Author: Jasmeet Singh

DISCOGRAPHY

Discography is a diagnostic tool used to determine whether certain discs of the spine are the source of a patient’s neck or back pain. Most of the population experiences low back pain, at least, sometime during their lifetime. It is the fifth leading cause of medical visits and the leading cause of workplace-related disability. Discography is used to pinpoint the cause of low back and neck pain, especially when non-invasive imaging, such as magnetic resonance imaging (MRI), has failed to reveal the source of pain (Wichman 2007). Discography is considered for patients with idiopathic (uknown), but disabling, neck and back pain.

Understanding the anatomy and function of the spine is important in evaluating back pain. The spine is made up of vertebrae (bones of the spine) that provide a flexible support for the back muscles and spinal cord. Certain conditions cause pain in, and around, the spine, including Spinal stenosis, vertebral body fractures, Osteoporosis, Osteoarthritis, Spondylolisthesis (scar tissue), neoplasms (Primary vs. metastatic lesions), and infections. Separating each individual vertebrae are discs that act as cushions to minimize the impact that the spinal column receives. The softness of the discs give them a tendency to herniate posterior (backwards) through the outer disc segment and ligaments. Bulging and leaking discs often cause irritation to the adjacent nerves. This results in disc disease, which accounts for about 10% of all doctor visits for low back pain. It can be acute, resulting from herniation or trauma, and can become chronic. Degenerative disc disease is progressive, causing a thinning and degeneration of the discs over time.

Discography Procedure

After you skin is thoroughly cleaned, s small needle will numb the area with a local anesthetic. A larger needle will then be inserted and positioned near the outer layer of the disc. Fluoroscopy, real time X-ray, is used in order to assure proper placement of the needle. A contrast solution is injected into the disk and your response to the injection is observed at different locations. If pain is experienced, then it is possible that your doctor has located the source of your pain. This process is typically repeated twice for maximum relief. The procedure usually takes less than an hour. A CT scan may be ordered directly after the procedure to ensure that the contrast die has spread properly.

Discography Benefits

Although MRI is considered a very good method for showing disc abnormalities, it does not show direct causes of pain. A study in 2007 revealed that Discography is more accurate at locating disc pain and ruptures than is MRI. This is true for similar conditions as well (Montes Garcia 2007). Since discography is considered a minimally invasive procedure it is performed when your physician highly suspects the cause of your pain. Generally, when students undergo discography, they have tried a myriad of other ineffective treatments for isolating the precise area of their pain. An MRI and CT scan can show abnormalities, but a discography reveals the exact location of the pain. Sometimes, moderately effected discs can cause severe pain, and run the risk of being treated improperly if based solely on MRI and CT findings (MRI/CT scan).

Discography Risks

As with all treatments, there is risk. However, the risk with discography is usually small. Although very uncommon, discitis (infection of the disc) can be severe. Other risks include bleeding, hematoma, headache, and increased pain.

Discography Outcome

Once your discography has been performed and your doctor has been able to isolate the source and location of your pain, you will be described an effective treatment plan. Discography is believed to be the best source of investigative protocol for disc disease (Buenaventura 2007). If you are suffering from chronic back pain that has been refractory to other treatments contact Arkansas Pain Specialists today to see if you can benefit from discography, or any of their other innovative, pain-relieving services.

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Adam Sewell MD

DISC DENERVATION

Disc pain is one of the most common forms of back pain across the world. Disc Denervation is a pain procedure used to treat chronic disc related pain. Pain occurs when discs compress or irritate local spinal nerves. Disc denervation, in a sense, deactivates the irritate nerves and blocks the affected nerves from sending anymore messages of pain. This is accomplished when the messages are heated and destroyed with radiofrequency. The heat generated from the radiofrequency modifies certain nerve fibers and blocks the perception of pain that is received by the brain.

Radiofrequency denervation is often more effective than other treatments, precisely, because of the temperature manipulation of irritated nerves (Ahmet 2006). Neuropeptides, or pain sensing chemicals along the periphery, or edges, of your nerves control both inflammation and the sense of pain. Nerves connected to the spinal cord eventually send a signal of pain to the brain. When the pain-sensing nerves are identified, successful pain relief can occur after they are denervated (Koscharskyy 2007).

Anatomy:

Spinal discs are designed to be soft and provide support, but they have a tendency to herniate backwards causing irritation to the adjacent nerves. Disc disease is one of the most common causes of chronic neck or back pain and accounts for approximately 10% of all lower back pain complaints. Disc disease can be acute, caused by herniation, trauma, or more commonly, degenerative disc disease. Degenerative disc disease causes as thinning and degeneration of the discs over time and can lead to spinal dysfunction, nerve impingement, or peripheral nerve irritation. Disc denervation is considered for most patients who have disabling chronic pain, especially when due to one of the aforementioned conditions and when conservative treatments have failed. Disc denervation is a common treatment for people with chronic neck and back pain.

Procedure:

Using a small thin needle, your physician will administer a local anesthetic to numb your skin and subcutaneous tissue (tissue just below the surface of your skin). A radiofrequency needle is advanced under fluoroscopy or real-time x-ray to the source of pain. Electrical stimulation is initiated through the needle and your disc pain is duplicated. When the correct nerves have been identified, the nerve supply to the disc is denervated with the radiofrequency. This procedure destroys pain-causing nerves and lessens the effects of pain on the surrounding area. The entire procedure lasts about an hour, and the site receives a small bandage after the treatment is complete.

Benefits

Disc denervation is a minimally invasive procedure which may provide significant relief. No hospitalization is required and the procedure is performed with local anesthesia and, sometimes, sedation. There is, often, some post-procedure discomfort, but you will be able to quickly resume your normal activities. Disc denervation is that it can be controlled, minimizing the risk of damaging adjacent nerves. If pain reoccurs, the procedure can be repeated.

Risks

As with all procedures, disc denervation carries some risk. However, that risk is quite rare. The complication rate per patient is 1.0% (Kornick 2004). There is a small risk of bleeding, infection, or nerve damage. The most common complaint is pain at the procedure site after the local anesthetic has worn off, but this tends to go away within 24 hours.

Outcomes

Disc denervation has been used as pain management for over two decades. In a 2007 study, it was revealed that more than half the patients treated with radiofrequency denervation had moderate to excellent pain relief lasting up to a year (Gofeld 2007). The best results were seen in patients with low back pain, who found that they were able to return to their normal daily activities very shortly after treatment (can Kleef 1999). If you are suffering from chronic back or neck pain that has been resistant to other treatments, contact Arkansas Pain Specialists today to see if you can benefit from this innovative treatment.

Journal Articles

Adam Sewell MD

CONTINUOUS CATHETER NERVE BLOCKS

Post author By Jasmeet Singh
Post date April 13, 2020
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Continuous peripheral nerve infusions involve inserting a small catheter under the skin, near a peripheral nerve in order to provide a continuous supply of an analgesic medication for pain relief (Ilfeld 2005). The conditions mostly likely to benefit from this treatment are post-operative surgical pain and Complex Regional Pain Syndrome or RSD (Dadure 2005). Our physicians are experienced in offering these techniques as an innovative means of pain management. Although most often used in treating post-operative surgical pain and RSD, the following conditions also benefit –

Back and Neck Pain
Traumatic Nerve Injuries
Peripheral Vascular Disease Neuropathy
Post-amputation Pain
Herpetic Neuralgia
Trigeminal Neuralgia
Brachial Plexus Neuropathies

Procedure:

It, generally, takes less than 15 minutes to place the catheters. Your physician will first cleanse the skin and, under some circumstances, provide IV sedation. Then local anesthetic is applied, and a needle is placed through the anesthetized tissue. Using nerve stimulation with twitch-monitor or ultrasound guidance, your physician will place the needle next to the irritated nerve. The catheter is, then, manipulated in place and the needle withdrawn. The catheter remains, delivering much needed pain medication to the area. The catheter will be secured with adhesive and a bandage, and the catheter is maintained in a carrying pouch, about the size of a softball. This pouch holds the medication, providing a constant stream of pain management for 5 to 7 days, after which time, it will be removed.

Benefits:

Patients who received continuous infusion local anesthetic were much less likely to experience breakthrough pain when compared those who managed pain through oral analgesics only (Ilfeld 2005). Oral opioids come with their own collection of side effects, some serious, so those who are able to utilize another pain management source, do not have the pharmacological side effects of oral pain medications as well. If the affected nerves are severely and regularly irritated, a continuous infusion may provide prolonged pain relief.

Risks:

Most continuous catheter placements are performed on an outpatient basis with minimal risks. However, as expected with any procedure, there are associated risks. With continuous catheters the risks are bleeding, infection, inadequate pain surface area coverage, and nerve injury (Ilfeld 2007). The catheter site must be kept dry and clean while healing in order to avoid infection. While the catheter site is healing it is important to keep it dry and clean so an infection does not occur. If there is any drainage or redness at the site, you’ll need to contact your doctor immediately.

Outcome:

A 2006 study revealed that a group of patients recovering from knee surgery, receiving continuous catheter infusion, healed faster than those using oral or intravenous opiates after surgery. Their recovery time was shorter and rehabilitation time more effective. (Ruyter 2006). In several other large studies, involving both adults and pediatric patients, continuous catheter infusion resulted in excellent pain management solutions for a myriad of chronic pain issues (Singelyn 2005).

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Adam Sewell MD

CERVICAL EPIDURAL STEROID INJECTION

Post author By Jasmeet Singh
Post date April 13, 2020
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Cervical epidural steroid injections (CESIs) are one of the most commonly used treatments for chronic neck pain and cervical radiculitis (radiating spinal pain). Headaches and cervical spinal stenosis may also benefit from this treatment.

Cervical radiculitis is a result of nerve compression in the neck, also known as the “cervical spine”, and it radiates down the length of the arm or into some other location. The pain center actually stems from the cervical nerves in the spine and cause irritating and inflammation. This can results in pain, numbness, or weakness, especially, when a cervical disk is bulging. Cervical radiculitis can be caused by spondylitis and arthritis of the facet joints. Both issues can be effectively resolved with CESIs (cervical epidural steroid injections).

Procedure:

With CESIs, a steroid is injected into the epidural space in the cervical canal. This is where the irritated and inflamed nerve roots reside. The injection includes a long-lasting steroid and a local anesthetic (usually, Lidocaine or Bupivacaine). The steroid reduces the inflammation, while the other medication numbs the area and prohibits some of the pain spasm cycle. The entire procedure usually takes less than 15 minutes.

Benefits:

Cervical steroid injections are simple and relatively painless. Most people, more than 70%, experience immediate pain relief from the procedure. If pain relief is only moderate after the first injection, up to two more can be administered at later dates. Subsequent injections are usually needed to experience complete relief.

For many people, cervical steroid injections cause rapid relief of symptoms, which allow them to become active again. The pain relief achieved from this treatment often allows patients to resume their normal daily activities within a short time, even in more treatments are needed to maintain the relief.

Risks:

As with all procedures, there are risks with cervical epidural steroid injections. However, they are low. It is a non-surgical pain effective pain treatment, but it can cause Cervical epidural steroid injections do have risks, but they are typically low. This pain treatment is considered an appropriate non-surgical treatment for many patients who suffer from neck pain and headaches. Complications of the injection can include bleeding, infection, headaches, and nerve damage. The medications used can also cause pharmacological complications, like anaphylaxis, in the rare case that an individual has an allergy to them or an ingredient. Additional pharmacological risks are – high blood sugars, decreased immune response, and the potential for weight gain, as with all steroids.

Along with proper technique, the procedural risks are reduced by using fluoroscopic guidance (x-ray) for proper positioning and administration.

Outcome:

Cervical epidural steroid injections have proven to be highly effective in relieving neck pain. A 2007 study revealed a 72% effectiveness with the procedure (Kwon 2007).

The amount and duration of pain relief vary from person to person. Some find immediate relief from just one injection, but most require all three for maximum effectiveness.

If you are experiencing chronic neck pain that has lasted longer than four weeks or is severe you should contact Arkansas Pain Specialists about this highly effective treatment. Early intervention may decrease the chances of developing a worsening chronic pain syndrome.

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Adam Sewell MD

CAUDAL STEROID INJECTION

This treatment is a combination of a steroid and a local anesthetic that is delivered to your lower back to treat chronic back and lower extremity pain.

Most Common Conditions Treated Are:

Sciatica/Lumbar Radiculitis –This is a condition that is characterized by pain, weakness, or sensory changes along the sciatic nerve pathway in the lower extremity. Pain typically radiates down the back of the buttock into the lower leg and foot. Some people describe the sensory changes as “pins and needles” and “sharp shooting pain”.

Herniated/Bulging Disc (most common cause of sciatica) – Disk disease is one of the most common causes of chronic lower back pain and accounts for approximately 10% of all low back pain complaints. Between the vertebrae (spine bones), are discs that cushion impact received by the spinal column. Since the discs are designed to be pliable and supportive, they have a tendency to herniate (or bend/squeeze) backwards through the outer ligaments, causing irritation to adjacent nerves.

Degenerative Lumbar Spinal Stenosis (DLSS) – DLSS is a narrowing of the spinal canal, causing nerve impingement or encroachment. Spinal stenosis can result in persistent pain in the lower back and lower extremities, like the legs and feet. Those affected often complain of difficulty walking, chronic back and leg pain, and decreased sensation in the lower extremities. All of this results in diminished physical activity. Many people with spinal stenosis present with bilateral (both left and right) lower extremity pain radiation.

Procedure:

Caudal epidural steroid injections involve injecting a steroid into the epidural space, where the irritated nerve roots are located. The caudal injection is performed through the sacral opening. The combination treats low back pain. It has, both, a long-lasting steroid and an anesthetic (Lidocaine, Bupivacaine). The steroid reduces inflammation and irritation, while the anesthetic interrupts the pain-spasm cycle and nociceptor transmission (Boswell 2007). The medicines spread to the most painful levels of the spine, reducing inflammation and irritation. The entire procedure usually takes less than 15 minutes.

Epidural steroid injections often result in a rapid relief of symptoms. This allows patients to experience enough relief to become active and resume their normal daily activities.

A large study in 2005, included two hundred and twenty-eight patients with a clinical diagnosis of unilateral sciatica, who experienced a 75% improvement in pain over a placebo group in a three week period, when they received a caudal steroidal injection. (Arden 2005).

This technique can be combined with other medications as well and a small catheter. Additionally, an Epidural Lysis or Racz Procedure can be performed to remove any pain-causing scar tissue. Scar tissue often results from prolonged irritation, inflammation, or previous surgery in the area and should be removed for effective pain management to continue.

Benefits:

Low back pain (LBP) is one of the most difficult conditions for physicians to treat. Commonly LBP goes into remission with periods of decreased or absent symptoms, but the pain can return, causing a chronic pain syndrome.

Treatment for LBP is specific to the type of injury presented. There are several options available ranging from surgery to acupuncture to physical therapy. Surgical procedures are typically done when conservative options are exhausted and are not successful in reducing pain. Surgery is also indicated when the LBP is causing new weakness, bowel or bladder incontinence, spinal instability, or infection. Potential causes for these changes include severe lumbar disc herniation, vertebral body fracture or displacement, and progressive spinal stenosis.

Degenerative lumbar spinal stenosis (DLSS) is the most common reason adults over the age of sixty-five receive spinal surgery (Barre 2004). More recently, a large study has shown that fluoroscopically (x-ray) guided, caudal epidural injections represent a relatively safe option for the management of DLSS generated pain (Barre 2004).

Risks:

Many people are afraid to undergo spinal surgery because of the risks perceived to be associated with it. However, the risks associated with Caudal Steroid Injections are low. This pain treatment is considered an appropriate non-surgical treatment for many patients who suffer from unrelenting back pain. Rare complications of the injection can include bleeding, infection, headaches, and nerve damage. The medications used can also cause pharmacological complications. These risks include allergic reaction, high blood sugar, decreased immune response, and the potential for weight gain. Along with proper technique, the procedural risks are reduced by using fluoroscopic guidance (x-ray/camera) to position the needle and monitor the proper spread of medication.

Outcome:

Many patients who receive Caudal Steroidal Injections enjoy improved function and diminished pain for years and can benefit from additional procedures for prolonged relief (Barre 2004).

If your pain has lasted longer than four weeks or is severe in nature you should see a pain specialist about the most appropriate treatment options. Early intervention may decrease the chances of developing a worsening chronic pain syndrome.

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Adam Sewell MD

ADHESIOLYSIS

Adhesiolysis is the dissolution of epidural adhesions, or scar tissue. This minimally invasive surgery was developed in the mid-1980s by Dr. Gabor Racz (Boswell et all, 2007) and continues to be an effective way to eliminate the chronic, intense scar-tissue related pain that often radiates from the lower spine to the legs (Machikanti et all, 2000).

Scar tissue causes inflammation when nerve roots are compressed. This results in chronic injury and incredible pain for many patients. Typically, the scar tissue forms after spinal surgery or even injury and can block pain medications from reaching the area of pain. For this reason, adhesiolysis, is an excellent corrective treatment for this troublesome and painful issue. It directly dissolves the tissue that interferes with traditional pain management treatments.

Spinal scar tissue can result from:

Spinal Surgery

Most patients who undergo spinal surgery develop scar tissue that adheres to the nerve roots. This fixes the nerve into a certain position, often causing tension and nerve compression. In other cases, the scar tissue causes inflammation, which results in the same compression and pain (Belozer et al, 2004).

Annular Tears

An annular tear is a tear in the outer-most portion of the intervertebral discs, where cartilage cushions the joint and acts as a ligament to hold the joint in place. A tear in this location will cause mechanical or chemical irritation (Cooper, 2011). Mechanical irritation caused by an annular tear occurs when the axial load of the center of the disc compresses the nerve endings. A chemical irritation happens when the glutamate from the intervertebral disc material causes inflammation around the nerve root, which results in swelling that can pin the nerve roots. This will cause the adhesions to remain after the inflammation disappears (Trescot et al, 2007). Annular tears are often caused by collagen genetics, trauma, or disc degeneration (Cooper 2011) and can be a continuous source of pain.

In addition to spinal surgery and annular tears, trauma is also a known cause of scar tissue along the spine (Hammer et al, 2007).

Procedure:

An MRI of the patient’s spine is the first step in step in determining if scar tissue is the cause of chronic pain. Once, the source and site of injury have been determined, the patient’s pain will be addressed with a series of epidural steroid injections. If these treatments fail, as they sometimes do when scar tissue blocks the medication from reaching the nerve roots-the source of the pain, an adhesiolysis procedure will be the best option.

The patient is first given an injection of local anesthetic, using a very small needle. Once the injection site is numb, a larger needle is inserted. This needle contains a catheter/guide wire and is fluoroscopically (with a camera) guided to prevent nerve damage (Boswell et al, 2007). Once the catheter is in the right place, a series of medications (omnipaque, hypertonic saline, hyaluronidase, local anesthetics and steroids) are injected near the nerve root. These medications help to eliminate the inflammation and dissolve scar tissue. Usually, an adhesiolysis treatment is completed in less than an hour. However, it can also be performed over a two-day period if a second immediate injection is needed. After a brief recovery period, the patient is allowed to return home. Patients who undergo this procedure may feel some discomfort as the numbing anesthetic wears off near the injection site, and even fewer, experience a heavy feeling in their legs which wears off within a couple of hours.

Benefits:

The scar tissue causes the nerve roots to be fixed into one position, often causing deep and relentless pain, and preventing pain medications from even reaching the site. This makes adhesiolysis the best possible treatment for this specific kind of pain. It dissolves the tissue, and therefore, often eliminates the problem and even further need for oral pain medications (Trescot et al, 2007). Adhesiolysis has been proven to be the best treatment after epidural steroid injections and other traditional pain-blocking attempts have failed (Boswellet et al, 2007). In the short term, adhesiolysis, has shown great success and moderate success in long term pain magagement situations. In a recent study, it was revealed that 100% of patients experienced relief in the first three months after treatment (Bosewell et al, 2007). An additional study showed 93% pain relief in 14 patients who underwent adhesiolysis procedures, and 93%, experienced immediate relief. This number decreased to 71% within one month, and to 57% at the three month mark, 43% at six months and 21% at one year (Hammer et al, 2001). While the short term success rate is very high, more than one treatment is needed to sustain the positive pain management results long-term (Manchikanti et al, 2000).

Risks:

In general, adhesiolysis is considered a safe procedure, but all medical procedures have their risks and side effects. A patient scheduled for an adhesiolysis procedure should not be on blood thinning medications, pregnant, allergic to any of the anesthetics used or have an active infection (Hammer et al, 2001).

Some additional, but rare, risks are:

Spinal cord compression.
Mild pain at the injection site.
Catheter shearing.
Excessive intraspinal and intracranial pressures.
Epidural hematoma.
Bleeding at the injection site.
Infection.
Visual deficiencies and even blindness (Boswell et al, 2007).

Outcomes:

The most common form of spinal pain, low back pain, affects 15% to 39% of the population. Scar tissue is often the culprit. Adhesiolysis is the best option to treat scar tissue, as it is a safe and effective treatment and has a high success rate. Additionally, it is minimally invasive and requires only a short recovery period. And according to a recent study, patients that have undergone adhesiolysis treatment reported an improved emotional and physical state and were less dependent on pain medications (Manchikanti et al, 2000).

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Adam Sewell MD

WHIPLASH PAIN

Whiplash pain is a term used to describe the soft tissue injuries of the neck that can occur when the neck moves in an abnormal way. It typically occurs following a motor vehicle accident, but may also occur following any activity which causes forceful movement of the neck, including falls, trauma, and sports-related injuries. The neck is forced to an extreme range of motion, which can cause significant injury to the muscles, ligaments, discs, and facet joints. This injury can lead to pain for many months, or even years.

Common symptoms associated with whiplash include neck pain, swelling along the back of the neck, muscle spasms, and difficulty turning the head from side-to-side or up and down. X-ray and MRIs can help to determine the extent of damage that has occurred. Common treatment following a whiplash injury includes anti-inflammatory medication, muscle relaxers, ice, heat, and rest. Chiropractic therapies, decompression, and massage therapy can also be very useful. Sometimes people experience symptoms following a whiplash injury that require immediate medical care.

Treatment

Most whiplash injuries resolve within six weeks of the initial injury. However, about 40% of people continue to have pain three months following the accident, and about 18% of people will continue to have pain after two years. Common treatment for whiplash injury includes chiropractic treatment, medication management, physical therapy, and injection therapy. Chiropractic adjustments and decompression therapies can help to relieve pain. Some medications used to treat whiplash pain include anti-inflammatories, anti-depressants, neuropathic medications, and occasionally short-term opioid use. Physical therapy helps to strengthen core muscles in the neck, thus reducing pain. Some injections used to treat whiplash injuries include trigger point injections (for muscle spasms), cervical epidural steroid injections (for discogenic pain with radicular symptoms), and medial branch blocks, for pain related to the cervical facet joints.

In a study by Manchicanti, Boswell, and Singh, et al (2004), it was estimated that 55% of all neck pain originates from the facet joints. For these patients, diagnostic and therapeutic facet injections, or medial branch blocks, have been very helpful. Facet injections involve injection of an anesthetic agent along the medial branch nerves of the facet joint. A positive response to this block is a 50% reduction in pain for the first several hours following injection.

Sometimes, a second block will be performed to confirm the diagnosis. If a person has a positive response to the medial branch block, they are considered candidates for radiofrequency ablation of the medial branch nerves. Radiofrequency is a procedure in which destruction of a nerve occurs. A study by Lord, Barnsley, and Wallace, et al (1996) showed that radiofrequency ablation can provide significant, long-term relief for facetogenic neck pain.

For people who are experiencing chronic neck pain related to a whiplash injury, there are many treatments available. At Arkansas Pain, we offer comprehensive and complementary treatments for people in Ft. Smith, Arkansas. You don’t need to suffer. Contact one of our locations today to schedule an appointment!

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Adam Sewell MD

VERTEBRAL COMPRESSION FRACTURES

Post author By Jasmeet Singh
Post date April 9, 2020
No Comments on VERTEBRAL COMPRESSION FRACTURES

Vertebral Compression Fractures is commonly referred to as an achy back. One of the more common causes of back pain is a vertebral compression fracture where one or more of the vertebrae in the spine have either broken or collapsed. While the majority of these injuries remarkably cause no significant pain they can result in limited movement and long term nagging pain.

The most common cause of compression fractures is osteoporosis. This condition is caused when bones soften. A compression fracture of this sort may cause sudden pain or it may cause nagging, long-term pain felt after attempting minor movements. Vertebral compression fractures do not present in one consistent manner. They can cause no pain or they can cause severe discomfort.

These cracked vertebrae are most common in the upper back, down to the lower back. While pain normally resolves within a month, severe pain or pain that lasts longer than four weeks will require medical attention. In this circumstance a physician will likely conduct an exam and possibly diagnostic imaging. Key indicators are kyphosis – or having a humpback – and loss of height with age. An x-ray can see if vertebrae are compressed or broken, though a bone scan for osteoporosis may also be required.

Conservative care may include medications, physical therapy and lifestyle changes. A calcium rich diet is recommended. Some surgical procedures for more severe cases may be offered.

Two minimally invasive, surgical procedures include a percutaneous vertebroplasty and a kyphoplasty. A vertebroplasty is a procedure where cement is pushed into the fractured bone to provide more support and allow for healing. A kyphoplasty is when a small balloon is injected into the injured vertebrae and slowly inflated to the original size.

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Adam Sewell MD

VERTEBRAL BODY FRACTURES

Vertebral Body Fractures are a fracture of the vertebrae (bones of the spine) that eventually cause a collapse of the vertebral body. These fractures are most commonly located in the thoracic spine (the middle portion of the spine). The major risk factor for vertebral body fractures are increasing age and occur when the upper body weight exceeds the ability of vertebrae to support the load. Although more frequently seen in women, men can be affected as well (Old, 2004).

Certain conditions that can produce chronic pain affecting the vertebrae include spinal stenosis, vertebral body fractures, Osteoporosis, Osteoarthritis, spondylolisthesis, neoplasms (Primary vs. metastatic lesions), and infections. Vertebroplasty and Kyphoplasty are extremely effective treatments for many of these conditions.

Diagnosis

Your physician will perform a physical exam and may find tenderness over the vertebrae as well as kyphosis (curving of the spine). Other manifestations of nerve involvement include constipation, loss of lower extremity reflexes, and the sensory function. The physician may also order radiological imaging. An x-ray commonly ordered to see the classic wedge-shaped vertebral body with narrowing of the anterior portion in most compression fractures. However, the physician may want to order additional studies such as MRI, CT scan, or a bone scan.

Treatment

NSAID’s and analgesics are used in the acute management of pain to help relieve discomfort. Patients can also be treated with some bed rest.

Patients that do not respond to the more conservative management described above may be good candidates for minimally invasive procedures by your pain physician that have been proven effective, including Vertebroplasty and Kyphoplasty (Old 2004). Results of a clinical research trial concluded that both Vertebroplasty and Kyphoplasty significantly reduce pain and improve mobility in patients with vertebral fracture (De Negri 2007). Vertebroplasty is a procedure which involves injecting acrylic cement into the fractured vertebra to stabilize and strengthen the vertebrae. Kyphoplasty is a method that involves placing an inflatable balloon into the vertebral body. When the balloon is inflated, it makes a space in the center of the vertebrae where an acrylic is injected.

There is good evidence that diagnosing and treating Osteoporosis reduces the incidence of compression fractures of the spine (Kim 2006). Consistent exercise and activity to help with muscle strengthening and flexibility should also be done to help decrease vertebral fractures and back pain associated with Osteoporosis.

Journal Articles

Adam Sewell MD

UPPER BACK PAIN

Upper back pain occurs in the thoracic region of the spine, and is less common than lower back pain due to the stability, strength and limited movement of the upper back. The pain may be acute or chronic, a dull ache or a sharp stabbing sensation, and may be accompanied by stiffness. Typically the discomfort interferes with the activities of daily living, whether it is a constant pain or brought on only by specific movements. However, if upper back pain is present along with difficulty breathing or chest pain, this may indicate a heart attack and requires immediate emergency treatment.

The causes of upper back pain include:

Arthritis, a condition causing deterioration of the bony structures and cushioning discs between bones.
Physical injury to the muscles, tendons, or ligaments of the vertebrae.
Fibromyalgia, a type of rheumatism, which affects the soft tissues and muscles.
Herniated disc.
Referred organ pain from the heart or lungs.
Bone cancer.

Injury to the muscles and ligaments of the upper back may be caused by:

Traumatic situation, such as a car accident or other physical trauma
Incorrect posture, especially while sitting at a desk with a computer
Sporting activity, particularly sudden or extreme movements
Overuse injury

Another less common cause of upper back pain is joint dysfunction, which may be a result of any of the following conditions:

Arthritis, leading to damaged cartilage and decreased lubrication between bony structures of the spine
Bulging discs, due to pressure on vertebrae forcing spinal discs to bulge out of position
Herniated disc, marked by weakness and internal damage to the disc
Spinal stenosis, or narrowing of the spinal canal due to arthritis, herniated discs, Paget’s disease, or congenital defects

All the conditions mentioned above result in pinched nerves, inflammation and impaired movement leading to upper back pain.

Bone cancer, pulmonary disease and referred organ pain may also be the root cause of upper back pain.

Diagnosis

The doctor will need to know how movement affects the pain and how the upper back pain has interfered with activities of daily living. A physical exam will be performed, in which the physician will look for signs of inflammation such as tenderness, redness and swelling and with an assessment of range of motion. Imaging studies, such as X-rays, CT scans or MRIs may be performed to help the physician diagnose joint dysfunction or problems with surrounding muscles, ligaments and tendons. Discography, an imaging tool using contrast dye, may be used to help the physician visualize details of the intervertebral discs.

Treatment

In the case of upper back pain caused my myofascial injury, treatment is based on strengthening muscles, improving alignment of the spine and increasing flexibility.

These noninvasive treatments include:

Physical therapy
Massage therapy
Chiropractic or osteopathic manipulation
Acupuncture

Medications to reduce inflammation and decrease upper back pain may be prescribed:

COX-2 inhibitors
NSAIDs — Nonsteroidal Anti-Inflammatory Drugs
Acetaminophen
Ibuprofen

Muscle relaxants reduce pain by treating muscle spasms.

If the pain is severe or if it’s caused by joint dysfunction, local injections to the joint are a minimally invasive treatment:

Medical Branch Blocks (MBBs) for arthritis related pain
Facet Injections to reduce inflammation in the facet joints of the vertebrae
Epidural Steroid Injections for degenerative disc disease

Selective nerve blocks are a procedure performed by physicians to identify which nerves are responsible for transmitting pain signals. Identifying the route of pain signals may help the physician find the cause of pain to assist in treatment determination.

The goal of treating upper back pain is to relieve discomfort by treating the underlying cause. Noninvasive treatments are usually effective in relieving pain and returning the patient to an active lifestyle.