Tiger Woods Out Of U.S. Open With Back Pain

May 29, 2014June 23, 2014 / Thomas Cohn, MD

Tiger Woods will not play in next month’s U.S. Open as he’s still rehabbing from lumbar microdiscectomy surgery he underwent back on March 31. Woods made the announcement on his website earlier this week.

“Unfortunately, I won’t be [at the U.S. Open] because I’m not yet physically able to play competitive golf,” Woods said. “I’d like to convey my regrets to the USGA leadership, the volunteers and the fans that I won’t be at Pinehurst. The U.S. Open is very important to me, and I know it’s going to be a great week. Despite missing the first two majors, and several other important tournaments, I remain very optimistic about this year and my future.”

While the move may come as a surprise to some, I’m not that shocked. As I hypothesized earlier on the blog, it simply seemed like too short of a timetable for Woods to make a return to professional golf. While the rehab is fairly quick, a person usually needs three months to regain normal activity. The U.S. Open will begin roughly two and a half months after Woods underwent the back operation, and he doesn’t want to take any chances when it comes to his health. As I said back in April, a more realistic return date would be in July, perhaps ahead of The Open Championship in late July.

Woods wouldn’t speculate on when he’d return to the course.e

“There’s no date, there’s no timetable, just taking it day by day and just focusing on trying to get stronger and come back,” said Woods during a media day last week. “I want to play today, but that’s just not going to happen. So just taking it step by step.”

Woods underwent a lumbar microdiscectomy back in March, which is a minimally invasive surgery used to remove a small portion of an offending disc. Patients can walk just days after the operation, but swinging a golf club is a different story, especially when you consider the force and precision needed to preform at the highest level. Last time I wrote about Woods, I guessed he’d miss The U.S. Open, but I’m going out on a hunch and saying that he’ll be back in time for The Open Championship, a place where he’s won three times.

Related sources: TigerWoods.com, ESPN

Sports and Pain Medication Abuse

May 27, 2014June 23, 2014 / Thomas Cohn, MD

The latest news out of the NFL is that the league is being sued for causing prescription pain medication abuse. A study done at Washington University revealed the severity of the problem. Researchers found:

52% of retired NFL players used prescription pain medications during their playing days.
Of those players, 71% misused the drugs, and 15% continue to misuse these medications.
63% of the retired players obtained the medications from non-medical sources including trainers and the Internet.
In general, the rate of prescription drug abuse for professional athletes was four times that of the general population.

The statistics on drug abuse among athletes points to the level of the problem in society. Performance as a professional athlete is a premium quality. Our society has been pushing athletes to perform at the highest level no matter the cost. Now, we are finally starting to uncover the stark reality of the cost. Abuse often becomes a lifelong problem. Pain and damage from athletics can definitely be a long-term struggle.

Abuse Treatments

Pain is a medical issue that has multiple treatments based on the pathology; only in the United States do people heavily rely on opioid medications. Addiction is a psychological and physical issue due to the brain and body’s dependence on these drugs. Addiction is extremely hard to treat, and is often a lifelong struggle.

The take home message is likely that as a nation, we need to become more realistic in the management of injuries, especially in sports. Ruining our life to just play a sport for a short time more is dangerous. Pain is a sign in an acute injury that there is ongoing damage. Masking the pain with an opioid leads to further injury and damage. The cycle keeps going and the athlete gets to the point where the injury is severe enough to never heal completely and the pain becomes lifelong experience.

Masking the pain with drugs and preventing normal healing is the wrong technique to use in sport injury management. The danger of addiction and lifelong pain is not an adequate reward for sports performance. NFL players or other athletes are not invincible. Chronic pain can lead to a miserable life, so seek professional services if you need help.

Epidural Injections for Chronic Pain Management

May 21, 2014December 11, 2015 / Thomas Cohn, MD

Chronic pain often has spinal level sources. The problems may be as subtle as an overly sensitive spinal level, disc degeneration, disc herniation, vertebral bone fracture, and muscle or nearby nerve irritation. Determining the exact cause may be difficult, and often a combination of factors contribute to the symptoms perceived by the patient. Structures in the spine, especially the discs and joints, can directly or indirectly irritate spinal nerves and refer pain to spinal segments. MRI scans may have small changes that look insignificant, but they are often contributing factors to pain.

Epidural injections are implemented in chronic pain management to treat conditions that may be related to the irritation of nerves controlled at the spinal level. The spine travels from the head to the pelvis, and the nerves of the spine are the wiring that connects the brain to the rest of the body. The spinal nerves and spine itself can be overly sensitive; calming them down by injection is sometimes very useful to control pain. The two most common uses for epidural injections are for surgery and pregnancy. These use only local anesthetics and sometimes opioids to control pain for hours during these short periods of time. In pain management, epidural injections are direct procedures used to control pain for long periods of time.

How It Works

Epidural injections for pain can be done at practically at any region of the spine. The exact level of intervention is determined by the problem being treated. Injections are done by many different specialists, but perhaps best practiced by a Physical Pain Specialist. The more experienced the specialist, the better the quality and success of the injection, and hopefully with the least amount of pain. Technique and skill improves over time, and some interventionalists are superior in their ability to make a scary experience comfortable.

The epidural space is a very small region of insulation consisting of fatty tissue surrounding the spinal cord and spinal nerves. It is located inside the spinal column, and the space can be approached centrally, know as an intralaminar, or from the side where the nerves exit, known as a transforaminal route. The technique used depends on the specific patient, previous surgeries, and the problem being addressed. All these procedures are done sterilely, under real time X-ray guidance, and of course, require a special needle to deliver the medication to the right place.

Depending on exactly what is being done, it usually only takes a few minutes to complete the injection. At the start of injection, the patient is usually laying face down on a special X-ray table. The skin is then cleaned with an antiseptic solution and draped sterilely to prevent infections. Using real time fluoroscopy, the correct location is identified and the skin is locally anesthetized with short-acting lidocaine. Then, using a special needle and fluoroscopy, the specialist guides the needle into the correct position for the injection. Next, a special X-ray contrast is injected to confirm needle location, followed by the injection of a long acting steroid and possibly a longer acting local anesthetic to immediately reduce pain in the region. Sometimes more than one injection several weeks apart is needed to control symptoms since only so much steroid is safe to use at any one time. For some patients, periodic injections, once every several months, is the best way to manage a chronic problem.

Risks

Every injection has risks when performed. There are generally four risks for any injection. They are:

Risk of infection
Risk of bleeding
Risk of allergic reaction
Risk of needle damage

The first risk is an infection from sticking the needle through the skin. This is controlled by cleaning off the skin. The risk of a contaminated medication now is extremely low since the Food and Drug Administration has started controlling all producers of injectable medications. The second risk is bleeding. As long as the patient is not on blood thinners, this risk is very low – About 1 in 50,000 or less. If it does occur, it can be treated surgically. The third risk is an allergy to a medication, and this usually just causes itchiness, which is also easily treated. The last risk is the needle damaging a structure around the spine or the spine itself. By doing the injection with real time X-ray, and by an experienced physician (not a NP or Physician Assistant, some practices are using these providers, ask the person) this risk can be minimized. Spinal headaches are also a risk, but again, with an experienced provider it should not occur and can be easily treated if necessary.

Epidural injections can be a very successful management strategy for pain. When done well, they are quick, effective and almost painless for most patients. Physical Medicine Pain Specialists are often some of the best physicians to see help determine the cause of pain and initiate treatment, especially when spine injections would be beneficial.

Treatment of Facet Joint Pain

May 19, 2014December 11, 2015 / Thomas Cohn, MD

Facet joints, also known as zygoaphoseal joints, are the posterior joints that articulate on each side of the spine between each vertebral body. The joints are at each level of the cervical, thoracic and lumbar spine.

The facet joints are similar to the joints in your fingers. The wear and tear of the finger joints is similar to what happens in the rest of the body, but in the back it is caused by increased weight carried by these joints in the cervical and lumbar regions. Degeneration often occurs starting at about age 30, but trauma can cause earlier changes to these joints.

Diagnosing Facet Joint Pain

The facet joints can cause pain. The pattern of pain for the neck joints has been mapped out by extensive studies. The thoracic and lumbar region have less defined patterns of pain but are generally midline at about the level of the problem. Unfortunately, imaging studies like MRI scans and CT scans often do not show changes in these joints that correlate to pain. If the discs in the spine have degenerated at a certain level, the space between the bones is decreased. Definitive diagnosis of facet joint pain can only be made through diagnostic nerve blocks to the joints.

The initial management of suspected facet joint pain is always conservative. Acute pain often responds to a variety of treatments, including:

Chiropractic adjustments
Massage
Physical therapy
Heat and ice
Stretching

Nonsteroidal anti-inflammatory medications like naproxen or ibuprofen and crèmes can also be very effective. Acute pain often responds to the above measures within a short period of time.

Prolonged Pain

Facet pain and spinal pain that continues for more than six months often needs more aggressive treatment if conservative methods have failed. At this point in management, having a Physical Medicine Pain Specialist is helpful to best guide treatment tailored to the patient’s needs. Diagnostic imaging of the spine at the level of concern is beneficial to determine an effective management program. Starting with an epidural injection in the region is effective to help lower the overall level of spine sensitivity to pain signals. The next step involves diagnostically blocking the nerves to the joints to confirm the joints are actually causing the pain. If the tests are positive, then the treatment is usually “burning” the nerve, or using radiofrequency neurolysis or ablation. A special needle and machine are used to create a microwave signal along the nerve, severing it from the joint. This is often done with sedation, but is still a quick outpatient procedure. Pain relief will often last about a year, is about 70% successful, and combining this with good conservative care may completely resolve the problem.

Antidepressants and Kidney Stones

May 14, 2014December 11, 2015 / Thomas Cohn, MD

Kidney stones, also referred to as renal stones, are extremely painful. These stones are not like rocks found on the ground. In fact, kidney stones are usually about the size of a grain of sand, which is surprising considering how much pain they can cause. It can be a terribly painful event for a person to “pass” a kidney stone from the kidney to the bladder and out the body. So how can we prevent against these minuscule monsters?

Causes of Kidney Stones

Kidney stones are caused by numerous things, only some of which are preventable. The three main causes of kidney stones are:

Poor Diet
Medications
Genetics

A person can change their diet and they are stuck with the genes passed on from their parents, but today I want to talk about role medication plays in the development of kidney stones. More specifically, if antidepressants can cause kidney stones.

Antidepressants and Kidney Problems

There area wide variety of antidepressants on the market. The newer antidepressants have significantly less adverse problems then many of the original medications. As with all medications, antidepressants have been linked to some adverse reactions.

Developing a kidney stone as a side affect from antidepressants is a rare adverse reaction. In my research on the subject, I found that there weren’t many cases directly linking antidepressants to kidney stone development, but some medical professionals believe antidepressants could be the reason why a patient developed a stone if no other causes could be identified. It was very hard to find any definitive evidence that kidney stones were related to the use of common antidepressant medications.

The conclusion correlating kidney stones and antidepressants is weak. There are many much more common causes of stones. If you develop a stone it is best to look for the common causes, and have your primary care physician do a comprehensive evaluation. Oftentimes patients want to know exactly why a condition developed, and without strong evidence doctors sometimes blame the medication. The reality is that stones are likely not related to most antidepressants.