Accuracy of Diagnostic Facet Joint (Medial Branch Nerve) Blocks
Lumbar Facet Joint Pain
Lumbar facet pain is a common cause of both acute and chronic pain in the low back. Most people experience low back pain at some time in their life. Lumbar facet (zygoapophyseal joint) pain is the cause of this in many of these cases, particularly as people age. The pain usually comes from degenerating facet joints becoming inflamed. Estimates range that from 16% to 41% of patients with chronic back pain without a herniated disc or "radicular" pain extending below the knee, have pain related to the lumbar facet joints.
Over the years, the diagnosis of this condition has been somewhat of a challenge. Conventional studies such as x-rays, CT scans, and MRIs are often inconclusive. Lab tests are also usually not helpful.
Even physical exam findings, although suggestive of facet syndrome, are not conclusive and have shown very poor reproducibility and correlation with diagnostic blocks.
The way that lumbar facet joint pain is usually diagnosed is by anesthetizing the joints using x-ray guided injections known as medial branch nerve blocks. The medial branch nerves are the tiny nerves that come off of the spinal nerve roots and connect to the lumbar facet joints. These tiny nerves and pain signals back down to the nerve root and then on up to the spinal cord and finally the brain where they are interpreted as painful sensations.
Unfortunately, a single diagnostic block is often not helpful. False positive rates with a single diagnostic block can be as high as 49%. In these situations, this invasive test may be no more of effective or informative than flipping a coin. So, given these findings, how do we diagnose lumbar facet joint pain.
After reviewing a total of 25 studies, the authors in the study found that there was GOOD EVIDENCE for diagnostic facet joint nerve blocks when using a 75% to 100% pain relief as the criterion standard with the dual blocks. The authors found that there was only FAIR EVIDENCE when using a 50% to 74% pain reduction criterion. Using only a single diagnostic block resulted in limited accuracy whether using 50%-74% or 75%-100%.
Facet joint syndrome is spinal pain that originates in the joints on the back side of each of the vertebra. These joints are designed to help stabilize the spine as it moves. There are two such joints at each spinal level. Working in unison the joints assist in making it possible for your back to be more flexible and they support and stabilize the spine as it flexes, extends, and rotates.
What causes facet joint pain?
Causes. Facet joint syndrome can be caused by a combination of aging, pressure overload of the facet joints, injury, and/or trauma. As the lumbar discs degenerate, they wear down and begin to collapse. This degeneration causes the approximation of the facet joints and more weight and pressure is placed on the joints.
What does facet sclerosis mean?
Facet sclerosis is another term for the degeneration of the joints. It is usually referred to in this way to describe the appearance of the generated joints on x-ray images.
What is facet joint tropism?
Facet joint tropism is a difference in shape or size of the facet on one side of the spine when compared with that on the other side. Facet tropism may also describe differences in angulation of the facet joints. Overall, the word tropism describes an asymmetry of a facet joint on one side of the spine compared with the other. facet tropism can occur at one level or several levels of the spine. This condition is not uncommon. Estimates of the exact frequency of this condition vary widely. However, most experts agree that the incidence is somewhere around one in six people. Some estimates, however, estimate the incidence of facet tropism as high as 70%. Many experts believe that the presence of asymmetry or tropism in the facets had a spinal level increases the likelihood of irregular wear and degeneration at that level.
What are the symptoms of arthritis in the lower back?
There are several different types of arthritis and arthritis can present in several different ways in the lumbar spine, also known as the low back. The most common type of arthritis is osteoarthritis or arthritis that comes from normal wear and tear over time as part of the normal aging process. This is degenerative arthritis as opposed to inflammatory arthritis such as rheumatoid arthritis. Osteoarthritis usually presents as a goal or sharp pain at and around the science of degeneration. This type of arthritis is often associated with bone spur formation. The degeneration or these bone spurs may cause pressure on a nerve root or other nerve structure. If this occurs, a shooting or burning pain may be felt. In some cases, these degenerative changes can place pressure on the nerve to the point that sensation is lost or weakness occurs. In severe cases, enough pressure can be placed on a nerve or nerves to cause paralysis.
How is facet syndrome treated?
The initial treatment of facet syndrome is usually conservative. This may include rest for a few days to allow a decrease of the inflammation. Icepack treatments over the facet joints are often helpful. Some people find heat more beneficial if the pain is not due to an acute injury. With heat and ice, however, care must be taken to avoid burning or frostbite of the skin. Over-the-counter medications such as acetaminophen or NSAID's may be appropriate for individuals without contraindications to these medications. Physical therapy or chiropractic care is often used to decrease pain, strengthen core musculature, and improve range of motion. Sometimes back braces can give symptomatic relief. However, caution must be used to avoid wearing the back braces too much of the time so as to avoid weakening of the core muscles. Chiropractic care may be helpful to realign the facets and decrease restrictions in motion. For persistent pain from facet syndrome, physicians often prescribe pain medications such as tramadol or other weak opioids. Interventional pain management options such as facet joint injections or medial branch nerve blocks are often prescribed. Although commonly used, injection of corticosteroid anti-inflammatory medication into the joint space itself has shown only limited efficacy in recent research studies. Blocking the nerve to the facet joints, the medial branch nerves, helps physicians confirm the diagnosis of pain coming from the joints. For cases where the pain is persistent, destruction of these nerves with a radiofrequency neurotomy may provide more extended relief. The nerves usually do grow back over a period of time that may range from six months to two years. If they do grow back and the pain returns, the radiofrequency procedure may be repeated.
Lumbar spinal stenosis is a narrowing of the central spinal canal in the lumbar spine (lower back) or the neuroforamina where the spinal nerves exit the spine. Narrowing of the central canal is called central spinal stenosis. Narrowing of the neuroforamina is called foraminal stenosis. Narrowing in either of these areas can cause pain and/or weakness in the extremities as well as multiple other symptoms. In more severe cases, permanent nerve damage or paralysis can occur. Spinal stenosis can put pressure on the nerves traveling through the spinal canal and the neural foramina because of a narrowing of the canal or foramina. The most common sites for spinal stenosis of the lumbar spine in the cervical spine (low back and neck).
What is the cause of lumbar spinal stenosis?
Degenerative disc disease and degeneration of the other structures in and around the spine is the most common cause of lumbar spinal stenosis. Degenerative changes are a normal part of the aging process in the body usually accommodates these changes without a large loss in function and with only mild pain as the years go by. However, in some people, the combination of these changes results in a significant narrowing of the spinal canal or the neuroforaminal openings to a degree that the nerves or the spinal cord are impinged or compressed. When this occurs, the person is said to have lumbar spinal stenosis.
Can spinal stenosis be caused by an injury?
Lumbar spinal stenosis can be caused by trauma or injury to the spine. Such trauma may involve a motor vehicle accident or fall. Other possible injuries may occur when a disc is herniated due to a personal lifting while not using proper technique. Such injuries may result in the nerves or spinal cord being compressed, resulting in lumbar spinal stenosis.
Is Spinal Stenosis bad?
There are several degrees of severity with lumbar spinal stenosis. This severity can range from very mild to very severe. In most cases, the mild to moderate degrees of stenosis caused little if any reduction in overall function. Usually, in these cases, there is little if any pain associated with the narrowing of the spinal canal or neural foramina caused by the stenosis. The person may, however, have pain associated with herniated discs or arthritic degenerative joints. With the more severe cases of spinal stenosis, there may be pain associated with activity and sometimes even at rest. One of the classic symptoms of lumbar spinal stenosis is known as neurogenic claudication. With this condition, the nerves do not get enough blood supply during activities such as walking. Therefore, when the person walks, they begin to have both pain and weakness with extended exertion. However, when they sit down for a few minutes, the problem resolved and they are able to get up and walk for a distance once again. However, when more blood supply is needed during this next bout of activity, the pain and weakness resume. In very severe cases, a condition known as cauda equina syndrome may occur. In cauda equina syndrome, nerve damage can occur that may result in incontinence of bowel and/or bladder control as well as possible paralysis. If these symptoms occur, it is a medical emergency that must be treated quickly, usually with surgery, in order to prevent the symptoms from being permanent. Sometimes, however, even with appropriate and timely surgical intervention, the nerve damage can be irreversible.
Can exercise help spinal stenosis?
Doctors often refer people with spinal stenosis to physical therapists or prescribe home exercise programs. Some physical therapy protocols may be beneficial with lumbar spinal stenosis. Although the exercise will not reverse the degeneration, some protocols can help decrease the extent of bulging discs and can help strengthen the core muscles that support the spine. Exercise may be conducted either in the setting of a physical therapy office, with home physical therapy, or with a home exercise program. If exercise brings on pain or other symptoms, the person should not try to "work through the pain". Instead, they should discuss these occurrences with their physician
Can physical therapy cure spinal stenosis?
Physical therapy does not usually "cure" lumbar spinal stenosis. The therapy may help strengthen muscles, improve coordination, improve function, and help relieve some of the pain associated with the more severe cases of lumbar spinal stenosis. Some of the techniques that physical therapist used to help patients with this condition include Williams Flexion Protocol, electrical stimulation, traction, ice, and heat among other physical therapy modalities and treatment protocols.
Is lumbar spinal stenosis curable?
While there is no cure for lumbar spinal stenosis, there are several treatments. Many if not all of the symptoms associated with lumbar spinal stenosis such as pain and numbness in the legs can be reduced or even eliminated with these treatments. These treatments range from simple home exercise programs to extensive surgical decompression in the more severe cases.
Can you get surgery for spinal stenosis?
There are many surgical options for lumbar spinal stenosis, depending on where the narrowing is occurring and the severity of stenosis. Many of the surgical treatments such as the MILD technique or minimally invasive endoscopic laminectomy techniques can be performed with small incisions and relatively short recovery times. In other cases, more extensive surgical decompression is necessary. Sometimes, there is residual pain that has to be treated as well. This may require medications, further therapy, injections, or neuromodulation with devices such as spinal cord stimulators.
How long does it take to recover from a back operation?
Most people are able to return to a reasonable degree of activity fairly quickly. However, it usually takes several months for the healing in bones to reach maximum strength. It is not uncommon for some patients to take up to a year or more to obtain maximum improvement. While some of the minimally invasive surgeries may require only a few days for a person can return to sedentary activity, more extensive surgeries such as laminectomies and surgical fusions usually require people to be off work for at least 4-6 weeks. The person has a strenuous job, they may be able to return to light-duty after 4-6 weeks but it may take significantly longer for them to be able to return to full duty. Even with successful surgery, some people may not be able to return to their former level of activity, especially if their job required them to do a large amount of heavy lifting, bending, and twisting. For these individuals, it may be necessary to find a job that has lower physical requirements.
How do you prevent spinal stenosis?
Some factors that lead to lumbar spinal stenosis can be prevented but others cannot. Avoiding trauma is the most obvious way to prevent spinal stenosis from occurring. However, there does seem to be a genetic component that current technology cannot prevent. Some of the factors that can help prevent the development or worsening of lumbar spinal stenosis include avoiding tobacco. Use of tobacco products, even smokeless, has been linked to increased back, poor healing, and accelerated degeneration of the spine. Good posture can help prevent degeneration of the lumbar spine to some degree. This is because good posture helps avoid uneven pressures on the various structures of the spine. Regular exercise helps maintain both flexibility and good muscle tone to support the lumbar spine. Finally, maintaining a healthy weight is important since obesity add significantly to the weight burden that the spine has to support year after year. These lifestyle changes can both help prevent and may help reduce the symptoms of lumbar spinal stenosis.
The term “pinched nerve” is used to describe the condition when a nerve is being compressed by the surrounding tissues
What are some of the symptoms of a pinched nerve?
Some signs and symptoms associated with pinched nerves include changes in sensation or numbness along the distribution of the nerve.
Sometimes a burning pain that may have an aching or sharp quality can be associated with a pinched nerve.
When a nerve is pinched and not functioning properly, you may get the feeling that your foot or hand has fallen asleep.
What causes a pinched nerve?
There are many causes of nerve compression. For instance, in the case of a herniated disc, the center of the disc is often protruding out into the spinal canal causing compression on a nerve or the spinal cord. In carpal tunnel syndrome, thickening of ligaments, inflammation of tendon sheaths, and/or arthritic changes can cause pressure over the median nerve. Sometimes, repetitive stress is from work, hobbies, or other activities can cause thickening of tissues and pressure on nerves. Obesity is also associated with increased incidence of nerve compression.
Sometimes inherent differences can lead to increase risk of certain problems. For instance, women tend to have smaller carpal tunnels so they are more prone to get carpal tunnel syndrome than men.
Women tend to also have increased risk of nerve compression during pregnancy because of water retention and weight gain during that time.
Inflammatory processes such as rheumatoid arthritis can cause changes in bones and joints as well as inflammatory changes in surrounding tissue that can compress nerves.
Having conditions like thyroid disease or diabetes can increase the likelihood of having nerve compression.
Sometimes occupational risk or activities can increase the risk of having a pensioner. Examples of this include jobs with highly repetitive movements such as assembly-line work.
Cortisone, also known as corticosteroid, shots are injections that may help relieve Inflammation and associated pain in various parts of the body. They're most commonly injected into joints-- such as your ankle, elbow, hip, knee, spine, wrist as well as shoulder. Even inflammation in the small joints of the hands and feet might benefit from corticosteroid shots. When these injections are given, your doctor will often use image guidance like ultrasound or fluoroscopy to make sure that the needle is in the correct position before injecting the medication.
What Kind of Medication is Used?
The medication injected usually includes a local anesthetic like Xylocaine or Sensorcaine along with a corticosteroid such as triamcinolone, Depo-Medrol, or dexamethasone. Corticosteroid injections are usually performed in an office setting if they are in peripheral joints such as the ankle, elbow, hip, knee, or shoulder. Injections in smaller joints such as wrists, ankles, fingers, and toes are also usually performed in an office setting. Corticosteroid injections of deeper structures such as the spine may be performed in a specialized procedure suite in an office or may be performed in a hospital or an ambulatory surgery setting.
What Can I Expect?
In most cases, your doctor will numb the area of the injection prior to injecting the corticosteroid. This is particularly true if the injected steroid is composed of suspended crystals as in the case of Depo-Medrol or triamcinolone. However, if a particle free formulation such as dexamethasone is used, your doctor may be able to use a very thin needle that is much less painful and may not require the discomfort of an injection for local anesthetic.
How Many Steroid Injections Can I Have?
There is usually a limit on the number of corticosteroid injections you can receive in one year because of potential side effects of receiving too much corticosteroid medication. Your doctor can assess the risks and recommend appropriate dosages. However, recent research has indicated that beneficial effects of corticosteroid injections in some parts of the body can be obtained with much lower dosages than we had previously thought.
Some of the conditions that corticosteroid injections can be helpful for include herniated discs, rheumatoid arthritis, tendinitis, bursitis, gout, carpal tunnel syndrome, and plantar fasciitis. In addition to these problems, steroid injections have been used to treat many other inflammatory conditions.
What Are Some of the Risks Associated with Steroid Injections?
Corticosteroid injections, however, are not without risk. Some of the potential side effects or complications of these injections include:
Steroid flare (temporary flareup in pain at the site of the injection)
Thinning or weakening of bone (Osteopenia or Osteoporosis)
Color changes in the skin around the site of the injection.
Osteonecrosis or death of bone
Elevations in blood glucose
Temporary decrease in immunity from infection
As a general rule, you shouldn't obtain cortisone injections more than three or four times a year. The main limitation is the total dose of corticosteroid per year. Your doctor can advise you on the current recommendations.
The area around the injection site is cleaned up. Your medical professional could additionally apply an anesthetic spray to numb the area where the needle will be placed. In many cases, your doctor could use ultrasound or a kind of X-ray called fluoroscopy to see the needle's progression into the targeted structure-- to assure it in the ideal place.
You'll likely feel some pressure when the needle is inserted. If you have a lot of discomfort, let your physician know.
The medication is then injected. Generally, cortisone shots consist of a corticosteroid medicine to alleviate pain and inflammation gradually and also an anesthetic to supply prompt pain alleviation.
After the cortisone shot.
Some individuals have soreness and also a sensation of warmth of the upper body and also face after a cortisone shot. A cortisone shot might raise your blood sugar levels if you have diabetics issues.
Outcomes of cortisone shots generally depend on the reason for the treatment. Cortisone shots commonly create a short-term flare hurting and inflammation for as much as 2 days after the injection. Afterwards, your pain and also inflammation of the affected joint will likely reduce and the relief could last several months.
Boston Scientific describes some of these advantages as follows.
PRECISION MONTAGE™ MRI SCS SYSTEM
* Full-Body MRI. Multiple Waveforms. Providing access to Full-Body MRI Scans, Precision Montage delivers Multiple Waveforms, all powered by Illumina 3D. No longer compromise Pain Relief for Full-Body MRI — Precision Montage MRI couples the most advanced programming proven Illumina 3D to provide excellent pain relief and Full-Body MRI.
AVISTA™ MRI LEAD
with Heat-Canceling Technology
The Avista™ MRI Lead is the only lead designed using advanced Heat Canceling Technology for safe access to Full-Body MRI Scans. The layers of the lead were engineered to work together to cancel out the RF waves that cause heat, creating a safe environment for MRI scans. This unique construction was also designed for optimal steering and durability.
MULTIPLE WAVEFORM PROGRAMMING OPTIONS
Pain is dynamic, and every patient is unique. With the MultiWave Platform, you can offer customized pain relief using Waveforms that are as unique as your patient’s pain. Each waveform can be precisely targeted using our Illumina 3D Algorithm, and delivered through a system that offers your patients safe access to Full-Body MRI scans.
* MR Conditional Statement
The Precision Montage™ MRI SCS System provides safe access to Full-Body MRI Scans only when used with the Avista MRI Leads and exposed to the MRI environment under the specific conditions defined in the ImageReady MRI Full-Body Guidelines for Precision Montage™ MRI Spinal Cord Stimulator System.
It appears that moderate coffee consumption may be healthy after all. In a recent study published in the Annals of Internal Medicine, coffee consumption is associated with an overall reduced risk of death.
The study was published in the August 15, 2017 edition of the Annals of Internal Medicine. It was entitled "Association of Coffee Consumption With Total and Cause-Specific Mortality Among Nonwhite Populations” and its primary funding source was the National Cancer Institute.
The participants included 185,855 individuals from various ethnic descent age 45-75 years old at time of recruitment. The study was a prospective population-based cohort study that was started between 1993 and 1996.
The outcomes measured were total and cause specific mortality (death rate).
During this time period, coffee consumption was associated with lower risk of death in all ethnic populations studied. Native Hawaiians, however, did not reach statistical significance in the lower risk of death. Overall, however, the trend toward a lower risk of death was very significant with a P value <0.001. The trends between caffeinated and decaffeinated were similar.
The improvement in death rates was observed for patients with several diseases including heart disease, cancer, respiratory disease, stroke, diabetes, and kidney disease. Improved overall risk of death was also noted in individuals who did not report having a chronic disease.
The researchers found that individuals drinking one cup of coffee a day had a “hazard ratio” for death from all causes that was 9-15% less than non-coffee drinkers. Individuals drinking 2-3 cups of coffee per day had a 14-21% improvement. Those drinking > 4 cups per day showed a 13-22% improvement.
The authors of this study concluded that:
"Higher consumption of coffee was associated with lower risk for death in African-Americans, Japanese Americans, Latinos, and whites."
Park S, Freedman ND, Haiman CA, Le Marchand L, Wilkens LR, Setiawan VW. Association of Coffee Consumption With Total and Cause-Specific Mortality Among Nonwhite Populations. Ann Intern Med. 2017;167:228–235. doi: 10.7326/M16-2472
A recent study in Pain Physicianstudied the question regarding whether or not the shape of a person's sacroiliac joint can make a difference as to whether or not they have sacroiliac joint pain.
Sacroiliac Joint Pain
Sacroiliac joint pain is a common problem that accounts for 10-25% of chronic low back pain. However, in patients who have previously had surgery or trauma to the lumbar spine and/or pelvis, the rate can be much higher. Some studies have documented rates of sacroiliac joint pain as high as 75% in patients that have had previous lumbar fusions.
Sacroiliac Joint Pain Diagnosis
Although this problem is quite common, diagnosing it is somewhat of a challenge. Regular studies such as x-rays, CT scans, and MRI scans do not usually show significant findings in the majority of people with sacroiliac joint pain. Physical exam for sacroiliac joint pain is notoriously inconsistent and unreliable for most of the provocation tests. Using a combination of physical exam tests can give a significantly higher likelihood of accurate diagnosis. Even with this, however, the accuracy of the physical exam is only about 80%. The gold standard for diagnosing sacroiliac joint pain is a diagnostic sacroiliac joint injection with local anesthetic. Usually, two injections with different anesthetics are required to rule out placebo effect. Even this injection protocol, however, is not perfect and some studies have questioned the sensitivity and specificity of the dual block diagnostic technique.
SI Joint Pain Treatment
Various treatment options ranging from watchful waiting to physical therapy, joint injection, radiofrequency ablation, and SI joint fusion have been used to try to help those suffering from SI joint pain.
This study was a case-control study that compared the shapes of the sacroiliac joints and 223 normal controls and 34 patients with sacroiliac joint (SI) pain syndrome.
The researchers used CT scans with 3-D reconstructions of the joints. They then took the scans and use virtual reality to disarticulate and measure the joints.
Using this technique, they were able to classify the shape of human sacroiliac joints into three different classifications. Type 1 was described as “scone-shaped”. Type 2 was described as (auricle-shaped). Type 3 was described as "crescent-shaped”.
SI Joint Shapes
Analysis of the morphologies of sacroiliac joints revealed that the shape of the sacroiliac joint did not correlate with pain in men. In women, however, there was a significant correlation with the likelihood of SI joint pain and the shape of the joint. The authors found that approximately 32% of women with a type 3 (Crescent-shaped) joint at SI pain. Approximately 17.5% of women with type 2 joints at SI pain. Only 5% of women with type I SI joints had SI joint pain.
The authors concluded that:
"SI joint morphologic variability can be classified into 3 types (type 1, type 2, type 3) based on the relative width of the joint at the axis nutation… Type 3 (crescent) morphology was more highly represented in the SI joint pain population."
In this study there were 120 patients. The patients in this study ranged from 18 to 70 years old and were randomly divided into two groups. Each of these patients had back pain for less than one year. They were taking medications such as opioid analgesics, nonsteroidal anti-inflammatory drugs, or neuropathic medications such as Lyrica for low back pain associated with unilateral (one-sided) leg pain, symptoms suggestive of sensory impairment in the affected lamb, and imaging suggestive of spinal stenosis or herniated/degenerated disc, and patients with positive straight leg raise test.
By the end of one month, the straight leg raise test had become negative in 98% of those treated with transforaminal epidural steroid injections compared with only 72% of those treated with conservative care.
In regards to becoming pain free, 93.33% of the transforaminal epidural steroid group was pain-free at one month compared with only 23.33% of the conservative care group at one month. The statistical value of this study is highly significant with a P value <0.0001.
The amount of drug required for pain control was also markedly reduced in the transforaminal study group. The average amount of medication reduction in the transfer in group was 94.33% compared with 72.17% in the conservative care group. Again, the findings were highly statistically significant.
The authors concluded that it is, therefore, a reasonably safe procedure to provide short-term pain relief and allow patients to remain active with much reduced analgesic requirements and its associated systemic side effects.
Sciatica is a general medical term that describes a set of symptoms. The symptoms include low back pain and radiating pain into the leg and foot along the course of the sciatic nerve. This pain may be sharp with tingling and numbness often associated with it.
However, prior to any tests, a thorough history and physical exam is in order. Some of the things that physicians look for include the timing of the pain, location of the pain, severity, associated symptoms, and what makes the pain better or worse.
Some of these physical exams and questions help the physician determine if the pain is likely coming from a spinal problem such as a herniated disc or spinal stenosis. Other tests can point toward muscular issues such as piriformis syndrome or a muscle strain. Still other history and physical findings can alert doctors to more ominous causes of sciatica such as tumors along the nerve or in the spine.
"X-rays" is a common name for radiographic images produced by passing x-ray radiation through body tissues on to film or a digital sensor that converts the pattern into an image. The reason that the image is formed is because different tissues in the body absorb or blocked the x-ray radiation to different degrees. For instance, bone blocks more x-rays than fat or muscle. This causes the bone to show up as white on the film or image and softer tissues to show up darker. In the soft tissues, more of the x-rays get through to the film or sensor plate.
MRI technology works by using a very strong magnet which affects the polarity of cells in the body. The MRI machine that measures the degree and speed at which the magnetic fields in the body returned to normal. It converts this information into an image which is much more refined and specific in regards to soft tissues such as nerves, discs, and blood vessels. It is also useful in detecting subtle changes in bone such as edema which can occur with a fracture.
CT scans (Computerized Tomography) use x-ray beams but give images somewhat similar to MRIs. Although CT scans are usually not as clear as MRI in regards to soft tissue, they can have some advantages in diagnosing problems with bones. Additionally, if an MRI cannot be used due to implanted metallic hardware such as a spinal cord stimulator, shrapnel, aneurysm clips, or other similar metallic structures in the body; CT scans can often give adequate imaging to help the doctor make a clinical decision. Although util recently, individuals with spinal cord stimulators could not have MRI studies, some of the new spinal cord stimulator models are MRI copatible. CT scans can also be used in conjunction with contrast dye to help diagnose problems with blood vessels or evaluate the degree of compression on nerve structures as in a CT myelogram. CT scans can also be combined with other studies such as nuclear bone scans to give very precise images with 3-D reconstruction.
EMG/Nerve Conduction Studies
Electromyogram (EMG) and nerve conduction studies are used to determine if there is compression or damage along the route of a nerve. These studies can also be used to determine if the nerve itself is diseased. These sorts of studies can be useful in determining whether the electrical energy along the path of a nervous being interrupted by compression such as occurs with carpal tonal syndrome or a herniated disc. Diseases of the nerves such as diabetic neuropathy can be evaluated with this type of study. The severity of nerve damage can be determined with an EMG to see if motor nerves are adequately sending signals to the muscles that they innervate. This information can be helpful in determining both the prognosis as well as the appropriate treatment for a variety of musculoskeletal and neurological disorders.
Adam Lewis, MD, neurosurgeon at Jackson Neurosurgery Clinic recently implanted the first Boston Scientific Precision Montage spinal cord stimulator system with a full-body MRI compatible paddle lead in the state of Mississippi.
Full-Body MRI Compatible Spinal Cord Stimulation
This is a significant advance in technology for chronic pain patients in our state. The Precision Montage system is a new technology that offers the multiple advantages in spinal cord stimulator programming of the Boston ScientificIllumina 3D platform along with the added advantage of full body MRI compatibility. Now safe access to full-body MRI can be achieved when ImageReady MRI Full-Body Guidelines for Precision Montage™ MRI Spinal Cord Stimulator System
Boston Scientific describes the advantages of the Precision Montage platform as follows:
"Providing access to Full-Body MRI Scans, Precision Montage delivers Multiple Waveforms, all powered by Illumina 3D. No longer compromise Pain Relief for Full-Body MRI — Precision Montage MRI couples the most advanced programming proven to provide excellent pain relief and Full-Body MRI."
Several more patient resources regarding the Precision Montage as well as the other Boston Scientific spinal cord stimulator platforms can be found at controlyourpain.com. Here you can learn about the basics of spinal cord stimulator technology.
How SCS Works
SCS works by interrupting pain impulses before they reach the brain for processing.
A small battery called an implanted pulse generator (IPG) connected to thin wires or a silicone paddle called a lead. The leads contain electrical contacts. The leads are placed under the skin and inside the spinal canal. These electrical contacts deliver small electrical impulses to scramble pain signals as they go up the spinal cord on the way to the brain. Most patients feel a gentle tingling or fluttering (paresthesia) that replaces their usual pain. With the new Spectra settings, there are even high frequency programs that can control the pain in many patients without the usual tingling feeling (sub-threshold stimulation).
Boston Scientific SCS Systems are designed to tailor stimulation to target your specific pain areas.
You can learn about all the basics of acute and chronic pain and use the online questionnaire to determine if spinal cord stimulation is for you.
According to the report In Crux, the Pope has been receiving massages and injections twice weekly for his pain. The Vatican has not officially commented on the Pope's condition or about who is administering the treatments.
The report quoted the 80 year old Pontiff as saying,
“The worst thing that happened - excuse me - was an attack of sciatica - really! - that I had the first month, because I was sitting in an armchair to do interviews and it hurt. Sciatica is very painful, very painful! I don’t wish it on anyone!”
Journalist Massimo Franco reported on the Pope's sciatica in 2007, prior to his election to the papacy. Franco reported that Pope Francis (then-Cardinal Jorge Mario Bergoglio of Buenos Aires) had visited a Roman physician, Valter Santilli for treatment of the disorder.
Santilli reportedly told Cardinal Bergoglio that sciatica was a "prophetic disease. Santilli referenced the Bible in his explanation.
“Because in the Book of Genesis in the Old Testament, in chapter 23, there’s the episode of Jacob’s struggle with the angel, who touched his sciatic nerve, on the hip joint, and that night, after his sciatic problem, the Lord changed his name to Israel.”
Santilli reports that Cardinal Bergoglio called him after being elected Pope and told him:
"I used to be called Jorge Mario Bergoglio, but the Lord has changed my name and now I’m called Pope Francis!"
The risks of opioid medication including unintentional overdose and death has gained increasing attention by physicians, the FDA, law enforcement, and the media. Opioids are a class of potent pain medications including morphine, codeine, oxycodone, oxymorphone, hydrocodone, hydromorphone, and fentanyl among others.
A new study published in the June 29 in the European Journal of Clinical Pharmacologyhas found increased cardiovascular risk with starting opiate therapy in patients with COPD (chronic obstructive pulmonary disease). Specifically, there was an 83% increase in deaths related to coronary artery disease in community dwelling COPD patients. In patients living in long term care facilities, the risk was more than doubled compared to the COPD patients not taking opioids.
Previous research by Dr. Vozoris found a significant increase in respiratory related deaths of COPD patients started on opiates.
"We know that opioids are prescribed frequently to these vulnerable patients," he said, "and I think we have to ask ourselves, 'How much are we helping and how much are we hurting with this therapeutic approach?"
The study included records from over 130,000 COPD patients living in a community setting and 14,000 patients living in a long term care facility. The rate of prescription opioid use in this population was 67% and 60% in the community dwelling portion.
The main findings noted in the Medpage Today article included the following:
Incident use of any opioid was associated with significantly decreased rates of emergency room visits and hospitalizations for congestive heart failure among community-dwelling older adults (HR 0.84; 95% CI 0.73-0.97)
Incident use of any opioid was associated with significantly increased rates of ischemic heart disease-related mortality among long-term care residents (HR 2.15; 95% CI 1.50-3.09)
In the community-dwelling group, users of more potent opioid-only agents without aspirin or acetaminophen combined had significantly increased rates of ER visits and hospitalizations for ischemic heart disease (HR 1.38; 95% CI 1.08-1.77) and ischemic heart disease-related mortality (HR 1.83; 95% CI 1.32-2.53)
Vozoris offered several possible causes for these findings. Some of these include opiates masking the symptoms of a heart attack, decreased respiratory drive and blood oxygen levels, and increased inflammation.
"The message is not that narcotics should be avoided in the treatment of older patients with COPD," he said. "Rather, it is that vigilance is needed when prescribing these drugs to this population. And clinicians should tell their patients about this potential side effect."
Fibromyalgia is a chronic pain condition that effects approximately 5 million Americans. It is much more common in women than men. The diagnosis and optimal treatment is controversial. Below are answers to many of the most common questions related to this condition. Along with the questions are links to helpful referenced resources for those suffering with fibromyalgia or those with loved ones afflicted with this condition.
What Exactly is Fibromyalgia?
The word fibromyalgia comes from the Greek myos meaning "muscle", Greek algos meaning "pain", and New Latin fibro meaning "fibrous tissue". Fibromyalgia is a common and chronic disorder. ... Fibromyalgia is seen as a rheumatic condition. A rheumatic condition is one that causes joint and soft tissue pain.
Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals.
Every muscle in their body shouted out in pain. ... Pain - Fibromyalgia pain has no boundaries. People describe the pain as deep muscular aching, throbbing, shooting, stabbing, or intense burning. Quite often, the pain and stiffness are worse in the morning, and muscle groups that are used repetitively may hurt more.
Some researchers theorize that stress or poor physical conditioning are factors in the cause of fibromyalgia. Another theory suggests that muscle "microtrauma" (very slight damage) leads to an ongoing cycle of pain and fatigue. These mechanisms, like all the others, are still unproven for fibromyalgia.
Fibromyalgia a 'Real Disease,' Study Shows. ... Fibromyalgia is a chronic disorder characterized by widespread muscle pain and fatigue. It affects 2%-4% of people, mostly women. It has been called the "invisible syndrome" because it can't be diagnosed based on a lab test or X-ray.
You may experience pain and fatigue that interferes with daily activity. But yet your family, friends, and even your doctor may not understand your concerns. Also, some people may not think fibromyalgia is a “real” condition and might believe symptoms are imagined. Fibromyalgia is a real condition.
Is fibromyalgia hereditary? ... In fact, studies of DNA from family members of people with fibromyalgia and other chronic pain syndromes have turned up a number of genes that could help explain why these disorders seem to run in families. Each of these genes plays a role in your nervous system's response to pain.
Fibromyalgia has symptoms that resemble those of some rheumatic illnesses, including rheumatoid arthritis and lupus (systemic lupus erythematosus). These are autoimmune diseases in which a defective immune system mistakenly attacks the body's own healthy tissue, producing inflammation and damage.
Because there is no test for fibromyalgia, your doctor must rely solely on your group of symptoms to make a diagnosis. In the American College of Rheumatology guidelines for diagnosing fibromyalgia, one of the criteria is widespread pain throughout your body for at least three months.
Fibromyalgia is a complicated condition. It has no specific causes and no known cure. Yet for those who have it -- as many as one in 50 Americans -- the chronic pain, fatigue, and psychological strain of fibromyalgia are all too clear. Fibromyalgia symptoms are treatable, however.
Transforaminal epidural steroid injections are used to treat pain associated with spinal conditions such as herniated discs, degenerative disc disease, and spinal stenosis. The most common body region that these injections are used is the lumbar spine. This treatment involves placing a needle in the opening between the vertebra known as the intervertebral foramen where the nerve roots come out of the spine. In the lumbar spine, there are usually five nerve roots on each side. Additionally, there are also foramina and nerve roots in the sacrum which is often called the tailbone.
Is Single or Multilevel Better?
A transforaminal epidural steroid injection can be placed at one or more nerve root levels, depending on the pathology being treated. There has been some debate regarding whether or not there was any benefit in injecting at more than one level.
Recently, a study of 266 patients was carried out at the University of Rochester medical Center in Rochester New York. The findings of the study were presented at the 2017 national convention of the American Society of Interventional Pain Physicians (ASIPP).
The study was entitled "Comparison of Single Level and Multilevel Transforaminal Epidural Steroid Injections Utilizing PROMIS Outcomes Data".
This study looked at physical function, pain interference, and depression 3-5 months following either a single level or a multilevel transforaminal epidural steroid injection. The findings of this study concluded that the multilevel injection demonstrated significantly greater improvement in all three of these parameters. The multiple injection group also had a greater proportion reaching MCID (minimal clinically important differences) compared with the single injection group.
in regards to physical function, the multilevel group had a 38.8% improvement compared with the 25% in the single injection group. Likewise, pain interference was improved 48% in the multilevel group compared with 34.5% in the single level group. Pain associated depression was improved 30.6% in the multilevel group compared with 28% in the single level group.
Based on these findings, it appears that using a multilevel transforaminal approach may give superior clinical results for patients suffering with pain secondary to problems such as herniated lumbar disc, degenerative disc disease, and spinal stenosis.
Morphine is in a class of medications called opiates. This class of medication ranges from weak opiates such as tramadol and codeine to much stronger opiates such as hydrocodone, oxycodone, oxymorphone, and fentanyl. A recent study from Ghent Belgium found no significant difference between placebo and 10mg of oral morphine a day in patients with rheumatoid arthritis. The only differences detected was in pain pressure thresholds in patients with Chronic Fatigue Syndrome, Fibromyalgia, and/or Rheumatoid Arthritis. The study was published in the July 19, 2017 issue of Pain Practice.
"Naloxone did not significantly affect nociceptive modulation in the healthy participants. These results suggest that temporal summation and conditioned pain modulation are not primarily mediated by opioid mechanisms," said Linda Hermans, P.T., from Ghent University in Belgium
Scoliosis is an abnormal curvature of the spine that usually occurs around the time of the growth spurt before puberty. While there are some diseases like muscular dystrophy and cerebral palsy that can cause scoliosis, in most cases, the cause is "idiopathic" or unknown. The curvature may stabilize or may progress in severity. Most cases are mild but some can be severe and require extensive surgery correction. Untreated, the severe cases can result in decreased function and possibly even compromise of the cardiac or respiratory system. Patients and parents of patients diagnosed with scoliosis have many questions regarding this condition. The following questions, summary answers, and links are meant to be a starting point to answering some of these questions. While this article is not a substitute for an evaluation by a physician or other health care provider, the information may be helpful in discussing the issues associated with your physician or surgeon.
Plantar fasciitis is like, but painful condition affecting the heels. It often is the most symptomatic with the first steps taken in the morning. It usually presents with pain around the medial or inside aspect of the calcaneus (heel bone). Often there is tenderness along the soft tissue extending from the heel to the mid-arch or beyond. In 20 to 30% of patients, the problem occurs on both sides (bilateral). (more…)