Why should I visit a neurologist in the case of a disc herniation: ?
Why should I go and visit a neurologist in the case of a disc-herniation? Should I not rather go to an orthopedic surgeon?
The main problem with a herniated disc is usually, that the disc exerts pressure on a nerve (more precise: nerve root). The work of a neurologist is to examine nerve function. With additional training in a certain subspecialist area of neurology (clinical neurophysiology, NCS, EMG), the function of nerves can be measured precisely. This is very important information to decide on the adequate therapy. Here, a close collaboration between specialists of the spine, orthopedic surgeons and neurologists is often very helpful to decide on the best treatment.
This interdisciplinary collaboration is especially useful in the following situations:
- if “nerve-symptoms” occur – possible symptoms of a “pinched nerve” at the level of the cervical or lumbar spine are: pain is not restricted to neck or lower back but radiates into arm or leg; possibly further symptoms, such as sensation of tingling, „pins and needles“, numbness, muscle weakness, etc.
- if the question has been raised, whether for instance „falling asleep“ of the hands is actually caused on the level of the cervical spine or might be caused as well by a pinched nerve in the further course of the arm (in this situation, of course, the therapeutic approach is quite different)
- if the results of the MRI suggest, that a herniated disc is exerting pressure on a nerve root
- if the MRI shows a „big“ disc herniation
- in case the MRI shows not only one but several disc herniations, possibly causing narrow passages of nerve roots, and now the question arises, which level causes the symptoms and should be targeted therapeutically – (The main advantage of modern therapeutic approaches is an oftentimes quite astonishing accuracy in the range of millimeters. The more accurate the therapy can be targeted though, the more accurate should the symptom-provoking process be localized beforehand. Targeting therapy very precise in the range of millimeters, but at the wrong spot, will not help)
- if MRI suggests, that a nerve damage might occur and the risk of persistent neurological deficits exists
- if important therapy decisions have to be made: is an operation necessary? Is there impending nerve damage?
Disc Herniation: Is an operation necessary?
Frequently I do see the constellation of a huge disc herniation that causes astonishingly little functional impairment as measured by exact neurophysiological methods. The opposite situation also occurs: the disc herniation seems only minor on MRI but clearly affects nerve function.
By means of the neurological examination, it can be distinguished, whether a nerve root is „only“ irritated or actually damaged. In my eyes, this is by far the most important criterion to decide, whether an operation is necessary or not.
Because disc herniations are frequently found on MRI (even in totally asymptomatic people), seeing a disc herniation on MRI does not mean necessarily, that this actually causes the symptoms! There are quite a number of other possible “neurological causes” that can mimick the symptoms of a disc herniation. If the symptoms are not caused by a herniated disc, the best spinal surgery will not remove the cause of the symptoms. To clarify these questions beforehand is another important aspect of the neurological examination.
So why again should I see a neurologist in the case of a disc herniation? I do see the role of the neurologist as an important part of the whole team; the neurological examination in the beginning is mainly for diagnostic purposes, to answer the following questions:
Are my symptoms actually caused by changes of the spine? Is a nerve root affected? Which one? Is the nerve root irritated or damaged? Is there a measurable deficit in nerve function? Am I at risk for persistent neurological deficits? Is an operation necessary? Is there a reasonable time-window for non-surgical therapies? etc.
Most important is a good teamplay (of course only if you want this; some people come for a second opinion only or are under care of a multi professional spine team and only come for neurological evaluation), which means discussion of findings and therapeutic approaches with the whole team involved in diagnosis and treatment (general practitioner, orthopedist, neurosurgeon, spine specialist, physiotherapist, osteopath, etc).
For more information on what exactly happens during a neurological examination in the case of suspected disc herniation, please press here
Numbness/Tingling in the hands: Is the cause an entrapped nerve? What can I do?
Why should I go and visit a neurologist in the case of a suspected carpal tunnel syndrome? Should I not rather go to a hand surgeon? – Also, a lot of people think, that tingling and numbness are caused by a deficit of blood circulation.
In fact, the so-called carpal tunnel syndrome is by far the most frequent cause of tingling and numbness of the hands. This happens far more frequent than a cause at the level of the cervical spine or a disturbance of blood supply. Even if the MRI shows degenerative changes of the cervical spine (which is the case by the way in most people, even if they are asymptomatic; the same holds true for muscle tension in the neck-shoulder-area), this could still be incidental and does not mean, that these changes are actually causing tingling and numbness in the hands.
Whether or not the symptoms are caused by carpal tunnel, another nerve entrapment syndrome (“pinched nerve”), a problem of the cervical spine or a disturbance of blood supply –it is very important to accurately examine for the actual cause of the symptoms. Only if the cause of the symptoms has been defined precisely, an effective therapy can be started.
A subspecialty area of neurology is the exact measurement of nerve function using clinical neurophysiology (NCS = nerve conduction studies, EMG = electromyography). As a neurologist trained and specialized in clinical neurophysiology, I have special expertise in testing nerve function. Using NCS and EMG, the function of the nerves or nerve roots can be very accurately measured. In the case of the hands “falling asleep” this is very useful, in order to answer the following questions:
Are my symptoms caused by a “pinched nerve”? If yes, which nerve and where exactly? Is it carpal tunnel? Another nerve compression? Or is the cervical spine actually causing my symptoms? In the case of a carpal tunnel syndrome: is there a deficit of nerve conduction („nerve damage“)? Can the nerve damage be graduated as mild, moderate or severe? That is: is it “dangerous”? Is there a risk of persisting neurological deficits? Should I opt for surgery? Is there a reasonable time-window for non-surgical therapies? Which therapeutic options exist? etc.
So, why again should I go to see a neurologist if my hands are „falling asleep“?
I do think, the question is neither “who does it best?”, nor “who knows it all?”. The question rather is, who can contribute important puzzle pieces in order to see the whole picture at the end. To see “the whole picture” a good teamplay with different medical specialists (general practitioner, hand surgeon, orthopedist, neurosurgeon, spine specialist, physiotherapist, osteopath, etc) is most important.
For more information on what exactly happens during a neurological examination in the case of a suspected “pinched nerve” (for example carpal tunnel syndrome), please press here
When do I need a NCV/EMG examination?
In the following situations the NCS/EMG examination is a valuable tool and aids in important therapeutic decisions.
- repeatedly “falling asleep” of hands or feet
- tingling, “pins and needles” of arms or legs
- numbness of arms or legs
- other sensory disturbances or paresthesias of arms or legs
- pain, especially if going along with other sensations (tingling, pins and needles, burning sensations, „like an open wound“, „like a sunburn“, etc).
- suspected pressure palsy
- muscle weakness of arms or legs
- carpal tunnel syndrome
- ulnar neuropathy at the elbow (UNE)
- Sulcus ulnaris syndrome (SUS)
- Cubital tunnel syndrome
- Loge de Guyon Syndrom
- Pressure palsy of the radial nerve
- “wrist drop”
- “Saturday night palsy”
- “Honeymonn palsy”
- Thoracic outlet Syndrome (TOS)
- Meralgia paresthetica
- Pressure palsy of the peroneal nerve
- “foot drop”
- “strawberry pickers palsy”
- “slimmers palsy”
- Tarsal tunnel syndrome
- Muscle weakness, muscle pain, muscle ache
- Muscle cramps if not reponsive to magnesium are frequently due to neurological causes
- myopathy, diseases of muscles
- Myasthenia gravis
- Lambert Eaton Syndrome
- Amyotrophic lateral sclerosis or motor neuron disease
- Due to diabetes
- Due to other causes
- Subacute comined degeneration (e.g. due to B12-deficiency)
- Disc herniation
- cervical root problems
- lumbar root lesions
- Spinal stenosis
- cervical spondylosis
- spondylotic radiculo-myelopathy
- cervical myelopathy
- spinal intermittent claudication