Spinal Disc Imaging and Discograms for Back Pain Problems

September 15, 2014August 25, 2016 / Thomas Cohn, MD

The spine has discs between each vertebral body in the cervical, thoracic, and lumbar spine. These discs are dynamic spacers between the bones and facilitate the motion between segments. The structure of the disc varies between the cervical, thoracic and lumbar levels. The differences in structure lead to different stabilization patterns in each area of the spine. The strongest discs are in the lumbar region and the weakest are in the neck, with the thoracic discs being of moderate strength.

The discs have two components, the outer anulous fibrosus, and inner nucleous pulposus. The outer ring is made of interlaced collagen fibers. The nucleous is a loose fibrous network with a gelatinous acidic mucoprotein. The combination of the outer core and inner gel is to provide the ability to absorb forces between the bones as the body moves. Extreme forces and sudden movements as well as age can damage the disc integrity. The strength and weave of the fibers is the strongest in the lumbar region and the weakest in the cervical region. Lifting and twisting heavy objects is main primary reason a person suffers a low back injury, while whiplash injuries account for the majority of neck problems. Repetitive activities and age can also damage the discs throughout the spine. Damaged discs can bulge, crack and leak, and herniate. The discs injuries can be very painful, and treatment should not be ignored.

Diagnosing Disc Injuries

Studying the spine is done in multiple ways. The simplest is by an X-ray; They can give basic information on the integrity and alignment of the bones, the height of discs, and the presence of degenerative changes. In a young person, X-rays are usually normal, but in the older person they tend to show age related changes. The problem with an X-ray is that it often can identify the area of pain, but it gives very little information about a cause of pain. CT-scans are sophisticated computer enhanced X-rays that give significantly more information about the bony structure of the spine and some limited information about the discs and spinal nerves. An MRI scan can give significant information about the discs, spinal nerves and cord, joints and bones of the spine. Electromyography can map whether the nerves of the spine are functioning properly. Discograms pressurize the disc with contrast and then they are viewed under X-ray or CT scan to determine the integrity of the disc and whether they are painful. Your doctor will determine which method is best for identifying your issue.

Discograms & MRI Scans

Discograms can tell valuable information in the lumbar region, however, in the thoracic and cervical region the data is of questionable value. In the lumbar region, a discogram can help identify whether a disc has internal disruption and if it is painful. If only one disc is painful, a doctor may be able to preform routine surgery to address the problemed disc. That said, multiple painful lumbar discs do poorly with surgical management. Often, MRI scans can give sufficient information such that a discogram is not necessary. In the thoracic region, a discogram would not clarify surgical options since the MRI can provide sufficient information along with physical exam. The nature of the discs in the cervical region makes discograms vary unreliable for useful information.

I typically suggest that a patient undergoes an MRI if they are experiencing back pain, as it provides a comprehensive look into the inner workings of the back. If you are plagued by constant low back, spine or neck pain, stop in for an assessment. We’ll work with you to find a solution to your pain.

Causes and Symptoms of Pelvic Pain

September 8, 2014August 25, 2016 / Thomas Cohn, MD

Both men and women can be plagued pelvic pain, but it is more common in women. Common causes include bladder infections, stones, and bowel issues. In women it can include endometrial issues and ovarian cysts. Treatment is based on the cause, and these pains usually end once the acute condition resolves. Pelvic pain is usually caused by issues like:

Hormonal changes

Tissue scarring

Bladder issues

Hernias

Sensory nerve degeneration, entrapment, etc.

Below, we examine these causes.

Hormones, Bladder and Hernia Issues Causing Pelvic Pain

Chronic pelvic pain in women is often related to several problems related to the unique pelvic anatomy. Endometriosis and fibroids are uterine tissues that form outside the normal uterine location. Their growth is stimulated by the normal hormonal cycles. The tissue eventually causes scar tissue in the pelvic region and the scarring can cause sporadic pelvic pain. Surgery is often used to help resolve some of the problems. Physical therapy and neuropathic medications can be helpful for long-term management.

Chronic interstitial cystitis is an issue in mainly women, and is often referred to as irritability of the bladder. The lining in the bladder becomes scarred, has pinpoint bleeding, and then the bladder becomes shrunken and stiff. Frequency of urination (up to 60 or more times a day) and constant pelvic pain occur. Bladder distention can be helpful and sometimes medication is instilled into the bladder. Bladder stimulators are sometimes implanted to help control symptoms.

Hernias more commonly appear in men than in women in the pelvic region. The muscle wall in the groin region weakens and abdominal contents push out of the injured area. The patient and doctor can decide if surgery is the best option, but if left to heal on its own, nerves can get entrapped in the resulting scar tissue. Physical therapy to release scarring, medications, and sometimes steroid injections are used to relieve symptoms.

Nerve Problems

There are multiple small sensory nerves in the pelvic region and they can become entrapped, irritated, or damaged by trauma in the area. Feedback from these sensory nerves can cause ongoing pain. Evaluation by a pain specialist or neurologist often clarifies the specific nerves involved. Sometimes physical therapy or manipulation of pelvic tissue can release these nerves or relieve the pain. Medications including anti-inflammatories and neuropathics (seizure or antidepressant drugs). At times, local steroid injections help or more regional sympathetic nerve blocks are useful.

Pelvic pain can be extremely difficult to diagnose and treat. Virtually any of the structures in the pelvis can be the eventual source of pain. Often it is a combination of structures causing pain. When the initial treatment is not working, the problem may be more complex, and a pain specialist may be helpful at finding the sources and recommending a combination of interventions that manage the symptoms. Sometimes there are permanent changes in the body and damage that is not reversible, and the goal needs to be managing the symptoms. A pain specialist can be especially helpful in designing a program that meets the needs of any particular individual.

Cowboys’ Romo Looks to Rebound After Back Surgery

August 28, 2014 / Thomas Cohn, MD

The National Football League kicks off exactly one week from today when the Green Bay Packers travel to Seattle to take on the defending champion Seahawks. With the regular season fast approaching, teams are doing everything in their power to ensure their players enter the season with a clean bill of health. One such player is Dallas Cowboys quarterback Tony Romo, who missed the end of last season after undergoing surgery to address his ailing back.

Romo initially hurt his back right before Christmas last year, and he needed an epidural injection and eventually surgery to fix a herniated disc in his lower back. Romo has been rehabbing ever since, and Cowboys owner Jerry Jones said it won’t be an issue for the quarterback in 2014.

“No issue with his back at all,” said Jones. “As a matter of fact, we all were pleased that he got the kind of test he got, and he is too. There is no issue, after being sacked three times, other than we need everybody to get in there and move in ways that we can keep that from happening.”

The three sacks Jones is referring to occurred during the team’s third preseason game against the Miami Dolphins. Keeping Romo upright will be key for the Cowboys, something they were able to do well last year. The Cowboys allowed the seventh-fewest sacks in the league in 2013, and the third-fewest quarterback hits.

“I took some hits; that was good just in regard to getting up and keep playing,” Romo said about the shots he took in the third preseason game. “That part of it was positive. The hits in general, hopefully we can avoid, but it was good to get back up and keep going and see how I felt and go play football.”

The Cowboys are set to play their final preseason game tonight against the Denver Broncos, but don’t expect to see Romo under center. Regardless of previous injuries, the majority of teams hold most of their starters out of the final preseason game to help their bodies recover before playing 16 games in 17 weeks. The Cowboys have already announced that Romo won’t play.

It will be interesting to see how Tony Romo preforms this season. He’s getting up there in age – he’s 34 years old entering this season – and although geezers like Peyton Manning and Tom Brady have proven that you don’t need to be young to preform at the highest levels, recovering from a back injury to play on the biggest stage can be extremely difficult. Don’t believe me? Just ask Tiger Woods.

Related source: ESPN

Pain-Free Tiger Woods Struggles at PGA Championship

August 7, 2014 / Thomas Cohn, MD

Tiger Woods felt fine physically during his opening round at the PGA Championship today, but his golf game wasn’t up to par with his body as he shot a first round 74 to finish Thursday at +3.

After his exit at the Bridgestone Invitational last week, many wondered if Tiger would attempt to play in golf’s final major. Woods arrived to the tournament Wednesday morning in time to get a practice round in, telling reporters after the round he felt “pain-free.”

“I felt pretty good about how I played and the shots I hit,” Woods said of Wednesday’s practice round. “I have to get used to how this golf course is playing.”

Woods looked a little flustered by the course on Thursday, shooting +1 on the back nine and +2 on the front. Currently he sits nine strokes behind Lee Westwood and Kevin Chappell, who both carded an opening round 65.

Back to His Back

Woods opened up about the back injury he suffered at Bridgestone during Wednesday’s press conference. He said he jarred his back when he stepped into a bunker and displaced his sacrum bone.

“Yeah, basically when I landed in the bunker, my sacrum went out,” Woods said. “So pinched the nerve, and hence the spasm. My physio put it back in, and we’ve just been treating it.”

Woods added that he still needs to build strength in his ailing back.

“My physio is here,” he said. “If it does go out, he’s able to fix it. One of those things, again, I still need to build strength, still continue to get stronger. Just going to take more time.”

Woods also noted that his sacrum issue was unrelated to the microdiscetomy operation he underwent on March 31 to address a pinched nerve.

“It was a different pain than what I had been experiencing, so I knew it wasn’t the site of the surgery,” Woods said. “It was different, and obviously it was just the sacrum.”

Woods said he took anti-inflammatory medication prior to his practice round, but he didn’t take any pain meds or receive a cortisone shot. He’ll try to end up on the right side of the cut line when he tees off Friday at 1:45 pm ET.

Related source: ESPN, USA Today

Tiger Woods Is Past His Prime

August 5, 2014February 17, 2016 / Thomas Cohn, MD

Tiger Woods is an excellent athlete who has strived to stay in the best of condition, but unfortunately he is no longer in his prime. To be a top-notch athlete, one needs to be able to perform without distraction and have a perfectly tuned body. Tiger is no longer 25 years old and in perfect health. Today, there are many professional golfers who are younger and in better health. A 25-year-old Woods may be better than a 25-year-old Rory McIlroy, but Woods doesn’t have the luxury of a time machine. The injuries that Tiger has had are not going to heal perfectly and his performance is clearly in decline.

Tiger Woods is now 38 years old and he is certainly past his prime. Woods has had significant knee surgeries and recently underwent a Microdiscectomy for a lumbar disc protrusion in his back. The body and all its parts age and show signs of wear in everybody. Typically by the age of 30, there are often subtle changes in the spine and joints as we stress them. The cartilage in the knee joints can show changes, and in the spine the discs bulge, tear, and show degeneration. By age 40, everyone has different signs of deterioration throughout the body. The design of the body is such that we can do most activities well until about age 40. 150 years ago, it was typical that people would die due to trauma, disease, infections, or even heart problems by age 40-50 years. Today, we are outliving the design of our body since we have better medical care.

The difference between amateur and professional athletes is the level of perfection they achieve in their sport. Physically, to achieve that level of perfection, everything in the body must be in perfect shape. A slight abnormality in the body sometimes can be compensated for, but often the level of ability is diminished. Today, the difference between the best athletes and an average athlete is the ability to do everything in a sport without compromise. Tiger’s back and knee injuries are forcing him to compromise. Tiger may be able to golf and occasionally win, but he will not be a future force and consistent top contender.

PGA Championship in Doubt

Woods was forced to withdraw from last week’s Bridgestone Invitational after suffering another setback with his surgically repaired back. The injury occurred as Woods took a step into a bunker on the 9th hole, and he withdrew from competition shortly thereafter. Some speculate that Tiger only withdrew because he was out of contention and didn’t want to jeopardize his chance to play in golf’s final major of the year this week at the PGA Championship, but his absence from the course Tuesday shows that something is clearly wrong with Woods.

Woods’ agent said the 38-year-old was at his home in Florida resting, but Tiger’s caddie went to the tournament to scout the course in case he decides to play, so there’s still a chance the 14-time major winner will chase another tour victory this week. We should know more about his status by the end of the day Wednesday. We’ll provide an update once more is known.