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I have been diagnosed with disc herniation, is an operation necessary? – What other therapy options exist? …- What can happen, what is the worst case scenario? – How do you decide, whether or not an operation is necessary? – How can nerve function objectively be measured? – Is there a time-window for non-surgical approaches in my case?

With these and similar questions oftentimes people come for consultation into my office.

In the following section, I want to show you step by step the course of a neurological and neurophysiological examination, what examinations are done to answer these questions.

Disc herniation, Radiculopathy
  • detailed medical history
    • This means: In this step, it is important that the doctor listens carefully and fully understands the presenting complaints. In some circumstances, it is important to talk about what is the major complaint, what is the personal goal of medical therapy (these are not always the same points as the doctor thinks and not always the same between two individuals despite identical medical diagnosis)
    • Questions to be answered in this step of the examination: which symptoms exist, when did the symptoms start, what implications do these symptoms have for everyday life, what are individual therapy goals, etc.
During this important first step oft he neurological examination, the concept for the further examination develops, where to take a closer look, where to plan more detailed investigations, etc.
  • Neurological examination
    • This means: A clinical neurological examination includes testing of muscle strength, reflexes, sensory system, coordination, etc. Each nerve or nerve root is responsible for certain skin areas, muscles and reflexes –the examination should focus on the nerve root possibly involved by disc herniation.
    • Questions to be answered in this step of the examination: Are symptoms really caused at the level of the spine? Are other causes possible? Are there any hints for deficits of nerve function? Which nerve root is involved? How severe are nerve deficits?

neurologische-untersuchung

As you can see, I place a lot of emphasis on the first „simple“ examination steps: history taking and clinical-neurological examination.

During each step of the examination hypotheses are established, tested or discarded. After having taken the medical history and after clinical examination a good neurologist has in most cases already reached a working hypothesis about the diagnosis.

Although a general approach I have outlined here, there is no „set formula“ for a good neurological examination. It is important to say, that the focus and details of the examination are always individually planned.

  • Nerve conduction studies (NCS)
    • This means: measuring nerve conduction velocity and nerve conduction ability in general
    • Questions to be answered in this step of the examination: Does the disc herniation causes damage or only irritation of a nerve? Are there cues, that the nerve damage happens in another localization than the spine/intervertebral disc? For instance, is a nerve entrapment syndrome causing the reported symptoms, imitating symptoms caused by disc herniation?

nlg-untersuchung

It is not a rare finding during a thorough neurological examination, that symptoms are actually not caused by disc herniation but are due to a „pinched nerve“ in another place (nerve entrapment e.g.). In this case, it would be advisable to proceed with nerve ultrasound examination, to take a closer look at the suspected nerve entrapment site (for more information see: www.nervenultraschall.de).
  • Electromyography (EMG)
    • This means: assessing muscles and the nerve cells that control them (motor neurons). In this case: assessment of exactly those motor nerve fibers that are suspected to be damaged by a herniated disc
    • Questions to be answered in this step of the examination: has a damage of motor nerve fibers occurred (that is, those nerve fibers that control a muscle, causing the muscle to twitch)? If yes, is this damage mild, moderate or severe? Acute or chronic?
  • Sensory evoked potentials (SEP)
    • This means: testing sensory nerve fibers. In this case: assessment of exactly those sensory nerve fibers that are suspected to be damaged by a herniated disc
    • Questions to be answered in this step of the examination: has a damage of sensory nerve fibers occurred (that is, those nerve fibers that convey sensory information from skin areas e.g.) If yes, how severe?
Depending on the exact symptoms, the examination steps may vary in individual cases.
  • Discussion of results:
    • What is the medical diagnosis? How to estimate the diagnostic accuracy? Are further examinations necessary? What can be said about nerve function? Is a nerve/nerve root actually damaged or “only” irritated? What does this mean for the planning of therapy?
  • Discussion of further course of action:
    • Is a surgery advisable? Are there impending irreversible neurological deficits? Can a time-window for non-surgical approaches be defined? What possibilities exist?
  • Written Report
    • After the consultation, a written report is usually sent to the referring doctor and at your home address. This facilitates coordination of subsequent therapy measures.
Here you can book an appointment for a neurological examination, second-opinion consultation e.g. In the case of a disc herniation scheduled examination time is 60minutes for the initial examination.

A diagnosis has been made – what happens next?

A good therapy of patients suffering from disc herniation relies on a good „teamplay“ of the whole therapeutic team involved (GP, orthopedist, spine specialist, neurosurgeon, physiotherapist, manual therapy, acupuncture …). If you wish, I can counsel on further therapy steps and provide support for subsequent therapy measures. Sometimes during the course of time, therapy has to be adapted to new situations, changed, tapered or intensified. In these situations, a neurological control examination is advisable, if necessary also the question about the necessity of an operation might has to be reviewed again.

Carpal Tunnel Syndrome

A detailed description oft he steps of the neurological examination in the case of a suspected pinched nerve (taking the example of carpal tunnel syndrome) you will find here

Closing remarks

Above you will find a representative example for a detailed and reliable neurological and electrophysiological examination, as offered in my practice. I do hope, I could convey my concept, the focus of my work and my way of working. Of course, there are numerous other situations, in which a neurological examination and therapy can be helpful. If you have any questions, please do not hesitate to ask me or if you want to discuss these personally, you can book an appointment here.