Painkillers May Not Be Necessary After Some Knee And Shoulder Surgeries

October 14, 2022 / Thomas Cohn, MD

Medical researchers are always looking for more information about how they can help patients recover following a surgical procedure. The prevailing wisdom is that opioids and painkillers are needed to help patients manage discomfort following arthroscopic surgery, but new research found that these strong medications may not be necessary.

For the most recent study, researchers wanted to get a better understanding of how necessary opioid pain relievers were after arthroscopic knee or shoulder surgery compared to non-opioid pain relievers. To do this, they looked at 193 patients who underwent outpatient surgery on their shoulders or knees at three different participating hospitals. Roughly half of the patients received opioids for postoperative pain, while the other half received naproxen and acetaminophen for pain, as well as pantoprazole, a medication normally used to treat heartburn and acid reflux. Both groups had access to emergency opioids if needed to aid in pain relief.

Post-Op Pain Control

After six weeks, patients in the opioid group had used an average of 72.6 mg of opioids, compared to 8.4 mg in the opioid-sparing group. Two patients in the opioid-sparing group asked for opioid medication after their discharge. Researchers noted that there was no significant differences in patient satisfaction, pain levels or adverse events when comparing the two groups.

“This study clearly shows that many of these surgical patients can be treated safely without opioid medications in a select population,” said lead author Olufemi Ayeni, MD, a professor of surgery at McMaster and an orthopedic surgeon at Hamilton Health Sciences. “Furthermore, by reducing the number of opioids prescribed, we can collectively reduce the development of a reservoir of unused medications that can cause harm to many in society.”

More than one million arthroscopic surgeries are performed in the United States every year, and if it turns out that many of these patients can manage post-op discomfort without the need for potentially addictive and dangerous opioids, that’s a huge win. In fact, doctors have already started to make this shift. Data shows that since 2017, the number of opioid pills prescribed to patients undergoing minimally invasive surgeries has fallen by 50 percent, although that may be driven by a number of factors.

As we’ve always said on the blog, opioids can absolutely play a crucial role in a pain management program, but we have to be careful about becoming over-reliant on them. Opioids are never intended to be a long-term option, but they can certainly make it easier to participate in a rehab program after injury or surgery. Make sure that you take full advantage of the benefits of opioids when you need them most, and odds are you’ll find that you need them less and less.

For more information about appropriately managing pain after an injury or surgery, or for help overcoming a chronic condition, reach out to Dr. Cohn and his team today at (952) 738-4580.

Spine Surgery and Work Ethic Fueled Tiger Woods’ Masters Win

May 1, 2019May 1, 2019 / Thomas Cohn, MD

Tiger Woods coming back to win a major tournament in golf after multiple spinal surgeries appears to be a sports miracle. Most physicians wrote Tiger off once he developed low back problems. Performing at the level of a professional athlete with any physical dysfunction, especially with lumbar disc problems, is extremely difficult.

To compete at the highest level of any sport usually requires excellent physical and mental fitness. Anything that is less than perfect usually generates only average results and not the level necessary to be at the top of a sport, especially in golf, where even tiny issues with your swing can cause the ball to end up far away from your intended target. Aside from the physical aspects, there are also significant mental components, and one must not have any distractions like pain.

Tiger’s Journey

News reports with regards to Tiger Woods have clarified his struggle over the last several years. Tiger has had a single L5-S1 disc problem for several years. This is the bottom disc in the lower back and often takes the most force from activities. It is also the disc that most likely will go bad over time and degenerate or have a disc protrusion. For the last several years, Tiger has struggled with treatment, doing extensive conservative options to no avail. Additionally, he has had multiple surgical decompression operations with removal of parts of the herniated disc. Despite all the work, he still had pain and difficulties related to the L5-S1 disc. Ongoing symptoms impaired his ability to mentally and physically play golf.

The last option for Woods was for a lumbar fusion at L5-S1. He underwent that surgery with an extensive anterior interbody fusion type intervention. After removing the offending disc, the L5-S1 disc space was restored with a spacer device and packed with bone so the L5 vertebral body becomes fused to the sacrum. Once healed, the hard work of rehabilitation began with extensive strengthening and conditioning. Fortunately, everything went well and his strength as well as his coordination returned. The fusion healed and his pain improved.

So far for Tiger Woods, everything has gone well after his surgery. Unfortunately, this probably isn’t the last we’ve heard about his spine. The lumbar spine is incredibly well balanced, and every single level is important to control motion properly. Golf requires a lot of twisting of the back with some bending. These motions put an extreme amount of force through all of the segments in the lumbar spine. Now that one segment does not move in the normal way, forces that once went through the bottom level now are transitioned to the next level, as well as the forces that naturally occur at the L4/5 level.

This level will likely have a degree of premature degeneration and could easily start causing problems within a few years. Having good body mechanics, range of motion and strength is key to a good outcome. Tiger has spent a year rehabilitating his back and strengthening it in order to play golf. If he is lucky, the stress of golf will not cause further back problems. Avoiding overstressing a surgically repaired area is often key to avoiding re-injuring, but Tiger will be testing that theory every time he tees it up from here on out.

Psychological Interventions Could Help Chronic Pain Patients

May 22, 2018 / Thomas Cohn, MD

New research published in JAMA Internal Medicine found that patients with noncancer chronic pain can benefit from psychological interventions, which can help to reduce perceived pain levels.

Dr. Bahar Niknejad and colleagues at the Department of Medicine at Eastern Virginia Medical School conducted a systematic review and meta-analysis of the effectiveness of psychological therapies for noncancerous chronic pain. The main factor they wanted to analyze was psychological therapy’s role in managing pain intensity, but they also examined how it influenced pain interference, depressive symptoms, anxiety, negative thoughts, self-efficacy for pain management, physical function and overall health.

The meta-analysis looked at 22 studies involving more than 2,600 individuals, and after looking at the data, researchers concluded that psychological therapies were associated with small decreases in pain intensity, pain interference, depressive symptoms, anxiety and negative thoughts, while there were small increases for self-efficacy, physical function and overall health.

“Psychological interventions for the treatment of chronic pain in older adults have small benefits, including reducing pain and catastrophizing beliefs and improving pain self-efficacy for managing pain,” the authors reported. “These results were strongest when delivered using group-based approaches. Research is needed to develop and test strategies that enhance the efficacy of psychological approaches and sustainability of treatment effects among older adults with chronic pain.”

Types of Psychological Treatments To Chronic Pain

Psychological treatments of chronic pain center around the idea that if we understand our pain and why it’s happening, then we can learn to control or better cope with flare ups. Knowing this, here’s a look at some of the more popular psychological treatments for chronic pain:

Patient education about the condition.
Biofeedback (A technique where patients learn to interpret feedback regarding certain physiological functions).
Relaxation Training.
Operant Conditioning.
Cognitive-Based Approaches.
Acceptance-Based Approaches.
Expectation Management.
Emotional Stress Management.

By helping the patient find new psychological strategies to control or better cope with their pain, people often feel more in control of their symptoms, which in turn can decrease the perception of pain. If you are suffering from chronic pain, talk to your doctor about psychological approaches to best manage your condition. Reach out to Dr. Cohn for more information.

Chronic Pain After Surgery

August 15, 2017 / Thomas Cohn, MD

In the vast majority of cases, a surgical procedure helps to eliminate or reduce pain in the targeted area. However, in rare cases, complications or unforeseen circumstances can result in the onset of what’s known as chronic postsurgical pain.

Today, we’re going to take a closer look at CPSP, and how it is prevented and treated.

Treating Chronic Pain After Surgery

Medical experts define chronic postsurgical pain as pain that persists for at least two months after surgery and is not attributable to a preexisting condition. Oftentimes CPSP is considered neuropathic in nature, and patients describe the pain as shooting, burning, tingling or electrical in nature. Some procedures that have a higher rate of CPSP after surgery include:

Amputation
Coronary artery bypass surgery
Thoracotomy
Spine surgery
Breast surgery
Hip surgery
Hysterectomy
Inguinal hernia repair
Cesarean section

Doctors believe that CPSP develops because stress from the operation, inflammation or nerve damage results in neuronal hypersensitivity that results in the expression of chronic pain flare ups long after the surgical site has healed.

Risks and Prevention

There are a number of factors that increase a person’s risk of developing chronic postsurgical pain after an operation. Those factors include undergoing repeat surgeries, lengthy surgeries, open procedures instead of minimally invasive surgeries, and undergoing an operation in a previously injured area. On the doctor’s end, a surgeon can increase a person’s risk of developing CPSP if there is intraoperative nerve damage, which is more likely to occur in difficult operations, surgeries involving severe trauma, or surgeries near the spinal cord and central nervous system.

The main way surgical teams prevent CPSP is through surgical techniques and improved operative practices. If possible, the surgeon will opt for a laparoscopic procedure in lieu of an open procedure, because minimally invasive options have a decreased likelihood of CPSP. Another thing surgical teams will do is carefully administer analgesic agents with different mechanisms of actions during the pre-, intra- and post-operative periods. These approaches reduce peripheral and central sensitization and are associated with enhanced efficacy and fewer adverse reactions.

Should you develop CPSP after an operation, reach out to a chronic pain doctor in your area to see what solutions are available to you.

Tiger Woods Undergoes Second Microdiscectomy on Back

September 23, 2015September 23, 2015 / Thomas Cohn, MD

Tiger Woods went under the knife again recently, opting to have a second microdiscectomy operation preformed on his ailing back.

The surgery means that Woods will withdraw from the final three scheduled events he had on his calendar, and it brings another disappointing season to a close. Woods failed to contend in any of the year’s four majors and he missed five cuts in 2015. Woods announced on Friday that he hopes to return to competitive golf in “early 2016.”

“This is certainly disappointing, but I’m a fighter,” Woods said. “I’ve been told I can make a full recovery, and I have no doubt that I will.”

This is the second time Woods has undergone the intricate operation on his back. His first microdiscectomy was back in March of 2014, and he only competed in seven events that season.

Surgery and Looking Ahead

Woods said on his personal website that he pursued a second back surgery after feeling pain and discomfort in his back and hips in recent weeks. Woods is used to playing through some discomfort after undergoing a host of operations throughout the course of his career, but the spinal compression came as surprise, as he had recently committed to playing in three tournaments to round out the year.

“He committed, thinking it was going to be a regular checkup,” said Woods’ agent, Mark Steinberg. “Obviously, that area where he had the microdiscectomy had to be treated again. And it leads us to where we are now.”

The microdiscectomy operation removed a small disk fragment in his back that was compressing a nerve, which was the source of his pain. Woods announced that he “will begin intensive rehabilitation and soft tissue treatment within a week,” adding that “healing and recovery times differ for each individual based on many physiological factors, but Tiger is encouraged he can return early in 2016.”

Dr. Cohn Comments

Here’s the deal with Tiger Woods. At this stage in his career, the only thing on his mind is chasing Jack Nicklaus on the career major’s list. Jack finished with 18, and Tiger currently sits at 14.

Tiger said he hopes to return to competitive golf by early 2016, but let’s be honest, he doesn’t care about the Sony Open of the Farmers Insurance Open. Tiger Woods wants to be back and healthy for The Masters, golf’s first major in 2016, which takes place in April. Obviously Tiger would like to get some rounds in before April, but I don’t expect to see him playing in minor tournaments in January or even early February. He’s always stuck to his schedule, and I believe his ultimate goal is to have his body and his short game in their best form at Augusta National.

That’s easier said than done, however. Tiger Woods will turn 40 in December, and unlike a fine wine, athletes don’t typically get better with age. Tiger has been playing golf professionally for more than half of his life, and although it’s less physical than football, it still takes a big toll on your body. What’s more, the smallest imperfections in your body can cause you to hit the ball a long distance from where you’re aiming, so pain and discomfort is less than ideal for an athlete who depends on precision. When you consider his age, his health and the formidable foes he has in young players like Rory McIlroy, Jordan Speith and Jason Day, I think it will be incredibly difficult for Tiger to win one more major, let alone catch Jack.

I wish him the best in his recovery, and I hope we can once again catch a glimpse of the golfer that took the world by storm back in the late 90’s and early 2000’s.