Ch 63 Low Back Pain and Intervertebral Disc Disease

Etiology and Pathophysiology •Low back pain common because lumbar region -Bears most of body weight -Is most flexible -Contains nerve roots -Has poor biomechanical structure

Low back pain is a common problem because the lumbar region (1) bears most of the weight of the body, (2) is the most flexible region of the spinal column, (3) contains nerve roots that are at risk for injury or disease, and (4) has a naturally poor biomechanical structure.

Chronic Low Back Pain Interprofessional Care •Weight reduction •Sufficient rest periods •Local heat and cold application •Physical therapy •Exercise and activity throughout day •Complementary and alternative therapies •Back School

Weight reduction, sufficient rest periods, local heat or cold application, physical therapy, and exercise and activity throughout the day assists in keeping the muscles and joints mobilized. Cold, damp weather aggravates the back pain, which can be decreased with rest and local heat application. Complementary and alternative therapies such as biofeedback, acupuncture, and yoga may also help to reduce the pain. "Back School" can significantly reduce pain and improve body posture.

Charite Disc This artificial disc is made up of a high-density core sandwiched between two cobalt-chromium endplates.

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Chronic Low Back Pain •Lasts longer than 3 months or involves a repeated incapacitating episode •Often progressive •Various causes -Degenerative or metabolic disease -Weakness from scar tissue -Chronic strain -Congenital spine problems

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Chronic Low Back Pain •Spinal stenosis -Narrowing of spinal canal -Acquired conditions •Osteoarthritis most common •Rheumatoid arthritis, tumors, Paget's disease, trauma -Inherited conditions •Congenital spinal stenosis •Scoliosis

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Degenerative Disc Disease Visual depicting various stages of degenerative disc disease. The disc can first bulge before herniating.

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Intervertebral Disc Disease Surgical Therapy •Laminectomy -Surgically remove disc through excision of part of vertebra •Diskectomy -Surgically decompress nerve root -Microsurgical or percutaneous technique

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Intervertebral Disc Disease Surgical Therapy •Spinal fusion -Spine is stabilized by creating an ankylosis (fusion) of contiguous vertebrae -Uses a bone graft from patient's fibula or iliac crest or from a donated cadaver bone -Metal fixation can add to stability -Bone morphogenetic protein (BMP) to stimulate bone grown of graft

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Nursing Implementation Ambulatory and Home Care •Goal is to make an episode of acute low back pain an isolated incident •Patient teaching imperative •Occupational counseling •Emotional support

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Nursing Implementation Health Promotion •Proper body mechanics •"Back School" •Appropriate body weight •Proper sleep positioning •Firm mattress •Stop smoking

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Nursing Implementation Patient Teaching •Do Not -Lean forward without bending knees -Lift anything above level of elbows -Stand in one position for prolonged time -Sleep on abdomen or on back or side with legs out straight -Exercise without consulting health care provider if having severe pain

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Nursing Management Spinal Fusion: Postoperative •Prolonged limited activity •Rigid orthosis -Verify and teach how to apply •Cervical spine -Observe for spinal cord edema -Immobilize neck

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Nursing Management Spinal Fusion: Postoperative •Teaching regarding activity -Proper body mechanics -Avoid prolonged sitting or standing. -Encourage walking, lying down, shifting weight -No lifting, twisting -Use thighs and knees to absorb shock -Firm mattress or bed board

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Nursing Management Spinal Surgery: Postoperative •Monitor GI and bowel function -Administer stool softeners •Monitor and assist with bladder emptying -Loss of tone may indicate nerve damage •Notify surgeon immediately if bowel or bladder incontinence

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Nursing Management Vertebral Disc Surgery •Maintain proper alignment •Allowed activity varies •Post lumbar fusion -Pillows under thighs when supine -Between legs when side-lying •Reassure patient

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Intervertebral Disc Disease Surgical Therapy •Interspinous process decompression system (X Stop) -Titanium →fits into mount placed on vertebrae -To treat lumbar spinal stenosis -Lifts vertebrae off pinched nerve

A third procedure involves use of an interspinous process decompression system (X Stop). This titanium device fits onto a mount that is placed on vertebrae in the lower back. The X Stop is used in patients with pain due to lumbar spinal stenosis. The device works by lifting the vertebrae off the pinched nerve.

Nursing Implementation Patient Teaching •Do -Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing -Maintain appropriate body weight

Advise patients to maintain appropriate body weight. Excess body weight places additional stress on the lower back and weakens the abdominal muscles that support the lower back.

Acute Low Back Pain Acute Care •Teach patients -Cause of their pain -Ways to prevent additional episodes -Strengthening and stretching exercises

Although exercises are often taught by a physical therapist, reinforce the type and frequency of prescribed exercise and the rationale for the program.

Intervertebral Disc Disease Surgical Therapy •Intradiscal electrothermoplasty (IDET) -Minimally invasive outpatient procedure -Needle inserted into affected disc -Wire threaded into disc and heated → denervates nerve fibers

An intradiscal electrothermoplasty (IDET) is a minimally invasive outpatient procedure for treatment of back and sciatica pain. A needle is inserted into the affected disc with x-ray guidance. A wire is then threaded down through the needle and into the disc. As the wire is heated, the small nerve fibers that have invaded the degenerating disc are destroyed. The heat also partially melts the annulus fibrosus. This causes the body to generate new reinforcing proteins in the fibers of the annulus.

Intervertebral Disc Disease Surgical Therapy •Radiofrequency discal nucleoplasty (coblation nucleoplasty) -Needle inserted similar to IDET -Radiofrequency probe generates energy → breaks up nucleus pulposus -Up to 20% of nucleus is removed -Decompresses disc

Another outpatient technique is radiofrequency discal nucleoplasty (coblation nucleoplasty). A needle is inserted into the disc similar to IDET. Instead of a heated wire, a special radiofrequency probe is used. The probe generates energy that breaks up the molecular bonds of the gel in the nucleus pulposus. Up to 20% of the nucleus is removed. This decompresses the disc and reduces pressure on the disc and the surrounding nerve roots. Subsequent pain relief varies among patients.

Audience Response Question When caring for a patient following a lumbar laminectomy, the nurse should a.place a pillow between the patient's legs before turning to the side. b.elevate the head of the bed 30 degrees and then turn the patient to the side. c.ask the patient to flex the knees and push the heels into the bed during turning. d.have the patient grasp the side rail on the opposite side of the bed to help with turning.

Answer: A Rationale: Place pillows between the legs before turning the patient and when in the side-lying position to provide comfort and ensure alignment. Twisting movements are not allowed. Also, the patient's spine will need to be kept in alignment without flexion of the hips by elevating the head of the bed.

Nursing Management Spinal Surgery: Postoperative •Potential for cerebrospinal fluid (CSF) leakage •Monitor for and report severe headache or leakage of CSF -Clear or slightly yellow drainage on dressing -+ For glucose

Because the spinal canal may be entered during surgery, cerebrospinal fluid (CSF) leakage is possible. Immediately report leakage of CSF on the dressing or if the patient complains of severe headache. CSF appears as clear or slightly yellow drainage on the dressing. It has a high glucose concentration and will be positive for glucose when tested with a dipstick. Note the amount, color, and characteristics of drainage.

Nursing Implementation Patient Teaching •Do -Exercise 15 minutes in the morning and evening regularly -Carry light items close to body -Use local heat and cold application -Use a lumbar roll or pillow for sitting

Begin exercises with 2- or 3-minute warm-up period by moving arms and legs, alternate relaxing and tightening muscles; exercise slowly with smooth movements.

Intervertebral Disc Disease Etiology and Pathophysiology •Degenerative disc disease (DDD) -Loss of elasticity, flexibility, and shock-absorbing capabilities -Disc becomes thinner as nucleus pulposus dries out → load shifted to annulus fibrosus → progressive destruction →pulposus seeps out (herniates)

Degenerative disc disease (DDD) results from increased wear and tear on the intervertebral discs with aging. The discs lose their elasticity, flexibility, and shock-absorbing abilities. Unless it is accompanied by pain, this wear and tear condition is a normal process. Thinning of the discs occurs as the nucleus pulposus (gelatinous center of the disc) starts to dry out and shrink. This limits the disc's ability to distribute pressure loads between the vertebrae. The pressure is then transferred to the annulus fibrosus (strong outside portion of the disc), causing progressive destruction. When the disc is damaged, the nucleus pulposus may seep through a torn or stretched annulus. This is called a herniated disc (slipped disc), a condition in which a spinal disc bulges outward between the vertebrae.

Intervertebral Disc Disease Interprofessional Care •Conservative Therapy -Drug therapy •NSAIDs •Short-term corticosteroids •Opioids •Muscle relaxants •Antiseizure drugs, antidepressants -Epidural corticosteroid injections

Drug therapy to manage pain includes NSAIDs, short-term use of corticosteroids, opioids, analgesics, muscle relaxants, antiseizure drugs, and antidepressants. Epidural corticosteroid injections may reduce inflammation and relieve acute pain. However, if the underlying cause remains, pain tends to recur.

Acute Low Back Pain •Few definitive diagnostic abnormalities •Straight-leg raising test -Positive for disc herniation when radicular pain occurs •MRI and CT scan only for trauma or suspected systemic disease

Few definitive diagnostic abnormalities are present with nerve irritation and muscle strain. One test is the straight leg raising test. MRI and CT scans are generally not done unless trauma or systemic disease (e.g., cancer, spinal infection) is suspected. MRI findings may also be limited in the acute phase of an injury due to increased edema near the injury.

Acute Low Back Pain Nursing Assessment •Objective Data -Guarded movement -Depressed or absent Achilles tendon or patellar reflex -+ Straight leg raise test -+ Crossover straight leg test -+ Trendelenburg test -Tense, tight paravertebral muscles -↓ Range of motion in spine

Focused assessment findings include the following: General Guarded movement Neurologic Depressed or absent Achilles tendon reflex or patellar tendon reflex Positive straight leg-raising test, positive crossover straight leg-raising test, positive Trendelenburg test Musculoskeletal Tense, tight paravertebral muscles on palpation, ↓ range of motion in spine

Nursing Management Spinal Surgery: Postoperative •Frequently assess peripheral neurologic signs •Every 2 to 4 hours during first 48 hours post surgery •Compare with preoperative status •Assess circulation (temp, capillary refill, pulses)

Frequently assess the patient's peripheral neurologic condition after spinal surgery. Movement of the arms and legs and assessment of sensation should at least equal the preoperative status. Paresthesias (numbness and tingling) may not be relieved immediately after surgery. Report any new muscle weakness or paresthesias immediately to the surgeon and document this finding in the patient's medical record. Assess extremity circulation using skin temperature, capillary refill, and pulses.

Intervertebral Disc Disease Surgical Therapy •Indicated when -Conservative treatment fails -Radiculopathy worsens -Loss of bowel or bladder control -Constant pain -Persistent neurologic deficit

If conservative treatment is unsuccessful, radiculopathy becomes worse, or loss of bowel or bladder control (cauda equine syndrome) occurs, surgery may then be considered. Surgery for a damaged disc is generally indicated when the patient is in constant pain and/or has a persistent neurologic deficit.

Acute Low Back Pain Acute Care •Treat as outpatient if not severe -NSAIDs, muscle relaxants -Massage -Back manipulation -Acupuncture -Cold and hot compresses •Severe pain - corticosteroids, opioids

If the acute muscle spasms and accompanying pain are not severe and unbearable, the patient may be treated as an outpatient with NSAIDs and muscle relaxants (e.g., cyclobenzaprine [Flexeril]). Massage and back manipulation, acupuncture, and the application of cold and hot compresses may help some patients. Severe pain may require a brief course of corticosteroids or opioid analgesics.

Nursing Management Spinal Fusion: Postoperative •Regularly assess bone graft donor site -Posterior iliac crest -Fibula •Usually more painful than fusion area •Pressure dressing •Neurovascular assessments if fibula is donor site

In addition to the primary surgical site, regularly assess the bone graft donor site. The posterior iliac crest is the most commonly used donor site, although the fibula may also be used. The donor site usually causes greater pain than the spinal fusion area. The donor site is bandaged with a pressure dressing to prevent excessive bleeding. If the donor site is the fibula, frequent neurovascular assessments of the extremity is a postoperative nursing responsibility.

Intervertebral Disc Disease Clinical Manifestations •Cervical disc disease -Pain radiates to arms and hands. -↓ Reflexes and handgrip -May include shoulder pain and dysfunction

In cervical disc disease pain radiates into the arms and hands, following the pattern of the involved nerve. Similar to lumbar disc disease, reflexes may or may not be present. The handgrip is often weak. Because manifestations of cervical disc disease may include shoulder pain and dysfunction, the HCP must rule out shoulder disorders as part of the diagnosis.

Intervertebral Disc Disease Clinical Manifestations •Low back pain most common •Radicular pain •+ Straight leg raise •↓ or absent reflexes •Paresthesia •Muscle weakness

In lumbar disc disease the most common manifestation is low back pain. Radicular pain that radiates down the buttock and below the knee, along the distribution of the sciatic nerve, generally indicates disc herniation. A positive straight leg raising test may indicate nerve root irritation. Back or leg pain may be reproduced by raising the leg and flexing the foot at 90 degrees. Low back pain from other causes may not be accompanied by leg pain. Reflexes may be depressed or absent, depending on the spinal nerve root involved. Paresthesia or muscle weakness in the legs, feet, or toes may occur.

INTERVERTEBRAL DISC DISEASE Intervertebral Disc Disease Etiology and Pathophysiology •Intervertebral discs separate vertebrae and help absorb shock •Disease involves deterioration, herniation, or other dysfunction •Involves all levels

Intervertebral discs separate the vertebrae of the spinal column and help absorb shock for the spine. An intervertebral disc disease involves the deterioration, herniation, or other dysfunction of the intervertebral discs. Disc disorders can affect the cervical, thoracic, and lumbar spine.

Etiology and Pathophysiology •Occupational risk factors -Repetitive lifting -Vibration -Extended periods of sitting -Health care personnel engaged in patient care

Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and extended periods of sitting are also associated with low back pain. Health care personnel who perform direct patient care activities are at high risk for the development of low back pain. Lifting and moving patients, excessive bending or leaning position, and frequent twisting can result in low back pain that causes lost time and productivity and/or disability.

LOW BACK PAIN Incidence •Affects ~80% of adults in United States at least once •Second only to headache as most common pain complaint •Leading cause of job-related disability •Major contributor to missed work days

Low back pain is common and has affected about 80% of adults in the United States at least once during their lives. Backache is second only to headache as the most common pain complaint. Low back pain is the leading cause of job-related disability, and a major contributor to missed work days.

Etiology and Pathophysiology •Most often due to musculoskeletal problem •Localized or diffuse •Radicular pain- irritation of nerve root •Referred pain- source of pain is another location

Low back pain is most often due to a musculoskeletal problem. It may be experienced as localized or diffuse. In localized pain patients will feel soreness or discomfort when a specific area of the lower back is palpated or pressed. Diffuse pain occurs over a larger area and comes from deep tissue layers. Low back pain may be radicular or referred. Radicular pain is caused by irritation of a nerve root. Radicular pain is not typically isolated to a single location, but instead radiates or moves along a nerve distribution. Sciatica is an example of radicular pain. Referred pain is "felt" or perceived in the lower back, but the source of the pain is another location (e.g., kidneys, lower abdomen).

Chronic Low Back Pain Interprofessional Care •Minimally invasive treatments -Epidural corticosteroid injections -Implanted devices to deliver analgesia •Surgery

Minimally invasive treatments, such as epidural corticosteroid injections and implanted devices that deliver pain medication, may be used for patients with chronic low back pain that fails to respond to the usual therapeutic options. Surgical intervention may be indicated in patients with severe chronic low back pain who receive no benefit from conservative care and/or have continued neurologic deficits. Specific surgical interventions will be discussed after intervertebral disc disease.

Intervertebral Disc Disease Clinical Manifestations •Multiple nerve root (cauda equina) compression -Sever low back pain -Progressive weakness -Increased pain -Bowel and bladder incontinence -Medical emergency

Multiple nerve root compressions (cauda equina syndrome) from a herniated disc, tumor, or epidural abscess may be marked by (1) severe low back pain, (2) progressive weakness, (3) increased pain, and (4) bowel and bladder incontinence. This condition is a medical emergency that requires surgical decompression to reduce pressure on the nerves.

Acute Low Back Pain Nursing Diagnoses •Acute pain •Impaired physical mobility •Ineffective coping •Ineffective health management

Nursing diagnoses for the patient with osteomyelitis may include, but are not limited to, the following: Acute pain related to muscle spasm and ineffective comfort measures Impaired physical mobility related to pain as evidenced by movement restrictions and muscle spasms Ineffective coping related to effects of acute pain Ineffective health management related to knowledge deficit, complexity of therapeutic regimen, or lack of perceived benefits regarding posture, exercises, and body mechanics

Chronic Low Back Pain Interprofessional Care •Similar to acute low back pain •Drug therapy -Mild analgesics -Antidepressants -Gabapentin (Neurontin)

Nursing management and treatment of chronic low back pain are similar to those recommended for acute low back pain. Manage the patient's pain and stiffness with mild analgesics, such as NSAIDs, is integral to the daily comfort of the individual with chronic low back pain. Antidepressants (e.g., duloxetine [Cymbalta]) may help with pain management and sleep problems. The antiseizure drug gabapentin (Neurontin) may improve walking and relieve leg symptoms.

Acute Low Back Pain Nursing Assessment •Subjective Data -Acute or chronic lumbosacral strain/ trauma, osteoarthritis, degenerative disc disease -Use of opioid analgesics and NSAIDs, muscle relaxants, corticosteroids, OTC remedies -Previous back surgery, epidural injections

Obtain the following important health information from the patient: Past health history: Acute or chronic lumbosacral strain/trauma, osteoarthritis, degenerative disc disease, obesity Medications: Use of opioid analgesics, nonsteroidal anti-inflammatory drugs, muscle relaxants, corticosteroids, over-the-counter remedies (e.g., topical ointments, patches) Surgery or other treatments: Previous back surgery, epidural corticosteroid injections

Acute Low Back Pain Nursing Assessment •Subjective Data -Smoking, lack of exercise -Obesity -Poor posture, muscle spasms, activity intolerance -Constipation

Obtain the following important health information related to pertinent functional health patterns: Health perception-health management: Smoking, lack of exercise Nutritional-metabolic: Obesity Activity-exercise: Poor posture, muscle spasms, activity intolerance Elimination: Constipation

Acute Low Back Pain Nursing Assessment •Subjective Data -Interrupted sleep -Pain in back, buttocks, or leg -Numbness or tingling -Occupational risks and impact on family

Obtain the following important health information related to pertinent functional health patterns: Sleep-rest: Interrupted sleep Cognitive-perceptual: Pain in back, buttocks, or leg associated with walking, turning, straining, coughing, leg raising. Numbness or tingling of legs, feet, toes Role-relationship: Occupations requiring heavy lifting, vibrations, or extended driving, change in role within family structure due to inability to work and provide income

Nursing Implementation Patient Teaching •Do -Sleep in a side-lying position with knees and hips bent -Sleep on back with a lift under knees and legs or back with 10-inch-high pillow under knees to flex hips and knees

Position assumed while sleeping is important in preventing low back pain. Tell patients to avoid sleeping in a prone position because this produces excessive lumbar lordosis, placing excessive stress on the lower back.

Acute Low Back Pain Nursing Assessment •Objective Data -Lesion or disorder on myelogram, CT scan, or MRI -Nerve root impingement on electromyography (EMG)

Possible Diagnostic Findings Localization of site of lesion or disorder on myelogram, CT scan, or MRI Determination of nerve root impingement on electromyography (EMG)

Nursing Management Spinal Surgery: Postoperative •Opioids for 24 to 48 hours •Patient-controlled analgesia (PCA) •Switch to oral drugs when able •Muscle relaxants •Assess and document pain intensity, and pain management effectiveness

Postoperatively, most patients will require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia (PCA) allows maintenance of optimal analgesic levels and is the preferred method of continuous pain management during this time. Once the patient receives oral fluids, oral drugs such as acetaminophen with codeine, hydrocodone (Vicodin), or oxycodone (Percocet) may be used. Diazepam (Valium) may be prescribed for muscle relaxation. Assess and document pain intensity and pain management effectiveness.

Acute Low Back Pain Acute Care •Brief period of rest at home may be necessary -Avoid prolonged bed rest •Avoid activities that increase pain -Lifting, bending, twisting -Prolonged sitting

Some people may need a brief period (1 to 2 days) of rest at home, but should avoid prolonged bed rest. Most patients do better if they continue their regular activities. Patients should refrain from activities that increase the pain, including lifting, bending, twisting, and prolonged sitting. Symptoms of acute low back pain generally improve within 2 weeks and often resolve without treatment.

Etiology and Pathophysiology •Causes -Lumbosacral strain/instability -Osteoarthritis -Degenerative disc disease/herniation

The causes of low back pain of musculoskeletal origin include (1) acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5) herniation of an intervertebral disc.

Intervertebral Disc Disease Surgical Therapy •Artificial disc replacement -Charité or Prodisc-L disc for lumbar DDD -Prestige cervical disc system -Surgically placed in spine through small incision after damaged disc is removed -Allows for movement at level of implant

The goals of artificial disc replacement surgery are to restore movement and eliminate pain. The Charité disc is used in patients with lumbar disc disease associated with DDD. This artificial disc has a high-density core sandwiched between two cobalt-chromium endplates (Fig. 63-5). After the damaged disc is removed, this device is surgically placed in the spine (usually through a small incision below the umbilicus). The disc restores movement at the level of the implant. The Prodisc-L is another type of artificial lumbar disc that can be used to treat DDD. Options for treatment of DDD of the cervical spine include the Prestige cervical disc, Mobi-C disc, and Secure-C artificial cervical disc.

Acute Low Back Pain Planning •Overall Goals -Satisfactory pain relief -Return to previous level of activity -Correct performance of exercises -Adequate coping -Adequate self-help management

The overall goals are that the patient with acute low back pain will Report satisfactory pain relief with pain <4 on 10-point scale. Demonstrate return to prior level of mobility within prescribed restrictions. Demonstrate correct performance of exercises. Uses coping behaviors effectively to adapt to effects of acute pain. Integrate a program of appropriate posture, body mechanics, exercises, and weight management into daily routine.

Chronic Low Back Pain •Spinal stenosis - lumbar -Pain in low back and radiates to buttock and leg -↑ With walking/ prolonged standing -Numbness, tingling, weakness, heaviness in legs and buttocks -Pain ↓ when bends forward or sits down

The pain associated with lumbar spinal stenosis often starts in the low back and then radiates to the buttock and leg. It is worse with walking or prolonged standing. Numbness, tingling, weakness, and heaviness in the legs and buttocks may also be present. History of decreased pain when the patient bends forward or sits down is often a sign of spinal stenosis. In most cases the stenosis slowly progresses.

Intervertebral Disc Disease Interprofessional Care •Conservative Therapy -Limitation of movement -Local heat or ice -Ultrasound and massage -Skin traction -Transcutaneous electrical nerve stimulation (TENS)

The patient with suspected disc damage is usually managed with conservative therapy. This includes limitation of extremes of spinal movement (brace, corset, or belt), local heat or ice, ultrasound and massage, traction, and transcutaneous electrical nerve stimulation (TENS).

Intervertebral Disc Disease Etiology and Pathophysiology •Radiculopathy -Radiating pain -Numbness -Tingling -↓ Strength and/or range of motion •Osteoarthritis

The spinal nerves emerge from the spinal column through an opening (intervertebral foramen) between adjacent vertebrae. Herniated discs can press against these nerves ("pinched nerve") causing radiculopathy (radiating pain, numbness, tingling, and diminished strength and/or range of motion). Osteoarthritis of the spine is associated with DDD as the stresses placed on the vertebrae can result in osteoarthritis. As the poorly lubricated joints rub against each other, the protective cartilage is damaged and painful bone spurs occur as one of changes found in osteoarthritis.

Intervertebral Disc Disease Interprofessional Care •Back-strengthening exercises -Twice a day -Encouraged for a lifetime •Teach good body mechanics •Avoid extremes of flexion and torsion •Most patients heal in 6 months

When symptoms subside, the patient should begin back strengthening exercises twice a day and continue for life. Teach the patient the principles of good body mechanics. Discourage extremes of flexion and torsion. With a conservative treatment plan, most patients heal with after 6 months.

Intervertebral Disc Disease Diagnostic Studies •X-rays •Myelogram, MRI, or CT scan •Epidural venogram or discogram •EMG

X-rays are done to detect any structural defects. A myelogram, MRI, or CT scan is helpful in localizing the damaged site. An epidural venogram or discogram may be needed if other diagnostic studies are inconclusive. An EMG of the extremities can be performed to determine the severity of nerve irritation or to rule out other conditions such as peripheral neuropathy.