Author: Jasmeet Singh

POST LAMINECTOMY SYNDROME

Post author By Jasmeet Singh
Post date April 9, 2020
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Post-Laminectomy Syndrome (PLS), also known as failed back syndrome, is a chronic and painful condition that some patients experience after undergoing laminectomy back surgery.

A laminectomy is a surgical procedure that removes the lamina, a portion of the vertebrae that connects the spinous process (the protrusions felt on the back through the skin) to the main body of the bone, and any associated bone spurs to relieve pressure on spinal nerves that can occur in many back conditions.

PLS is not a diagnosis, but rather a general term to describe the chronic pain symptoms experienced by patients as they emerge from back surgery. The exact cause of PLS is unknown, however one prominent theory points to epidural fibrosis, in which the development of scar tissue during post-surgical healing compresses nearby nerve roots and causes pain.

Other possible causes include:

Surgical intervention at the wrong spinal level
Incomplete removal of the lamina
Arachnoiditis – inflammation within the protective layers of the spinal cord
Psychosocial problems, such as depression

Diagnosis and Treatment

Diagnosis of PLS is made difficult due to the many possible presentations of chronic pain post-surgery. A doctor must recognize the developing pattern of chronic pain and poor post-surgical outcomes. A physician may order laboratory or imaging studies to identify possible inflammation or other structural abnormalities where the lamina was removed. The physician may also perform a mental health screening to rule out any psychosocial causes. Treatment options will be different for every patient.

Some of the possible treatment options include:

Opioids can be used for pain management
Spinal cord stimulation
Adhesiolysis – the disconnection of fibrotic scar tissue after surgery

References

Adam Sewell MD

POST HERPETIC NEURALGIA

Post herpetic neuralgia is a side effect of shingles. It presents as a painful nerve and skin condition caused by the virus herpes zoster. The same virus is responsible for chickenpox in youth and inexplicably causes shingles in some adults. Post herpetic neuralgia is the persistent, often quality of life altering pain associated with a shingles outbreak.

The most common symptom is a burning pain as nerves are damaged during a shingles outbreak. The nerves no longer communicate properly with the brain. The result is sharp, annoying pain that can intensify with even a light touch. Post herpetic neuralgia pain is typically located at the same site as the shingles outbreak. Usually it’s located on one side of the back, chest or stomach.

Other common symptoms include:

Itching or numbness
Muscle weakness or paralysis

There is no specific test for post herpetic neuralgia, nor is there a specific cure. A variety of pain medications and options may be prescribed until the patient and physician find the right combination. These may include: antidepressants, anticonvulsants, pain relieving skin patches, opioids, and topical pain creams. It’s important to note, that shingles patients who are able to see a pain physician within the first 72 hours of the signature rash appearing and can start a course of antivirals are half as likely to develop post herpetic neuralgia. Additionally, shingles and related post herpetic neuralgia are entirely preventable via vaccine.

References

Adam Sewell MD

PLANTAR FASCIITIS

Fascia is a thick tissue that connects the ball of the foot to the heel. The tissue is responsible for the arch of the foot. When this connective tissue becomes inflamed to the point of pain, it’s called plantar fasciitis.

Patients who suffer with plantar fasciitis often experience sharp pain in the morning. When the fascia loosens during normal physical activity such as walking, the pain will subside a bit. The first few steps of the day are often the most painful because the fascia is not used during sleep.

Risk factors include arch problems such as flat and high arches. Other causes are obesity or sudden weight gain, long distance running, or running on uneven surfaces, and having a tight Achilles tendon. Finally, wearing shoes without proper arch support can cause fascia inflammation as fascia can adjust only so far before it is stretched to the point of pain.

This condition is most commonly found in men age 40-70. It’s the leading cause of orthopedic care. While heel spurs caused by calcium deposits are commonly found in plantar fasciitis patients, they are not the cause of the pain. They are a reaction by the bone to the fascia’s inflammation.

Symptoms include stiffness on the bottom of the heel, an ache on the arch and a sharp pain or burn when first putting weight on the foot. The pain may be more severe if climbing stairs or performing intense activity. The pain may come over a period of time or may be intense and sudden. It is not uncommon for swelling and redness to also be present.

To diagnose plantar fasciitis, a pain physician will take a series of X-rays of the foot. If a bone spur is present, plantar fasciitis is a likely diagnosis. Additionally, physicians will look for a thickening and inflammation of the fascia from the ball of the foot to the heel. The physician may also look for hairpin fractures in the bones around the foot, which are also a common source for this type of pain.

Treatment options range from over-the-counter NSAIDS, such as acetaminophen and ibuprofen to reduce inflammation and stretching. Cortisone shots and sonic wave procedures are also used. Depending on the severity of the inflammation, the patient may respond favorably to stretching, ice, rest, or wearing orthotics when standing. Additionally, athletic tape and splints specifically manufactured for fascia stretching can ease plantar fasciitis-related pain.

References

Adam Sewell MD

PHANTOM LIMB PAIN

Phantom limb pain is a sensation felt when a body part or limb has been amputated, but still feels as if it is attached. Many amputees will have phantom sensations that are not painful. It is estimated that 85% of people experience phantom limb sensations in the first several weeks following amputation. However, a smaller population will continue to feel these sensations for prolonged periods of time. It is reported that 60% of people will continue to experience sensations one year after surgery (Manchikanti and Singh, 2004).

Some patients have severe painful and debilitating phantom limb sensations. Some of the sensations include tingling, numbness, hot or cold sensations, cramping, stabbing, and burning. The most common sensation that patients continue to feel is pain in the missing limb area. These painful sensations often diminish over time, but some suffer from long-term pain, which can be difficult to treat.

Treatment

Some treatments for phantom limb pain include:

Medications
Physical Therapy
Mirror Therapy
Interventional Injections
Spinal Cord Stimulation

Medications: Studies have shown that tricyclic antidepressants, sodium channel blockers, and anticonvulsant medications can be useful in neuropathic pain conditions like phantom limb pain. Currently, gabapentin is the most commonly used medication for phantom limb pain. Many studies have shown that oral opioid medications are not effective at treating neuropathic pain. However, other studies have shown that intrathecal administration of buprenorphine was effective in many patients, and provided them with prolonged resolution of their phantom limb symptoms.

Physical Therapy: Desensitization therapies along with sympathetic nerve blocks may provide relief for patients who have “sympathetically mediated pain.” Proper fit of any prosthetic is also important in decreasing pain for many who suffer from phantom limb pain.

Mirror Therapy: One of the more promising treatments for phantom limb pain is mirror therapy. Mirror therapy involves the use of a mirrored box with two openings: One for the amputated limb, and one for the other limb. The patient then performs isometric exercises with the non-amputated limb, so it appears as though the amputated limb is moving. In a randomized controlled study by Chan, et al. (2007), it was found that the patients who had mirror therapy for four weeks experienced a significant reduction in pain.

Interventional Injections: Injection therapy such as interscalene blocks or stellate ganglion blocks can be used for upper extremity phantom limb pain. Lumbar sympathetic blocks are used for lower extremity phantom limb pain. Neuroma injections can also be beneficial for those who suffer with extremity neuromas. The blocks are often combined with physical therapy.

Spinal Cord Stimulation: Transcutaneous Electrical Nerve Stimulation (TENS) or spinal cord stimulation offers significant relief too many patients who have not had success with other treatments. Spinal Cord Stimulation (SCS) is often described as a “pacemaker for pain” and uses groundbreaking technology that works by introducing an electrical current into the epidural space near the source of chronic pain. After a local anesthetic and minimal sedation your doctor will first place the trial SCS leads into the epidural space. The SCS lead is a soft, thin wire with electrical leads on its tip and is placed through a needle in the back into the epidural space. The trial stimulator is typically worn for 5-7 days. The lead is taped to your back and connected to a stimulating device. If the trial successfully relieves your pain you can decide to undergo a permanent SCS.

References

Adam Sewell MD

PELVIC PAIN

It is estimated that approximately 33% of all women will suffer from pelvic pain at least one time in their lives. For 12-20% of these women, pelvic pain may become chronic. The causes of pelvic pain, include infection, ectopic pregnancy, ovarian cysts, and endometriosis.

A common type of pelvic infection is pelvic inflammatory disease (PID). PID is an infection of the uterus, ovaries, or fallopian tubes, and may be caused by sexually transmitted disease. Infections of the kidneys, bladder, or urethra can also cause pelvic pain. If an infection is suspected, treatment with antibiotics is necessary in order to alleviate the pain.

Ectopic pregnancy is a pregnancy that occurs outside of the uterus, typically in the fallopian tubes, and can be very painful. Ectopic pregnancy can lead to serious complications, and warrants surgical intervention.

Ovarian cysts are fluid-filled sacs within the ovaries, and typically cause pain during mid-menstrual cycle. These cysts usually resolve spontaneously, but sometimes require surgery to remove.

Endometriosis is a condition in which uterine tissue grows on other reproductive organs, and can cause severe pain and cramping during menses. Certain medications and surgical procedures can help to lessen the pain associated with endometriosis.

Diagnosis and Treatment

Pelvic pain can also be neuropathic. It is extremely important to establish an accurate diagnosis, because some of the causes for pelvic pain can be reversible. The diagnosis is usually made by an OB/GYN, and involves pelvic examination, lab testing, ultrasounds or CT scans of the abdomen and pelvis. Treatment is based on the underlying cause, and can include medications and physical therapy.

Common types of medications used to treat pelvic pain include anti-inflammatories, anti-depressants, neuropathic medications and occasionally opioids. Physical therapy for pelvic pain can include muscle training, hot and cold applications, ultrasound therapy, and stretching.

Biofeedback is a technique in which a person learns to control pain through thoughts, and can be very helpful for treating pelvic pain. A licensed therapist can teach biofeedback, relaxation techniques, and guided imagery, all of which are very effective techniques in controlling chronic pain.

Neuropathic pelvic pain can also responds very well to various nerve blocks. Nerve blocks are determined by location of pelvic pain and symptomatology. A study by Weschler, Maurer, Harpern, and Frank (1995) showed that superior hypogastric plexus blocks are very effective in treating chronic pelvic pain related to endometriosis. Another type of nerve block used to treat pelvic pain is an ilioinguinal nerve block which is especially useful in treating pain in the lower pelvic region and groin.

For pelvic pain that does not respond to more conservative treatment modalities, a spinal cord stimulator may be beneficial. Spinal Cord Stimulation (SCS) is often described as a “pacemaker for pain” and uses groundbreaking technology that works by introducing an electrical current into the epidural space near the source of the chronic pain. With a local anesthetic and minimal sedation your doctor will first place the trial SCS leads into the epidural space. The SCS lead is a soft, thin wire with electrical leads on its tip and is placed through a needle in the back into the epidural space. The trial stimulator is typically worn for 5-7 days. The lead is taped to your back and connected to a stimulating device. If the trial successfully relieves your pain you can decide to undergo a permanent SCS.

References

Adam Sewell MD

OSTEOARTHRITIS

The most common cause of joint pain is osteoarthritis (OA), a chronic (long term) disease characterized by a loss of cartilage and bony spur (osteophyte) formation in joint spaces. Normally cartilage cushions the joints preventing adjacent bones from contacting each other. The cartilage can’t be repaired. Bony spur formations rub together causing pain and inflammation.

The specific cause of OA is unknown; however it is not just a disease of aging, but rather the result of a combination of factors including genetics and joint degeneration. Symptoms of OA typically include joint pain with movement, limited range of motion, joint swelling or joint stiffness after periods of inactivity. This pain usually occurs within minutes, and can last hours. As OA progresses, pain can occur during rest or sleep.

Joints most affected by OA include the knee, hip, and joints in the hand closest to the fingertips, the thumb, and the spine in both the neck and lower back regions. Besides aging other risk factors include obesity, muscle weakness, joint overuse or repetitive use, joint trauma, and joint instability. OA is also more prominent in females than males.

Diagnosis of OA is primarily confirmed by x-ray showing narrowing of the joint spaces, cartilage loss and spur formation. A doctor will also perform a comprehensive physical exam, paying close attention to joint tenderness, limited range of motion, joint deformity and enlargement, swelling and crackling sounds heard in joints. A doctor may order additional laboratory tests to rule out other potential causes of arthritis.

The goal for treating OA is to control pain and minimize. Treatment options depend on the progression of the disease and the severity of pain, and may include lifestyle changes, medications or surgery.

At early stages of OA, pain can be alleviated with conservative treatment; primarily rest and over-the-counter analgesics such as acetaminophen and non-steroidal anti-inflammatory drugs such as ibuprofen. For severe cases of pain and inflammation, more selective anti-inflammatory and opioid medications can be prescribed.

For certain joints, steroid and hyaluronic acid injections may help for the temporary control of pain. If OA progresses to the point where surgical intervention is necessary, joint replacement, arthroscopy, or an osteotomy, in which bone is removed from the joint, may be beneficial. Surgery always involves certain risks. If diagnosed with OA, a pain management specialist can help navigate the proper course of treatment.

The best way to treat OA is to prevent progression of the disease through lifestyle changes with regular exercise, a proper diet and weight management.

References

Adam Sewell MD

NECK PAIN

Neck pain is one of the most common medical complaints and occurs slightly more often in women than men. However, many people experience some level of neck pain in the course of their lifetimes, and most of the time, it isn’t serious and may occur as a result of stress, improper body mechanics, like poor posture, or muscle strain from unusual or awkward positions.

Some serious symptoms that constitute a medical emergency that require immediate care include:

Loss of, or altered, consciousness
Changes in vision, such as blindness
Changes in bowel or urination
Nausea or vomiting
Fever
Weight Changes

The root cause or causes of neck pain can vary, but sudden severe pain, lasting less than three months, is classified as “acute.” Acute neck pain is commonly caused by facet syndrome (joint degeneration), muscle strain, or injuries, like whiplash. Pain lasting for more than three months, is classified as “chronic” neck pain and can originate from multiple locations, but is often from facet joints irritation, discs, ligaments, and muscles.

Anatomy

The cervical spine (neck) is complex and has many important functions, which include providing support and mobility to the head and neck, as well as protecting the spinal cord.

Bone structures

The cervical spine has seven small vertebrae and starts at the base of the skull. These small vertebrae provide a support structure that protects the spinal cord, the skull, and allows for movement.

Vertebral Discs

In between each of the vertebrae are jelly-like discs that cushion and minimize impact to the cervical spinal column. The same cushion that minimizes impact can cause discs to herniate “collapse backwards” or bulge through adjacent ligaments, nerves, or the spinal column itself. It’s this irritation or inflammation that leads to neck pain.

Spinal Ligaments and Muscles

Ligaments and muscles attach to each vertebra, providing support, mobility, and movement for the cervical spine. Spinal nerves are attached to the cervical spinal cord. These ligaments and muscles innervate the skin and surrounding structures of the neck and upper extremities (arms and hands). Damage to these structures is one of the major sources of neck pain.

Atlas and Axis

The Atlas and Axis are the first two cervical vertebrae, starting at the base of the head. These two vertebrae form pivot-type joints that support the head, control movement, and connect to the spine. They are part of the body’s coordination and balance system as well. The cervical spine is the most flexible portion of the spinal cord, and therefore, the most vulnerable to injury or trauma.If the first through third cervical nerves are compromised, compressed or inflamed, they cause neck pain and sensory issues in some head and face areas.

Greater and Lesser Occipital Nerves

If these nerves are injured, they can cause radiating pain to the face and head. The other nerves lower in the cervical spine form a large nerve group, which provides motor and sensory support to the upper extremities. Symptoms may include, weakness, pain, loss of feeling, or other issues in the arms, if they are damaged.

Procedure

Cervical epidural steroid injections (CESIs)

This procedure involves injecting a steroid into the epidural space within the cervical spinal canal. Two medications are used to complete this process – a long-lasting steroid and a local anesthetic (lidocaine, bupivacaine). The steroid reduces inflammation and irritation, while the anesthetic interrupts the pain cycle.

Benefits

Cervical steroid injections may provide immediate and longer-lasting pain relief and are considered simple and relatively painless.

Risks

Mainly considered a low-risk procedure, but with any procedure, there is the risk of infection

Pathology

The most common causes of neck pain include:

Muscle strains
Trauma or injury
Herniated or bulging cervical disc
Stress

Muscle overuse, and sleeping in awkward positions, often produce neck pain. When the muscles in the back of the neck tighten and become strained, chronic pain may develop. “Whiplash” is a common example of this kind of neck pain, and it occurs in motor vehicle accidents, most often in rear-end collisions. The pain results from the stretching and straining of soft neck tissues. This caused localized inflammation, muscle tension, and ligament strain. When ligaments and tendons become inflamed or damaged, they cause additional pain that worsens with certain movements. Neck facet joints are also commonly involved.

Conditions

Myofascial (muscle related) and ligament injury are the most common cause of neck pain, as ligaments are susceptible to strain and irritation from strenuous lifting and prolonged overuse.

Degenerative disc disease (DDD)

In degenerative disc disease, the discs begin to fall apart or shrink. It’s one of the more common reasons for spinal surgery. Disc disease can be acute, but more often, it’s chronic and the pain is caused by a slow degeneration, occurring as part of the aging process. DDD is progressive disease that develops after spinal discs begin to from disc thin. This can lead to compression of the vertebrae, or adjacent structures, and cause neck pain.

Cervical Spondylosis (neck arthritis)

Cervical Spondylosisis caused by degenerative cervical vertebrae and nearby facet joints. Symptoms typically start around the age of 40, but may start earlier with trauma or is a person has a genetic predisposition to it. Arthritis is a progressive disease, and degenerative disc changes occur as a result of the aging process. The disc may decay, herniate, or bulge, causing local nerve root irritation or spinal cord compression. The pain is often worse when the head is extended backwards.

Spinal Stenosis

Spinal Stenosis is another common cause of neck pain that occurs, from a narrowing of the central spinal canal. It may cause the compression of surrounding nerves roots, and some symptoms may include, cramping or shooting pain, and numbness in the legs, back, neck, shoulders or arms. Symptoms typically depend on the area of the spine that is compromised. In cervical spinal stenosis, the upper extremities (arms) and shoulders are most commonly affected.

Mental health

Mental health issues, like depression, anxiety and stress, all have a tendency to exacerbate neck pain and other chronic pain syndromes, and emotional issues often cause neck pain to grow worse. There are several identified risk factors in the development of spine pain. They include, but are not limited to, physical, socioeconomic status, general medical health and psychological state. Occupational environmental factors contribute to the risk for experiencing pain as well (Rubin 2007).

Central Sensitization

Central Sensitization (sensory hypersensitivity) is a common complication for those suffering from chronic pain syndromes. It involves both the peripheral nervous system (PNS) and the central nervous system (CNS) and occurs when a local tissue injury and inflammation activate the PNS. This action sends pain signals through the spinal cord to the brain. Central sensitization occurs when there is an increase in the excitability of neurons within the CNS at the level of the spinal cord and higher.

The once normal PNS signals begin to produce abnormal responses. Low-threshold sensory fibers activated by very light touch of the skin activate neurons in the spinal cord that should only respond to pain. Sensations that normally produce a harmless reaction now produce significant pain.

Other Conditions

Less common causes of neck pain include vertebral compression fractures, spinal cord disorders, tumors, and infection. Metastatic tumors (cancer spread from another organ system) are the most common type of malignant lesions of the spine, but are still very rare among the general population. Up to 10% of patients with a primary cancer suffer spinal metastases. Breast, lung, prostate, and renal cell carcinomas are the most common tumors that metastasize into to the spine. However, myeloma, lymphoma, and gastrointestinal carcinoma can also invade the vertebral column as well (James 2003). Oropharyngeal cancers of the oral cavities and neck may also cause neck pain.

Diagnosis

To diagnose neck pain, a physician will perform a medical history and physical exam, looking over certain areas of the spine. He or she will perform various muscle tests, as well, to find any limitations in movement in the upper extremities.

The doctor will, also, most likely order some imaging like, X-ray, computerized magnetic resonance imaging (MRI) or a bone scan. MRI’s are considered the standard of care to detect the cause acute or chronic neck pain.

Treatments

Before beginning any treatment, please consult a physician.

It’s vital to not only treat the physical symptoms, but the emotional stressors as well. Massage, acupuncture, biofeedback, and behavioral therapy can all be extremely beneficial those suffering from chronic neck pain.

Alternative or Complimentary Options

Alternative therapies offer very little risk and are successful in many individuals with chronic neck pain.

In acupuncture, the acupuncturist inserts small needles just under the skin. It’s thought that the needles trigger the release of hormones called “endorphins“, which are the body’s natural pain reliever. Acupuncture may aid in relaxation and decrease stress and tension.

Physical therapy is often helpful in reducing or alleviating neck pain as well.

Pain Relievers

Over-the-counter Pain relievers such as ibuprofen (like Motrin), or acetaminophen (like Tylenol) may provide neck pain relief.

Benefits

May offer pain relief for mild to moderate neck pain caused by muscle or ligament strain

Risks

Prolonged and frequent use of over-the-counter medications may lead to gastrointestinal conditions, such as ulcers; or liver damage in the case of acetaminophen.

For more information about neck pain, or the pain relief options described, please see your pain physician.

Resources

Adam Sewell MD

MOTOR VEHICLE INJURIES

A migraine is characterized by intense, throbbing pain, that is often experienced at the temples, the front or back of one or both sides of the head, and there is sometimes eye involvement. Women are far more likely to experience migraines, but they are found in any gender and all age groups. One culture or ethnicity is not more likely to experience them than any other.

The severe pain, and associated neurological symptoms, are often described as debilitating with migraines. The head pain may be either unilateral (one-sided) or bilateral (both sides), and the entire experience usually lasts from one-to-four hours. Sometimes, however, a migraine can linger for several days, or return several times a week as a “chronic migraine”. With some migraines, there is nausea and vomiting.

Migraines are categorized as “Classical” and “Common.”
The Classical Migraine produces one-sided pain, and many people see an aura about 30 minutes to an hour before a migraine. Auras can include flickering lights or other visual disturbances. In a common migraine the pain is felt on both sides of the head, and there are, typically, no visual disturbances. Some other sensory manifestations include: smells, blurry vision, numbness or tingling in the face, unsteadiness and weakness.

Although the exact cause of migraines is unknown, it’s thought to be a combination of environment and genetics. Some common environmental triggers are: bright lights, loud noises, certain foods (chocolate, peanut butter, avocado, banana, citrus, dairy products, and fermented/ pickled foods, MSG), alcohol drinks (red wine), certain medications (birth control pills), menstrual cycle fluctuations, exertion activities; as well as mental health disorders, such as depression.

Mechanism

In the past, it was believed that blood vessel changes caused migraines. However, recent research reveals that migraines aren’t just caused by blood vessel changes in the brain, but also, the various brain nerve pathways and neurotransmitters. Migraines are thought to have a genetic link or predisposition, as they often run in families. The theory is those with a family history of Migraines, may have a gene that predisposes them to migraine HA’s (2007 Goadsby).

Diagnosis

Severe headaches are one of the most common reasons people visit an emergency room or see a physician. However, because most headaches are chronic in nature, it is important to seek your general practitioner’s advice in managing headache symptoms. Additionally, most headaches, even severe migraines, are not dangerous or life threatening. There are some instances where headaches are associated with other diseases or conditions, so it is important to always seek treatment for a headache that does not go away or that is sudden and severe or described as “the worst headache of your life”.

There are many medical conditions that cause secondary headaches. A physician evaluation is critical to determine an accurate diagnosis of any chronic headache conditions.

Some of the more serious conditions that require immediate medical attention are: intracranial hemorrhages/ hematomas, meningeal infections (viral, bacterial, and fungal), strokes, and malignant hypertension. Again, if there seems to be anything unusual about the headache(s) that you are experiencing, seeking medical attention is of utmost importance. In order to accurately find the source of a headache, a physician may order a series of tests and studies including: radiological scans (MRI, CT), neurological exam, blood work, or an eye/vision assessment.

Treatment

There are two pharmacological treatment categories for primary headaches, and are classified as “abortive” or “preventive.”

Abortive therapy

Abortive therapy’s goal is to stop head pain immediately. These medicines may provide pain relief; but they don’t promise a decrease frequency or intensity, and they will not prevent reoccurrences of pain. In addition, the effectiveness varies from person to person, and depending on the cause and type of headache, these medications may not work for some people at all. Over-the-counter medications don’t usually work for cluster headaches, and they only work for some people with certain kinds of migraines. Also, they rarely effects cases of intense head pain.

Common abortive therapies for Primary HA’s:

Oxygen – most commonly used for a Cluster HA.
Ergots
Triptans
NSAID’s
Anti-emetics
Opiates
Butalbital with aspirin or acetaminophen

Many patients have pain relief with abortive treatments, but there is serious concern about overuse and medication dependency, especially when the medications cause secondary concerns. In May 2007, the National Neurological Institute in Milan Italy published an article stating “Most patients with frequent headaches eventually overuse their medications, and when this happens, the diagnosis of medication-overuse headache is clinically important, because patients rarely respond to preventive medications whilst overusing acute medications” (2007 Grazzi).

Additionally, overuse of abortive headache medications, may eventually cause a resistance to such medications in the future. This can cause the attacks to become more frequent and severe.

Preventive therapy

Preventive therapies are directed at reducing frequency and severity of headaches. Most of these medications don’t work to alleviate acute pain symptoms. As a result, they are often used in conjunction with abortive therapy medications.

Some common preventive medications for headaches:

Cardiovascular drugs (Beta blockers, Calcium channel blockers)
Antiseizure medications
Antihistamines
Antidepressants

Antidepressant medications may help where there is a relationship between a Depression/Anxiety Disorder or sleep disturbance and migraines.

Addressing both the physical and mental health of a patient who experiences chronic headaches, will improve their quality of life and headache symptoms (2007 Frediani F). Mental health disorder treatments can be both medication and/or behavioral therapy.

Another aspect of successful headache treatments, are behavioral interventions and modifications. Behavioral modifications, include: biofeedback training, mind and body relaxation (yoga, acupuncture, massage), and cognitive behavior therapy. All of these treatments have proven quite successful for migraine prevention (2006 Holroyd).

Behavioral and supplemental treatment options:

Acupuncture
Cognitive Behavioral Therapy
Group Therapy
Massage
Exercise and Nutrition Counseling, Vitamin Supplements
Prayer
Biofeedback
Chiropractic Manipulations
Hormone Supplements

Recent studies have proven the effectiveness of Botulinum A toxin (Botox) injections as a migraine treatment option. Some of those who have received Botox injections for facial wrinkles, also, noted headache relief. The Botox injection is offered in the same area for headaches, as it is for wrinkles in cosmetic procedures.

In 2007, The Chicago Medical School at Rosalind Franklin University of Medicine and Science, compared the efficacy of Botox for migraines and tension headaches and reported positive findings using Botox as a headache treatment (2007 Freitag).

A 2006 publication stated that 75% of patients who received Botox injections for the preventative migraine treatments, reported eventual compete pain relief from headaches. No adverse effects have been reported, as “Botox (BTX-A) showed good efficacy and tolerability as a prophylactic agent” (2006 Anand). Trained pain physicians can safely offer Botox injections as a migraine treatment option.

Proven treatment options for reducing migraine frequency:

Botox Injections
Occipital Nerve Stimulation
Cervical Facet Injections
Cervical Epidural Steroid Injections
Sphenopalatine Nerve Blocks
Occipital Nerve Blocks
Supratrochlear Nerve Blocks
Supra/ Infraorbital Nerve Blocks

There has been a tremendous amount of research on the effectiveness of treatments for headache relief, and research has, generally, shown that conventional and conservative therapies are often not effective in treating the associated facial pain and peripheral/ central desensitization. Both are common in migraines.

One migraine study, conducted by the Department of Anesthesiology, Intensive Care and Pain Management in Italy reported, 85% of patients responded favorably to supraorbital and greater occipital nerves blocks (1997 Caputi).

Transnasal sphenopalatine ganglion (SPG) block injections can be helpful for migraines as well. .

The combinations of therapies above have been proven to reduce painful symptoms for all types of headaches.

Headache Journal

Lastly, a headache journal can be a helpful way to monitor headache triggers and symptoms and can be an excellent personal resource that you can share with your physician. Often, just realizing the environmental or physical triggers of your headaches, can have tremendously positive results and give you a sense of control over the pain you are experiencing. It can be a written record of detailed symptoms and notes on food, sleep routines and other important information, revealing possible headache triggers. Additionally, pain management can be noted. What treatments work? Which ones don’t? These things can all be recorded in your headache journal.

For more information or questions about headaches, treatments, and other items mentioned, please see your pain physician.

Resources/Journal Articles

Adam Sewell MD

MIGRAINES HEADACHES

Mechanism

Diagnosis

There are many medical conditions that cause secondary headaches. A physician evaluation is critical to determine an accurate diagnosis of any chronic headache conditions.

Treatment

There are two pharmacological treatment categories for primary headaches, and are classified as “abortive” or “preventive.”

Abortive therapy

Common abortive therapies for Primary HA’s:

Oxygen – most commonly used for a Cluster HA.
Ergots
Triptans
NSAID’s
Anti-emetics
Opiates
Butalbital with aspirin or acetaminophen

Additionally, overuse of abortive headache medications, may eventually cause a resistance to such medications in the future. This can cause the attacks to become more frequent and severe.

Preventive therapy

Some common preventive medications for headaches:

Cardiovascular drugs (Beta blockers, Calcium channel blockers)
Antiseizure medications
Antihistamines
Antidepressants

Antidepressant medications may help where there is a relationship between a Depression/Anxiety Disorder or sleep disturbance and migraines.

Behavioral and supplemental treatment options:

Acupuncture
Cognitive Behavioral Therapy
Group Therapy
Massage
Exercise and Nutrition Counseling, Vitamin Supplements
Prayer
Biofeedback
Chiropractic Manipulations
Hormone Supplements

Proven treatment options for reducing migraine frequency:

Botox Injections
Occipital Nerve Stimulation
Cervical Facet Injections
Cervical Epidural Steroid Injections
Sphenopalatine Nerve Blocks
Occipital Nerve Blocks
Supratrochlear Nerve Blocks
Supra/ Infraorbital Nerve Blocks

Transnasal sphenopalatine ganglion (SPG) block injections can be helpful for migraines as well. .

The combinations of therapies above have been proven to reduce painful symptoms for all types of headaches.

Headache Journal

For more information or questions about headaches, treatments, and other items mentioned, please see your pain physician.

Resources/Journal Articles

Adam Sewell MD

LOW BACK PAIN

Low back pain (LBP) is a common and frequent complaint. Pain may be either acute or chronic and can be due to injury, trauma, overuse, or from lifting heavy objects. If the inflammation or irritation results in significant damage to the back structures, the pain result in a chronic pain disorder. Structural damage to the lower back (lumbar spine) may include injury to the vertebrae, facet joints, vertebral discs, vertebral ligaments, lower back muscles, spinal cord and peripheral nerves, as well as internal organs in the pelvis (spleen, kidney, pancreas, and liver). Most of the time, LBP is acute and resolves within four weeks, however, depending on the pain cause. LBP can be a recurring condition and is very common among the American population.

Though unlikely, there are serious conditions that cause back pain as well. Seek medical attention if your back pain is severe and is accompanied by a high fever.

Back Anatomy

Bony Structures

The bony structures of the back, the vertebrae, connect together. At the top and bottom of each vertebra are facet joints, connection points, for the vertebrae to attach to one another. The five lumbar spine vertebrae provide a flexible, movable support structure, which also protects the spinal cord.

Spinal bone conditions that can cause chronic LBP include:

Facet Joint Osteoarthritis
Spinal Stenosis(narrowing of the spinal canal)
Vertebral Body Fractures
Osteoporosis
Spondylolisthesis
Neoplasms (Primary vs. metastatic lesions)
Infections

Disc Conditions that can produce chronic LBP include:

Degenerative Disc Disease
Disc Protrusion
Disc Herniation
Disc Extrusion
Facet Joint Osteoarthritis
Spinal Stenosis(narrowing of the spinal canal)
Sciatica(Nerve Root Irritation or Compression)
Disc Infection.

Spinal Ligaments and Muscles

There are three major spinal ligaments that attach, support and protect each vertebra. The many muscles, also, provide the same support and are responsible for movement. The spine has a complex spinal nerve system. Each nerve has two roots attached to the spinal cord. They exit the spine to innervate the skin, muscles, and surrounding structures of the back and lower extremities (legs and feet).

Spinal ligaments and muscles have a tendency to become strained from excessive lifting, exercise, or improper body mechanics. This can cause local nerve irritation, resulting in LBP, and myofascial (muscle and connective tissue) and ligament injury account for the majority of this kind of back pain.

Conditions that can produce chronic pain from ligaments and musculature include:

Myofascial Pain Syndrome
Muscular Strain
Torn Muscle
Ligamentous Strain
Ligamentous Tear

Referred pain

Referred pain is any pain that has its source in one area but is felt in a completely different location in the body. Organs in the abdomen and pelvis can cause referred back pain. Specifically, the kidney, pancreas, spleen, and liver are known to cause LBP due to: enlargement, infection, inflammation, obstruction, decreased blood supply and sometimes cancer. All the nerves in the body connect to the spine and may travel into the spinal cord at the same level as other structures in the lower back. This can cause pain perception in the back, instead of the organs.

Pathology

Common causes of LBP include: Herniated Discs, Spinal Stenosis, Strained Muscles Sciatica, Arthritis (auto-immune vs. non-auto-immune), Fibromyalgia, Vertebral Body Fractures, and Osteoporosis. Far less common causes are infections, Ankylosing Spondylitis, Psychological causes and Metastatic Cancer. There are several different risk factors for malignancy (cancer), but some are: an age greater than 50, pain not improved by lying down, symptoms worsen at night, and pain for longer than four weeks.

Acute Lower-Back Pain

Acute LBP comes on quickly, and occurs either during or after, a specific activity. This kind of injury is often caused by overuse, excessive exercise, heavy lifting, sports injuries, motor vehicle accidents, or any trauma to the lower back. Acute pain of this kind is usually the result of inflammation from strain or sprain to muscles and surrounding ligaments. Acute pain from ligament and muscle irritation responds well to anti-inflammatory drugs (Ibuprofen).

Vertebral body fractures, ruptured discs, and spinal cord compressions can also cause acute pain. This is, especially, true if there are pre-existing conditions, like osteoporosis, cancer, or spinal stenosis.

Acute back pain should be evaluated by a physician to rule out other causes like: kidney stones, kidney infection, and acute pancreatitis. In some cases of acute back pain, a specialist and proper imaging is required for immediate evaluation.

These causes and symptoms might include:

Acute Vertebral Compression Fractures
Acute Disc Herniation
Fever/Chills
Weakness or Paralysis
Loss of Bowel or Bladder Control
Spinal Cord Compression

Chronic Lower Back Pain

Chronic LBP is any persistent pain that lasts, at least, three months. Usually this kind of pain manifests gradually and worsens over time. A person with chronic LBP may experience additional pain down either leg. This is called sciatica.

Causes of chronic LBP are numerous and include:

Arthritis, Facet Joint
Sacroiliac Joint Disease
Spinal Stenosis (narrowing of the spinal canal)
Fibromyalgia
Degenerative Disc Disease
Disc Protrusion
Disc Herniation
Disc Extrusion
Facet Joint Osteoarthritis
Nerve Root Irritation or Compression (Sciatica)
Central Sensitization
Excessive Breast Size
Poor Posture
Psychological and Emotional Factors
Vertebral Body Fractures
Osteoporosis
Spondylolisthesis
Ankylosing Spondylitis
Neoplasms
Infections

Central Sensitization is common with any chronic pain syndrome and involves, both, the peripheral nervous system (PNS) and the central nervous system (CNS). Tissue injury and inflammation activate the PNS, which sends pain signals through the spinal cord to the brain.

Central sensitization is when neuron over-activity occurs within the CNS, (brain and spinal cord). Normal responses from the PNS begin to produce abnormally high responses, so that a sensory reaction that once normally produced a harmless normal sensation, now produces significant pain. This is often seen in patients suffering from chronic LBP.

Sacroiliac Joint (SIJ) Disease

SIJ is another chronic pain cause that is centered in the sacroiliac joint disease. Many strong ligaments and muscles support these joints, which are located on both sides of the lower back. The main function of these joints is for weight support and weight transfer, which makes them susceptible to injury.

The SIJ is innervated by multiple nerves and spinal nerve roots, and inflammation in this joint causes severe pain. SIJ pain can worsen with prolonged sitting, twisting motions, or other sudden movements. The pain often starts spontaneously; or as the result of specific injury or trauma.

Conservative treatment options, such as anti-inflammatory drugs and physical therapy, are often effective. A 2007 report found that the effectiveness of a lidocaine injection into the SIJ resulted in a 96% pain improvement in patients with SIJ (2007 Murakami).

Diagnosis

Making a LBP diagnosis can be difficult, because so many different conditions can cause similar symptoms. After a physical exam and detailed history, he or she will most likely order one or more visual tests, like, an X-ray, Computerized tomography (CT) scan, Magnetic resonance imaging (MRI) or Bone scan. All of these depend on clinical suspicions and findings during the exam.

Treatment Options

Spinal bone conditions

A 2007 report stated that lumbar facet joint nerve blocks, with local anesthetics, may be effective for treating chronic lower back pain, especially, of facet joint origin. Physical therapy, cognitive behavioral therapy, biofeedback, diet and exercise have also proven to be effective (Manchikanti 2007).

Procedures like, facet injections/denervation, vertebroplasty, SI joint injection/denervation, lysis of adhesions, spinal cord stimulation, intrathecal pumps and other treatments may provide pain relief for many spinal bone conditions.

Disc treatments

Facet injections, epidural steroid injections, lysis of adhesions, epidural infusions, spinal cord stimulation, intrathecal pumps and other treatments can be a beneficial pain management option for many disc injuries and conditions.

Spinal Ligaments and Muscles treatments

Trigger point injections have proven successful for pain relief for musculoskeletal pain. Prolotherapy is an alternative therapy that specifically targets ligaments. This sort of therapy, also called Regenerative Injection Therapy, is beneficial for many sufferers of chronic pain. Physical therapy, acupuncture, massage, yoga, diet, and exercise, and other alternative therapies, can beneficial pain management options for myofascial pain and other ligament and muscle pain.

Individuals with LBP pain lasting longer than four weeks or who are experiencing uncontrollable pain should see a pain specialist for treatment options.

Recent research shows that early treatment lowers the risk of developing a chronic pain syndrome. Contrary to some belief, bed rest generally doesn’t help LBP. Staying active and physical therapy are suggested instead. There are many pain relief options for those with severe LBP.

Pain Relief Option Overview

Pharmacotherapy – NSAIDs (Ibuprofen like drugs), Acetaminophen (Tylenol), muscle relaxants, and membrane stabilizing medications can offer significant relief from LBP.

Minimally-Invasive Procedures

Epidural Steroidal Injections are commonly used for chronic back pain syndromes, like degenerative disc disease. Medications are injected into the epidural space (area outside the spinal cord) and in the area where the pain originates. ESI’s are used to alleviate symptoms for a range of back-pain conditions. The medications spread to other areas and portions of the spine to reduce inflammation and irritation.

Medial Branch Blocks (MBBs) are often used to treat neck and back pain related to arthritis. Medial branches are spinal nerves that branch out from the vertebra and connect to the facet joints. The procedure is an injection of medications that reduce inflammation and irritation of the facet joint.

Lysis of adhesions is a type of ESI that removes excessive scar tissue from the epidural space. It’s typically performed when other more conservative treatments have failed to provide adequate pain relief.

Infusions Techniques involves inserting a small catheter into the epidural space or next to the affected nerves. A local anesthetic, and other medications, are administered through the catheter. The continuous infusion of medicines and anesthetic has the potential to result in long-lasting pain relief.

Spinal cord stimulation is typically used for individuals with chronic and severe LBP. A small electrical pulse generator is implanted under the skin, decreasing pain to the spinal cord and brain pain processing centers. An initial trial period is done to see if it will help with longer-term pain relief. If the trial period offers pain relief, than a permanent SCS device is implanted.

Peripheral Nerve Stimulation is typically used for individuals with chronic and severe LBP. Tiny electrodes are placed close to the affected nerves, and low-level electrical impulses block pain perception originating from the nerve. An initial trial period is done to see if it will help with longer-term pain relief. It may offer significant pain relief from chronic LBP as well.

Kyphoplasty and vertebroplasty are two procedures that treat compression fractures, which are often related to osteoporosis. Acrylic bone cement is injected into compressed or fractured vertebrae, strengthening the vertebrae, restoring vertebral height, and reversing spinal deformities.

Intrathecal pump implants allow delivery of pain medications (opiates, local anesthetics, and/or muscle relaxants) to affected area. Sixty-six percent of cancer patients, who use intrathecal pumps, experience pain reduction (Becker 2000).

Percutaneous discectomy, is a procedure for herniated or bulging discs, where a needle is inserted through the skin into the bulging disc. The extra material is suctioned out of the disc, relieving pressure on the disc and on other nearby structures.

Disc denervation uses heat to deaden or dull a nerve. Needles are placed along the vertebral bodies, close to the discs, and when the appropriate nerve placement is located, the nerves are anesthetized and destroyed using heat, generated from radio frequency.

Cryotherapy utilizes freezing temperatures to deaden or dull a nerve. A probe is placed through a needle, near the irritated and painful nerves, and electrical stimulation is used to pinpoint the proper location, and nerves are anesthetized. Several freezing cycles are initiated over the painful nerves.

Peripheral nerve blocks and ablation is a nerve block that uses injected medications on, or near, irritated nerves. Peripheral nerves are often are sources of LBP. Once the painful sensations are blocked with a local anesthetic, then ablation or destruction of the nerves can be performed.

Trigger points are specific muscle areas that cause pain, and trigger point injections involve injecting a local anesthetic and steroid, onto a “Trigger Point.” Often this procedure can offer significant pain relief from muscle spasms.

The use of Botox for LBP is a relatively new and innovative treatment option. In 2005 “Botulinum toxin Type A” (BtA) became the first line therapy for the treatment for cervical dystonia. Although a single injection of BtA is effective, multiple injections often work better for patients (Costa 2005). Along with pain reductions, many patients have had an improved range of motion ((Juan 2004). Not everyone can receive Botox injections, so it is important to speak with your doctor about all your medical conditions before proceeding.

Transcutaneous Electrical Nerve Stimulation (TENS) – TENs uses a small, battery-operated device that delivers low-voltage electrical current through the skin via electrode patches. The electric impulses interfere with pain sensations and replace pain perceptions with different stimuli.

Alternative/Complimentary Treatment Options

Always consult a physician before beginning any alternative or complimentary therapy. There are many different alternative therapies that are very helpful in relieving LBP including, acupuncture, biofeedback, physical therapy, exercise, nutrition, therapeutic massage, chiropractic manipulations, nutrition, and prolotherapy.

Surgical Options

Surgical procedures are typically performed conservative pain management options have failed, or when the spinal cord nerves are severely compressed. Serious compressions are characterized by bladder and/or bowel incontinence, lower extremity weakness, spasticity, and/or loss of sensation.

Invasive Surgical Procedures Include:

Discectomy
Laminectomy
Spinal Fusion
Spinal Instrumentation

For long-term pain relief, surgical fusion or discectomy may not be successful. In addition, these procedures have greater risks for serious complications, including: bleeding, nerve damage, epidural scarring, and prolonged recovery times.

Surgery is generally the last resort, when pain specialists have exhausted other avenues of treatments; or when life-threatening complications have developed, or neurological symptoms like weakness, bowel or bladder changes, and/or loss of sensation are experienced. Surgical fusion or surgery for the chronic pain treatment is not usually routine.

For more information about lower back pain causes, conditions, procedures, treatments or other items mentioned, please consult your pain physician.