Common Pain Problems

Pain medicine is less of an exact science than other medical specialties. Patients rarely present as they would in text books, and often biopsychosocial issues affect prognosis, diagnosis and treatment. Often times, a few interventions or medications must be tried before a patient receives the pain relief that they seek. As pain medicine is a new field, it is still in its developmental stages, and two practitioners may offer a patient two completely different options for treatment. While both may be correct, many patients respond best to a multidisciplinary approach. The multidisciplinary team may involve a neurologist, physical therapist, psychiatrist, psychologist, the patient him/herself and a family member.

Back Pain

Back pain is one of the most common problems that our physician’s treat. 20% of the working US population experiences back pain per year. By age 50, 97% have degeneration of their intervertebral discs. Back pain is often related to obesity and poor body mechanics. Repetitive traumas secondary to poor body mechanics is often the culprit. Age and arthritis also contribute to this common problem. Pharmacologic therapy is often inadequate, and very often patients need to have injections or procedures. While the most beneficial treatment for back pain is physical therapy, it is often necessary to prescribe medications and perform injections to enable the patient to get out of bed and perform physical therapy and avoid muscle atrophy.

  Prolonged bed rest has been shown to be ineffective for managing back pain. In fact, it has been shown to worsen pain. Inactivity leads to obesity, depression, and deconditioning. These three factors are unfortunately way too commonly observed in patients. A comprehensive “pain plan” should address these issues, and get the patient to tolerate ambulation, physical therapy and possibly a return to work. One of the reasons why it is so difficult to treat back pain is because diagnosing is sometimes difficult. Patients often present with multiple complaints and physical findings or imaging studies that contradict the complaints.

  While useful, MRIs and CTs are limited. Studies have shown that asymptomatic people often have herniated discs. So, who is to say that just because a patient has back pain and a herniated disc, that the pain is secondary to that disc herniation? In addition, the back lacks the fine two point discrimination that is present on more sensitive structures like the palm. It is often difficult for the patient to accurately pinpoint the exact structure where the pain is originating from. When physicians palpate painful areas in the back, it is not always obvious what is causing the pain. Certain spots in the back have muscle, joints, bone, nerves and fat underneath the skin. The physician must be able to distinguish which one of these structures is causing the pain. Sometimes the pain is from a distant area and radiates to another point. This is called referred pain. A knowledgeable physician takes all of this into account to make his diagnosis. Often times, it is accurate, but sometimes, a diagnosis is made by ruling out other diseases, this could take some time, but is usually worth it.

Radiculopathy

Facet Arthropathy

Disc Degeneration

Spinal Stenosis

With aging, sometimes there is narrowing of the spaces in which nerves pass. (The central canal and transforaminal spaces where spinal nerves exit can become tight). This causes symptoms of shooting pain and is often the reason why elderly people often need to hunch their backs forward. Bending forward often relieves the pain of spinal stenosis. The stenosis (tightening is often due to bone overgrowth (sometimes called osteophytes), or herniated discs. It is a condition that is often difficult to treat. Most patients will require physical therapy, and epidural steroid injections. Medications often help, but seldom give meaningful relief.

Headaches

Headaches often vary from patient to patient. While most pain medicine trained physicians are capable of treating any type of headache, neurologists often bear the grunt of the severe migraine population. Patients are usually referred to pain specialists for headaches that are secondary to neuralgias. One of the most common headaches is Occipital neuralgia. This is a headache that often starts in the back of the head (occiput) and radiates laterally and forward to the front. It is often resistant to medical management. It is usually secondary to muscle spasm, or narrowing of the space (secondary to fibrosis or scar tissue) where the occipital nerve passes.

Treatment is an occipital nerve block. Blocking this nerve with local anesthetic is sometimes enough to give long as well as short term pain relief. Often times a steroid is indicated to decrease inflammation around the nerve and give long term pain relief. Other headaches and neuralgias of the head and neck include trigeminal neuralgia, glossopharyngeal neuralgia, etc. Dr. Rosenblum is trained to perform cranial nerve blocks, and has even performed ablations for patients with carcinomas (cancer) of the head and neck.

Myofascial Pain Syndrome

This is probably one of the most common reasons for pain. Everyone has experienced muscle pain at some point in their life. It is the most common reason for back pain, and it usually occurs in conjunction with the above mentioned pathologies. Some patients who have many tender points in their body and coexisting depression are often labeled with Fibromyalgia. While fibromyalgia is a disorder that affects many, the diagnosis is often overused by physicians who do not truly understand the varieties and complexities of myofascial pain syndromes. It is often easier to just label a patient as having fibromyalgia, than it is to investigate each tender muscle or body point and try to figure out why the patient is having the pain and how we can target our treatments.

Muscle pain is often secondary to disuse or misuse of a muscle. Poor body mechanics (ex. lifting objects the wrong way), lack of activity and certain disease states often lead to spasms, taut bands, and an accumulation of metabolic waste products. This causes pain syndromes that are not always amenable to pharmacotherapy. Muscle relaxants can decrease pain in some patients, but can produce side effects (sedation, low blood pressure, etc.). Muscle injections (trigger point injections) are a useful method of breaking spasms, and washing away the metabolites that contribute to the pain. The technique involves using a local anesthetic and puncturing the muscle in many places. The local anesthetic is to relieve the pain, but the needle itself is the true treatment. The needle trauma, causes a small amount of bleeding in the muscle which has been shown to be beneficial, especially when it is followed by physical therapy and muscle stretching.