Now that it’s official, I wanted to make an announcement that I have accepted a position with the Pain Care team at the Center for Diagnostic Imaging in St. Cloud. I am very excited about my new opportunity at CDI.
I decided to join CDI to take on a new challenge as part of their expanding CDI Pain Care program. Some of the services the program will be offering include:
I am very grateful to have this wonderful opportunity at CDI, and I also want to say thanks to all my friends, colleagues, coworkers, and patients at MAPS Medical Pain Clinic. I learned a lot during my time at MAPS and met a bunch of wonderful people. I am blessed to have met all of you, and I wish you all the best going forward.
CDI has three offices in the greater St. Cloud area. I will be working out of the Sartell office. You can reach the office by calling 320-251-0609 or by visiting our website. We are open Mon-Fri 6:30am-10pm, and on Saturdays from 7am-3pm. Please call the office if you have any questions or would like to set up an appointment.
Tiger Woods will not play in next month’s U.S. Open as he’s still rehabbing from lumbar microdiscectomy surgery he underwent back on March 31. Woods made the announcement on his website earlier this week.
“Unfortunately, I won’t be [at the U.S. Open] because I’m not yet physically able to play competitive golf,” Woods said. “I’d like to convey my regrets to the USGA leadership, the volunteers and the fans that I won’t be at Pinehurst. The U.S. Open is very important to me, and I know it’s going to be a great week. Despite missing the first two majors, and several other important tournaments, I remain very optimistic about this year and my future.”
While the move may come as a surprise to some, I’m not that shocked. As I hypothesized earlier on the blog, it simply seemed like too short of a timetable for Woods to make a return to professional golf. While the rehab is fairly quick, a person usually needs three months to regain normal activity. The U.S. Open will begin roughly two and a half months after Woods underwent the back operation, and he doesn’t want to take any chances when it comes to his health. As I said back in April, a more realistic return date would be in July, perhaps ahead of The Open Championship in late July.
Woods wouldn’t speculate on when he’d return to the course.e
“There’s no date, there’s no timetable, just taking it day by day and just focusing on trying to get stronger and come back,” said Woods during a media day last week. “I want to play today, but that’s just not going to happen. So just taking it step by step.”
Woods underwent a lumbar microdiscectomy back in March, which is a minimally invasive surgery used to remove a small portion of an offending disc. Patients can walk just days after the operation, but swinging a golf club is a different story, especially when you consider the force and precision needed to preform at the highest level. Last time I wrote about Woods, I guessed he’d miss The U.S. Open, but I’m going out on a hunch and saying that he’ll be back in time for The Open Championship, a place where he’s won three times.
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.
Augusta National Golf Club will have a different feel to it when golf’s first major gets underway tomorrow as its most polarizing figure, Tiger Woods, won’t be in attendance. Instead, he’ll be recovering from a recent back surgery.
Tiger Woods has been having back problems for over a year. The initial reports said he was only dealing with a bulging disc that would not need surgery, but this week it was announced that Tiger underwent an operation called a Microdiscectomy since conservative care failed. Since we can only make educated guesses as to what is wrong, we can give only a basic primer on Tiger and lumbar pain management.
Woods’ Woes
Hopefully Tiger is only dealing a single lumbar disc problem. This type of injury and corresponding surgery is best only for pain into the leg caused by an isolated herniated lumbar disc. He has tried the basics; rest, physical therapy, working with another golf pro on body mechanics, and medications to control pain and back spasms. It sounds like he has also tried injections, and despite all these efforts, he is still having issues. The latest MRI scan of his back showed a disc herniation bumping a nerve root that is most likely the cause of his pain. After not being able to play up to his usual standards, Tiger decided it was time to consider surgery.
A Microdiscectomy is a minimally invasive surgery, often using only a small incision of about an inch in length. Using special tools, the surgeon removes a small portion of bone, possibly a joint, and the offending piece of disc. The surgery is usually done as a hospital inpatient operation with an overnight stay to monitor for complications. The patient should be up and active within a day, and often has significantly improved leg pain. This stands to reason, as Tiger didn’t announce that he had undergone surgery until a few days after the operation, and the media was none the wiser. If one does not perform heavy work, returning to employment can occur within a week.
Complications and Rehab
As with any surgery, especially back surgery, there are risks of complications. In properly selected patients, success is at about 90 percent. Spinal fluid leaks, infection, recurrent disc problems, scar tissue, and ongoing pain may be seen despite surgery. The surgery will only be successful for very select group of patients who have failed all conservative care. It will not cure back problems that are related to multi-level disc problems.
The rehabilitation from a Microdiscectomy surgery is fairly rapid. Activity including stretching and walking is encouraged within a week. Guided strengthening and back exercises are often reasonable to start within a month. By three months post surgery, most activity should be possible if treatment has been successful.
Hopefully Tiger will be able to return to golf within three months. Looking at the timetable, that puts his return right around the U.S. Open, which is historically played on the third weekend in June. A more reasonable projection would be that he could return for The Open Championship, which takes place in late July.
Time will only tell what more may happen with his back. Since professional golf at the highest level is very demanding, hopefully this surgery will work and there will not be any complications. If Tiger retires, we will know, it was not the perfect cure.
A recent presentation at the North American Spine Society (NASS) meeting, points to the fact that a third of spine surgery patients are still using narcotic/opioid medications one year after surgery.
Further, the study indicates that of those patients using opioids before surgery, 51% continued a to use them a year later. The article goes on to discuss the concern that too much opioid prescribing is occurring. This is the wrong concern. The real concern should be whether spine surgery should have been done in the first place.
Reasons for Spine Surgery
The United States has one of the highest rates of spine surgery. Compared to most other countries, the spine surgery being done is mostly unnecessary. There are appropriate reasons for spine surgery, such as:
Trauma
Scoliosis
Changes in the spine causing nerve damage with loss of muscle or organ function
Pain alone is a poor reason for spine surgery. Most spine pain is caused by degenerative discs and joints. Treating this surgically most often only changes the location of pain, and does not resolve pain. Nonsurgical management of most spine conditions has been shown to be much more successful in numerous studies. Ask a group of surgeons, the answer of course is that the surgery works.
Pain management experts will usually have a more conservative view with regards to surgery. Spinal fusion surgery has at most a 30% success rate for helping with pain. Spinal surgery in general also has a 20% rate of significant surgical complication. The above statistics highlight the real issues with spine surgery – that it often causes more problems than solutions.
Alternative Treatment Options
Treatment for spine pain involves many different options, including a variety of medications and possibly opioids. Every person has different needs, and a Pain Medicine physician can evaluate you and help determine an appropriate treatment program. Surgery should only be considered if neurologic compromise is occurring and without intervention, loss of motor control or organ function may result.
Opioid medication use in the United States may be out of control, but so is spine surgery. Surgery and opioid use are truly independent problems. Pain and opioid use after surgery is not a surprising issue. The problem is too much surgery and not enough good pain management of spine problems by qualified experts.
Now that it’s official, I wanted to make an announcement that I have accepted a position with the Pain Care team at the Center for Diagnostic Imaging in St. Cloud. I am very excited about my new opportunity at CDI.
Augusta National Golf Club will have a different feel to it when golf’s first major gets underway tomorrow as its most polarizing figure, 