Adam Sewell MD


Degenerative Disc Disease (DDD) refers to the degeneration, or normal ‘wear and tear,’ of intervertebral discs. It is one of the most common causes of low back and neck pain, and is generally, considered an unfortunate part of the aging process. 

With DDD, the degeneration in the disc, or discs, leads to an inability to effectively distribute pressure through the spinal column and associated joints. Some people will experience significant pain, while others will experience none. A ‘degenerative cascade’ process begins with DDD:

  • Acute injury occurs to the disc
  • The injury causes instability of the spine and inflammation, with intermittent bouts of pain
  • With healing, the instability is corrected and fewer episodes of pain occur

Pain associated with DDD is thought to be caused by the inflammatory compression of discs, and the instability of spinal discs. This leads to a reflexive spasm of associated muscles, and it tends to be intermittent, fluctuating from minor to intense. As instability heals, however, pain generally improves with time. If pain is continuous and/or severe, it might be something other than DDD, and additional issues should be investigated.

Symptoms associated with DDD include – numbness, tingling, and radiation of pain into the limbs. If these symptoms get worse, or weakness develops, it is possible that a disc herniation has begun, compressing and possibly, damaging, nearby nerve roots.

Diagnosis and Treatment

Diagnosis of DDD is a diagnosis of exclusion, made by a doctor who takes into account history, a thorough physical exam, and imaging studies such as Magnetic Resonance Imaging. A MRI cannot diagnose DDD alone, but it can assist in creating an overall picture.

Most patients will respond with conservative management, including:

  • Activity modification, and exercise such as core strengthening and aerobic conditioning
  • Medications such as acetaminophen (Tylenol™) or ibuprofen (Advil™) can be used to manage mild chronic pain. Opioids like codeine can be prescribed for the short term relief of more severe pain
  • Physical therapy that includes therapeutic exercise, gentle stretching, electrical stimulation, traction and more can be beneficial
  • Heat and ice can be used at the site of pain to relieve inflammation

If conservative treatments fail, a variety of surgical treatment options exist for DDD2:

  • Spinal fusion of the vertebrae around an affected disc to restrict joint motion.
  • Dynamic stabilization is similar to fusion, but used more flexible materials as an internal ‘brace’
  • Disc arthroplasty, or artificial disc replacement
  • Nucleoplasty, or removal of disc material
  • Nucleoplasty, or removal of disc material

Approximately 65% of individuals will experience improvement following surgical intervention. Sometimes, however, post-operative pain and stiffness may prevent a full return to pre-operative activity levels.


  1. Degeneraton Disc Disease–
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  5. Anderson, B.; Isaac, Z.; Devine, J. (2010). Treatment of neck pain. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
Adam Sewell MD


Carpal tunnel syndrome (CTS) is one of the most common causes for pain in the U.S.It is marked by numbness and tingling in the hand, caused by compression of the median nerve as it travels through the wrist. Women are, at least, twice as likely to be affected as men.

Pain, numbness and tingling usually occur on the palm and palmar side of the first three fingers from the thumb. Weakness can, also, occur in the thumb and adjacent fingers. Symptoms are aggravated by the position of the wrist, and are usually occur at night, after a long day of use. They may radiate up the arm as far as the shoulder, too. Other symptoms can include decreased dexterity, a weak grip, atrophy of muscles in the hand, and feelings of hand swelling. 

Common causes and predisposing factors for CTS include:

  • Repetitive strain and prolonged flexion/extension of the wrist, notably from activities such as driving, reading, typing, and holding a telephone
  • Rheumatoid arthritis
  • Diabetes
  • Wrist fracture and associated swelling
  • Pregnancy/oral contraceptive use leading to swelling in the limbs
  • Underlying nerve dysfunctions

Diagnosis and Treatment

A physician may perform a variety of tests and nerve conduction studies to confirm the diagnosis.

The goal of treatment is to reduce pain, numbness and tingling, and prevent loss of motor function. Treatment depends on the severity of CTS and patient preference. Most mild to moderate cases of CTS can be effectively managed with a combination of conservative treatments:

  • Minimizing contributory factors such as repetitive use/strain
  • Wrist splinting helps keep the wrist in a neutral position, limiting prolonged extension/flexion
  • Glucocorticoids (steroids) can be taken orally or injected into the carpal tunnel to reduce inflammation and compression
  • Deep, pulsed ultrasound can be used to decrease pain and promote soft tissue healing
    Yoga has been shown to be effective for pain control

For symptoms that do not improve within 6 months of conservative treatment, surgical decompression of the median nerve may be necessary. Surgical intervention is generally more effective than conservative treatments.  Improvement is seen in, approximately, 85-90% of cases. Surgical treatments include open incision or endoscopically:

  • An open release is performed via standard incision under local anesthesia, and allows a surgeon the best view
  • An endoscopic release is performed with scopes and surgical tools through one or two small openings, and can result in less scar tissue and post-operative pain

The prognosis for CTS is good, although a minority of patients, particularly those with advanced CTS, may fail to improve after treatment. Additionally, scarring post-surgery can lead to a recurrence of symptoms, even months or years later. The best way to treat CTS is to practice ergonomically appropriate habits at home and at work, to avoid repetitive tasks previously, and to keep wrists in a neutral position as often as possible.


  1. Wrist Anatomy–
  2. Carpal Tunnel Syndrome–
  3. Scherger, J.E.; et al. (2007). Carpal tunnel syndrome. First Consult. MD Consult Web site, Core Collection. Retrieved from 
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  5. Hunter, A.A.; Simmons, B.P. (2010). Surgery for carpal tunnel syndrome. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.

Adam Sewell MD


Cancer is a devastating diagnosis, and it can effect people in many different ways. Most people with cancer eventually experience pain due to their condition and/or the treatments themselves. Approximately, 25% of patients with newly diagnosed malignancies complain of pain, and up to 90% percent of those with advanced cancer experience pain (Grossman 1994).

Pain associated with cancer can take many forms, and it can be sharp and severe, or a dull constant ache. Regardless of the type of pain, a diagnosis of cancer does not mean you have to suffer with debilitating pain. The physicians at Arkansas Pain Specialists understand the devastating effects pain related to cancer, and will develop a treatment plan that meets your specific needs.


Cancer pain can be experienced when a tumor presses on nerves or expands inside a hollow organ. It, also, commonly originates from bone destructive lytic lesions. Bone marrow infiltration commonly causes bone pain that can be severe as well. Unfortunately, the radiation and chemotherapeutic treatments used to treat cancer can, also, result in fairly intense pain.


The treatment for pain due to cancer must specific to an individual, because the pain is specific as well. It is important that your pain physician develops a treatment regimen that will be most beneficial and successful for you. Some of the commonly used non-drug pain treatments are:

  • Pharmacotherapy: NSAIDs (Ibuprofen like drugs), opiod type medications, muscle relaxants, and membrane-stabilizing medications can be very effective in treating cancer pain.
  • Nerve blocks: Specific nerve blocks and neurodestructive procedures can help relieve pain conditions due to cancer. One such block is used for patients with unresectable pancreatic cancer, Celiac Plexus Blocks< can be extremely effective at treating difficult pain. Recent studies show this technique helped to control pain and reduce pain medication consumption (Yan 2007). Your pain physician will determine which nerve block treatment is right for you.
  • Transcutaneous Electrical Nerve Stimulation (TENS): is a technique that relieves pain by applying mild electric current to the skin at the site of the pain. The electric impulses interfere with normal pain sensations and alter perceptions that were previously painful.
  • Intrathecal Pumps: Implanted pain pumps are also available which can be extremely helpful providing long-term pain control. The effectiveness of intrathecal therapy in patients suffering from nociceptive pain showed a pain reduction in 66.7% of patients experiencing pain due to cancer (Becker 2000).
  • Biofeedback: This is a treatment that teaches a patient to become aware of processes that are normally thought to be involuntary inside of the body (such as blood pressure, temperature and heart rate control). This method enables you to gain some conscious control of these processes, which can influence and improve your level of pain. A better awareness of one’s body teaches one to effectively relax and this can help to relieve pain.
  • Massage: Gentle focal rubbing of the tender areas may help relieve muscle spasms or contractions and improve associated discomfort. Massage can also be help patients relax, decreasing stress and tension.
  • Radiation therapy and surgery: can also have palliative outcomes for cancer patients.


  1. Cancer Pain –
  2. Current management of pain in patients with cancer. Oncology (Williston Park). 1994 Mar;8(3):93-107; discussion 107, 110, 115 Grossman SA, Staats PS. PMID: 7912540 Neurolytic celiac plexus block for pain control in unresectable pancreatic cancer. Yan BM, Myers RP. Am J Gastroenterol. 2007 Feb;102(2):430-8. Epub 2006 Nov 13 PMID: 17100960 The significance of intrathecal opioid therapy for the treatment of neuropathic cancer pain conditions. Becker R, Jakob D, Uhle EI, Riegel T, Bertalanffy H. Stereotact Funct Neurosurg. 2000;75(1):16-26 PMID: 11416261
Adam Sewell MD


Healthy vertebrae and discs are crucial to spinal movement, and discs provide a cushion between each of the 33 vertebrae in the spine. The vertebrae, stacked on top of each other with discs in between, provide nerve protection. Discs connect and form the spine, absorb weight placed on the spine, and to allow for movement. When discs are compressed, they become misshapen. Intervertebral discs are composed of a tough, fibrous outer layer called the annulus fibrosis. Nerve pain is caused when the disc is compressed or bulging.

The lower back is where most bulging discs occur, and less commonly, in the upper back and neck. More than half the people with bulging discs don’t experience any symptoms. For others, the pain can be mild to quite intense, and a physician may order a CT scan or MRI to diagnose the source of the pain. This kind of testing is suggested for people who’ve had  4-6 weeks of severe, or unmanageable, pain. The cause of the bulge, which could be disc herniation or degenerative disc disease, will be determined.
Most bulged discs will not require treatment, but for those that do, there are many options. Most physicians begin with conservative care, including the following:

  • Over-the-counter anti-inflammatory/pain relief medications
  • Short-term prescription pain relief from opiate medications
  • Steroid injections for inflammation
  • Physical therapy to help strengthen and improve stability
  • Acupuncture
  • Chiropractic traction
  • Rest

In most cases, surgical treatment is generally not necessary. Once a physician can identify the underlying cause for the bulging disc, it can be treated with an open discectomy if other, more conservative, treatments have not worked.  .


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  3. Milette, P. The Proper Terminology for Reporting Lumbar Intervertebral Disc Disorders. American Journal of Neuroradiology. Vol 18, 1859-1866. 1997.
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  6. Steiger, T.; et al. Diagnostic testing for low back pain. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.
  7. Robinson, J.; Kothari, M. Clinical features and diagnosis of cervical radiculopathy. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010.
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  9. Chou, R. Subacute and chronic low back pain: pharmacologic and noninterventional treatment. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010.
  10. North American Spine Society 2009: Lumbar (open) Microscopic Discectomy. Patient Handouts page. Available at Accessed April 15, 2011.
  11. Buckwalter, J. A.. Aging and Degeneration of the Human Intervertebral Disc. Spine. Vol 20, 1307-1314. 1995.
Adam Sewell MD


The only condition more common, in the United States, than common headache is back pain (National Institutes of Health, 2011). It is estimated that nearly a quarter of the population is suffers from it. Billions of dollars are spent each year on back pain treatments (Jones et al, 2010; National Institutes of Health, 2011). Both men and women suffer equally from this common annoyance that interferes with functioning, daily activities, work performance and leisure (National Institutes of Health, 2011). It is the leading cause of missed days at work and job-related disability (National Institutes of Health, 2011). Often, back pain will go away on its own, but sometimes it returns and a qualified pain physician needs to be consulted.

Common Causes of Back Pain

Pain that lasts several weeks is acute, or severe, and this is different than chronic back pain which lasts for more than three months progressively (National Institutes of Health, 2011). Back pain can be the result of trauma, disease, spinal stress, muscle strain, car accidents, sports or work related injuries, and herniated or ruptured discs (National Institutes of Health, 2011). Non-traumatic medical issues can include, malignancy, osteoporosis, degeneration, nerve tissue damage, arthritis, viral infections, bone diseases, disc disease, congenital abnormalities, vascular dysfunction, bone infection, or joint or disc irritation (Jones et al, 2010; Lin, 2009; National Institutes of Health, 2011).

Symptoms of Back Pain

Any part of the back may experience acute to chronic levels of pain, though the most common form of back pain is found in the lower portion of the spine. Symptoms may present as restricted range of motion, the inability to stand straight, limited flexibility, sharp shooting pains, sudden stabbing pains, stiffness, soreness, tenderness, numbness, tingling and muscle aches (National Institutes of Health, 2011). The pain often radiates to other areas and/or extremities or becomes aggravated with strenuous activity or movement (Jones et al, 2010). Any of symptoms of back pain can cause serious damage if left untreated by a physician (National Institutes of Health, 2011).

Immediate Attention Required

Some back pain symptoms are indicate an emergency and require immediate attention from a medical professional. These are – fever, pain when coughing, weight loss, numbness or tingling, loss of bladder control, bowel dysfunction, pain that radiates into the legs or progressive weakness in the legs, and increasing pain that lasts more than three months (National Institutes of Health, 2011).

Back Pain Diagnosis

A physician will perform a comprehensive evaluation before back pain treatment can begin. The initial exam should include a thorough patient history, a full neurological workup, and a physical examination. Blood work, scans and imaging, may be ordered, based upon levels of pain and symptoms. Additional tests may reveal broken bones, fractures, injury, disc herniation, bone infections, tumors, ruptured disc, malignancy, spinal stenosis, vertebral damage or degeneration (Jones et al, 2010; Lin, 2009; National Institutes of Health, 2011).

Back Pain Treatment

Back pain treatments are meant to alleviate pain and improve daily functioning (Lin, 2009). Within a few weeks of conservative back pain treatments, pain is usually reduced (Jones et al, 2010; National Institutes of Health, 2011). Physicians may prescribe several conservative back pain treatment methods (Jones et al, 2010; Lin, 2009; National Institutes of Health, 2011). These may include muscle relaxants, anticonvulsants (to treat nerve pain), antidepressants (relieves pain and aids in sleep) or pain medications (National Institutes of Health, 2011). Physical therapy may be recommended to stretch and relax muscles, strengthen the back and speed recovery (National Institutes of Health, 2011). Reducing risk factors, losing weight, and eliminating strenuous activities that aggravate pain, are all important in aiding back pain relief. Massage, acupuncture, biofeedback, or yoga may be suggested as alternative therapies as well (National Institutes of Health, 2011).

Invasive Back Pain Treatment for Serious Pain Sufferers

Physicians might suggest more aggressive pain management treatments if conservative treatments are not producing adequate results. Pain can be reduced or, even completely eliminated, with interventional therapy using injections that pain signals from getting to already irritated nerves (National Institutes of Health, 2011). These include narcotic, steroid or local anesthetic injections (National Institutes of Health, 2011). For more severe pain, nerve blocks, spinal cord stimulation or drugs administered by catheter into the spinal cord (National Institutes of Health, 2011). Pain management procedures such as spinal fusion, discectomy, foraminotomy, rhizotomy, cordotomy or spinal laminectomy are surgical options used in cases of extreme chronic back pain (National Institutes of Health, 2011).


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  2. Lin, M. (2009). Upper Back Pain. Marx: Rosen’s Emergency Medicine, 7th Ed. MD Consult Web site, Core Collection. Retrieved from
  3. National Institutes of Health 2011. Low Back Pain Fact Sheet. NINDS. Available at NIH Publication No. 03-5161
  4. Nidus Information Services 2010: Low Back Pain – Chronic. Patient Handouts page. MD Consult Web site, Core Collection. Available at Accessed January 14, 2011