Spinal Disc Imaging and Discograms for Back Pain Problems

Back PainThe spine has discs between each vertebral body in the cervical, thoracic, and lumbar spine. These discs are dynamic spacers between the bones and facilitate the motion between segments. The structure of the disc varies between the cervical, thoracic and lumbar levels. The differences in structure lead to different stabilization patterns in each area of the spine. The strongest discs are in the lumbar region and the weakest are in the neck, with the thoracic discs being of moderate strength.

The discs have two components, the outer anulous fibrosus, and inner nucleous pulposus. The outer ring is made of interlaced collagen fibers. The nucleous is a loose fibrous network with a gelatinous acidic mucoprotein. The combination of the outer core and inner gel is to provide the ability to absorb forces between the bones as the body moves. Extreme forces and sudden movements as well as age can damage the disc integrity. The strength and weave of the fibers is the strongest in the lumbar region and the weakest in the cervical region. Lifting and twisting heavy objects is main primary reason a person suffers a low back injury, while whiplash injuries account for the majority of neck problems. Repetitive activities and age can also damage the discs throughout the spine. Damaged discs can bulge, crack and leak, and herniate. The discs injuries can be very painful, and treatment should not be ignored.

Diagnosing Disc Injuries

Studying the spine is done in multiple ways. The simplest is by an X-ray; They can give basic information on the integrity and alignment of the bones, the height of discs, and the presence of degenerative changes. In a young person, X-rays are usually normal, but in the older person they tend to show age related changes. The problem with an X-ray is that it often can identify the area of pain, but it gives very little information about a cause of pain. CT-scans are sophisticated computer enhanced X-rays that give significantly more information about the bony structure of the spine and some limited information about the discs and spinal nerves. An MRI scan can give significant information about the discs, spinal nerves and cord, joints and bones of the spine. Electromyography can map whether the nerves of the spine are functioning properly. Discograms pressurize the disc with contrast and then they are viewed under X-ray or CT scan to determine the integrity of the disc and whether they are painful. Your doctor will determine which method is best for identifying your issue.

Discograms can tell valuable information in the lumbar region, however, in the thoracic and cervical region the data is of questionable value. In the lumbar region, a discogram can help identify whether a disc has internal disruption and if it is painful. If only one disc is painful, a doctor may be able to preform routine surgery to address the problemed disc. That said, multiple painful lumbar discs do poorly with surgical management. Often, MRI scans can give sufficient information such that a discogram is not necessary. In the thoracic region, a discogram would not clarify surgical options since the MRI can provide sufficient information along with physical exam. The nature of the discs in the cervical region makes discograms vary unreliable for useful information.

I typically suggest that a patient undergoes an MRI if they are experiencing back pain, as it provides a comprehensive look into the inner workings of the back. If you are plagued by constant low back, spine or neck pain, stop in for an assessment. We’ll work with you to find a solution to your pain.

Marijuana and the Reduction in Painkiller Overdoses – Part 2

Medical Marijuana mnLast month we discussed the new study published in JAMA (The Journal of the American Medical Association) showing that drug overdose deaths due to opioids declined in 13 states that legalized medical marijuana. The study just looked at death rates overall due to opioids and noted that they happened to decline up to 30% in states that legalized medical marijuana. Today, I expand on the findings.

This study is great, sensational news, but in reality, it is a leap of faith that these two subjects are truly correlated. Opioid overdose and deaths are a very complex issue. The overdose of opioids is linked to many things, especially recreational use. The death rate from overdose is related to many factors, including whether the overdose was accidental or on purpose, such as a suicide. Furthermore, the access to treatment for overdose is important, especially whether first responders can recognize it and provide drug reversal rapidly and then get a person to a hospital for support. So, if you are using opioids to get high, it does not matter if marijuana for medical use is legal since they are not using it.

Medical marijuana is used for a variety of problems, including nausea related to cancer, seizures, and glaucoma. None of those conditions have much to do with opioids and drug overdoses. So if marijuana is legal for glaucoma or treating seizures, why would death rate due to narcotic overdose change? Rationally, it would not.

Unfortunately, this is just another example of a study finding a nice statistic that has no true correlation to the data. This study did not specifically look at factors that are related to opioid overdose death. If the study actually looked at reasons related to opioid overdoses, treatments, and deaths, there may be some validity. Rewarding medical marijuana with this lofty success is poor research and data interpretation. A prestigious journal, JAMA, should do much better at critically analyzing research and publishing articles. This is an amazingly poor job of data analysis and conclusions with an over simplification of causes of opioid related deaths.

Causes and Symptoms of Pelvic Pain

Pelvic PainBoth men and women can be plagued pelvic pain, but it is more common in women. Common causes include bladder infections, stones, and bowel issues. In women it can include endometrial issues and ovarian cysts. Treatment is based on the cause, and these pains usually end once the acute condition resolves. Pelvic pain is usually caused by issues like:

  • Hormonal changes
  • Tissue scarring
  • Bladder issues
  • Hernias
  • Sensory nerve degeneration, entrapment, etc.

Below, we examine these causes.

Hormones, Bladder and Hernia Issues Causing Pelvic Pain

Chronic pelvic pain in women is often related to several problems related to the unique pelvic anatomy. Endometriosis and fibroids are uterine tissues that form outside the normal uterine location. Their growth is stimulated by the normal hormonal cycles. The tissue eventually causes scar tissue in the pelvic region and the scarring can cause sporadic pelvic pain. Surgery is often used to help resolve some of the problems. Physical therapy and neuropathic medications can be helpful for long-term management.

Chronic interstitial cystitis is an issue in mainly women, and is often referred to as irritability of the bladder. The lining in the bladder becomes scarred, has pinpoint bleeding, and then the bladder becomes shrunken and stiff. Frequency of urination (up to 60 or more times a day) and constant pelvic pain occur. Bladder distention can be helpful and sometimes medication is instilled into the bladder. Bladder stimulators are sometimes implanted to help control symptoms.

Hernias more commonly appear in men than in women in the pelvic region. The muscle wall in the groin region weakens and abdominal contents push out of the injured area. The patient and doctor can decide if surgery is the best option, but if left to heal on its own, nerves can get entrapped in the resulting scar tissue. Physical therapy to release scarring, medications, and sometimes steroid injections are used to relieve symptoms.

Nerve Problems

There are multiple small sensory nerves in the pelvic region and they can become entrapped, irritated, or damaged by trauma in the area. Feedback from these sensory nerves can cause ongoing pain. Evaluation by a pain specialist or neurologist often clarifies the specific nerves involved. Sometimes physical therapy or manipulation of pelvic tissue can release these nerves or relieve the pain. Medications including anti-inflammatories and neuropathics (seizure or antidepressant drugs). At times, local steroid injections help or more regional sympathetic nerve blocks are useful.

Pelvic pain can be extremely difficult to diagnose and treat. Virtually any of the structures in the pelvis can be the eventual source of pain. Often it is a combination of structures causing pain. When the initial treatment is not working, the problem may be more complex, and a pain specialist may be helpful at finding the sources and recommending a combination of interventions that manage the symptoms. Sometimes there are permanent changes in the body and damage that is not reversible, and the goal needs to be managing the symptoms. A pain specialist can be especially helpful in designing a program that meets the needs of any particular individual.

Tips For Relieving Shoulder Pain

Shoulder PainThe shoulder is one of the more unique joints in the body. The stability of the shoulder is not due to the joint and joint capsule; instead, it’s due to the muscles and tendons as well as ligaments that hold the bones in place. Most of the stability is actually due to the muscles holding the arm into the joint. The excellent motion of the shoulder makes the joint very unstable.

The shoulder joint is like a golf ball on a tee,  it is very easy to bump the ball off , unlike the hip that is more akin to a ball in a cup.  The shoulder can become painful when one of the structures maintaining stability becomes strained or sprained. It is also easy to perform repetitive actions that cause the shoulder to become painful.

The Anatomy of Shoulder Pain

The anatomy of the shoulder is complex and unique. Three bones are part of the shoulder base including the scapula, the collarbone, and the humerus. Muscles and tendons maintain the position of the humerus in the joint region. The muscles and tendons cover the shoulder joint, and damage to any these structures can cause pain. Some common causes of shoulder problems include:

  • Bursitis
  • Tendonitis
  • Tendon tears
  • Impingement
  • Arthritis
  • Fractures

Examining Common Shoulder Problems

Bursitis of the shoulder is categorized by inflammation in the fluid filled sacs that provide cushioning and lubrication between muscles, tendons, and bone. In the shoulder, they are in the area of the deltoid and underneath the scapula. Repetitive motion of the shoulder or lying on your side are common causes. Rest, ice and heat, and anti-inflammatory medication often take care of the problem. Occasionally, a steroid shot in the area is helpful.

Impingement occurs when the acromion bone, the top of the shoulder blade, puts pressure on the muscles, bursa and tendons that move underneath it. The natural shape of the bone can cause this or small degenerative changes. The irritation can lead to bursitis and sometimes rotator cuff tears. If  the impingement is constant, causing inflammation or tears, surgery is may be necessary to open the space and relieve the pressure.

Tendonitis and tendinopathy are irritations of the end of the muscle as it connects to the bone. Acute tendonitis is usually related to repetitive motion, such as overhead activity or throwing. If treated rapidly, often this will resolve with rest and icing. Chronic tendonitis is due to repetitive wear and can lead to tears or tendon ruptures, often seen as rotator cuff issues. These may be best treated with surgery.

Tendinopathy is chronic changes of wear and degeneration in the tendon. Since the muscles and tendons are critical to shoulder function, this is common as a person ages. These changes do not respond to treatment for inflammation, but sometimes they do well with treatments like prolotherapy to rebuild more normal tissue or surgical repair.

Since the shoulder is so mobile and unstable, damage over time can become severe. Torn muscles, ligaments, tendons and arthritic degeneration can make the shoulder painful and difficult to use. When the changes are beyond normal surgical repair, artificial joint replacement sometimes becomes an option. These decisions can only be made with the help of an Orthopedic surgeon after all conservative care has failed.

The shoulder is a complex joint. Intrinsically, it is very unstable by its design. The structures holding the parts together are easy to damage over time because we use our arms for so many activities. If pain is not going away in the shoulder with simple treatment of rest, ice, heat, and over the counter medications, then having a physician help with the diagnosis and treatment would be beneficial.

Examining Germs, Bacteria and the Hand-Washing Debate

Hand WashingThe prevention of the spread of disease is important. Lately in the news there have been stories saying we should stop shaking hands to prevent disease. For doctors, wearing ties is out, and coats is of serious question. Sterile technique for any procedure is a major ritual. In reality, are we going a bit crazy with our fear of germs? The answer is probably yes, but we do need to use some common sense.

Our bodies depend on bacteria to maintain our health. The mouth and colon are filled with bacteria that digest our food and are essential to us getting the right nutrition. The skin has bacteria all over it, which prevents the wrong bacteria from taking hold. We use yeast to create food and drink for us daily.

There are microorganisms that help us live, and others that make us sick. If we live in a germ-free bubble, the body never learns to distinguish good and bad, and the immune system in our bodies becomes unable to fight the correct germs. The best example is our ability to fight the flu virus. Children are much more prone to get sick from the flu every year since they have not had exposure to these viruses and the body has no antibodies to fight the virus. Older adults have developed antibodies to many strains of the flu and often do not get sick from the various strains spreading every year.

Hand Washing and Bacteria

Healthy people will have a variety of germs on their hands. Touching another person or shaking their hand should not be an issue. As a physician, washing hands between patients is logical, especially if treating sick people who may have contagious problems. Treating healthy people with pain problems, or many other problems like high blood pressure or high cholesterol, should not be an issue of spreading disease.

In the past, physicians that touched their patients – categorized as hands-on doctors – were found to be the best liked and most successful healers. For a physician, washing hands in-between patients makes sense to prevent the accidental spread of unknown infections. Shaking a patient’s hand and touching a patient allows one to establish a good relationship and do a good exam. The body can handle normal germs in the environment and our immune system is geared with this ability. Recognizing the conditions when contamination can occur and preventing those issues is the important message. If you are healthy, the body should be able to control most common germs and it is okay to shake a person’s hand and not panic.

Cowboys’ Romo Looks to Rebound After Back Surgery

Tony RomoThe National Football League kicks off exactly one week from today when the Green Bay Packers travel to Seattle to take on the defending champion Seahawks. With the regular season fast approaching, teams are doing everything in their power to ensure their players enter the season with a clean bill of health. One such player is Dallas Cowboys quarterback Tony Romo, who missed the end of last season after undergoing surgery to address his ailing back.

Romo initially hurt his back right before Christmas last year, and he needed an epidural injection and eventually surgery to fix a herniated disc in his lower back. Romo has been rehabbing ever since, and Cowboys owner Jerry Jones said it won’t be an issue for the quarterback in 2014.

“No issue with his back at all,” said Jones. “As a matter of fact, we all were pleased that he got the kind of test he got, and he is too. There is no issue, after being sacked three times, other than we need everybody to get in there and move in ways that we can keep that from happening.”

The three sacks Jones is referring to occurred during the team’s third preseason game against the Miami Dolphins. Keeping Romo upright will be key for the Cowboys, something they were able to do well last year. The Cowboys allowed the seventh-fewest sacks in the league in 2013, and the third-fewest quarterback hits.

“I took some hits; that was good just in regard to getting up and keep playing,” Romo said about the shots he took in the third preseason game. “That part of it was positive. The hits in general, hopefully we can avoid, but it was good to get back up and keep going and see how I felt and go play football.”

The Cowboys are set to play their final preseason game tonight against the Denver Broncos, but don’t expect to see Romo under center. Regardless of previous injuries, the majority of teams hold most of their starters out of the final preseason game to help their bodies recover before playing 16 games in 17 weeks. The Cowboys have already announced that Romo won’t play.

It will be interesting to see how Tony Romo preforms this season. He’s getting up there in age – he’s 34 years old entering this season – and although geezers like Peyton Manning and Tom Brady have proven that you don’t need to be young to preform at the highest levels, recovering from a back injury to play on the biggest stage can be extremely difficult. Don’t believe me? Just ask Tiger Woods.

Related source: ESPN

Study: Medical Marijuana Leads to Fewer Overdose Deaths

Medical Marijuana MNA new study published in the Journal of the American Medical Association found that states that have legalized medical marijuana report significantly fewer overdose deaths than states that haven’t legalized medical cannabis.

For their study, researchers analyzed mortality data and medical marijuana adoption across the US between 1999 and 2010. Only 13 states adopted medical marijuana by the end of data collection, but the results were fascinating.

“We found that there was about a 25% lower rate of prescription painkiller overdose deaths on average after implementation of a medical marijuana law,” said lead author Dr. Marcus Bachhuber.

Looking solely at 2010, Bachhuber said states with medical marijuana laws experienced about 1,700 fewer deaths than what would have been expected based on numbers prior to medical marijuana legislation. Bachhuber said medical marijuana can be a viable option for individuals suffering from certain chronic pain conditions.

“It can be challenging for people to control chronic pain, so I think the more potions we have, the better,” he said. “But I think it’s important, of course, to weigh the risks and benefits of medical marijuana.”

As I mentioned in previous blog posts, the issue I have with marijuana is that it contains so many compounds that haven’t been sufficiently studied. I’m all for conducting more research on medical marijuana, but I don’t think the results of this study mean every state should immediately legalize medical marijuana.

It’s certainly an eye-opening study and raises many good points, but one of the main objectives of any good pain doctor is to control for as many variables as possible. That’s much harder to do with marijuana. You don’t know how the compounds in that specific plant are going to react with that specific person.

The American Academy of Pain Medicine echoed similar sentiments when discussing the recent findings.

“AAPM believes that we need to do research on cannabinoids to determine its safety and efficacy,” said Dr. Lynn Webster, former AAPM president. “The problem with medical marijuana is that we never know using marijuana what chemicals are being ingested. That makes it really unpredictable, but the use of cannabinoids may well have a place in the treatment of pain and other diseases. The AAPM believes that the DEA should reschedule cannabinoids from Schedule I to Schedule II so that it will make it easier for research to be conducted.”

There will almost certainly be more research on medical marijuana in the near future, but until more is known, it can’t be viewed as a perfect solution.

Related source: CNN.com