Category: Painful Conditions

FACET ARTHRITIS

Overview

The spinal column is composed of a number of structures. The most delicate is the collection of nerves that operates our muscles and allows us to move. Those nerves are called the spinal cord, which is protected by a combination of bones, disks and ligaments called the spinal column. The bones have a number of joints called the facet joints that give the spinal column its flexibility and allow it to bend and twist. We have facet joints at every level of the spine, including the neck, mid and low back. Gradual deterioration of these joints develops as we grow older. By 50 years of age, 100 percent of people X-rayed will have arthritis in the facet joints. Fortunately, most people are not symptomatic. However, a significant number of people develop pain due to arthritis in these joints.

Diagnosis

Patients with cervical facet arthritis will complain of pain in the neck that can also be felt in the back of the head, shoulder or arm. The pain is usually worse with neck movement. In the lumbar spine, facet arthritis causes low back, hip and thigh pain. The pain is usually aggravated by extension or bending backwards. When the doctor examines the patient, he or she will find tender muscles overlying the lumbar or cervical facets. The diagnosis can be confirmed with plain X-rays and CT scan studies.

Treatment

In the event of a sudden flare up, bed rest, ice over the painful area and anti- inflammatory agents such as aspirin or Motrin will usually bring relief. Sometimes a sudden flare-up can also cause muscle spasms. In this case, the doctor can prescribe muscle relaxants in addition to the anti-inflammatory agents.  Once the situation is stabilized, a cautious increase in activity can begin. Over a period of a few weeks, most flare-ups will resolve without invasive treatment. If a significant amount of pain remains, the patient can be treated with physical therapy using ultrasound, back exercises, traction and soft tissue mobilization or massage. If physical therapy does not completely resolve the discomfort, the patient can be referred to a specialist for local injections into the inflamed joints. Under X-ray, these joints can be injected with a powerful anti-inflammatory drug, usually bringing relief within 48 hours. The X-ray procedures are customarily performed under light intravenous sedation with drugs like Valium so that the patient is comfortable during the procedure.

Prevention

Preventing flare-ups is essential.

• The most critical factor in cervical facet arthritis is sleep position. It is best to use a firm non-feather pillow that keeps the neck in good alignment with the rest of the spine while sleeping. If you routinely sleep on your back, use a fairly narrow pillow that does not bring your head too far forward, but once again, keeps it in good alignment.
• In preventing back injuries, be careful bending, lifting and twisting. Ideally, patients with low back problems should attend “back school” offered by a physical therapy department in order to learn how to take proper care of the back.
• Proper strength training.
• Proper flexibility training.

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CARPAL TUNNEL SYNDROME

Overview

Carpal tunnel syndrome is a disorder affecting the middle nerve of the wrist. This nerve is important because it helps operate our hand and supplies sensation to the skin of the hand. This nerve can get pinched where it passes over the bones of the wrist and underneath a strong ligament through an area called the carpal tunnel. The tunnel and surrounding tissues can get inflamed from repetitive use. This inflammation causes the tissues to swell, which puts pressure on the nerve and results in nerve damage. This compression of the median nerve is called carpal tunnel syndrome. Carpal tunnel syndrome is common in people who use their hands for repetitive activity, such as meat packers, computer keyboard operators, mechanics, carpenters and hairdressers. It is associated with diabetes, pregnancy and rheumatoid arthritis.

Diagnosis

The symptoms of carpal tunnel are numbness, pain and tingling in the hand, which is confined to the thumb, index finder and middle finger. This pain can occasionally shoot up the arm as far as the shoulder. The patient may also complain of weakness in the hand and decreased grip strength. There are certain physical signs the doctor will look for when he examines the patient with possible carpal tunnel syndrome.  These are called Tinels and Phalens. During both of these tests, the doctor will stress the median nerve by either tapping it or bending the hand. He will look for increased symptoms and pain. The diagnosis can be confirmed with a nerve conduction study, in which the electrical potential of the nerve is recorded with a fine needle. The neurologist will look for a decreased velocity of conduction in the median nerve. If this is present, the diagnosis is confirmed.

Treatment

The mainstay of treatment with carpal tunnel syndrome is to avoid the activities causing the disorder. In addition, splints are prescribed to keep the hand and wrist straight, especially during sleep because the middle nerve is compressed when we bend our wrist. Many of us bend our wrists unconsciously at night while we sleep especially when we grasp a pillow. That is why it is so important to wear the splint at night. Injections of anti-inflammatory drugs into the middle nerve can help as well. If it is impossible to change our daily activities or if carpal tunnel syndrome does not respond to injections and splinting, surgery becomes an option. During surgery, the doctor will splint the ligaments that are binding the nerves. This is called a carpal tunnel release, which is done as an outpatient procedure under local anesthetic. The patient can be back home within a few hours. Carpal tunnel syndrome can be readily treated if it is diagnosed early. The results of treatment are usually good. It is important to work closely with your doctor when managing carpal tunnel syndrome.

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SPINAL STENOSIS

Overview

Spinal stenosis is defined as the narrowing of the spinal column around the spinal cord or nerve roots. The spinal column is composed of a number of structures. The most delicate of these is the nerves that make up the spinal cord and branch out into nerve roots. These nerves are protected by a combination of bones, disks and ligaments. The bones have a number of joints, called the facet joints, at every level of the spine. Studies show that spinal stenosis occurs when degenerative arthritis of these facet joints leads to calcium deposits on the interior spinal ligaments. When this is coupled with a bulging disk, the result can lead to compression of a nerve root, which then causes pain and irritation. Patients may limp as a result of the pain and the reduced blood flow to the nerves. Patients may notice these symptoms occur after they walk a short distance. Resting may help relieve the symptoms. Patients will also find themselves leaning forward or flexing the lower spine to help relieve irritation of the affected nerves. Sitting for a time may also help relieve the pain. Research shows that the pain from spinal stenosis can mimic pain brought about by other spinal disorders. For most patients the condition develops slowly over time. It is quite rare for the condition to be brought about by a single incident.

Diagnosis

Doctors will often find during a physical examination that a patient with spinal stenosis will have an abnormal gait pattern. There is usually tenderness over the affected portions of the spine, with restrictions in range of motion at the waist. Doctors will often utilize X-rays, such as a CT scan, to better study the joints and bony structures in the spine. For patients who may be facing surgery, a MRI or myelogram is sometimes used to better study the nerve structures within the spine.

Treatment

Nerve block treatments or injections of anesthetic medication with anti- inflammatory medications can be quite helpful in treating the pain. These are epidural injections and are usually given in a series of three treatments over a two to three week period. If the epidural injections are not helpful, the doctors may use a nerve block designed to reduce irritation from the joints of the back that can be contributing to the symptoms. The use of oral nonsteroidal anti-inflammatory medications in conjunction with pain medications may be useful as well.

Doctors may prescribe physical therapy exercises that will initially address flexibility and proceed to strength training exercises for the surrounding muscles in order to provide support for the affected parts of the spine. For some patients with spinal stenosis, surgery is a last resort to relieve pressure on the effected nerves in the spine. This is usually reserved for patients with neurologic weakness in the affected extremities.

Behavioral interventions, including biofeedback and muscle relaxation training, in conjunction with counseling are used for patients with recurring pain when all other methods fail.  The goal is to develop coping mechanisms to live more productively with the residual pain.

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CONSTIPATION

Overview

Constipation is defined as: Difficulty passing stool Incomplete passing of stool Infrequent passing of stool

Causes of constipation may include:

• Chronic use of medications
• Chronic use of enemas
• Diagnostic procedures
• Emotional stature Neuromuscular impairment
• Gastrointestinal lesions
• Immobility
• Inactivity
• Lack of privacy for personal habits
• Less than adequate intake of bulk
• Medication side effects
• Musculoskeletal impairment
• Obstructive lesions
• Pain on defecation
• Pregnancy
• Weak abdominal musculature fibers

Constipation in pain management is common as many patients receive opioids to manage their chronic pain. Opioids decrease the motility of the gastrointestinal tract, thereby delaying the passage of the stool. Tolerance does not develop to constipation as it does to the other side effects of opiates.

Diagnosis

Patients with constipation complain of:

• Abdominal pain
• Appetite impairment
• Abdominal pressure
• Back pain
• Feelings of fullness
• Hard formed stool
• Headache
• Inability to defecate
• Nausea
• Pain with defecation

Along with attaining the patient’s history, the health care provider can further determine constipation by noting the lack of bowel sounds, palpating the rectal mass, and palpating the abdomen for a mass. If the problem has been noted and addressed for a couple of days without resolve, the physician may order an abdominal x-ray to view the blockage and the cause of the blockage if visible.

Treatment

Constipation can be treated with a liberal diet of fruits, vegetables, and plenty of water.         These tend to increase the hydration in the stool allowing it to move more readily through the system. Exercise helps the colon to initiate movement to move the stool through the system. Stool softening medications may be recommended and/or prescribed by the physician.

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HERNIATED DISK

Overview

The spinal column is composed of a series of 24 bones called vertebrae that are separated from each other by a disk. These disks help absorb the shock from every day wear and tear. The disks are about the size of four silver dollars stacked on one another. Their consistency is like a jelly donut and is surrounded by tough ligaments. The jelly center is called a nucleus.  This nucleus will flatten out and bulge depending on the stress applied to the back. If the force is too much, the nucleus can rupture and break through the surrounding ligament. When this happens a nerve is pinched causing pain.

Diagnosis

A ruptured disk does not produce low back pain, but instead causes pain at the end of the pinched nerve at the arm or leg into the hand or foot. It can be associated with tingling, numbness or weakness in the extremity. The onset may have been associated with excessive physical activity or a traumatic incident such as a car accident. When the doctor examines the patient, he or she will look for signs of nerve involvement through a careful neurologic exam, checking sensation, strength and reflexes. To confirm the presence of a ruptured disk, the doctor will order a myelogram, CAT scan or a magnetic resonance test (MRI) to visualize the spinal column.

Treatment

Depending on the pain and potential for nerve damage, there are a number of ways to treat a herniated disk. In some patients, the nerves can be severely injured, causing loss of bowel or bladder function. If this is the case, it is an emergency and the disk must be surgically removed. Fortunately, in most patients, this rarely occurs. Patients usually present with pain and minimal loss of nerve function. Conservative treatment consists of a combination of physical therapy, medications, and injections. Physical therapy is useful for reducing a bulging disc and taking pressure off the nerve. A specific set of exercises, called the McKenzie program, is usually used. Medications can be given over a short-term basis to allow the patient to sleep more comfortably and to increase his or her level of function. These medications consist of anti-inflammatory drugs, muscle relaxants and a reasonable dose of narcotics like Tylenol with codeine, Darvocet 100’s, or vicodin. Under no circumstances should more than three to four doses of narcotics be consumed in a 24-hour period because of potential injury to the liver or kidneys. If physical therapy and medications are inadequate for control of pain, injections can be given to ease the discomfort. Epidural steroid injections apply powerful anti- inflammatory drugs to the involved nerve root, easing pain and swelling secondary to disc irritation. The injections are usually given as a series of two to four over a period of weeks. Relief can begin within 72 hours of the first injection. Patients experiencing severe pain despite medications, physical therapy and injections may decide to have surgery. Surgery is advised only if a ruptured disk is confirmed with the CT scan, MRI or myelogram along with severe pain in the foot or hand.

Prevention

• The best way to treat a ruptured disk is to prevent it from happening.
• Spine care
• Stop/avoid smoking
• Maintain ideal body weight
• Proper strength training
• Proper posture

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