Not Every Pain Study Should Be Taken As The Truth

radiofrequency lesioning spineYears ago when first entering into the world of medicine, I thought that if a study appeared in a leading scientific journal then it would have to have been a good scientific study. As an undergraduate and in my medical student years I was never really taught how to read a paper and analyze it for its quality. Over the years more articles stopped making sense, and as one would delve into the details, it often became clear that many studies that were published were just bad research.

Often if one knew something about the subject being studied, either the conclusions were obvious or they were not clearly defined such that the answer found may not really have a true correlation to the problem. Good medical studies are often very hard to perform. If you are not very careful, the answer will be junk, even if it is published in a good medical journal. Recently, this has occurred in a major medical journal.

Insurance Sponsored Studies

A recent study in the Journal of the American Medical Association (JAMA) was published with the finding that radiofrequency lesioning does not work in the lumbar region. Unfortunately, this again was a seriously flawed study and on top of everything from a research perspective, it was an insurance sponsored product. The pain societies across the world have been surprised and highly critical of the poor quality of the research and conclusions drawn in this paper.

If one has done their research, they would see that there are multiple excellent studies supporting the use of radiofrequency techniques for some specific uses. This technique has been around since the 1970’s and good equipment and understanding was established in the 1990’s. The technique is very successful for removing a nerve pathway for sensation feedback from facet joints. The science has been proven in detailed and has benefited thousands of pain sufferers. It is a common treatment for facet pain in both the neck and lumbar region and is highly successful when diagnostic blocks done first are indicative of pain relief.

This type of intervention has also been used for a number of other things including knee joint problems, sacro-iliac joint pain, and a variety of peripheral nerve problems and lumbar disc issues. All the other areas treated have had less success due to complex nerve locations. Lumping all radiofrequency treatments together and saying that they do not work is a true disservice to medicine and the patients. Further, since the JAMA is a highly regarded journal, the editors should have more closely scrutinized the study for its validity. Understanding the anatomy in the body also makes a huge difference; nerve location for most areas of the body can be highly variable from person to person and therefore it may be difficult to be successful in severing a nerve with limited ability to visualize its location.

Pain is a very complex sensation in the human body. The overall perception of the stimuli is based on the interpretation of signals in the brain. The brain may actually be receiving signals from multiple structures but interpreting them all as similar and from one location. Eliminating one piece of the signal may be sufficient to solve a pain problem. If the signals are coming from multiple locations, eliminating just one part of the signal may not change the brain’s perception of pain. The joints along the spine have very well defined sensory nerves and feedback; If the pain is from this structure it can be clearly determined and successfully treated. The discs and sacro-iliac joints have poorly defined sensory feedback, trying to eliminate the signals from these regions is still a matter of study. If the editor of JAMA used some critical thinking, the poor quality of the study would have been easily seen and the disservice of its publication could have been avoided.

Radiofrequency management of pain can be highly successful. It is definitely a science with some very technical variables that impact its success. To use this as a tool in pain management, understanding its science, capabilities, risks and benefits is necessary. It is well proven to work in certain situations. A good clinician can maximize radiofrequency effectiveness for a variety of problems but it does have limits. It is not experimental but it does have its inherent challenges in its ability to safely remove enough nerves to relieve pain. If you have pain, a good board certified pain physician can often help a patient find strategies that may lead to more successful management of your symptoms.

Chronic Pain After Surgery

chronic pain cpspIn the vast majority of cases, a surgical procedure helps to eliminate or reduce pain in the targeted area. However, in rare cases, complications or unforeseen circumstances can result in the onset of what’s known as chronic postsurgical pain.

Today, we’re going to take a closer look at CPSP, and how it is prevented and treated.

Treating Chronic Pain After Surgery

Medical experts define chronic postsurgical pain as pain that persists for at least two months after surgery and is not attributable to a preexisting condition. Oftentimes CPSP is considered neuropathic in nature, and patients describe the pain as shooting, burning, tingling or electrical in nature. Some procedures that have a higher rate of CPSP after surgery include:

  • Amputation
  • Coronary artery bypass surgery
  • Thoracotomy
  • Spine surgery
  • Breast surgery
  • Hip surgery
  • Hysterectomy
  • Inguinal hernia repair
  • Cesarean section

Doctors believe that CPSP develops because stress from the operation, inflammation or nerve damage results in neuronal hypersensitivity that results in the expression of chronic pain flare ups long after the surgical site has healed.

Risks and Prevention

There are a number of factors that increase a person’s risk of developing chronic postsurgical pain after an operation. Those factors include undergoing repeat surgeries, lengthy surgeries, open procedures instead of minimally invasive surgeries, and undergoing an operation in a previously injured area. On the doctor’s end, a surgeon can increase a person’s risk of developing CPSP if there is intraoperative nerve damage, which is more likely to occur in difficult operations, surgeries involving severe trauma, or surgeries near the spinal cord and central nervous system.

The main way surgical teams prevent CPSP is through surgical techniques and improved operative practices. If possible, the surgeon will opt for a laparoscopic procedure in lieu of an open procedure, because minimally invasive options have a decreased likelihood of CPSP. Another thing surgical teams will do is carefully administer analgesic agents with different mechanisms of actions during the pre-, intra- and post-operative periods. These approaches reduce peripheral and central sensitization and are associated with enhanced efficacy and fewer adverse reactions.

Should you develop CPSP after an operation, reach out to a chronic pain doctor in your area to see what solutions are available to you.

Doctor Killed For Not Prescribing Pain Pills To Patient

pills doctor killedLast week one of my colleagues in the Pain Medicine community was shot and killed for not writing an opioid prescription to a patient. I was sent an email from a manager who came across the information in passing, and I was shocked at the incident.

The worst part of this incident was that the victim and colleague was once a medical student and then a medical resident with me while I was in training. I have not kept in touch with him but he was an excellent doctor and a caring individual. Unfortunately, that did not matter to the person who killed him. The only thing they understood was he did not feel it was indicated to prescribe opioids, which in retrospect was clearly the right choice.

Addictions and Opioid Dependence

Pain management and treating pain has always been more than prescribing medications like opioids. Anyone who has read this blog knows my field is all about how complex treating pain has become. If you as a patient believe that the only thing you can do for your pain is taking opioids, you likely have an issue with addiction that is far beyond just managing pain.

Addiction is a psychological problem and one does irrational things to obtain whatever substance you want for the dopamine support. The things one would do are beyond societal norms and are often illegal. The problem is not only about pain; it is about how to manage the addiction. There are countless ways to manage pain and unfortunately there often is not a cure. Pain management clinics are faced with the problems of opioid use every day and one of the most important jobs we have is to find other options beyond these medications to help patients. There is a shortage of professionals who have the training and ability to work in this challenging area, and it is tragic that someone has lost their life doing the right thing.

Alternatives To Opioids

Having pain is a common occurrence in this world. Worldwide about 30 percent of the population has problems with pain on a regular basis. The use of opioids to solve pain problems has become an American solution. The United States uses 95 percent of the narcotics produced in the world, yet we are only 5 percent of the world’s population. If your doctor is saying no to opioids, there usually is a good reason, and working with a specialist to find a better solution is indicated.  Most people, once they develop significant neck or back issues, will not be pain free, but one needs to make some life changes to control the symptoms. Pain is a tough medical issue and the United States does have an opioid epidemic.  

If it is upsetting that there are not better treatments for pain, become vocal about this problem. Start with your insurance company and with your legislators and make it known you want money to be spent on paying for more treatments for pain. Money is being spent on addiction but one of the more important issues is spending money on treating the pain problem before it becomes an addiction. Pain is a grueling and depressing part of life. There are hundreds of pain professionals trying to make life better for those suffering with pain, please do not let your anger out on them.

The Benefits Of Being An “Old School” Doctor

old school doctorSince I have been in practice, medicine has changed drastically over the years. Technology and improved practice standards have given way to great changes in the care of patients. When I first started in medicine, there were no electronic charts, most notes were handwritten, and computers were not a standard part of practice. CT scans were relatively new and the MRI scan was not yet invented. Medical students were trained to do a comprehensive history and then a physical exam. Part of the history had to include a detailed account of how the condition the patient has had developed over time. Another part was a detailed exam, including looking at the patient, often with minimal clothes obscuring the body. These are very simple things – listening to a story and looking at the patient.

Unfortunately, many doctors have lost the skill to be able to evaluate a patient. Oftentimes the patient has a classic story to tell and it fits exactly to a particular medical problem. Just spending a couple of minutes listening and asking some questions will lead you to the solution, and it probably matches a common or uncommon medical problem. After many years in practice, looking and listening to a patient tells most of the story of what is wrong.  Adding a physical exam will fill in the missing parts most of the time. The fancy diagnostic studies usually are a confirmation of the problem.

Relying On Technology

Many doctors are now trained using technology. The patient history is on the computer and the first thoughts are what do the studies indicate. If the picture (imaging) shows problems, then that must be what is wrong. Treating a test or picture can be okay, but the body has a remarkable way to adapt to changes, and the true problem is usually more complex then the picture and the way to navigate to a solution is to stop and ask the patient what is wrong, then correlate to an exam and picture.

Last week being old school paid off. A new patient showed up at my office frustrated that she had years of pain and no explanation. The patient had been everywhere, including the Holy Grail –The Mayo Clinic – and still no answer on what was wrong. The patient did have a confusing history, but it was important and the details gave the clues. Watching the patient walk and looking at her legs and arms was truly remarkable. The patient was in her 20’s and was significantly weak with loss of muscle bulk.

She had a significantly abnormal exam and likely had a serious muscle and nerve disorder. If the previous physicians only took the time, they would have figured out there was a problem and could have guided the patient towards better solutions years ago. Now, hopefully the patient can get the right diagnosis and help. It may take time and a few more tests, but an answer can be found. One of the best skills a doctor can have is the ability to listen and look at a patient. It is simple, but medicine has changed and doctors are rarely paid to take the time to do the basics.

The Benefits of Hyaluronate Sodium For Knee Osteoarthritis Injections

knee injectionsIn general, the development of hyaluronate sodium for knee osteoarthritis dates back to the early to mid 1990’s. The full mechanism on how these compounds work has not been fully understood, but it is believed that they stimulate the cells in the joints to produce joint fluid and thus provide lubrication and cushioning within the joint. In the United States, these compounds have only been FDA approved for the use in the knee joint, but around the world they have been used successfully in a number of joints including shoulders, hands, hips and feet.

Knee Joint Injections

The first compound used was Synvisc. This has been produced from the rooster combs (the flesh on the top of their head) and was highly refined. Initially, it was administered in a series of five injections and has gradually been changed to a single injection. Orthopedic knee surgeons were the first to perform such injections and still probably perform the most of these injections. Since it was the first product on the market, many physicians are likely to use it.

From experience, however, it has significant drawbacks. The number one is that since it is refined from an animal product, there is a definite significant percentage of people who will have an acute inflammatory reaction to this injection. The reaction in the joint is not distinguishable from a joint infection and does often require further intervention, from checking the patient for infection, aspirating the joint, possible hospitalization, and further injection of the joint with steroid.

Since the early 2000’s, artificial hyaluronate sodium compounds have been genetically engineered and are absolutely pure compounds without any material that could cause an allergic response. All these compounds are somewhat similar and have similar effectiveness. Again, initially they came in a series of five injections, but they then refined it to a series of three injections, and now some are a single dose injection. The effectiveness in a variety of studies ranges for reducing knee pain from about 10 percent of people to 30 percent and a maximum of up to 50 percent. Injections often have to be repeated every six months to be most effective.

Who Would Benefit From Knee Injections?

The indications for these injections are osteoarthritis of the knee. Patient selection includes those who cannot take NSAID medications like ibuprofen, those who have not had long relief with steroid joint injections or are limited with steroid use, and those who have mild to moderated degenerative changes to the joint.

Once a patient is found to be a candidate for hyaluronate sodium joint injections, product selection is the next issue. In reality, this is the grey zone for recommendations, and experience with these products is helpful. Manufacturers of the products are pushing the single dose compounds, which these are convenient, however from providers it seems these may be somewhat less effective at producing results than those that are a series of three injections. Again, patient selection may be the most important factor but this is hard to tell definitively. The products that are a series of five injections do not seem to work better than those that are three injections. Further, none of the products are really better than the others when they are genetically engineered pure chemicals.

Choosing the hyaluronate sodium products for injection is based now on several practical issues. The first is to choose an artificial product that is pure. From personal experience, it is a nightmare to deal with an inflammatory reaction to one of these products and the only one that has this issue has been Synvisc, and you’d be best to avoid this injection unless you have a very experienced orthopedic surgeon who can assess your risk of a bad reaction. The best results are from genetically engineered pure products that are a series of three injections, since these tend to induce the cells in the knee to produce joint fluid on their own.

Single shot products may not be as good at inducing the knee cells to produce lubrication from a technical standpoint. The choices then are from three products that include Hyalgan, Euflexxa, and Supartz. These should all produce relatively equal results for the patients, but again on average if the knee osteoarthritis is not extreme, relief in about 30 to 50 percent of the patients is expected. All these products are FDA approved for the knee and the services to provide injections are usually covered by all insurances and are not considered experimental.

The last selection criterion is based on product cost and if an insurance carrier has a specific drug preference. The recommendation for a hyaluronate sodium supplementation product therefore would be one of the three products that include Hyalgan, Euflexxa, or Supartz unless the insurance carrier requires a single shot product, either Orthovisc or Monovisc.

Beyond the above discussion, all these injections should be done with some type of visualization procedure, either fluoroscopy or ultrasound to prove needle location and delivery to the joint space. Secondly, for those patients who want the state of the art treatment and who can pay cash, studies indicate that PRP injections have about a 50 percent success rate for pain relief for at least six months at a time. Furthermore, for the cash paying clientele, they can also use hyaluronate products as well as PRP in many of the joints in the body with about a 50% percent success rate.