Spinal Stenosis: Causes & Pain Management Options

October 14, 2013June 24, 2014 / Thomas Cohn, MD

Spinal stenosis is a narrowing in the spinal canal where the spinal cord and nerves of the spine travel and exit the bony spine structure. It most commonly occurs in the neck and low back regions. It can be caused by normal changes relating to aging, such as:

Bony overgrowth
Trauma
Congenital changes

The body is highly adaptive, and if changes that lead to stenosis are slow, often no symptoms are present until the body can no longer compensate.

Causes & Symptoms

The symptoms of stenosis are signs of nerve damage at the spinal level that include:

Pain
Numbness
Muscle weakness
Bowel or bladder problems

Symptoms are dependent on the cause and location of the spinal narrowing. Trauma, like car accidents, can cause sudden fracture of the spinal vertebrae. The bone pieces can damage the spinal cord causing immediate paralysis. Congenital abnormalities may cause curvatures of the spine (scoliosis) and pinching of the nerves as they exit the spine.

Stenosis most commonly develops as one ages. The bone can become overgrown where the vertebral discs and joints are causing central and lateral spine narrowing. In the neck, symptoms of pain, numbness, and weakness occur in the arms and head, but can also occur in the legs. Low back stenosis causes symptoms in the low back and legs, and sometimes bowel and bladder control. Symptoms in the low back may be very positional. Bending forward and sitting may significantly relieve the pain. The most common symptoms that send a person to a doctor are pain or muscle weakness.

Diagnosis

Diagnosis of spinal stenosis is made based on symptoms, history, and physical examination. Pain is often in the distribution of a particular spinal nerve level and muscle weakness corresponds to that level. An exam shows sensation changes, weakness of muscles, and reflex changes. If stenosis is suspected, CT or MRI scans of the spinal region can confirm the diagnosis. Electrodiagnostic studies may also be useful to determine the extent of nerve damage, and are performed by Physical Medicine doctors or Neurologists.

Pain Management Options

Treatment for spinal stenosis needs to be individualized for every patient. Conservative care centers on physical therapy to strengthen spinal muscles and maintain proper posture, to medications for pain and spinal injections. Many people can control symptoms for years with a variety of conservative care techniques. If the conservative path is not controlling symptoms, then surgical care may be necessary to relieve spinal narrowing.

Spinal stenosis is a complex condition. A good Physical Medicine pain specialist can lead one through the maze of diagnosis and treatment. Most people do respond to conservative care. Narrowing of the spine does occur in many people and often can be treated with PT, medications and other types of care. Find a physician who can lead you through conservative care before you consider surgery.

Signs of a Pain Medicine Overdose

October 9, 2013November 17, 2015 / Thomas Cohn, MD

All medications can cause problems when not taken correctly. Pain medications, even those sold over-the-counter, can have deadly consequences when overdosed. Having the right balance of medications for pain and not having significant side effects is the trick that a good pain physician will try to develop for a patient. It is always necessary to keep track of the patient’s medications, even nonprescription to monitor for adverse reactions. This article will discuss the signs of overdose for opioids, over-the-counter meds, and neuropathic medication.

Opioid Overdose

Narcotic/opioid medications have had the most publicity concerning overdose. These are the drugs like Percocet, Vicodin, Oxycodone, and Morphine. These drugs are powerful analgesics and are commonly given for severe pain. Side effects are common and include:

Upset stomach
Constipation
Nausea
A tired or “drugged” feeling

Signs of an overdose of opioid medications include:

Excessive tiredness & sleeping
Low pulse and blood pressure
Decreased breathing

Significant overdose may be treated with a medication called Narcan to reverse these effects. There is a push for all emergency responders to carry Narcan since overdose of these medications is becoming common due to drug abuse.

Neuropathic Medication Overdose

Neuropathic medications include many antidepressants (like amitriptyline, and Cymbalta), and seizure medications (such as gabapentin, Topamax, and Lyrica). These medications often have annoying side effects such as:

Dry mouth
Short term tiredness

If they cause significant changes like memory problems or worsening depression, talk to the physician about problems. Overdose with antidepressants such as amitriptyline can cause severe respiratory problems and needs to be treated with acute hospitalization.

Over the Counter Medication Overdose

Over-the-counter medications like acetaminophen and ibuprofen also have problems if overdosed. Anti-inflammatories like ibuprofen can cause ulcers and stomach bleeds in some people, even at normal doses, but these affects can be treated. Acetaminophen however is very dangerous if taken in to high of a dose. Taking 1.5 times the recommended amount can lead to liver failure and even death. If you have been taking too much acetaminophen the eyes and skin can turn yellow indicating liver damage, and must be treated promptly by a physician.

Pain medicines can be very helpful in managing symptoms. Like all drugs, they need to be taken only as directed. Make sure your physician knows all the medications that you are taking. Additionally, be sure to talk to your doctor about whether you can eat certain foods, or drink alcohol with your medication. If side effects of a medication are a problem, talk to the doctor before stopping the medication, sometimes these drugs need to be tapered off or just changed slightly to be helpful.

Centipede Venom: The New Pain Medicine?

October 7, 2013June 24, 2014 / Thomas Cohn, MD

The search is on throughout the scientific community for new medications for every known disease. Cancer and heart research are often the glamour areas, now a new pain medicine may be on the horizon. Centipede venom has been found on an experimental basis to be a powerful pain killer in mice. It is a toxin that acts on a protein that influences pain sensation. Mice that are given an injection of the purified venom can withstand a significant increase in pain.

The Goal of Research

The goal of research is to find a chemical that helps with pain but does not have the side effects of current strong pain medications like opioids/narcotics. Morphine and similar compounds have many side effects and are addictive with high potential for abuse and overdose. The goal of new compounds is to minimize the bad parts and control pain better. In mice, the new centipede venom appears to be very effective in pain control.

Unfortunately, this is just the first step to determine if centipede venom will be useful in humans. Once a compound is found to be useful, the next step is to determine if it will be useful in mammals and then humans begins. Chemicals that work in mice do not necessarily work in humans.

Further Questions & Testing

Then there are the questions of whether the drug causes other problems, and what dose is safe and effective and for how long. Another issue is how the compound must be delivered to the body to be effective. One of the recent medications, snail venom (ziconotide) is only effective if given to the spinal fluid, which makes this drug very difficult to use. Many compounds cannot be taken orally because the stomach is highly acidic and often will destroy drugs. For a pain medication that is useful, an easy delivery system is essential for every day use.

Research goes on daily to find new medications that help improve our lives. As we live longer, pain is becoming a common problem that most people have to confront. Hopefully, science will find new and effective drugs to take care of pain.

Fibromyalgia Pain Treatment Options

October 2, 2013November 17, 2015 / Thomas Cohn, MD

Fibromyalgia is a painful condition in which the body hurts all over. It is more common in women, and often comes with other problems such as:

Stomach acid issues
Irritable bowels
Sleep issues
Depression
Headaches

Treatment is aimed at managing the symptoms and understanding the disease. Fibromyalgia treatment begins with making an accurate diagnosis, and educating the patient on the best treatment options.

A Team Approach to Treatment

The most effective approach to treatment is attacking the condition with a team of medical professionals consisting of:

Nurses
Physical therapists
A Psychologist
A Physical Medicine Doctor

A multi-disciplinary approach is helpful to shift the patient away from a perception of helplessness, defeat, and frustration and toward a positive and active lifestyle. Psychology is beneficial in changing attitudes from defeat and depression to understanding and self-motivation. Psychologists use a variety of techniques including cognitive behavioral therapy and biofeedback to influence changes. Physical therapy is necessary to teach the patient to go from being inactive, to exercising. Nursing is helpful to work with sleep problems, diet, nutrition, and understanding lifestyle and medication issues.

Medications & their Effectiveness

Pharmacologic strategies include prescription and non-prescription medications. There are three drugs approved for Fibromyalgia, and many others that have limited affects. The most commonly used drugs that are approved are Cymbalta and Lyrica. They both decrease the sensitivity of the nervous system to excessive signals that influence pain. Amitriptyline and Nortriptyline at low doses also have similar affects and are helpful with sleep. Narcotics and anti-inflammatory medications are not effective in management and usually lead to more problems than solutions.

Nonprescription medications have varied success rates and the research is not solid to support their effectiveness. S-adenosine-L-methionine(SAM-e) has been used for joint pain and general pain, and is commonly used in Europe. Tryptophan and melatonin may improve sleep and help with mood. Fish oil is felt to help with joint and spine pain, and may help control cholesterol levels. Glucosamine and chondroitin sulfate have been used to help control joint pain. These supplements are generally felt to be safe. Whether they are going to be helpful is open to question but they should not cause problems.

Fibromyalgia is best treated by a knowledge team of practitioners, headed by an experienced Physical Medicine pain physician. The goal of treatment is to improve function and activity level, and manage pain symptoms. Education and psychological well-being are important. Fibromyalgia is a real syndrome, when treated appropriately can be successfully managed.