Month: January 2014

Discograms – What are they & When are they Useful?

/ Thomas Cohn, MD

discogramA discogram is a special x-ray study of the intervertebral discs in the spine.  The test is used to determine the structural integrity of the disc and whether the disc is painful when pressurized.

The Procedure

During the study, a needle is placed in the disc and dye is injected into the disc.  The study is done under real-time fluoroscopy. Normal discs are not painful.  Abnormal discs may or may not be painful.  Tears in the outer layers of the disc and whether the disc actually leaks contents can be determined with a Discogram.  Any disc in the spine can be examined in this way but it is most useful in the lumbar region.

When Discograms are Useful

Discograms are not common tests. They are used when other tests are inconclusive and surgery is being considered.  MRI scans can give a physician a wealth of information about the structural integrity of a disc, but it cannot determine if it is causing pain.  It can show a herniated disc that is pressing on a spinal nerve root and from that it may be inferred whether it is causing damage.  Combining the information from a MRI scan with other studies, like an EMG that can determine whether a specific nerve is damaged, can limit the need for a Discogram.

Today, discograms are used mostly to identify abnormal and painful discs in the lumbar region prior to surgery when other studies are not providing adequate information, and conservative care has failed.  Performing discograms in the thoracic region and cervical region is often considered very questionable, since the disc structure is different and the information provided may not be accurate.  The most useful information provided from a Discogram is that only a single abnormal disc is present and that it is causing symptoms perceived by the patient.  When multiple abnormal discs are present, surgery is usually a poor option since pain is likely to be generated from multiple sources and will not be improved with intervention.

The Future of Discograms

In the future, abnormal discs that have cracks and bulges, but are not herniated and causing pressure, may be able to be treated without surgery.  The center of the discs contain acid, when cracks develop as they age and are stressed, the acid can leak out and cause a chemical irritation to nerves.  At this time, researchers are developing compounds known as bio-sealants to seal cracks and prevent this leaks that are causing pain.  Discograms will be useful in the future if these materials being studied actually work.

An experienced interventionalist – either a radiologist or pain physician, should perform a Discogram.  Discograms are very painful studies for most patients, and sedation can be used to control the pain.  They do have risks, especially for serious infection if not performed properly.

9 Tips for Communicating Effectively with your Doctor

/ Thomas Cohn, MD

doctor communicationEffectively communicating with your doctor is important whenever you have an appointment.  The time during a doctor visit is important and both the patient and doctor want it to be worthwhile.  Every person has a different style of communicating.  Most doctor visits today are too short (often because doctors are overscheduled).  Because of these time limits, it is necessary for the patient to be prepared for the visit. Below are some tips for effectively communicating with your physician.

Be Concise

Remember that all healthcare providers have limited be time to be with you.  Tell the provider about the problems you are experiencing. You can leave out the details about your most recent vacation that does not pertain to the visit.

Be Honest

Do not exaggerate or lie.  If you overused your medications, tell them why it happened.  Do not lie about losing your drugs. Most doctors will know if a story does not make sense.

Don’t Leave Anything Important Out

Do not leave out important details about your back pain. If you have had multiple back surgeries, tell that to your doctor.  Also keep track of the treatments that you have tried and what did or did not help.

If you have psychological problems, such as depression, these are also important issues to bring up.  Psychological problems are just as important as physical problems, so do not forget to include these in your history if you want successful treatment.

Medications

Medications are often an important aspect of treatment.  Keep track of what you are currently taking (including dose and frequency).  Nonprescription medications are equally important since many drugs may interact with each other negatively.

Be on Time

If you want your doctor to be on time, you must be on time.  If you are going to be late, notify the doctor’s office as soon as you can.

Ask Questions

If you have questions about your treatment or problem, ask them.  Doctors try to anticipate some of the questions and answer them when they explain the treatment plan, but we are not mind readers. We are trying to determine what is wrong and what needs treatment.  If you don’t tell us what you are concerned about, we cannot fully help.

Most Visits end with a Treatment Plan

This is a joint venture between the healthcare provider and the patient to solve the patient’s problems.  If you have questions about your treatment plan, ask them.  Please follow the advice given and the plan. Picking and choosing only parts of the plan will not lead to a good relationship or a successful resolution of your problems.

Respect the Office Staff

Everyone who has pain is uncomfortable at times, but do not be abusive or rude to the office staff when you are having a bad time. We understand you want to feel better, but everyone deserves a degree of respect.  In today’s world, both patient and doctor deserve respect, if the patient shows no respect to others, it is unlikely that you will receive ongoing treatment.

Remember that not all Problems are Curable

We are listening and trying to find an effective solution that is specific for your circumstances.  It is a team effort, and the patient is the most important member of the team.  You have to be involved, not passive, and need to participate in your treatment if you expect to improve.  In pain management, you need to be both physically and psychologically involved since the brain is an equal partner in pain.

How do Pain Medications Impact your Dreams?

/ Thomas Cohn, MD

weird dreamsMany medications used in pain management have been known to cause weird dreams. Medications that tend to have some effect on the brain can also have an effect on sleep and dreams.

Antidepressants & Muscle Relaxers

The most common medications that impact dreams and sleep are probably antidepressant drugs, followed by muscle relaxers.  These medications have direct actions on the brain and nervous system, and change the balance of brain chemicals that can lead to very odd cognition and disturbing dreams.

The older tricyclic antidepressants have a positive effect on pain but have had a significant reputation for bad dreams.  Newer antidepressants impact the neurotransmitter chemical balance in the brain, and can make emotions, depression, and sleep worse if they are not the right medication for the individual.  Muscle relaxers are compounds that have similar structures to drugs used for anxiety. They can cloud thinking and negatively impact sleep.

Neuropathic Medications

Neuropathic medications are drugs often used to treat pain.  These drugs include many different classes of chemical and all directly affect the central nervous system and the brain in a variety of different ways.  For most people, if prescribed with a degree of caution these drugs can be highly effective for pain.  However, as with any medication that acts on the brain, the side effects can include an alteration of cognition and weird dreams.

At this time, it is very difficult to know if a drug will cause bad dreams without trying it.  If you have had a problem with a medication, similar drugs may cause the same type of problem and should be monitored closely.  Sudden or rapid changes in drug levels can cause some of the problems tolerating certain medications.  Often, if a new drug is started at the lowest available dose, and slowly increased, side effects can be minimized.  It is also equally important to not suddenly stop these drugs to prevent side effects.  Working with an experienced physician with regards to medications is always advisable.  If a problem does occur, ask the prescribing physician to check if there are medications interacting with each other and causing problems.

Can Pain be all in your Head?

/ Thomas Cohn, MD

pain in the headMany patients wonder if their pain is all imagined and in their head.  Pain is a very complex problem.  Often the source is hard to determine and treatment is not totally effective.  The definition of pain also gives us a clue of the complexity.  The IASP, an international medical group that studies pain, defines pain as:

“An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Emotions are from the brain – therefore pain can be “all in your head” at times.

The Brain & Pain

The brain is the master of all sensory signals.  The role of the brain is to receive, interpret, and then provide a response to signals received.  Some sensory signals are from pain fibers in the periphery of the body, they travel to the brain, and the signals are then decoded in several different regions of the brain.  Acute pain sensory signals are often interpreted correctly and the body and brain can handle an appropriate response.  The body handles chronic pain signals differently.

There are multiple areas in the brain that respond to pain sensory signals.  When pain is chronic, there is an actual increase in pain sensory signals going to the brain and an increase in brain sensitivity to these signals.  Furthermore, areas of the brain that are near pain responders become stimulated, including emotional areas of the brain responsible for depression.  A short circuit occurs and emotions are often perceived as pain.  Treatment of pain that is it stimulated by emotions (such as depression) centers on successful treatment of the depression.

A Short Circuit in the Brain

There are also a few central pain syndrome triggered by damage to the spine or brain causing the brain to perceive pain, sometimes whole body pain, when there is no other injury.  The pain is very real, but the source is basically a short circuit in the wiring to the brain or within the brain.  Treatment of these problems is extremely difficult. Minimal pain medications help and central neuropathic medications like drugs for seizures are often the most helpful.

When pain is all “in the head,” there is likely an emotional component to the pain signals.  Chronic pain often stimulates this problem.  Treatments of the emotional components of pain are often as important or more important than medications for the pain itself.  Pain is complex, and treating all components is necessary, and since pain entails emotions, these must be treated equally.

Neck Pain – Nerve Irritation, Whiplash, & Muscle Spasms

/ Thomas Cohn, MD

neck pain x-rayThis is part two of our blog mini-series on Neck Pain. You can find the first installment here. Our first post focused on chronic neck pain causes and treatments at a general level. c

Nerve Irritation

Cervical discs in the neck that cause nerve irritation can have both axial pain or pain in the arms.  MRI or CT scans are necessary to see these structures and determine the severity of the changes.  If the changes have been slow degeneration, the body can often adapt to them even if there is severe narrowing where the nerves travel.  Treatment often includes cervical epidural steroid injections to calm spine irritation and inflammation.  Controlling nerve sensitivity can be helped by medications known as neuropathics that include some seizure drugs and antidepressants.  Physical therapy and behavioral health interventions are also beneficial.

Whiplash

Whiplash and cervical facets cause pain from abnormal movement or sensitivity of the joints between each of the cervical vertebra.  Patterns of pain from these joints are fairly specific, and are mostly along the spine from the base of the skull, out to the shoulders, and down through the shoulder blades.  Treatment ranges from heat and ice, massage, manipulation, acupuncture, anti-inflammatory medications, traction and physical therapy, to injections.  Most pain responds to simple things, about 5-10 percent need the more complex treatment such as steroid injections, nerve blocks, and radiofrequency lesioning to prevent pain feedback from the joints.

Muscle Spasms

Muscle spasms of the neck can be primary problems, or secondary to a deeper problem in the spine.  If the spasms are chronic, it is more likely they are due to a deeper structure like the facets or discs, and treating those problems will significantly improve the spasms.  At times, spasms continue despite treating all other problems and pain is chronic. For this type of problem, chronic use of muscle relaxers along with therapy is often necessary.  Botox, which is a medication that is injected into the muscle to partly paralyze it for several months, is also helpful.

Neck pain that is chronic and ongoing is a difficult problem to treat due to its many causes.  A Physical Medicine pain specialist can be especially helpful in the diagnosis and management of the problem.  They often can determine all the factors that are contributing to ongoing issues and develop a comprehensive strategy to manage the symptoms.  Treatment often is not simple, but working with an experienced specialist can help with a successful long-term solution to a frustrating problem.