Back pain

Discograms – What are they & When are they Useful?

/ Thomas Cohn, MD

discogramA discogram is a special x-ray study of the intervertebral discs in the spine.  The test is used to determine the structural integrity of the disc and whether the disc is painful when pressurized.

The Procedure

During the study, a needle is placed in the disc and dye is injected into the disc.  The study is done under real-time fluoroscopy. Normal discs are not painful.  Abnormal discs may or may not be painful.  Tears in the outer layers of the disc and whether the disc actually leaks contents can be determined with a Discogram.  Any disc in the spine can be examined in this way but it is most useful in the lumbar region.

When Discograms are Useful

Discograms are not common tests. They are used when other tests are inconclusive and surgery is being considered.  MRI scans can give a physician a wealth of information about the structural integrity of a disc, but it cannot determine if it is causing pain.  It can show a herniated disc that is pressing on a spinal nerve root and from that it may be inferred whether it is causing damage.  Combining the information from a MRI scan with other studies, like an EMG that can determine whether a specific nerve is damaged, can limit the need for a Discogram.

Today, discograms are used mostly to identify abnormal and painful discs in the lumbar region prior to surgery when other studies are not providing adequate information, and conservative care has failed.  Performing discograms in the thoracic region and cervical region is often considered very questionable, since the disc structure is different and the information provided may not be accurate.  The most useful information provided from a Discogram is that only a single abnormal disc is present and that it is causing symptoms perceived by the patient.  When multiple abnormal discs are present, surgery is usually a poor option since pain is likely to be generated from multiple sources and will not be improved with intervention.

The Future of Discograms

In the future, abnormal discs that have cracks and bulges, but are not herniated and causing pressure, may be able to be treated without surgery.  The center of the discs contain acid, when cracks develop as they age and are stressed, the acid can leak out and cause a chemical irritation to nerves.  At this time, researchers are developing compounds known as bio-sealants to seal cracks and prevent this leaks that are causing pain.  Discograms will be useful in the future if these materials being studied actually work.

An experienced interventionalist – either a radiologist or pain physician, should perform a Discogram.  Discograms are very painful studies for most patients, and sedation can be used to control the pain.  They do have risks, especially for serious infection if not performed properly.

Obesity and Pain – How are they Related?

/ Thomas Cohn, MD

obesityMany people who have pain are also obese.  A common question in these cases is which came first – the obesity or the pain? Additionally, will solving one issue make the other go away?

The answer is not simple, but both of these subjects are much related.  Obesity is a severe problem in developed countries like the USA.  Obese people stress the body, and develop pain in areas like the back and leg joints.  Having pain in the low back, or joints, and being obese does not mean that losing weight will resolve the problem since permanent injury may already be present.

Problems Associated with Obesity

Obesity is a primary problem affecting a large segment of society.  Treatment is varied – one single strategy will not work for everyone. Obesity can lead to many health problems that cause pain like:

Treating obesity before these problems occur is important.  Once permanent damage to the body is done, reversing the injury is often impossible and treatment can only be aimed at symptom management.  If you are obese, work with medical professionals to bring your weight under control to prevent permanent side effects.

Obesity & Low Back Pain

Having low back pain and obesity often makes symptoms worse.  Being overweight by 50 pounds is like constantly carrying 5 one-gallon jugs of water with you 24 hours a day without ever having a break. However, low back pain is often related to permanent changes in the lumbar region including the joints, discs, and bones.  Losing weight will not reverse the permanent changes present but may allow easier pain management.

Joint pain, especially degeneration of the knees and hips occurs with obesity.  Increased weight is a common factor that promotes increased wear and tear on the knees and hips.  Once the damage has occurred, the changes are usually permanent.  Weight loss will make the symptoms more manageable, but will often not cure degeneration that has occurred.

Obesity is a major health issue.  If it were easy to solve, then we would not be facing such challenges in society today.  Treating obesity early helps reduce secondary problems such as pain.  But solving obesity will often not solve a pain problem.  Keeping healthy, strong, and mobile will make many things better, and hopefully decrease obesity and pain.

Spine Surgery Often Unnecessary in Treating Back Pain

/ Thomas Cohn, MD

spine surgeryA 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.

Spinal Stenosis: Causes & Pain Management Options

/ Thomas Cohn, MD

spinal stenosisSpinal stenosis is a narrowing in the spinal canal where the spinal cord and nerves of the spine travel and exit the bony spine structure.  It most commonly occurs in the neck and low back regions.  It can be caused by normal changes relating to aging, such as:

  • Bony overgrowth
  • Trauma
  • Congenital changes

The body is highly adaptive, and if changes that lead to stenosis are slow, often no symptoms are present until the body can no longer compensate.

Causes & Symptoms

The symptoms of stenosis are signs of nerve damage at the spinal level that include:

  • Pain
  • Numbness
  • Muscle weakness
  • Bowel or bladder problems

Symptoms are dependent on the cause and location of the spinal narrowing.  Trauma, like car accidents, can cause sudden fracture of the spinal vertebrae. The bone pieces can damage the spinal cord causing immediate paralysis.  Congenital abnormalities may cause curvatures of the spine (scoliosis) and pinching of the nerves as they exit the spine.

Stenosis most commonly develops as one ages. The bone can become overgrown where the vertebral discs and joints are causing central and lateral spine narrowing.  In the neck, symptoms of pain, numbness, and weakness occur in the arms and head, but can also occur in the legs.  Low back stenosis causes symptoms in the low back and legs, and sometimes bowel and bladder control.  Symptoms in the low back may be very positional. Bending forward and sitting may significantly relieve the pain.  The most common symptoms that send a person to a doctor are pain or muscle weakness.

Diagnosis

Diagnosis of spinal stenosis is made based on symptoms, history, and physical examination.  Pain is often in the distribution of a particular spinal nerve level and muscle weakness corresponds to that level.  An exam shows sensation changes, weakness of muscles, and reflex changes.  If stenosis is suspected, CT or MRI scans of the spinal region can confirm the diagnosis.  Electrodiagnostic studies may also be useful to determine the extent of nerve damage, and are performed by Physical Medicine doctors or Neurologists.

Pain Management Options

Treatment for spinal stenosis needs to be individualized for every patient. Conservative care centers on physical therapy to strengthen spinal muscles and maintain proper posture, to medications for pain and spinal injections.  Many people can control symptoms for years with a variety of conservative care techniques.  If the conservative path is not controlling symptoms, then surgical care may be necessary to relieve spinal narrowing.

Spinal stenosis is a complex condition.  A good Physical Medicine pain specialist can lead one through the maze of diagnosis and treatment.  Most people do respond to conservative care.  Narrowing of the spine does occur in many people and often can be treated with PT, medications and other types of care.  Find a physician who can lead you through conservative care before you consider surgery.

Yoga and Pain Relief

/ Thomas Cohn, MD

yoga poseNote: this is a guest post by yoga instructor, Lynn Shuck.

As a yoga instructor, I’m expected to say that yoga can relieve pain.  And I truly believe it can.  But I do urge caution when approaching yoga for pain relief because, in fact, a class that moves too fast, or an instructor who pushes you beyond your limits can actually cause pain rather than relieve it.  With good instruction and personal attention, yoga can most decidedly help with pain relief by bringing the muscles and skeleton into their natural balance.

It’s All About Skeletal Alignment

When the skeleton is aligned, the muscles work in tandem the way they are intended.  If some muscles get overworked through habitual movement patterns, other muscles will stop doing their jobs and weaken.  Those tight muscles can bring the skeleton out of alignment (picture the person who sits at a computer all day and becomes hunched over, chin thrust forward). If those patterns are repeated on the yoga mat, tight muscles will just continue to overwork and the skeleton will not be supported any differently than it already is.

Imbalance can also occur starting with the skeleton.  Shin bones that bow back affect everything above the legs, tipping the thighs and pelvis out of alignment, which then impacts the spine.  A broken bone that doesn’t heal correctly or an accident that impacts any part of the skeleton will invariably affect the way the muscles work as well.  If the skeleton isn’t upright, muscles will do their best to hold up the body any way they can.

Fixing Imbalances

As an Eischens Yoga instructor and yoga therapist, I look for imbalances such as:

  • Tight, overly developed muscles
  • Bones that don’t stack properly
  • Collapsed or locked joints
  • Constriction in the breath

When a student wants to use yoga for pain relief, my intention is to keep the body from going further out of balance.  Often, using simple, easily accessible asanas, we can bring the body back to better alignment – thus reducing pain and tension. 

Uttanasana

As an example, Uttanasana is a simple forward fold commonly taught in most classes.  Sometimes, hip and low back pain can be addressed using this pose.  If I observe thighbones that sit too far away from the mid-line of the body, I might have the client roll up a towel to about 2 or 3” wide.  They would place the roll between the legs at the top of the thighs near the groin.  Pressing firmly into the towel at the top of the thighs without rolling onto the inside edges of the feet, I will then have the client perform Uttanasana, moving down and up in a limited range of motion several times, continually pressing into the towel.  When finished, the legs will usually come into better positioning in the hip sockets reducing hip and back pain momentarily.  The more regularly these muscles are used to re-align the thighbones, the longer the body will maintain this new positioning.  I refer to this as using effort in the pose to create effortlessness after the pose.

Utilizing yoga for pain relief requires understanding the physical imbalances, and then using asana to bring the body back into balance.  Practicing yoga without awareness may well be counter-productive, so find a teacher who specializes in pain relief and then trust your own experience.  Yoga shouldn’t hurt; it should make you feel better.

Lynn ShuckAuthor Bio:

Lynn Shuck is a certified Eischens Yoga Instructor.  She has been practicing yoga for nearly 25 years, and has been teaching yoga since 1996.  Her training with Roger Eischens led her to work specifically with alignment as well as injury recovery/prevention. From 1998 to 2011, she led workshops and classes throughout the Detroit metro-area.  Lynn is known for her keen eye for individual movement patterns, as well as her ability to bring yoga to all kinds of people:  experienced and beginning yogis, athletes, weekend warriors, and those who think they are too stiff for yoga.  Lynn relocated to Minnesota in 2011.