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 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.
It can occur at any level, but in the lumbar spine this is commonly referred to as sciatica. A radiculopathy is when a nerve root is irritated secondary to a herniated disc, osteophyte, spinal stenosis or any other structure that is coming into contact with it. Symptoms present as a shooting, electrical (funny bone sensation), pain or numbness and paresthesias (pins and needles). It may cause a muscle spasm, and frequently responds to anticonvulsants (Lyrica and Neurontin), NSAIDS (ibuprofen), and epidural steroid injections.
This is an inflammation of the joints that connect the vertebral bones to the corresponding bone above and below. It often occurs in osteoarthritis and after back surgery (especially spinal fusions). During spinal fusions, the stabilized segment is now immobile and translates extra stress on the joints above and below the fusion. This usually responds to NSAIDS, facet joint steroid injections and medial branch nerve blocks. Medial branch nerve blocks are blocking the nerves that innervate the facet joint. If this produces adequate pain relief, the next procedure would be a radiofrequency ablation of that nerve.
As this is mainly a sensory nerve, there are little side effects related to this procedure. It may need to be repeated every few months, but provides the longest pain free time compared to the other procedures. Facet joint pain occurs often with aging. Osteoarthritis is affiliated with facet pain, and causes distress among many patients. The pain is often central and may radiate down the legs. It is often exacerbated by bending backwards and twisting to the sides (axial loading). Many patients with herniated discs often present with facet arthropathy, as they are both related to degenerative changes in the spine. Facet arthropathy is also seen in patients who have back surgery. It is especially common in patients who have undergone spinal fusions. Normally the vertebrae share the weight loaded onto the spine. In cases where the spine is immobilized, an extra amount of load gets translated to the facets above and below the fusion.
This is another condition related to aging and arthritis. As time goes by, repetitive trauma and stress lead to disc desiccation. There is less cushioning, and the discs lose their height. This can exacerbate radiculopathy which commonly occurs when the outside (annulus fibrosis) ring of the disc is weak and the inner part of the disc herniates outward. This herniation irritates the descending and/or exiting nerve roots, causing a radiculopathy (shooting pain, numbness and/or tingling in the distribution of a particular nerve).
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 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.
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.