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usual until about three hours before the test. Prior
arrangements also include transportation home
from the hospital or outpatient clinic.
To explain the procedure, the Radiological Soci-
ety of North America (RSNA) said, “Within the
spinal canal, the spinal cord and nerve roots are
surrounded by a fluid-filled area, the subarachnoid
space. This fluid, called cerebrospinal fluid, is con-
fined by the arachnoid membrane and serves to
cushion and protect the spinal cord.” To guide the
placement of the needle, a radiologist uses
FLUO-
ROSCOPY, which also projects X-ray images onto a
monitor. Then, “for myelography, contrast material
is injected into the subarachnoid space and x-rays
are taken as the contrast flows into different areas.
The contrast material outlines areas of the spine
that usually are not visible on plain x-rays.”
According to Yale New Haven Health, “after the
contrast material is injected, you continue lying
on your stomach or side while the X-ray pictures
are taken. If pictures of your upper back or neck
are needed, the contrast material may be moved
into those areas by tilting the table or you may be
asked to move into different positions. You will be
held in position as the table is tilted, and your chin
will be placed on a small pillow to keep your neck
extended. This prevents the contrast material from
entering your head, which can cause headaches or
seizures. You need to lie very still to avoid blurring
the pictures. Your pulse, breathing rate, and blood
pressure may be monitored throughout the test.”
The RSNA added, “Myelography itself usually
takes 30 to 60 minutes, and a CT scan adds another
30–60 minutes to the total examination time. Some
facilities have patients stay in a recovery area for as
long as four hours, resting with the head elevated
at a 30° to 45° angle. You will be encouraged to
take fluids at this time to help eliminate contrast
material from your body and prevent headache.
You probably will be asked not to engage in strenu-
ous physical activity or bend over for one or two
days.”
Risks and Complications
Pregnant women, people who have seizures, and
patients with certain medical conditions may not
be able to take this test. Also, some medications can
not be taken within a day or two of a myelogram.
Commonly, patients experience sharp pain from
the
LUMBAR PUNCTURE or injection into the CERVICAL
SPINE. As the contrast dye enters the system, head-
ache or nausea may arise. Some patients have an
immediate reaction to the dye, while smokers may
get a severe headache after the test. At home, oth-
ers may get a fever. If the side effects worsen or do
not go away in about 24 hours, a doctor should be
notified. In rare instances, the test itself can cause
ARACHNOIDITIS or other inflammation by invading
spinal fluids or membranes.
Outlook and Lifestyle Modifi cations
If something blocks the flow of the contrast dye,
SURGERY may be needed. Commonly, a myelogram
detects a
SPINAL TUMOR, SPINAL INFECTION, SPINAL
STENOSIS, or HERNIATED DISC. Any inflammation in
the arachnoid membrane as well as any abnormali-
ties around the spinal cord can also be seen. As the
University of Maryland Medical Center Web site
said, “A myelogram examination assists your doc-
tor in making a diagnosis. The radiologist interprets
the information from the procedure and reports it
to your doctor, who in turn will discuss the report
with you.”
Payne, Kattie. “Myelogram,” Yale New Haven Health,
Healthwise, Inc. Available online. URL: http:// yale
newhavenhealth.org/library/healthguide/en-us/
Medicaltests/topic.asp?hwid=hw233057&. Downloaded
February 7, 2006.
RadiologyInfo™. “Myelography,” Radiological Society of
North America, Inc. (RSNA). Available online. URL:
http://www.radiologyinfo.org/content/myelography.
htm. Last reviewed November 5, 2004.
University of Maryland Medical Center. “Radiology,
Myelogram,” UMMC. Available online. URL: http://
www.umm.edu/radiology/myelog.htm. Downloaded
February 7, 2006.
myeloma bone disease Sometimes known as
multiple myeloma, this primary bone
CANCER could
be caused by
ENVIRONMENTAL INFLUENCES. Higher
instances occur among residents of industrialized
nations, with approximately 13,500 cases in the
United States diagnosed annually. Those statistics
mark a 400 percent increase in the last 30 years.
176 myeloma bone disease
An article posted by the National Institute of
Arthritis and Musculoskeletal and Skin Diseases
(NIAMS) explained, “Myeloma means, literally, a
‘tumor composed of cells normally found in bone
marrow.’ The majority of patients with myeloma
develop destructive bone lesions, also known as
osteolytic bone lesions. These lesions occur primar-
ily in the vertebrae, the ribs, the pelvis, and the
skull. They occur in the red bone marrow where
nests of myeloma cells accumulate,” eventually
causing bone destruction.
In writing for the Multiple Myeloma Research
Foundation, Dr. Sagar Lonial described the pro-
gression of this incurable disease: “As tumors grow,
they invade the hard outer part of the bone, the
solid tissue. In most cases, the myeloma cells spread
into the cavities of all the large bones of the body,
forming multiple small lesions. This is why the
disease is known as ‘multiple’ myeloma. In some
cases, collections of plasma cells arise either within
bone or in soft tissues as masses or tumors. These
collections are called plasmacytomas, and may rep-
resent a more aggressive form of myeloma.”
Symptoms and Diagnostic Path
According to the NIAMS, “approximately 70% of
myeloma patients experience pain of varying inten-
sity, often in the lower back.” Besides
LOW BACK
PAIN, the sharp onset of ACUTE PAIN may indicate
a
VERTEBRAL COMPRESSION FRACTURE. In about 30
percent of patients, kidney impairment results in
hypercalcemia, which releases too much
CALCIUM
from the bones into the bloodstream, thereby add-
ing symptoms of thirst, nausea, fatigue, and bone
loss. Bone pain or tenderness, fever, and night
sweats occur in some patients too.
Diagnostic tools include blood tests, X-
RAYS, a
BONE SCAN, biopsy, and MAGNETIC RESONANCE IMAG-
ING. Also, BONE MINERAL DENSITY TESTS assess the
degree of
OSTEOPOROSIS or bone loss that commonly
occurs in the ribs, pelvis, skull, and
SPINE.
Treatment Options and Outlook
Although no cure exists, a variety of treatments may
ease pain and improve quality of life. For example,
the Loyola University Health System listed options,
such as
PAIN RELIEVERS, treatment of FRACTURE,
radiation to control pain, chemotherapy, bone mar-
row transplant, and “alpha interferon—a biological
response modifier (a substance that stimulates or
improves the ability of the body’s immune system
to fight disease) that interferes with the division of
cancer cells, therefore slowing tumor growth. Inter-
ferons are substances normally produced by the
body,” but they can be produced in a laboratory.
An article on the International Myeloma Foun-
dation (IMF) Web site discussed several treat-
ments appropriate for various types of myeloma.
For example, “patients with hypercalcemia due
to myeloma usually respond very rapidly to treat-
ment. . . . However, efficacy of steroids in this set-
ting may be due in part to their rapid suppression of
myeloma tumor growth.”
Risk Factors and Preventive Measures
emy of Orthopaedic Surgeons, “this disease gener-
ally occurs in older adults. Fewer than 3 percent of
cases occur in people under the age of 40. Multiple
myeloma tends to be more common in men than
women. It is twice as common in African Ameri-
cans as it is in Caucasians,” with fewer cases than in
either group reported among Asians. G
ENETIC FAC-
TORS may need to be addressed as well as environ-
mental risks inherent in a particular area, country,
and lifestyle.
To investigate how the progression of bone loss
in myeloma might be prevented, a group of doc-
tors studied the effects of
BISPHOSPHONATES then
reported their findings in the Blood journal pub-
lished by The American Society of Hematology. As
the article summarized, “Our results suggest that
although not useful as a direct therapy to reduce
tumor burden in myeloma patients, ibandronate
may be extremely useful as an adjunctive therapy
for the treatment of the osteolytic component of
myeloma disease. Since it is this bone destruc-
tive component that causes the most distressing
and painful symptoms for the patient, the use of
bisphosphonates such as ibandronate in myeloma
disease may improve dramatically the quality of life
of the patient. However, other treatments, such as
chemotherapy, radiotherapy, and marrow trans-
plantation should continue to be the main thera-
pies directed at preventing growth of the myeloma
cells.”
myeloma bone disease 177
American Academy of Orthopaedic Surgeons. “Multiple
Myeloma/Plasmacytoma,” AAOS. Available online. URL:
http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_
ID=488&topcategory=Tumors. Downloaded February
8, 2006.
Dallas, Sarah L., I. Ross Garrett, Babatunde O. Oyajobi,
Mark R. Dallas, Brendan F. Boyce, Frieder Bauss, Jiri
Radl, and Gregory R. Mundy. “Ibandronate Reduces
Osteolytic Lesions but Not Tumor Burden in a Murine
Model of Myeloma Bone Disease,” Blood, 93, no. 5
(March 1, 1999): 1,697–1,706.
Lonial, Sagar, M.D. “Intro to Myeloma,” Multiple Myeloma
Research Foundation, MMRF. Available online. URL:
http://www.multiplemyeloma.org/about_myeloma/.
Downloaded February 8, 2006.
Loyola University Health System. “Myeloma Bone Disease/
Multiple Myeloma.” Available online. URL: http://
www.luhs.org/health/topics/bone/myeloma.htm. Last
reviewed January 5, 2005.
Mundy, Gregory R., M.D. and Babatunde O. Oyajobi.
“Myeloma Bone Disease—Update 2003,” Interna-
tional Myeloma Foundation, IMF. Available online.
URL: http://www.myeloma.org/main.jsp?tab_id=1&
type=article&id=1044. Downloaded February 8, 2006.
National Institutes of Health (NIH) Osteoporosis and
Related Bone Diseases, National Resource Center,
“Myeloma Bone Disease,” National Institute of Arthri-
tis and Musculoskeletal and Skin Diseases (NIAMS).
Available online. URL: http://www.osteo.org/newfile.
asp?doc=r605i&doctitle=Myeloma+Bone+Disease&
doctype=HTML+Fact+Sheet. Downloaded February 8,
2006.
myelomeningocele See SPINA BIFADA.
myofascial release See ACUPRESSURE, MASSAGE
THERAPY, TRIGGER POINT THERAPY.
178 myelomeningocele
179
naproxen
In 1976, this NONSTEROIDAL ANTI-
INFLAMMATORY DRUG (NSAID) received approval
from the Food and Drug Administration (FDA) as
both a prescription and an
OVER-THE-COUNTER PROD-
UCT. Best known by such brand names as Aleve
or Naprosyn, naproxen acts like any NSAID as a
PAIN RELIEVER, fever-reducer, and means of easing
inflammation. However, on December 23, 2004,
FDA issued this alert: “Based on emerging infor-
mation, the risk of cardiovascular and cerebrovas-
cular events may increase among patients taking
naproxen.” Therefore, “FDA recommends patients
not exceed the recommended dose” unless a doc-
tor says otherwise. For example, a physician may
prescribe a stronger dose of naproxen to treat the
CHRONIC PAIN and inflammation of ARTHRITIS, ANKY-
LOSING SPONDYLITIS, JUVENILE ARTHRITIS, and RHEU-
MATOID ARTHRITIS.
Dosage and Potential Side Effects
From the start, the FDA advised against the use of
naproxen by women in the last three months of
pregnancy, people with allergies to
ASPIRIN or other
NSAIDs, and patients with kidney problems or
other serious medical conditions. For most adults
though, the FDA recommended, “When taking an
over-the-counter naproxen product, 1 tablet (220
mg) should be taken every 8 to 12 hours while
symptoms last. You may take 2 tablets within the
first hour of symptoms for the first dose. However,
you should not exceed 2 tablets (440 mg) in any
8 to 12 hour period or 3 tablets (660 mg) in a 24-
hour period.”
For
CHILDREN, the dosage varies according to
body weight. Although a liquid form of naproxen is
available, it may not be suitable for a child who has
sensitivities to food dyes or artificial flavorings. For
patients of all ages, eating a little food and drinking
a full glass of water with this medication can help
to avoid an upset stomach.
Regarding other potential side effects, Drugs.com
cautioned that “naproxen may increase the sen-
sitivity of the skin to sunlight.” The Web site also
reminded patients to take naproxen for no more
than 10 days unless a doctor prescribes differently.
Also, “do not crush or chew the extended-release
forms of naproxen (e.g., Naprelan, EC Naprosyn,
others). Swallow them whole. These are specially
formulated to release slowly in the body. Ask your
pharmacist if you do not know if you have an
extended-release formulation.”
Statistics and Studies
As studies of NSAIDs continue, an article in Medicine
& Health said, “Some of the outside experts on the
FDA’s NSAID advisory panel suggested that differ-
ent NSAIDs pose different cardiovascular risks, with
the Cox-2’s perhaps on the more dangerous end
and naproxen . . . perhaps even giving some protec-
tion against cardiovascular ills.” The acting director
of the Office of New Drugs at FDA mentioned a pos-
sible “class effect” in NSAIDs, then added, “There
may be slight differences between the drugs, or even
larger differences, but we don’t have enough data to
really rank-order these drugs by risk.”
Drugs.com™. “Naproxen,” Drug Information Online,
Micromedex Physicians Desk Reference. Available
online. URL: http://www.drugs.com/naproxen.html.
Last updated December 1, 2005.
FDA Patient Information Sheet. “Naproxen,” Food
and Drug Administration. Available online. URL:
http://www.fda.gov/cder/drug/InfoSheets/patient/
Naproxen-pt.pdf. Downloaded February 8, 2006.
Staff. “FDA Beefs Up NSAID Warnings, Pulls Bextra,”
Medicine & Health 59, no. 13 (April 11, 2005): 1–2.
N
neck See CERVICAL SPINE.
neck brace See ORTHOTICS.
neck injury See CERVICAL SPINE; SPINAL INJURY.
neck pain Yes, that proverbial pain in the neck can
come from dealing with someone who is a pain in
the neck, mainly because of the resulting
TENSION.
More often, neck pain arises from poor
POSTURE,
DEGENERATIVE DISC DISEASE, SPINAL STENOSIS, or a HER-
NIATED DISC in the CERVICAL SPINE. In addition, ACUTE
PAIN comes in a whiplash as a FLEXION-EXTENSION
INJURY causes the neck to exceed its normal RANGE
OF MOTION. Although far less dramatic and, usually,
much less painful, problems similar to a whiplash
can arise with improper
LIFTING techniques, poor
ERGONOMIC FACTORS, and bad habits, such as cradling
a telephone on the shoulder. Forgetting
BACKPACK
SAFETY or slinging around a heavy shoulder bag can
also produce neck pain.
As the American Physical Therapy Association
(APTA) advised, “The basic rule is simple: keep
your neck in a ‘neutral’ position whenever pos-
sible. In other words, don’t bend or hunch your
neck forward for long periods. Also, try not to sit in
one position for a long time. If you must sit for an
extended period, make sure your posture is good:
Keep your head in a neutral position, make sure
your back is supported, keep your knees slightly
lower than your hips, and rest your arms if pos-
sible.”
Regarding those arms, the APTA said, “Pain
in the cervical region can cause arm pain as well
as the ‘pain in the neck.’ Why? In the case of the
arms, it’s because the nerves that branch out from
the neck go all the way down into the arms and
into the hands. . . . The uppermost cervical disc
connects the top of the spinal column to the base
of the skull. The spinal cord, which sends nerve
impulses to every part of the body, runs through
a canal in the cervical vertebrae and continues all
the way down the spine. The cervical nerves spread
down into the arms; because of this, arm pain is
sometimes traceable to a problem in the neck.” This
type of problem may begin at a computer station or
during
SLEEP but can usually be avoided by keeping
the
SPINE in a neutral position. Doing that, how-
ever, may take a bit of practice or a better pillow.
Risks and Complications
Along the same vertebral line, NeuroSurgery.com
said, “A muscle spasm, brought on by poor posture,
sleeping position, or stress, is the most frequent
cause of neck pain. But an aching neck can be a
symptom of a more serious problem. Disc degen-
eration, narrowing of the spinal canal, arthritis
and even cancer can cause neck pain. For serious
neck problems a primary care physician and often
a specialist, such as a neurosurgeon, should be con-
sulted.” For example, “cervical disc disorders are
typically marked by intermittent neck pain, fol-
lowed by severe neck and sometimes arm pain. The
pain is sufficient to awaken a person from sleep.
Irritated nerves also can lead to numbness or weak-
ness in the arm or forearm, tingling in the fingers
and coordination problems. Severe nerve impair-
ment or even paralysis can develop if the disorder is
left untreated.” In addition, “pressure on the spinal
cord from a herniated disc or bone spur in the neck
can also be a very serious problem. Virtually all of
the nerves of the body have to pass through the
neck to reach their final destination (arms, chest,
abdomen, legs).”
Statistics and Studies
Some studies focus on the effectiveness of
ACU-
PUNCTURE in treating neck pain. For example, one
trial studied the outcomes for 124 patients, 18 to
80 years old. As reported in the Alternative Medi-
cine Review, “Acupuncture reduced neck pain and
produced a . . . significant effect compared with
placebo.”
From Sweden, another study of neck pain
examined out-of-focus eyes. As reported in Opti-
cian, “People who suffer from back and neck pain
following computer use may need their eyes exam-
ined.” With the help of
POSITIVE EMISSION TOMOG-
RAPHY (PET) SCANS, the researchers, “examined
whether eye problems can cause musculoskeletal
complaints and vice versa.” Apparently, “focusing
the lens of the eye requires coordination between
various nerve and muscle groups in the eye, neck,
180 neck
and shoulder region.” Therefore, “tensing and
relaxing the neck, throat, and shoulders affect the
eyes,” whereas “eye complaints can trigger and/or
aggravate muscular aches in the shoulders and/or
neck region.”
Loosening up can prevent the pain of
MUSCULO-
SKELETAL DISORDERS anytime but especially as one
ages. According to an article in the Family Practice
News, “most osteoarthritic changes occur between
C5 and C6 and between C6 and C7” vertebrae in the
cervical spine. “Almost everyone eventually devel-
ops osteoarthritis in the neck. On average, 45% of
adults aged 40–49 years, 72% of adults aged 50–59
years, and 83% of adults aged 60–75 years have
some osteoarthritic changes, but those who keep
the neck and shoulders loose with stretching and
strengthening exercises don’t notice it.”
Special Aids and Adaptations
By practicing self-awareness, most people can
adapt their movements, thereby reducing incidents
of neck pain. For example, a sudden motion, such
as abruptly throwing back the head, can press the
SPINAL CORD and cause discomfort.
For gentle neck stretches, the Family Practice
News article suggested, “Stand or sit up straight on
a chair, with your feet flat on the floor. Keeping
the head level, slowly tuck your chin in toward the
back of the head. This movement should give you
a bit of a double chin. Hold for 6–8 seconds. Relax.
Repeat up to six times.”
Information from NeckSurgery.com empha-
sized neck flexibility, too, but also mentioned “safe
and effective abdominal exercises that will help
alleviate neck pain.” Resting on a floor mat “with
your arms crossed in front, bend your knees and
keep your feet flat on the floor. Lift your upper
back off the floor and lower down.” While empha-
sizing the contraction of abdominal muscles, “you
should exhale as you lift up and inhale as you
lower down. Go through a series of 10.” If getting
up and down from a floor mat or padded carpet
proves too strenuous, patients can adapt by exer-
cising in bed.
Besides stretching
EXERCISE, patients with a
CHRONIC PAIN in the neck may be helped by PAIN
RELIEVERS, such as ASPIRIN or other NONSTEROIDAL
ANTI-INFLAMMATORY DRUG (NSAID), and HEAT THER-
APY, such as a warm shower. If those conservative
treatments fail, medical tests, such as an X-
RAY,
MYELOGRAM, or DISCOGRAM, can aid the diagnosis
and direct the course of treatment, determining,
for example, if an
ANTERIOR CERVICAL DISCECTOMY
or other type of
SURGERY will be needed. According
to NeuroSurgery.com, however, “Surgery has its
limitations. It can’t reverse all the effects of overuse
or aging, and it carries risks. Yet it may be the only
way to relieve pain, numbness and weakness.”
American Physical Therapy Association. “What You Need To
Know About Neck Pain,” APTA. Available online. URL:
http://www.apta.org/AM/Template.cfm?Section=Search
&template=/CM/HTMLDisplay.cfm&ContentID=24761.
Downloaded February 9, 2006.
Medtronic Sofamor Danek. “Exercises For Neck Pain,”
NeckSurgery.com. Available online. URL: http://www.
neckreference.com/articles-exercise.html. Last updated
April 18, 2005.
Nagler, Willibald. “Strength and Flexibility for Older
Patients, Part 2,” Family Practice News 34, no. 23
(December 1, 2004): 52.
NeurosurgeryToday.org. “Neck Pain,” American Associa-
tion of Neurological Surgeons. Available online. URL:
http://www.neurosurgerytoday.org/what/patient_e/
neck.asp. Downloaded February 9, 2006.
Staff. “Pain in the Neck? Get an Eye Test,” Optician (July
1, 2005): 1.
White, P., G. Lewith, P. Prescott and J. Conway. “Acu-
puncture versus Placebo for the Treatment of Chronic
Mechanical Neck Pain: a Randomized, Controlled
Trial,” Alternative Medicine Review 10, no. 1 (March
2005): 65.
neck strain See RHOMBOID MUSCLE STRAIN.
neoplasm See SPINAL TUMOR.
nerve block As a diagnostic tool for assessing the
BACK or SPINE, a temporary nerve block may be
used to locate the precise source of spinal nerve
pain before
SURGERY is performed. As a treatment
to avoid surgery, a nerve block involves the injec-
tion of an anesthesia,
OPIOIDS FOR PAIN, or a steroid
nerve block 181
to reduce swelling and inflammation. If a long-term
PAIN RELIEVER is used, the patient may experience
increased
RANGE OF MOTION, thus improving flex-
ibility. This enables the person to resume regular
daily
ACTIVITY and spine-strengthening EXERCISES
that may break a cycle of
CHRONIC PAIN.
Information from The Cleveland Clinic discussed
common types of nerve blocks: “Trigger point injec-
tion—injection (shot) of small amounts of local
anesthetic and steroid in the area of the muscle
where you have pain or tenderness. Epidural ste-
roid injection—injection of a small amount of ste-
roid medication near nerves in your lower back.
Facet joint injection—injection of a small amount of
local anesthetic near facet joints (located on the side
of your spine, away from the spinal cord). Stellate
ganglion block—injection of local anesthetic around
a group of nerves (found in the neck area). Lumbar
sympathetic block—an injection of local anesthetic
around a group of nerves in your lower back (lum-
bar area). Intercostal nerve block—an injection of
local anesthetic in the area between the ribs.”
Procedure
A nerve block will seldom be used alone but, more
often, as part of a rehabilitation program involv-
ing therapeutic exercise, physical therapy, occupa-
tional therapy, or some type of
COMPLEMENTARY AND
ALTERNATIVE MEDICINE (CAM). Each type of nerve
block differs slightly, depending on the purpose and
location. For instance, some blocks involve a single
injection, while others require additional infusions
of medication. To guide needle placement,
FLUO-
ROSCOPY may also be used.
Risks and Complications
Patients on blood thinners or those with drug aller-
gies should avoid this treatment. Also, a nerve
block should not be performed on anyone with a
SPINAL INFECTION or other active illness. As a form of
PAIN MANAGEMENT, a nerve block aims to calm spi-
nal nerves, but the opposite can happen. Pain may
worsen or, worse, permanent numbness can occur
at an injection site.
Outlook and Lifestyle Modifi cations
In the
LUMBAR SPINE, an EPIDURAL INJECTION may
relieve pain caused by
SPINAL STENOSIS or a HER-
NIATED DISC. A nerve block may be used in the
THORACIC SPINE and the CERVICAL SPINE too, for
instance, to treat the chronic pain of a
CERVICO-
GENIC HEADACHE.
As Dr. Steven Richeimer explained in an arti-
cle for SpineUniverse, “The occipital nerves travel
from the cervical spine in the neck to the back of
the head and scalp. These nerves can be damaged
by arthritic changes in the cervical spine, by muscle
spasm, or by neck injuries. The result can be head-
aches which typically start in the back of the neck
and spread towards the forehead. Occipital nerve
blocks with steroids can often help.”
Similarly, the article “Nerve Root Block Probes
Cervicogenic Headache” in the Family Practice News
reported on a study of 114 patients, most of whom
“were aged 30–50 years and had a history of the
headaches for less than 2 years. About half had a
history of trauma.” Of these, “twenty-one patients
improved permanently after the block alone and
never required surgery.” All of these patients had
degenerative conditions “of the cervical spine and
were more than 60 years old.” With average follow-
up at 3.8 years, “70% of the entire cohort of 114
patients achieved complete improvement,” with
partial improvement noted in another 18%.
Baker, Barbara. “Nerve Root Block Probes Cervicogenic
Headache,” Family Practice News 30, no. 18 (September
15, 2000): 14.
Cleveland Clinic, The. “Nerve Block: Does It Work?” Depart-
ment of Patient Education and Health Information.
Available online. URL: http://www.clevelandclinic.org/
health/health-info/docs/0300/0325.asp?index=4417.
Downloaded February 10, 2006.
Richeimer, Steven, M.D. “Nerve Blocks: Medication
Injections,” SpineUniverse. Available online. URL:
http://www.spineuniverse.com/displayarticle.php/
article1518.html. Last updated June 27, 2005.
nerve compression Not one disorder but many,
nerve compression commonly occurs in the form
of carpal tunnel syndrome, but in the
VERTEBRAE
of the
BACK and SPINE, nerve compression can be
felt throughout the body. For example, a
BRACHIAL
PLEXUS INJURY can result from a BIRTH INJURY with
compression among the nerves running from the
182 nerve compression
SPINAL CORD through the CERVICAL SPINE and into
the shoulders and arms. Also, trauma or swell-
ing in the neck and shoulders can cause
THORACIC
OUTLET SYNDROME, which weakens and sometimes
numbs upper body muscles down to the fingertips.
If injury, overuse, or the effects of
WEIGHT weigh
too heavily on the lower
LUMBAR SPINE, nerve com-
pression may cause pain, tingling, or numbness in
the legs.
Symptoms and Diagnostic Path
A diagnostic path starts with a patient history and
physical examination, including an evaluation of the
person’s
RANGE OF MOTION. To assess such potential
causes as a
HERNIATED DISC or SPINAL STENOSIS, imag-
ing tests may begin with X-
RAYS. For clear images
of the spinal nerves,
MAGNETIC RESONANCE IMAGING
may be needed, whereas a
COMPUTED TOMOGRAPHY
(CT)
SCAN may best reveal the condition of the spi-
nal canal. If the doctor suspects nerve compression
caused by an
OSTEOPHYTE or SPINAL TUMOR, a MYELO-
GRAM may pinpoint the locale.
Treatment Options and Outlook
Besides various forms of
PAIN MANAGEMENT, treat-
ments usually include physical therapy, occupa-
tional therapy, or therapeutic
EXERCISE. Spinal
manipulation and other forms of
COMPLEMENTARY
AND ALTERNATIVE MEDICINE (CAM) may also provide
effective options.
For example, a study reported in the Journal of
Vertebral Subluxation Research considered
VERTEBRAL
SUBLUXATION. According to the article, “the major
variables of compression are the rate of onset, the
amount of pressure generated, and the time main-
tained. Another major variable in the recovery is age.
The younger the nerve tissue the better chance for a
full recovery.” Also, “the garden hose theory or hard
bone-soft nerve explanation of vertebral subluxation
is considered by some to be archaic but appears to
be a valid entity at least in the lower cervical spine.
More research is needed to decipher the susceptibil-
ity to mild pressure increases throughout the spine.”
If conservative treatments fail to alleviate nerve
pressure,
SURGERY may be needed in about 5 per-
cent of the cases. For instance, such procedures
as
CERVICAL LAMINAPLASTY and LAMINECTOMY can
decompress the pressure on spinal nerves.
Risk Factors and Preventive Measures
According to the North American Spine Soci-
ety (NASS), “people with cervical” pain and
other neck problems “frequently avoid activity.
Decreased activity reduces flexibility, strength
and cardiovascular endurance.” Conversely, “a
physical therapy or exercise program usually
begins with stretching exercises to restore flex-
ibility to tight muscles in the neck, trunk, arms
and legs. You may be asked to stretch frequently
to preserve flexibility.” Furthermore, “everyday
activities will be easier if flexibility, strength and
endurance are maintained and increased. Your
physical therapist and doctor can tell you how to
add a continuing exercise program into your life,
either at home using simple equipment or at a
fitness facility. . . . For people needing additional
assistance, home alterations and safety should be
considered. An occupational therapist can pro-
vide suggestions for easy performance of every-
day tasks such as bathing, dressing and fine motor
tasks such as turning keys, opening jars, using
phones and computers.”
Alderson, R. Scott and George J. Muhs. “The Effects of
Mild Compression on Spinal Nerve Roots with Impli-
cations for Models of Vertebral Subluxation and the
Clinical Effects of Chiropractic Adjustment,” Journal of
Vertebral Subluxation Research 4, no. 2, (May 2001).
Hoyle, Brian Douglas. “Nerve Compression,” eNotes.
com. Available online. URL: http://health.enotes.
com/neurological-disorders-encyclopedia/nerve-
compression. Downloaded February 15, 2006.
North American Spine Society. “Cervical Stenosis &
Myelopathy,” NASS. Available online. URL: http://
www.spine.org/articles/cervicalstenosis.cfm. Down-
loaded February 15, 2006.
nerve conduction study or nerve conduction
velocity (NCV) test Used to measure the speed
of electrical impulses soaring through the ner-
vous system, this diagnostic tool also assesses spi-
nal nerve damage. Results vary from one area of
the body and one person to another, but gener-
ally speaking, the faster the nerve conduction, the
stronger the nerve.
nerve conduction study or nerve conduction velocity (NCV) test 183
Procedure
A day or two before a nerve conduction velocity
(NCV) test, patients must stop using any
MUSCLE
RELAXANT and also skin oils or lotion. Fever and heat
affect the accuracy of an NCV, too, since a higher
body temperature can speed nerve impulses.
To describe the procedure, the St. John’s Mercy
Health Care Web site said, “A recording electrode
will be attached to the skin over the nerve with
a special paste and a stimulating electrode will be
placed at a known distance away from the record-
ing electrode. The nerve will be stimulated by a
mild and brief electrical shock given through the
stimulating electrode. You may experience minor
discomfort for a few seconds. The stimulation of the
nerve and the detected response will be displayed
on an oscilloscope (a monitor that displays electri-
cal activity in the form of waves).”
In writing for Yale New Haven Health, R.N. Jan
Nissl said, “With the nerve conduction studies, you
will feel a brief, burning pain, a tingling sensation,
and a twitching of the muscle each time the electri-
cal pulse is applied. It feels similar to the kind of tin-
gling you feel when you rub your feet on the carpet
and then touch a metal object. The testing can be
quite uncomfortable and makes some people ner-
vous. Keep in mind that only a very low-voltage
electrical current is used, and each electrical pulse
is very brief (less than a millisecond).”
An NCV may be part of a diagnostic program
during hospitalization. When given in an outpa-
tient setting though, the patient may need to curtail
regular daily
ACTIVITY for the remainder of the day.
Risks and Complications
This test should be postponed for patients with
ACUTE
PAIN, fever, or an injury to the SPINAL CORD. People
who wear a pacemaker or take blood-thinners may
not be able to have a nerve conduction study. Oth-
erwise, the electrical voltage used in an NCV should
cause no problem or injury.
Outlook and Lifestyle Modifi cations
Since an NCV evaluates various types of conditions
affecting the
BACK or SPINE, the outcome affects the
outlook. For example, the study may show a need
to treat
POST-POLIO SYNDROME, SCIATICA, or a HERNI-
ATED DISC.
According to the North Memorial Medical Cen-
ter, “Nerve damage or disease may still exist despite
normal NCV results. This is because other healthy
fibers in the same nerve may show a normal reac-
tion time.” To evaluate
MUSCULOSKELETAL DISOR-
DERS, an NCV may be used in conjunction with an
ELECTROMYOGRAM.
McLaughlin, Eileen. “Nerve Conduction Velocity Test,”
North Memorial Medical Center, Health Encyclopedia.
Available online. URL: http://www.northmemorial.
com/HealthEncyclopedia/content/1375.asp. Down-
loaded February 10, 2006.
Nissl, Jan. “Electromyogram (EMG) and Nerve Conduc-
tion Studies,” Yale New Haven Health. Available online.
URL: http://yalenewhavenhealth.org/library/health-
guide/en-us/Medicaltests/topic.asp?hwid=hw213
852&. Last updated October 5, 2004.
St. John’s Mercy Health Care. “Nerve Conduction Veloc-
ity (NCV),” Tests & Procedures. Available online. URL:
http://www.stjohnsmercy.org/healthinfo/test/neuro/
TP013.asp. Downloaded February 10, 2006.
neuropathy See CHRONIC BACK PAIN.
neurostimulation As an option after FAILED BACK
SURGERY, this treatment offers an alternative for
managing
CHRONIC PAIN without increasing medi-
cation. For example, neurostimulation can be used
to reduce pain in patients with
ARACHNOIDITIS and
DEGENERATIVE DISC DISEASE.
In describing the concept, Medtronic Pain
Therapies said, “Neurostimulation delivers low
voltage electrical stimulation to the spinal cord or
targeted . . . nerve to block the sensation of pain.”
This ongoing treatment may be administered
through an external device or system. As an inter-
nal device though, “the neurostimulation system,
implanted in the epidural space, stimulates these
pain-inhibiting nerve fibers, masking the sensa-
tion of pain with a tingling sensation.”
Procedure
The American Pain & Wellness Web site explained,
“The trial screening procedure—or test stimula-
tion—consists of a short test stimulation period
184 neuropathy
in the operating room followed by an evaluation
period of several days at home. During the evalu-
ation period, you and your doctor determine your
response to neurostimulation and your level of pain
relief. This trial gives you an opportunity to expe-
rience the system and enables the doctor to assess
your battery requirements. During the trial screen-
ing, your doctor will place a lead in your back to
deliver electrical stimulation to the spinal cord. The
lead placement is one of the keys to successful results
with a neurostimulation system. . . . Typically, you
will receive a local anesthetic and mild sedatives to
keep you comfortable during the procedure.”
Risks and Complications
Neurostimulation can interfere with a pacemaker,
whereas
MAGNETIC RESONANCE IMAGING and ULTRA-
SOUND THERAPY interfere with neurostimulation.
Also, the safety of the treatment has not been stud-
ied in
INFANTS, CHILDREN, and pregnant women.
Adverse events have included increased pain, elec-
trical jolts, and paralysis.
Outlook and Lifestyle Modifi cations
According to an article posted by The Spine Insti-
tute, “because neurostimulation works in the area
where pain signals travel, electrical impulses can be
directed to cover specific sites where you are feel-
ing pain. Neurostimulation can give effective pain
relief and decrease the need for pain medications. In
addition, this therapy is non-destructive. Typically,
patients who have success with neurostimulation
experience a 50% greater reduction in their pain
and improved ability to go about daily activities.”
American Pain & Wellness. “Spinal Injections/ Procedures,
Neurostimulation.” Available online. URL: http://
www.painandwellness.com/spinal_injections_neuro-
stimulation.html. Downloaded February 10, 2006.
Medtronic Pain Therapies™. “Neurostimulation.”
Available online. URL: http://www.medtronic.com/
neuro/paintherapies/pain_treatment_ladder/neuro
stimulation/neuro_neurostimulation.html. Down-
loaded February 15, 2006.
Spine Institute, The. “Electrical Stimulation,” Saint John’s
Health Center. Available online. URL: http://www.
espineinstitute.com/PainMngmt_ElectricalStimulation.
htm. Downloaded February 15, 2006.
nonsteroidal anti-inflammatory drug (NSAID)
therapy As the name partially implies, an
NSAID offers an option to steroids as a treatment
for inflammation, fever, and pain. Available as
either
OVER-THE-COUNTER PRODUCTS or prescription
strength drugs, NSAIDs include
ASPIRIN, IBUPROFEN,
NAPROXEN, and Nabumetone, but not ACETAMINO-
PHEN since the latter does not ease inflammation.
As the American Academy of Orthopaedic Sur-
geons (AAOS) explained, “NSAIDs work by pre-
venting an enzyme (a protein that triggers changes
in the body) from doing its job. The enzyme is called
cyclooxygenase, or COX, and it has two forms.
COX-1 protects the stomach lining from harsh acids
and digestive chemicals; it also helps maintain kid-
ney function. COX-2 is produced when joints are
injured or inflamed.” However, “traditional NSAIDs
block the actions of both COX-1 and COX-2, which
is why they can cause stomach upset and bleeding
as well as ease pain and inflammation.”
Risks and Complications
By inhibiting the protective action of COX-1,
NSAIDs can upset the stomach and even cause
internal bleeding. Therefore,
ELDERLY persons and
patients who have blood-clotting problems or who
take other types of blood-thinners should avoid
NSAIDs.
According to the December 23, 2004, FDA Talk
Paper, “The Food and Drug Administration (FDA)
today issued a Public Health Advisory summariz-
ing the agency’s recent recommendations concern-
ing the use of non-steroidal anti-inflammatory
drug products (NSAIDs), including those known as
COX-2 selective agents. The public health advisory
is an interim measure, pending further review of
data that continue to be collected.” Furthermore,
the FDA announced, “Preliminary results from
a long-term clinical trial (up to three years) sug-
gest that long-term use of a non-selective NSAID,
naproxen (sold as Aleve, Naprosyn and other trade
name and generic products), may be associated with
an increased cardiovascular (CV) risk compared
to placebo.” However, “non-selective NSAIDs are
widely used in both over-the-counter (OTC) and
prescription settings. As prescription drugs, many
are approved for short-term use in the treatment of
pain . . . and for longer-term use to treat the signs
nonsteroidal anti-inflammatory drug (NSAID) therapy 185
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