Tarlov Cysts and Back Pain

April 30, 2014December 11, 2015 / Thomas Cohn, MD

Tarlov cysts are fluid filled sacs in the spinal cord region along the nerve, usually close to where it enters the region to leave the spinal canal. The cysts are usually small, and not in a position that would cause symptoms. They became better known once we developed advanced imaging like MRI and CT scans. Their cause is not known, and usually they do not need to be treated, although occasionally they have been associated with connective tissue disorders including Marfans and Ehlers-Danlos syndrome.

Symptoms and Diagnosis

Tarlov cysts are sometimes larger than 0.5 inches in diameter, and at that size they may become symptomatic. The larger size may cause them to put pressure on a nerve root or even the spinal cord. Symptoms are related to the location; most likely in the sacrum. Problems include tailbone pain, pain in the groin region, sexual dysfunction, bladder dysfunction, and lower extremity numbness and weakness. Over time, without treatment, they do have a tendency to enlarge, meaning the cysts may start without symptoms and later develop into problems.

The diagnosis now is usually made by MRI scan, but may also be noted on CT scan. Tarlov cysts are usually found incidentally when scans are done looking for causes of back pain symptoms. Since most of these cysts are small, they usually are not correlated to symptoms being investigated.

Causes and Treatments

The cause of Tarlov cysts is unknown. There are many theories, but none appear to be definitively correlated to their development. Since there is no known cause, there is no known method to prevent their formation.

Treatment of Tarlov cysts is only necessary if they are definitely linked to symptoms or bone/neurologic compromise. Depending on the exact location, sometimes they can be ruptured by a radiologically guided needle under CT scan. Otherwise, they may need surgical management to drain. Unfortunately, they do have a propensity to re-occur and may need retreatment.

In summary, most Tarlov cysts are found by accident on an MRI scan for another issue. They are often small and usually cause no problems. If they are large, sometimes they do need treatment and your physician can help determine possible options that would relieve the problems.

Visculosupplements for Knee Pain

April 28, 2014December 11, 2015 / Thomas Cohn, MD

Degeneration of the knee is a common condition that occurs as we age. Early problems are often minor injuries to the ligaments and meniscus, and they usually heal with conservative or surgical care. Over the age of forty, we start getting deterioration of the joint space and cartilage. Pain then becomes more consistent, and the knee moves less well and becomes swollen and stiff. Ignoring the knees becomes difficult and walking hurts, so many individuals seek medical attention.

When the simple treatments for degeneration/osteoarthritis do not work, one of the next levels of management is injectable medication. At this point in treatment, a Physical Medicine Pain expert can guide you through the best comprehensive program with the least additional pain. Usually the first level of injection is a cortisone type of injection, best done either with ultrasound or fluoroscopy. Long-acting cortisones include methylprednisolone and triamenacelone, which help control inflammation in the knee for three to six months.

The Benefits of Visculosupplements

Visculosupplements may be beneficial if steroids are not helping. These are injections of buffered hyaluronic acid that promote normal joint fluid production and lubrication. The first compound approved by the FDA was about 20 years ago – Synvisc – and is still used but has significant problems with allergic reactions. Now there are many three-dose regimens that work very well and are very purified without any issues with allergic reactions. The three-dose process may be the best to actually stimulate joint fluid production. In February a single dose regimen, Monovisc, was approved. Whether this will work well remains to be seen. Previous single dose regimens have not been quite as effective.

With all osteoarthritis and degeneration of the knee treatments, conservative measures with injections are necessary. Lifestyle changes including weight loss, exercise, and sometimes using adaptive equipment like braces or canes can be helpful. Using anti-inflammatory medications including creams may also help.

In the United States these visculosupplements are only approved for the use in the knee. In other countries they are used successfully in many different joints. They can be used safely in other joints, but the medication cost would be the responsibility of the patient. They have been used in the hip, pelvis, elbows, and hands. As a safe conservative treatment especially for the knee, these injections are a time-tested success.

Can a Physical Medicine Pain Specialist Cure My Pain?

April 23, 2014December 11, 2015 / Thomas Cohn, MD

Pain is a very complex problem. Acute pain is usually associated with discrete injury and tissue damage. As the problem heals, the pain quickly disappears. In subacute and chronic pain, the nervous system changes and sensory nerve actions are perceived as pain.

Treating acute pain is often very straight-forward; treat the cause and the pain resolves. Chronic pain often takes special skills to determine the cause and develop a comprehensive treatment strategy. Many physicians are pain specialists and only do interventions, but a good Physical Medicine pain doctor will work at fully developing a comprehensive plan based on a full evaluation. The patient is more than the next procedure for the physician; they are truly concerned and will find the right solution tailored to the specific needs of that patient.

Pain Training

Physical Medicine pain specialists often have unique training. After medical school they participate in a 4-year training program that is extremely diverse. Time is spent in multiple related disciplines including Neurology, Orthopedics, Internal Medicine, and Rheumatology. The general course also includes extensive training in management of complex chronic medical problems from strokes, spinal cord injuries, traumatic brain injuries, and severe trauma. Extensive outpatient training is also included, especially in all varieties of musculoskeletal disorders, sport injuries, and muscle, nerve and skeletal problems. The training teaches the evaluation and management of every problem that causes pain, and the strategies to correct the issues. Furthermore, the best trained doctors learn early that they are members of a team, and they will coordinate with all the specialists from physical therapists to other physicians to solve a problem.

Pain that is not acute needs a specialist who is willing to fully listen, exam, evaluate and treat the patient as whole. The physician who is mainly interested in performing a procedure may not see the whole picture of what is wrong, and complex problems often are not solved. For the patient this leads to frustration. A good Physical Medicine pain physician will be board certified in his primary specialty and in the subspecialty pain. Many are extremely skilled in intervention techniques and have years of experience. In every specialty, 90% of the physicians will do a good job, and the other 10% are exceptional. They are the ones who really care and will try to find the solution. The 10% are those who are compulsive, some are in academics, some in private practice; they are the ones who have the sixth sense and go the extra mile.

Pain is a complex and frustrating problem. There are new problems and solutions being discovered in this field. Better solutions for complex problems appear to be on the horizon. Take the time to find a specialist who will help develop a plan for your needs.

Marathon Running Pain and the Weekend Warrior

April 21, 2014May 24, 2017 / Thomas Cohn, MD

The marathoner and all of us have something in common; when we do activities to the extreme, we all have pain. Running a marathon is a grueling event and it stresses the entire body. The whole body often is sore afterwards, both physically and mentally. The best trained athletes are even sore after this event. The weekend athlete and the rest of us often suffer from similar pain when we do too much of an activity that we are not used to performing.

A marathon runner will have pain after a run for a number of reasons. Most will have muscle soreness in the legs from build up of lactose and from some muscle strain. Ice, heat, fluids, and over-the counter medications will take care of symptoms. Joint pain may also be present for the repetitive bounding of pavement. Again, this pain should disappear in several days as the body heals itself. In general, all pain should resolve within days. If there is an isolated area of pain, sometimes a more severe injury has occurred and further medical evaluation and treatment may be necessary.

The weekend warriors suffer from similar issues. Spring yard work is the classic example of people stressing out the body. We rake the yard for hours, lift bags of dirt, move heavy rocks, and kneel in the garden. Then we exercise for several hours and wonder why we hurt the next day. The simple answer is we strained muscles and irritated joints that were not prepared to do that level of activity. The treatment is the same as it is for marathoners; short term rest, ice, heat, fluids, and if necessary, over-the-counter medications for several days. Rarely, do we strain or injure something bad enough to need medical attention.

Preventing Injuries

Preventing injury is the most important concept to remember whether you are a marathoner or weekend warrior. The marathoner needs to train for long distances, gradually increasing time and distant travelled. The weekend warrior needs to learn to pace themselves with activities. Do not try to get everything done in one short amount of time. Split up the tasks that need to be done. As one would say, stop and smell the roses. Take your time and you will not hurt yourself.

The long winter is over and we all want to get out and get active. Take it one step at a time. Try to remember to pace yourself through all those tasks that need to get done. It will all get done, just take your time and enjoy the journey. Have some fun, and there will be a lot less pain and you will still get to the end of the line.

New Pain Treatment: Platelet Rich Plasma

April 16, 2014December 11, 2015 / Thomas Cohn, MD

Recently, platelet rich plasma (PRP) has been making news as a treatment for hip bursitis after a presentation at the American Academy of Orthopedic Surgery annual meeting. PRP is blood that has been spun and has concentrated factors that stimulate tissue repair and growth. This concentrated solution can be injected back into the body in affected areas to improve healing in damaged tissue. New areas for use are being found regularly.

Initially, PRP was first used in trials for repair after a heart attack, but it has expanded into areas of tendon repair, nerve injury and bursitis. Most commonly it has been used in sports injuries, and for many of these patients it has been quite successful. Instead of just calming down inflammation like many medical treatments, PRP helps more intensely stimulate the body to repair the injury. The downside to this treatment is that it is still considered experimental and insurance rarely covers the cost which can be in the several thousand dollar range.

PRP for Tendonitis and Bursitis

The most common uses in pain management for platelet rich plasma is for shoulder, elbow, hip and knee pain especially related to tendinopathy, tenosynovitis and bursitis. Blood is taken from the patient and then spun in a centrifuge. The residual plasma is rich in a number of proteins and substances that promote healing in the body. The plasma then is injected with either ultrasound or X-ray guidance into the appropriate area, whether the shoulder, hip or by certain tendons to stimulate healing. A series of several injections may be necessary to fully promote healing. Since it is an all natural product of the patient themselves, it is very safe, and may be very effective for the right conditions.

Tendonitis, bursitis, joint and ligament pain is always treated conservatively first. Rest, heat and ice, and physical therapy are the first lines of treatment. If the problems are not improving, medications like oral or topical anti-inflammatory drugs combined with exercises and therapy may also be effective. If those treatments do not help, corticosteroid injections may also be indicated and evaluation by a physical medicine pain specialist to guide treatment would be beneficial.

The medical literature at this time is showing that the use of platelet rich plasma may have many benefits in the treatment of some of these joint related conditions of pain and inflammation. PRP is not the first line of treatment; it is used when other courses have failed. Furthermore, insurance has not endorsed its use and the cost will most likely be the responsibility of the patient. As of now, the injections are mainly for athletes or people who can afford the treatment when other avenues have failed.