Category: Procedures and decisions

DO I NEED SURGERY

Two questions get collapsed into one here. Whether an operation could help you is a different question from whether the structure causing your pain has been identified — and the second one has to be answered first.

Where surgery is clearly the right answer

There is no ambiguity in some presentations and it does nobody any good to manufacture some.

• Progressive neurological deficit. Strength that is measurably declining, not pain that is severe. This is a decompression question and it is time-sensitive.
• Degenerative cervical myelopathy with functional decline. Cord compression producing clumsy hands, imbalance, or a change in gait. The clinical practice guideline supports surgical management for moderate and severe presentations, and registry data consistently show that longer symptom duration before surgery predicts a worse functional recovery afterward. This is the one diagnosis where waiting has a measurable cost.
• Radiculopathy that has not settled with genuine conservative management and where a structural lesion matches the examination and the level. Surgery relieves arm pain faster than conservative care in that group; the systematic reviews are fairly consistent that the advantage is in speed, and that the gap narrows over one to two years.

The findings that should not wait are listed separately, and they are short on purpose.

Where the question is premature

Most neck pain is not in the categories above. Persistent axial neck pain — pain in the neck and shoulder blade, without a matching neurological deficit — is the commonest presentation we see, and it is the one where a scan showing degenerative change is least likely to be the explanation.

Fusing a level because it looks worn on imaging, in the absence of any test tying that level to the symptom, is how people arrive at a solid fusion and unchanged pain. The operation succeeded. The question it answered was never asked.

For that group there is a testable alternative sequence. Facet-mediated pain is identifiable with diagnostic blocks and treatable with ablation, and the two procedures treat different problems rather than competing for the same one.

What we do, and what we do not do

We are not a practice that routes patients away from surgeons on principle, and it would be dishonest to present restraint as a virtue when the real position is narrower than that. Dr. Padda is a surgeon; the practice performs stimulator and pump implants, nerve decompressions and microdiscectomy. For cervical fusion specifically, that operation is not part of the treatment plan here, and where it is genuinely indicated we say so and help you get to the right surgeon.

What we will not do is send you into that conversation with an unexamined diagnosis. The value we add before a surgical opinion is establishing which structure generates the pain, so the surgeon is answering a specific question rather than an open one. That is the same note we send to referring physicians.

The three questions worth asking any surgeon

• Which structure is generating my pain, and what established that? A level named on imaging is not the same as a level tested.
• What is this operation expected to fix, specifically? Arm pain, neck pain, weakness and numbness respond differently, and an operation aimed at one will be judged on all four.
• What happens to the levels above and below? Adjacent segments carry the load a fused level no longer takes, and the rotation you lose is not usually discussed beforehand.

None of these is an adversarial question. A surgeon with a clear indication answers all three quickly, which is exactly why they are worth asking. Whether any of this applies to you depends on which structure is causing it.

WHAT IT FEELS LIKE

Nobody asks this in the room and almost everybody wants to know. So here it is, procedure by procedure, without the reassurance that makes people trust the answer less.

You are awake, and that is deliberate

Almost everything we do diagnostically is done with you awake and able to talk. That is not a cost-saving decision and it is not stoicism. A block is a question put to a specific structure, and the answer is you telling us what changed. Sedate that away and you have performed the procedure and lost the information it existed to produce.

There is trial evidence on exactly this in the transforaminal epidural setting: adding sedation changes reported pain scores in a way that muddies the diagnostic read. For a therapeutic injection that trade may be acceptable. For a diagnostic one it defeats the purpose.

The other half of the reason is safety. A needle near a nerve root is safer when the person attached to the nerve can say “that went down my arm.”

Needle procedures, one at a time

• Medial branch block. Local anesthetic in the skin first, which stings for a few seconds. After that, pressure rather than sharpness. Two or three small nerves per level, a few minutes in total. Most people are surprised it is over. The block is a test, not a treatment, which is why it is short.
• Cervical epidural. The same skin anesthetic, then a deeper pressure sensation and occasionally a brief reproduction of your usual arm symptom as the space is entered. That reproduction is useful rather than alarming. It is delivered to a level, not to a neck.
• Occipital nerve block. Among the quicker ones. A small volume at the base of the skull, and scalp numbness for a few hours afterward that people rarely expect and occasionally find stranger than the injection. It answers a diagnostic question the same day.
• Radiofrequency ablation. The longest of them, and the one with the most sensation. Test stimulation first — a buzzing or tapping you will be asked to describe — then the lesion itself under local anesthetic. Aching for a few days afterward is normal. The nerves regrow, which is the deal nobody explains up front.
• Discography. The one we are most honest about, because it is designed to provoke. The question is whether pressurizing a given disc reproduces your pain, so a positive result hurts. It is the only test that asks a disc directly, and it is not ordered casually.

Electrodiagnostics, since this is the one people dread

Nerve conduction studies and EMG have a worse reputation than they deserve, and the published work on tolerability is reassuring: the studies are safe, and the discomfort is consistently rated lower afterward than people anticipated beforehand.

Two halves. The conduction half delivers brief electrical pulses — startling rather than painful, like a static shock you can see coming. The needle half uses a fine wire electrode in several muscles, held still while you contract gently. It aches. It does not require anesthetic and it takes a few seconds per muscle.

Anticipation is doing most of the work here, and that is not a dismissal. Trial data on procedural anxiety shows that simply describing what is about to happen lowers both anxiety and reported pain. Which is the entire reason this page exists.

What actually goes wrong, stated plainly

Corticosteroid injections are well characterized and the serious complication rates in trained hands are low; the common effects are a sore site for a day or two, a few days of flushing or disturbed sleep, and a transient rise in blood glucose that matters if you are diabetic and is discussed beforehand if you are.

We are not going to inflate that into a warning block, and we are not going to pretend it is nothing. It is a short list, it is known, and you should hear it before rather than after.

What we ask of you

Tell us during, not afterward. If something reproduces your symptom, say so at that moment — that is the data. If something is unpleasant in a way you did not expect, say that too, because almost everything can be adjusted. Nothing is done on the first visit, so you will have met us and seen the room before any of this applies to you.