Safety First: Surgical Centers vs. Pain Specialists

Recently there was an article on whether having a procedure done in a surgery center is safe. In the world of pain management, some practitioners only do procedures in these facilities (or hospitals) while others do most of their procedures in the office. Surgery centers can handle more complex procedures, and can typically handle a deeper level of sedation. In pain management, surgery centers can be beneficial for complex procedures such as implants, but often they rarely are necessary. Sedation for a pain management procedure usually does not need to be very deep, and should be able to be done without a surgery center.

Surgery Centers

The safety of a surgery center and a procedure in reality is no better than the quality, skill, and experience of the practitioner. After spending more than 20 years performing complex spinal procedures, as well as teaching courses to other physicians, it is the ability of the physician that really matters. Surgery centers are often profit centers for the physicians working in them. Furthermore, a physician who sedates most patients for procedures is often using the sedation to cover for a technique that may cause pain. A skilled interventionist should be able to do most procedures with a local anesthetic and ensure they are practically painless. The use of sedation for many practitioners is a crutch to reduce the need to talk to the patient and to perform the procedure with the least painful technique.

Pain Medicine Safety

In pain medicine, the most common injections – spinal and joint related procedures – should be able to be done quickly and comfortably. The main issue that most practitioners should be treating is the anxiety of the patient. Light medication to treat the anxiety can often be given orally. For longer procedures, IV medication is sometimes easier to use. Universally, procedures that are painful are most often due to the technique and experience of the provider. Experience often allows the practitioner the knowledge of how to perform a procedure when a patient presents a more complex situation.

In the end, safety of a center is dependent on the practitioners. If the provider does not fully know what they are doing or the best techniques, the patient is more likely to have issues with the procedure. Further, if the patient is significantly sedated, the patient will not react when the practitioner does something wrong, making it more likely that significant damage may occur. The best physicians will always care most about the patient and the problem, not the payment they might receive from doing an intervention. The best physicians have years of experience, are board certified, and have an intense, loyal patient following. Skill and experience help keep a patient safe and make a procedure safe and effective. Errors in pain management procedures are generally rare. Surgical centers and sedation are not important in patient safety; the quality of the practitioner is the most important variable.

Spine Surgery Often Unnecessary in Treating Back Pain

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.

Low Back Pain – A Common Problem, often Mistreated

low back pain minnesotaLow back pain is a very common issue – 85% of the population will experience back pain at some point in their lives. However, back pain is often treated improperly and as a result, it has become a costly problem in American society.  A lack of understanding of back pain, its causes, and usual treatment, leads to costly management.

Acute Low Back Pain

Acute low back pain is pain that has been present less than 3 months.  Most back pain can be treated conservatively.  Only rarely is back pain a serious medical emergency.  There are many structures in the back that cause pain, including:

  • Vertebral discs
  • Bones
  • Joints
  • Nerves
  • Muscles

All of these can cause pain.  Fortunately, most pain is caused by muscle strains and irritation of joints, discs or nerves.  Initially all of these are treated the same, with ice and heat, minimal rest, stretching, and then muscle strengthening of the core.

Medications should be kept simple – use Tylenol or anti-inflammatories like naproxen to manage the pain.  If pain is more severe, see a primary care physician for referral to a Physical therapist.  Very short-term use of narcotic pain medicine is useful if other medications cannot be taken but these are not advised for more than several weeks.

If Back Pain Persists

If back pain persists for more than a month, despite basic management, you should seek out an expert in low back pain.  The best medical doctors to evaluate and treat this type of pain are board certified physicians in Physical Medicine and Rehabilitation.  These physicians are experts in the musculoskeletal and nervous system.  They can guide a person through a detailed exam and diagnosis and more advanced treatments.

Surgery, MRIs, & CT Scans

Back pain is rarely a medical emergency.  If a patient has had cancer and has new onset of back pain, aggressive evaluation is necessary to determine if cancer is affecting the region.  Low back pain with loss of control of the bowels, or loss of muscle function in the legs is the other case when aggressive evaluation is necessary.

Back pain is usually relatively benign.  Most pain will resolve within weeks with conservative treatment.  Only in rare cases (such as cancer) should MRI or CT scans be obtained.

Surgery should only be considered if nerves are compromised, or bowel or bladder control is lost due to the spine being injured.

Osteoarthritis of the Knee – Treatment Options

osteoarthritis of the kneeEarlier this week, we discussed the signs and symptoms of osteoarthritis in the knee. Today we will further investigate this condition by discussing the treatment options for osteoarthritis.

Treatment of osteoarthritis of the knee includes a wide range of options, starting with lifestyle modifications, medications, and progressing to surgical management. 

Always start simple. Change starts with the individual and is not magical.  The most common first step is to lose excess weight so you are not stressing the joints.  Change the type of activity you are doing from high impact to low impact exercise. Go from jogging to cycling and swimming, or try an elliptical. Walking is always a good alternative as well.  Exercise maintains range of motion, flexibility, and health. Add in strengthening and function may also improve. 

Medication Management

Medication management is the next level of care. Having a physician involved in this level is beneficial to prevent negative side affects.  Natural substances you can take include:

  • A combination of glucosamine and chondroitin. These are natural substances found in joints. If taken orally they are supposed to promote normal joint health.  Scientific studies are mixed on whether they are truly helpful, but they rarely if ever would be harmful, if early in the disease, it may be worthwhile.
  • Fish oil. This can help with joint lubrication.

Prescription level medication starts with acetaminophen, to aspirin and anti-inflammatories, to steroids and injectable compounds.  Acetaminophen is only an analgesic and it treats pain.  Aspirin and ibufrophen or naproxen, are a class of medications known as nonsteroidal anti-inflammatory drugs (NSAIDs), and can treat pain and swelling.  These medications are stronger, may be taken orally and may be available as crèmes, but have many side affects and should be used with caution.  Skin preparations however are very safe and may be extremely helpful.

Corticosteroids are very powerful anti-inflammatory hormones, and sometimes on a limited basis orally or as injections can be helpful in controlling pain and swelling for long periods of time.  Lastly, viscosupplementation with injectable hyaluronic acid compounds is used to improve joint fluid production for periods of 3-6 months.

Surgical Options

End stage knee osteoarthritis can be treated surgically.  Orthopedic surgeons can do several things from cleaning up and removing damaged tissue in the joint arthroscopically when appropriate, to replacing the knee joint.  Surgical intervention is a consideration when the damage is severe, not responding to more conservative options, and otherwise when the patient is healthy enough to undergo surgery.

Osteoarthritis will occur eventually in all of us as we age.  The key to control degeneration is to maintain good health habits.  Keep your weight under control, excess weight will stress out your joints.  Exercise, this will keep everything moving, and maintain your strength.  Work with your doctor if more advanced treatments are needed.

Carpal Tunnel Syndrome Treatment Options

Carpal Tunnel Treatment st. cloudAs a follow up to our previous post about the causes and symptoms of carpal tunnel syndrome, we have put together this post outlining some treatment options for CTS. Carpal tunnel syndrome can be treated both surgically and non-surgically depending on the severity of symptoms.

Non-Surgical Treatments

For mild forms of carpal tunnel syndrome, non-surgical treatments are usually the best option. Here are some treatments that can help alleviate pain without having to undergo surgery:

  • Icing your wrist and hand. Applying cold to the area can decrease inflammation.
  • Taking breaks from activities that may be aggravating the condition, such as typing on a keyboard.
  • NSAIDs. Nonsteroidal Anti-Inflammatory Drugs (such as aspirin or ibuprofen) can be used to temporarily reduce pain from carpal tunnel syndrome.
  • A wrist splint can be applied at night or during the day when wrist movement is not needed.
  • Corticosteroid injections. These cannot be administered at home, but by a skilled pain management doctor. Injections like cortisone can cut down on inflammation, which in turn, decreases pain.

Surgical Treatments

If none of the above treatment options work for you and your symptoms persist or  worsen, surgery may be the best path.

Generally, surgery for this condition will be endoscopic or open. In endoscopic surgery, a small telescope-like device is inserted through a small incision. This allows the surgeon to perform the operation in the least invasive manner. With open surgery, an bigger incision must be made and the surgeon must cut through ligament to solve the problem.