessarily been mixed with any other substance or component such as a long acting steroid such as Decadron or similar therefore, the lasting effects of such a simple injection of just anesthetic without steroid mixed in would be expected to be extremely short....on the order of days, if that....whereas, by mixing the concoction up with steroid.....one may gain several weeks and if lucky, several months of pain relief. Make sense? So it makes a difference when answering this question to know what the ingredients were that went into the injection.

That way, when you go back to the neurosurgeon you can have the proper information and they would know right away why the injection was given and what the expected outcome was. You would assume that they would have that information ahead of time....but it is always best to do a little investigating into what you're being given and why for whatever purpose it may serve or benefit you....

If there is no improvement after receiving these 2 injections....although it's possible that there could be a misdiagnosis....it is also possible that the implication may also be that the particular medication or mixture of medications, or LOCATION was not optimal for what the neurosurgeon was hoping your wife would get for perfect relief. Remember, injection (especially if done blindly by the operator) is not an exact science....even when done with guidance and fluoroscopy, there is still an element of chance that says even when the medicine goes exactly where it should go....it may not work as expected. That is actually, what happens more times than not.

For these reasons precisely I am always partial to the idea of getting NERVE CONDUCTION STUDIES PERFORMED ahead of blocks and injections and certainly ahead of surgery. Many surgeons don't agree with this perspective and many pain management specialists feel that NCV tests are not essential to treating chronic pain because they will argue that even in the face of those tests and their results...outcomes can still be unpredictable. And you know what? They're RIGHT....again, this is not a perfect science....your wife's anatomy and physiology is unique, the injection site in her is not perfectly known...she may metabolize the medications differently once they hit her system, perhaps she wasn't positioned exactly the right way to get the foraminal injection or the block in whatever way she was placed and for that reason the medication flowed somewhere outside of the intended target area, etc. etc.

BUT...in my opinion, a NCV test has a fairly high degree of sensitivity and specificity when it comes to detecting a radiculopathy or plexopathy and that means that if the C6/C7 bulge is truly impinging upon the corresponding nerve root (C7) the NCV study should pick up an abnormal set of readings on C7 innervated muscles in the upper limb while C6 electrophysiology will look clean and free from irritations or compromises. That would be one possible scenario that the NCV study could have to support the notion that the C6/7 disk bulge were truly causing your wife's symptoms so that either conservatively or surgically speaking we are in the right neighborhood.

Often times MRI studies may show nerve root compressions that are so obvious in terms where the pathology is that we can get fooled into believing that it must be where we SEE a nerve to be pinched or compressed.....we surgerize or anesthetize that level and NOTHING HAPPENS....and we can't believe our eyes! How can that be? But if you look at the NCV test for that nerve root at that level of where the MRI there is a compression....the results are normal....no abnormalities....which are we to believe?

Well, as a neurologist I have to believe a combination of things.....one is what do my tests show me...and the 2nd is what does my history of the illness tell me, and finally, what the clinical examination show me with the patient in front that I can see, hear, and touch? That's my approach....some people consider it old fashioned....but I think it works...it's a bit more deliberate and time consuming....but I always insist with my patients that electrical studies come ahead of procedures, injections, and always surgeries. I can't tell you how many surgeries I've recommended not be done because the electrical studies simply did not support the basis that either a surgeon may have had..or someone else...or that injection blocks be done at a certain level....I've made alternative recommendations because of the electrical studies.

Bottom line and the answer to your question as far as I'm concerned is that I believe your wife SHOULD OBTAIN electrical studies to confirm the actual contribution to her symptoms by this C6/7 disk bulge. I should tell you that 40% of people who get MRI's have disk bulges both in the cervical as well as rest of the spine....and yet.....THEY DO NOT HAVE SYMPTOMS of anything...no back pain, no neck pain, no limb pain, no numbness, no tingling....they are symptom free....but the radiologist will swear on his medical license that they have disk bulges so clear that you could drive a truck at them if such were possible......and yet the patients have NO SYMPTOMS. Should we surgerize those people? Should they get nerve blocks? Should they get prescriptions? Should they get rhizotomies based on what things LOOK like? Well, what's the difference when someone says they are in pain?

I think we should do our very best with the tools available to identify WHERE THAT PAIN IS COMING from and then, based upon that information take actions...make sense?

My vote? NCV studies....

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Brief Answer:
No reason to panic based on what you're saying

Detailed Answer:
Not sure why there is desperation in the air based on what you're saying. I'm empathetic to the pain your wife may be going through and discomfort but this can be worked out with excellent results.

There just has to be good solid information obtained before doing anything like surgery or getting her too far down the road of pain management doctors who may be tempted to be giving chronic injections which are of little value.

The NCV study can be obtained at any time. Cortisone injections will not affect those results to any great extent..especially if she continues to have similar symptoms before and after the shots.

I'm unaware of any option to phone me through this network but you can continue to write questions so long as you understand that after the 4th question the thread should be closed and a new question entered with new payments as well according to the directions on this website. If you would like to continue with me as the consultant then, you should go to my website which is at:

bit.ly/drdariushsaghafi


and choose the option that sends the question directly to my attention. I am then, notified and will be back in touch with you as quickly as possible and you would then, have another series of questions that can be asked.

Of course, you could also call technical support with your request for telephone connectivity and see what they say. If they have such a modality available as a service then, I am happy to provide you with my office number and we will follow whatever the guidelines are for that type of transaction. I'm just not aware of it through this network and have never done one....but you can tell that I'm used to TYPING LOTS OF ANSWERS! :)

Please understand also that I am a neurologist and not a surgeon so if future questions revolve more around specific procedures and how they are performed with percentage chance of outcomes etc. then, a better specialist to answer those sorts of things would be a NEUROSURGEON and you can locate that specialty here as well but otherwise, I am happy to be of service as I hope I've been to this point.

And once again, I'm hoping that you and your wife can relax a bit as this situation can (and I'm sure will) be worked out to a very satisfactory point where she will get exactly the intervention she needs....but it may take a little time and effort to get the proper facts together.

It also depends on how she got this neck and back pain in the first place and how likely is it that the bulging disk is all there is to the problem? Other things can also cause pain in the parts you've mentioned on her that are not bulging disks. Has everything else been looked at? And that's just another reason why electrical studies are very useful as they can sometimes "SEE" things causing problems that imaging studies fail to fully appreciate or are hidden because the right studies were not done, etc.

I hope these answers satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?

Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?

Let me know what you find out about the telephone call situation. I am happy to give that on to you if the network agrees to a pricing structure and how it should be handled on my end so that proper credit is received and transacted with you/your wife as the patient.

Also, we'll have to take into consideration the time zone difference which is on the order of 12-15 hrs. depending on where DOWN UNDER exactly you're located.

The query has required a total of 66 minutes of physician specific time to read, research, and compile a return envoy to the patient.

Cheers!

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Brief Answer:
Many thanks for the updated information

Detailed Answer:
I did check with the people at HealthTap and confirmed with me the lack of any ability on this website's part to be able to offer to patients telephone connectivity to the doctors. However, you can get to me DIRECTLY and request that I specifically return answers to your questions by landing on my personal webpage at:

bit.ly/drdariushsaghafi

So that's that...now the updated information...very interesting....see what I mean about imaging studies sometimes showing us things that we don't know quite what to do with? You already figured it out....there is apparently this bulge at C6/7 in the spinal column....yet your wife's symptoms are all left sided....

Those 2 things clearly do not go together.....as the radiologist said though he could not rule out the possibility that some nerve fibers on the LEFT side couldn't be irritated or touching some element of either the disc bulge...or something else that we're simply not SEEING with your imaging study to explain the symptoms.

I think that other things need to be considered as well that are not necessarily spinal cord or spinal column related since there seems to be such a widespread distribution of pain itself which includes the left breast, the entire head, the neck, and the upper extremity on the left.

They're not going to get you the EMG/NCV until when????? November?? Really? Geez....I'm sorry for that mate....really....that's awful....maybe there'll be a cancellation or something?

How did her acupuncture go anyways?

Bottom line as far as I'm concerned is that the disc bulge is not very likely the cause of any of this and it's as I said it could be in the first place....a red herring...now you know she's got a disk bulge....and you also now know that it is simply there without causing any problems....

I think the electrical study can still be useful to get in a workup of that left side but only in the context of some neurological deficit on examination. The fact that the neurosurgeon told you to just play it cool and get some physical therapy....suggests to me that the neurological examination is normal. Did the surgeon examine your wife's left side? But I mean....really EXAMINE your wife....with a good motor and sensory examination from head to toe on the left side? Or did SOMEONE do that examination? If they did and it is DEAD NORMAL....then, I will predict that the EMG/NCV is going to come out normal...and if I were your wife...I'd probably ask not to have the test done....it won't show anything and it's an uncomfortable test....it's invasive....the acupuncture is fine.... but I don't like thinking that your wife is going to have be shocked and get currents of electricity running through her if it's not really going to help us.....

What I would consider would be a Cervical and Thoracic MRI with gadolinium contrast looking for a possible SYRINX as well as an MRI of the brain looking to see if there is a demyelinating plaque on the brain that could explain what the pain is all about.

If those studies are negative then, I might look at the possibility of this as being some form of possible headache syndrome with hemibody affectation and go down that path. You could have your GP make the connection for you to a local headache specialist or even a neurologist if one isn't already involved. She needs a good neurological examination...unless the neurosurgeon did one....

BTW, this also explains why the injections didn't do anything....there's nothing there to anesthetize if you know what I mean....MRI is clean on the left side for any nerve roots being impinged or compromised...so what could injection needles accomplished?

I hope these answers satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?

Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?

Let me know what you find out about the telephone call situation. I am happy to give that on to you if the network agrees to a pricing structure and how it should be handled on my end so that proper credit is received and transacted with you/your wife as the patient.

Also, we'll have to take into consideration the time zone difference which is on the order of 12-15 hrs. depending on where DOWN UNDER exactly you're located.

The query has required a total of 84 minutes of physician specific time to read, research, and compile a return envoy to the patient.

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Brief Answer:
EMG used to diagnose pure PAIN symptoms is poorly sensitive test

Detailed Answer:
Good evening. Thank you for your return comments. Perhaps, I can simplify the answers in the following format of pointed bullet statements which should help cut through too much rhetoric (of which I'm terribly guilty which surely clouded what I really wanted to get across...)

1. Right sided DISK BULGE at C6/7 DOES NOT explain left sided symptoms of your wife involving her face, chest, or left upper extremity.

2. The involvement of your wife's LEFT FACIAL area is not explained by ANY TYPE of disk bulge or herniation of the cervical spinal cord except perhaps in the rarest of cases in the upper most portions of the cord which would be C1 or C2. The MRI study is not seeing anything of a significant nature in this area of the cord.

3. Even though the radiologist states that he is unable to GUARANTEE that there is NO FIBER or nerve root irritation on the left side of the spinal cord- for your wife to be suffering from the degree of pain she has in a territory as large as is being seen clinically is simply improbable and as I stated in #2 even if it existed anatomically doesn't explain facial symptoms. This is because facial sensation (including pain) is not mediated through nerves originating in the spinal cord but rather through CRANIAL NERVES which come out from the brainstem and that is completely removed from the spinal cord geographically but a LARGE PHYSICAL DISTANCE.

4. EMG/NCV is a diagnostic study which is POORLY sensitive in cases where PAIN is the only symptom in the patient. It becomes even less useful as a tool to help localize or characterize a problem if imaging studies fail to demonstrate even a possible compression or "pinching" of a nerve root, branch, or cord.

Therefore, my prediction as to the chance that an EMG/NCV study will show you anything of beneficial use to either a neurosurgeon (who is looking to relieve symptoms through an operation of some sort) or even a neurologist who is looking for roughly the same thing to treat at least by way of some medication or physical therapy, or injection....is very small indeed...probably in the neighborhood of less than 5%.

It would be a much more reliable tool to use if your wife were either suffering from clinical WEAKNESS in her shoulder girdle area or anywhere in the left upper extremity from the arm down to the hand/fingers. Or at the very least to have a radiographic finding of a bulge, hernia, compression, etc. on the left side....but that's not the case.

Bottom line is that under the present circumstance of what's being shown in the current imaging study as well as what I assume to be an otherwise, normal neurological examination I think the EMG/NCV is unlikely to yield results of a useful nature to the physicians involved in this case.

To put it into the vernacular that you are using in your question I do not believe that an EMG/NCV study will RULE anything of significance OUT that could explain her symptoms. They need to look elsewhere than the spinal cord. Further proof that the spinal cord and nerves are not the explanation to her pain is the fact that the pain blocks did not work at all.

As a neurologist I would recommend an MRI with gadolinium contrast of the brain and I'd be looking for something on the RIGHT SIDE of the brain in the deep white matter region and I would ask the radiologist to comment on an area known as the anterior limb of the internal capsule or possibly the right thalamic area as well. I would also check an area of the brainstem called the PERIAQUEDUCTAL GRAY region on the RIGHT side in the region.

Regarding your question on communicating with me directly by telephone I certainly wish that were possible but I'd ask that you check with Customer Service as to how to go about initiating that type of transaction. I did place the question to one representative but was told that no such option existed for patients to call doctors though I believe they may be contemplating something like that in the future. Notwithstanding, if they are able to come up with something especially for your wife's case I'm happy to participate otherwise, doing that independently violates my agreement with the company so I'm afraid we would have to continue to rely on this current system of texting.

At any rate I wish your wife relief and full speed to at least a diagnosis ASAP. I know you are very concerned as must be your wife.

Of course, if you just happened to be hopping a bird from Down Under to XXXXXXX Ohio anytime in the near future while our weather is still commendable well, then, I'd invite to not only visit with me so we can take a look at your wife but I'd highly recommend taking a tour of The Rock and Roll Hall of Fame...not another museum like it in the WORLD! And if it's classical or even pop music that fits your fancy we have the XXXXXXX Orchestra now performing at beautiful Blossom Music Center or recently renovated Severance Hall.

Be well and all the best to the Mrs.

Don't forget use the following web address to recontact me personally for any reason after closing this query as this is the final question in this group which has been charged off. Going forward please use:

bit.ly/drdariushsaghafi

The query has required a total of 131 minutes of physician specific time to read, research, and compile a return envoy to the patient.

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