Medical Monday: Pain Management

Board-Certified Anesthesiologist Dr. Satish Reddy joins us to talk about pain management. Medical Mondays is sponsored by AdvancedHealth.

News Notes via
BACK PAIN Overview
Back pain includes lower back pain, middle back pain, upper back pain or low back pain with sciatica. Nerve and muscular problems, degenerative disc disease, and arthritis can result in back pain. Back pain symptoms may be relived with pain medication or non-medication alternatives (interventional procedures).
There can be many causes of back pain including accidents, strains, and injuries. Two types of back injury are spondylolisthesis and cervical radiculopathy. Both have their own set of symptoms, causes, and treatments.
The spine, or backbone, is made up of a column of 33 bones and tissue extending from the skull to the pelvis. These bones, or vertebrae, enclose and protect a cylinder of nerve tissues known as the spinal cord. Between each one of the vertebra is an intervertebral disk, or band of cartilage serving as a shock absorber between the vertebrae. The types of vertebrae are:
• Cervical vertebrae: the seven vertebrae forming the upper part of the spine
• Thoracic vertebrae: the 12 bones between the neck and the lower back
• Lumbar vertebrae: the five largest and strongest vertebrae located in the lower back between the chest and hips
• The sacrum and coccyx are the bones at the base of the spine. The sacrum is made up of five vertebrae fused together, while the coccyx (tailbone) is formed from four fused vertebrae.
What Causes Back Pain?
The causes of back pain can be complex. Some causes of back pain include accidents, muscle strains, and sports injuries.
How Is Back Pain Diagnosed?
In addition to performing a complete history and physical exam for your back pain, your doctor may suggest one of the following diagnostic studies:
• X-rays, which can be used to provide detail of the bone structures in the spine and to check for instability (such as spondylolisthesis, see below), tumors, and fractures
• CT scans, which can identify specific conditions, such as a herniated disc or spinal stenosis
• MRI scans, which can provide details about the backs' discs and nerve roots. MRI scans are most commonly used for pre-surgical planning
A number of other imaging and electrical studies may also be used to identify back problems, and some injections are used for diagnostic purposes as well as for pain relief.
Types of Back Injury
Two main types of back injury include:
• Spondylolisthesis: This is a slipping of vertebra that occurs, in most cases, at the base of the spine. Spondylolysis, which is a defect or fracture of one or both wing-shaped parts of a vertebra, can result in vertebrae slipping backward, forward, or over a bone below.
• Cervical Radiculopathy: Cervical radiculopathy is the damage or disturbance of nerve function that results if one of the nerve roots near the cervical vertebrae is compressed. Damage to nerve roots in the cervical area can cause pain, weakness, and the loss of sensation in the neck, arms, or shoulders, depending on where the damaged roots are located.
Causes of Spondylolithesis
There are many causes for spondylolithesis. A vertebra might be defective from the time a person is born, or a vertebra may be broken by trauma or a stress fracture. In addition, vertebrae can be broken down by infection or disease.
Symptoms of spondylolithesis may include:
• Lower back pain
• Muscle tightness and stiffness
• Pain in the buttocks
• Pain radiating down the legs (due to pressure on nerve roots)
• Muscle weakness
Spondylolithesis Treatments
Spondylolisthesis is treated with the strengthening of supportive abdominal and back muscles through physical therapy. Acetaminophen or nonsteroidal anti-inflammatory medicines, such as ketoprofen, ibuprofen, Motrin, Advil, naproxen or Aleve may help with pain. Epidural steroid injections may also be effective. For patients who continue to have severe pain and disability despite these treatments, there are options such as decompressive laminectomy, a procedure in which the spinal canal is widened (to provide more room for nerves and a spinal fusion is performed to stabilize the spinal cord), with or without surgical fusion (arthrodesis) of the vertebra, or the use of an implanted device to stabilize the vertebrae in the lower back while permitting more normal movement.
Causes of Cervical Radiculopathy
In cervical radiculopathy, damage can occur as a result of pressure from material from a ruptured disc, degenerative changes in bones, arthritis, or other injuries that put pressure on the nerve roots. In older people, normal degenerative changes in the discs can cause pressure on nerve roots. In younger people, cervical radiculopathy tends to be the result of a ruptured disc. This disc material then compresses the nerve root, causing pain.
Symptoms of Cervical Radiculopathy
The main symptom of cervical radiculopathy is pain that spreads into the arm, neck, chest, and/or shoulders. A person with radiculopathy may experience muscle weakness and/or numbness or tingling in fingers or hands. Other symptoms may include lack of coordination, especially in the hands.
Cervical Radiculopathy Treatment
Cervical radiculopathy may be treated with a combination of pain medications such as acetaminophen (Tylenol), or nonsteroidal pain medication such as ibuprofen (Advil, Motrin), ketoprofen, naproxen (Aleve), and physical therapy. Steroids may be prescribed either orally or injected epidurally (into the epidural space that surrounds the spinal cord).
Physical therapy might include gentle cervical traction and mobilization, exercises, and other modalities to reduce pain.
If significant compression on the nerve exists to the extent that motor weakness results, surgery may be necessary to relieve the pressure.

What Are the Symptoms of Sciatica?
Common symptoms of sciatica include:
• Lower back pain
• Pain in the rear or leg that is worse when sitting
• Hip pain
• Burning or tingling down the leg
• Weakness, numbness, or difficulty moving the leg or foot
• A constant pain on one side of the rear
• A shooting pain that makes it difficult to stand up
Sciatica is a common type of pain affecting the sciatic nerve, a large nerve extending from the lower back down the back of each leg.
Sciatica usually affects only one side of the lower body. Often, the pain extends from the lower back all the way through the back of the thigh and down through the leg. Depending on where the sciatic nerve is affected, the pain may also extend to the foot or toes.
For some people, the pain from sciatica can be severe and debilitating. For others, the sciatica pain might be infrequent and irritating, but has the potential to get worse.
Seek immediate medical attention if you have progressive lower extremity weakness, numbness in the upper thighs, and/or loss of bladder or bowel control.
What Causes Sciatica?
Sciatica is caused by irritation of the root(s) of the lower lumbar and lumbosacral spine.
Additional common causes of sciatica include:
• Lumbar spinal stenosis (narrowing of the spinal canal in the lower back)
• Degenerative disc disease (breakdown of discs, which act as cushions between the vertebrae)
• Spondylolisthesis (a condition in which one vertebra slips forward over another one)
• Pregnancy
• Muscle spasm in the back or buttocks
Other things that may make your back pain worse include being overweight, not exercising regularly, wearing high heels, or sleeping on a mattress that is too soft.

NECK PAIN Overview
What Is Cervical Spondylosis?
Cervical spondylosis is also called cervical osteoarthritis. It is a condition involving changes to the bones, discs, and joints of the neck. These changes are caused by the normal wear-and-tear of aging. With age, the discs of the cervical spine gradually break down, lose fluid, and become stiffer. Cervical spondylosis usually occurs in middle-aged and elderly people.
As a result of the degeneration of discs and other cartilage, spurs or abnormal growths called osteophytes may form on the bones in the neck. These abnormal growths can cause narrowing of the interior of the spinal column or in the openings where spinal nerves exit, a related condition called cervical spinal stenosis.
Cervical spondylosis most often causes neck painand stiffness. Although cervical spondylosis is rarely progressive, corrective surgery can be helpful in severe cases.
What Are the Risk Factors for Cervical Spondylosis?
Aging is the major factor for developing cervical osteoarthritis (cervical spondylosis). In most people older than age 50, the discs between the vertebrae become less spongy and provide less of a cushion. Bones and ligaments get thicker, encroaching on the space of the spinal canal.
Another factor might be a previous injury to the neck. People in certain occupations or who perform specific activities -- such as gymnasts or other athletes -- may put more stress on their necks.
Poor posture might also play a role in the development of spinal changes that result in cervical spondylosis.
What Are the Symptoms of Cervical Spondylosis?
The symptoms of cervical spondylosis include:
• Neck stiffness and pain
• Headache that may originate in the neck
• Pain in the shoulder or arms
• Inability to fully turn the head or bend the neck, sometimes interfering with driving
• Grinding noise or sensation when the neck is turned
Symptoms of cervical spondylosis tend to improve with rest. Symptoms are most severe in the morning and again at the end of the day.
If cervical spondylosis results in pressure on the spinal cord (cervical stenosis), it can put pressure on the spinal cord, a condition called cervical myelopathy. Symptoms of cervical spondylosis with myelopathy include:
• Tingling, numbness, and/or weakness in the arms, hands, legs, or feet
• Lack of coordination and difficulty walking
• Abnormal reflexes
• Muscle spasms
• Loss of control over bladder and bowel (incontinence)
Another possible complication of cervical spondylosis is cervical radiculopathy, when bone spurs press on nerves as they exit the bones of the spinal column. Pain shooting down into one or both arms is the most common symptom.
How Is Cervical Spondylosis Diagnosed?
The doctor will generally begin by asking you about symptoms and taking a medical history. This will be followed by a physical exam of the body, with a focus on the neck, back, and shoulders. The doctor is also likely to test reflexes and the strength of hands and arms, check for loss of sensation, and watch you walk.
Other tests that might be done include imaging exams such as X-rays, computed tomography (CT), and magnetic resonance imaging (MRI). MRI scans use large magnets, radio waves, and a computer to produce the best images of the body. You might also be referred to a neurologist.
What Are the Treatments for Cervical Spondylosis?
In most cases, cervical spondylosis treatments are conservative. They include:
• Rest
• Use of nonsteroidal anti-inflammatory drugs (NSAIDs) or other non-narcotic products to relieve pain from inflammation
• Wearing a cervical collar to limit movement and provide support
• Other forms of physical therapy, including the application of heat and cold therapy, traction, or exercise
• Injecting drugs (corticosteroids and a local anesthetic) into the joints of the spine or the area surrounding the spine, known as epidural steroid injection or cervical facet joint injection
When Is Surgery Needed for Cervical Spondylosis?
Cervical spondylosis tends to be a chronic (long-term) condition. But in most cases, it is not progressive. Surgery is required only in rare cases. The goal of surgery is to remove the source of pressure on the spinal cord and nerves. The surgery may also include adding stabilization in the form of implants or through fusion of the vertebrae. But surgery is considered only when there is a severe loss of function. For instance, it might be considered if you had a progressive loss of feeling and function in your arms, legs, feet, or fingers. Any type of spinal cord compression could result in permanent functional disability.
The surgeon can approach the cervical spine from the front (anterior) or the back (posterior). Approaching from the front might be used to remove the discs and spurs that are causing pressure. The disc may be replaced with an implant. A more extensive surgery calls for the removal of both discs and parts of the vertebra. These parts are replaced with a bone graft or implant.
Approaching from the back would be used to perform either a laminectomy or a laminoplasty. In a laminectomy, the rear parts of the vertebrae in the neck -- the lamina and spinous processes -- are removed. In a laminoplasty, the vertebra is left in place, but is cut free along one side. Both procedures relieve pressure on the spinal cord or nerves.
As with any surgery, there is risk of infection or complications with anesthesia. Surgery is usually followed by a rehabilitation program.

Print this article Back to Top