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.

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.

Zohydro in Minnesota: A New Twist on an Old Drug

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

In the last couple months, the FDA has approved Zohydro for use as a pain medication. It is an old medication – Hydrocodone – in a new package. Hydrocodone is the opioid/narcotic medication in drugs like Vicodin, Lortab, and Norco, and up until now has always been combined with acetaminophen. It is now made into a form that is extended release and is not combined with any other drug.

The drug is meant to last for up to 12 hours and comes in strengths from 10 mg to 50 mg. The big issue is that there is no abuse deterrent design in this new product.

Abuse Likelihood

Hydrocodone is currently one of the leading drugs that is abused. It is the most prescribed pain medication in the United States, and 98% of worldwide consumption occurs in the USA. Furthermore, this medication needs to be metabolized in the body into a broken down state to be effective, and in 5-10% of the population, it has very little effectiveness. Now, with this new formulation, it is available in a high concentration and has the potential to be easily abused.

Zohydro, in the Pain Specialist community, has received a very cold reception. It has one main benefit; it is no longer used in combination with other drugs. It has many more problems, and the manufacturer and FDA did not listen to the warnings by the specialists who might prescribe the medications. I was actually involved in a focus group evaluation by a manufacturer of either this drug or a similar drug. As with most pain specialists, this drug is likely going to be a highly abused drug that adds little to options for pain management.

Time will tell if this drug will be helpful in pain management. At this time, there are a number of other short and long acting pain medications. A generic short acting Hydrocodone without a combination drug would have been welcomed to help prevent side effects and toxicity of acetaminophen. It would be affordable and useful for short-term pain control. Any new potent pain medication should employ an abuse deterrent formulations, otherwise the increasing pain medication abuse problem will only worsen.

Implantable Pain Control Devices

May 5, 2014December 11, 2015 / Thomas Cohn, MD

Pain control has become a complex science, and new treatments and technologies are rapidly being developed. It was amazing to see the new scientific leaps that are being made in our knowledge of pain during my visit to the annual pain conference this year. The mechanisms of pain generation, transmission, and perception are all being intensely studied. New chemicals and methods to interfere with the eventual delivery of signals to the brain are being discovered. It is still several years until most of these research findings become part of our practical treatment of pain, but the future looks encouraging for those battling chronic pain.

As I mentioned above, pain management is a complex science. There is usually not a magic solution to control symptoms. Most treatments incorporate tools to help better control pain and optimize a patient’s ability to function. Treatments are to diminish the intensity of pain, not to eliminate all pain. Often a patient has multiple generators of pain signals and a combination of interventions is necessary to best control symptoms. Unlike a simple cut where a Band-Aid or stitches will cure the problem, pain often requires the skills of a Pain Management Specialist to develop an individualized strategy to control symptoms and maximize function.

The Role of IPCDs

Implantable pain control devices (IPCD) are tools employed when simpler strategies are not working. These are tools to use in combination with other treatments to maximize function. They do not totally eliminate pain. Two high technology devices have been developed to be implanted into the body: a spinal cord stimulator, and an implantable intrathecal medication delivery pump.

A spinal cord stimulator is the basic IPCD used to control pain. The spinal cord stimulation acts as a pacemaker that paces out the delivery of sensory signals at the spinal level that prevents pain signals from being delivered to the brain. These devices have been available for over 20 years, and three different companies make competing similar units. Over the last ten years, as technology has improved, so have these stimulators. They are programmed to deliver an electrical signal to the spine from a position in the epidural space. For the right patient, they can be a life saver, as they dramatically increase pain control and often reduce the need for medications.

An intrathecal implantable medication pump is more complex. These pumps deliver medication directly into the spinal fluid. The drugs need to be specially compounded by a pharmacy, and only a limited number of drugs have been used in this fashion. Pumps can deliver medications to receptors that are only accessible by being present in the spinal fluid, and often these same medications do not transfer from the blood to the spine or brain. A lot can go seriously wrong with medication delivery directly to the spine. These are also only effective in highly selective and very motivated patients. Once implanted, the patient is married to the pain clinic and there may be significant additional limitations especially on travel and freedom to be away from the clinic that fills the pump.

Pain is a very complex problem. If your pain is not well controlled, working with an experienced pain physician to develop the correct strategy is necessary. Implantable devices are tools to help control symptoms, but they are complex and not magical solutions. There are new developments in pain control being researched now. A good pain specialist will help find a pathway to a better solution.