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.

Medical Marijuana in Minnesota

May 12, 2014December 11, 2015 / Thomas Cohn, MD

The debate for legalizing marijuana is continuing in Minnesota. Bills are progressing through the legislature, but nothing as of yet has been decided. There are some very vocal groups supporting medical marijuana in Minnesota, with one of the most passionate groups being parents with children who are prone to seizures. The medical and law enforcement communities are less excited about the legalizing of medical marijuana.

It’s interesting to note that the Senate and House bills are not legalizing the smoking of marijuana. Instead, they’ve proposed the legalization of state-dispensed marijuana in pill or liquid form for vaporizing. There will be fees paid by the user and pharmacy, and it appears that it will be restricted to only certain medical conditions.

Qualifying Conditions

The Senate has created a list of conditions that would make a person eligible for medical marijuana. Some of the conditions include:

HIV
Glaucoma
ALS, MS, and Crohn’s Disease
PTSD
Seizures
Some forms of Chronic Pain

The Senate and the House do not agree on some eligible conditions, as the House is not supporting medical marijuana for PTSD or chronic pain.

The legal community is not thrilled with legalizing marijuana due to concerns about control and abuse. There are so many prescription medications that are currently being abused, and the law enforcement community does not want to add to the existing problems. Tight restrictions on use may control the availability and abuse potential, but these problems are unknown. In states where less restrictive medical marijuana laws are present, abuse is a large problem.

The medical community is not thrilled with marijuana at this time more on a scientific basis. There are at least 84 cannaboids associated with different forms of marijuana. All these compounds have different actions in the body and they have not been studied in depth. The compounds that are helpful in various conditions have not been isolated. In general, it is bad medicine to give people drugs without knowing all of the potential side effects. Medically, we have no idea if these compounds may cause cancer or other horrible problems later in life.

Marijuana may have some very good attributes for treatment in some conditions, but at this time we are only guessing what may be helpful or dangerous. The best solution would be to get serious in testing and scientifically studying the various ingredients in marijuana. Legalizing does not really help in our understanding of the plant. Research is needed to determine the real nature of the cannaboids in the plant. A national effort to appropriately study marijuana would be beneficial.

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.

Naloxone for Narcotic Overdoses

April 7, 2014December 11, 2015 / Thomas Cohn, MD

Opioid and narcotic abuse is rampant, and overdoses killed over 16,500 people in 2010 and the numbers are rising. The death toll is about one person every 30 minutes. The awareness of the problem has been rising with the deaths of prominent celebrities, but the problem strikes at all levels of society and all ages.

The FDA recently approved a new treatment for narcotic/opioid overdose called the Evzio auto-injector. The new medication is Evzio, a form of naloxone, which has been available for medical use since 1971. The drug reverses the opioids’s effectiveness and prevents the drug from binding to its normal receptors on a short-term basis. Opioids at too high of a dose cause people to have impaired ability to breathe, and this difficulty breathing is the major cause of death from an overdose. Naloxone can only be given by injection into a vein for best results, therefore it has been difficult for anyone but trained medical personnel to administer. Programs have been established in some areas to authorize some first responders to give the medications. This has saved over 200 lives in Philadelphia in one year.

Evzio’s Effectiveness

Evzio won FDA approval in record time, most likely due to its need and safety. The medication is in an auto-injector; all one has to do is press the unit against the leg and trigger the mechanism. The set dose will help most overdose victims. The initial unit comes with a training sample injector that has voice prompts to walk a person through the correct use. The dose of naloxone delivered by Evzio will likely reverse breathing problems for 1-3 hours, enough time to obtain full medical support and treatment.

There are many people at risk for accidental overdose. Many people using opioids for chronic pain also have anxiety and may be receiving benzodiazepines that potentiate drug effects and poor breathing. Combining sleep medications, alcohol and other drugs can have a similar effect with opioids. The ability to have the new Evzio auto-injector available to reduce the chance of an accidental overdose is wonderful.

The biggest challenge ahead is to have laws that allow easy access for family, friends and first responders to obtain and use this new medication. Currently the status is a bit unclear. Every state regulates these medications differently, and there is an urgent need to save lives versus argue about the morality of the issues. Hopefully, the availability and use will become common in the near future and lives will be saved.