The most common source of pain is muscle or myofascial pain. It is usually due to overuse, or poor conditioning and posture. (Poor conditioning is better called deconditioning for most adults over 40, especially for those with a desk-oriented career, since most of us were more fit in our youth.) Those who only exercise on weekends (weekend warriors) are also prime candidates for myofascial pain. So are people who age and fail to stretch before and after exercise, even though they did fine with minimal stretching for years. As people age, they become less fit and have less time – and perhaps less health – keeping them from exercising vigorously on a regular basis. Their deconditioned core muscles around the spine become an Achilles heel. Once they can no longer get away with using their limbs without core muscle support, they develop buttock and thigh pain, pain along the spine, shoulder and shoulder blade pain, and painful and even torn muscles controlling upper arm movement. Aside from the problems arising from being out of shape, the lack of flexibility of muscles, tendons (attaching the muscles to the bones), and ligaments (attaching bones to other bones) eventually takes its toll.
Another cause of muscle pain is inappropriate muscle use. Patients with temporomandibular joint dysfunction, or who grind their teeth at night (a common condition called bruxism ), have jaw pain and headaches due to muscle spasms. Those sleeping with you or near you may hear the grinding. Dentists typically diagnose people with this condition and usually treat them successfully with mouth guards and medication. This not only saves the teeth, but also reduces jaw pain and headache. Most of the time the muscle pain described above is associated with diffuse, or – more often- focal muscle spasm in areas called “trigger points.” Myofascial pain is diagnosed by clinical examination. There are no studies which can document it.
This kind of pain is relieved temporarily or permanently with local injections called trigger point injections, usually using local anesthetic and steroids although using a tiny hypodermic need in the trigger point, injection of either local anesthetics or steroid alone, and sterile saline – a saltwater solution for medical use, all have similar beneficial effects (See “Procedures” section). Occasionally, ethyl chloride spray is placed over the trigger point or parts of the muscle in spasm, and the muscle is stretched passively. Botox injections are also used in some cases of prolonged muscle spasm. (Click here to go to “Botox” mentioned in Procedures.)
For prolonged bouts of muscle pain, or ones which recur frequently and are troublesome to the patient, a physical therapy regimen should be instituted at the same time or just following the injections.
The next several sections deal with spine related pain. The evaluation of painful spines is not a “walk in the park”. In order for a specialist to evaluate pain and other symptoms of presumed spinal origin, it is imperative that the physician have extensive knowledge of a wide range of conditions. These include conditions which are detected on radiological studies and may require surgical treatment, as well as those which cannot be diagnosed with X-rays and other tests, and require more conservative therapy. Without such knowledge it is impossible to determine a correct diagnosis and successful treatment course. Moreover, the possibilities for therapeutic success and the risks and limits of both surgery and conservative treatments must be known to the specialist evaluating you.
The facets are joints on both sides of the back of the spine, from the upper neck down to the junction of the lumbar spine and the back of the pelvis, known as the sacrum. They, along with the discs between the vertebra in the front of the spine, help stabilize the spine. At about 30 yers of age, as the discs begin to dry out and shrink, the vertebra come closer together. This results in more pressure and wear on the facet joints connecting the vertebra, as well as on other spinal structures, resulting in painful, at times arthritic facets, nerve compression due to arthritic changes within the spine, vertebral slippage, and spinal instability. Scoliosis, an abnormal bending and rotational deformity of the spine, also causes facet pain. Scoliosis, with its bending and twisting of the spine, results in abnormal pressure on the facets, especially in the lower thoracic and lumbar spine, with concomitant pain and possible arthritic overgrowth of the mechanically stressed facets. Scoliosis induced facet pain may be treatable without scoliosis surgery (refer to Procedures and Surgery). Indeed, scoliosis surgery should only be considered for pain relief if 1) the pain is not due to nerve compression but is intractable (the pain cannot be controlled through medication, modest lifestyle changes, and, where appropriate radiofrequency lesions of the nerves to the painful facets or 2) the pain is progressive and due to compression of spinal nerve roots that does not improve with more conservative treatment over time.
Facet pain is most common in the low back or lumbar spine and sacral area or the back of the pelvis, followed by the neck or cervical spine pain and, in a distant third, by thoracic spine pain involving the part of the spine from which the ribs emanate. Facet pain may be one- or both-sided.
Pain emanating from facets is usually a clinical diagnosis, based on history and a physical examination. Facet pain may be elicited by deep pressure on the overlying skin, as well as various postural maneuvers in the office examination. Radiological studies do not prove facet pain is associated with arthritic facets or “twisted” facets in a scoliotic spine. Alternatively, normal looking facets may be painful.
Facet pain may appear to co-exist with radiological evidence of stenosis in the lumbar and cervical spine and myofascial pain for which there is no objective or verifiable test, aside from a clinical examination at any location. In the case of stenosis, evaluation of facet pain with diagnostic injections of the nerves to the facets is usually ineffective. Treatment with radiofrequency lesions is usually similarly desultory. Judicious use of steroid blocks or decompressive surgery are usually the only effective procedures for treating this pain. This said, sometimes treatment of facet pain is sufficient to make the neck more comfortable, able to move with greater freedom, and sparing the patient a decompression and fusion which are the usual surgical treatments for cervical stenosis.
In cases of myofascial pain and facet pain, treatment of the former is usually ineffective in the long term and treatment of the latter is usually the optimal therapy (see “Procedures”). In this case, the sore muscles are often due to the underlying facet pain. Just as leg muscles surrounding a painful fracture may be tight with spasm, muscles overlying painful facets may also contract, causing increased pain. However, some patients with facet pain and myofascial pain need radiofrequency lesions of the nerves to the facets, as well as physical therapy and possible trigger point or botox injections, to improve their quality of life substantially.
Physical therapy alone may help improve facet pain but in many cases does not. In fact, it may aggravate facet pain.
Most of the headache patients I treat have pain emanating from the upper cervical facets. Headaches due to cervical facets is under recognized and certainly not treated aggressively, with poor results for those suffering from it. I am one of the few physicians who recognizes and treats this condition with radiofrequency lesions of the facets and, where needed, of the ganglion or “computer” of the second cervical nerve root, which often must be lesioned to achieve a good result (see “Radiofrequency Lesioning).
Headaches originating from cervical facets typically ache and are located in the back of the head, as well as (at times) towards the front of the head. Looking either straight up, or up and to the painful side, may cause increased neck pain. Squeezing the painful facets may worsen the headache once it exists. Applying warmth to the painful neck may at times reduce the neck pain and the headache temporarily. These headaches may be made worse while driving cars due to jostling and turning of the head on the neck. Some patients have a sore neck and headache on arising from sleep, presumably due to tossing and turning of the head while asleep.
Whiplash-type injuries and certain falls may initiate a period of prolonged or even permanent cervical facet pain and headaches. These kinds of headaches also may arise from the development of arthritis of these joints, especially in the elderly.
I also have experience in interventional procedures for the treatment of cluster headaches.
On rare occasions, the second or third spinal nerve roots are irritated by arthritic protuberances and can cause headaches. These can usually be treated with good results using medication, radiofrequency lesions, and sometimes surgery.
A caveat is in order here. Injecting the back of the head where headaches exist (in an attempt to block the nerves residing there) is almost always a waste of time. It does not resolve the pain. Pain in the back of the head is commonly called “occipital neuralgia”—a misnomer. It implies that the pain in question is due to neuralgia, or inflammation or damage to the nerves supplying the skin overlying the back of the skull. The only time these nerves are damaged is when they are cut—in surgery or an accident—or damaged with a viral infection (see shingles below). In either case, the skin overlying the painful area should be numb or supersensitive. This condition almost never exists and is rarely a cause of headaches—the cervical facets are the most common cause of cervicogenic headaches. A distant second is compression of the upper two cervical spinal nerve roots, as mentioned above.
As a rule, I do not treat many headache patients who require complex medication regimens but are not candidates for an interventional procedure. (Refer to Nerve Blocks and Radiofrequency Lesioning for more information.)
This condition is highly over diagnosed. Most back pain, like most neck pain that does not involve the legs or arms, is due to sore muscles or painful facets. However, for those suffering from discogenic pain, the treatments available are multiple, but many remain inadequately substantiated and are often not covered by insurance. Fusion surgery, which is reimbursed well, may not only fail to relieve your back pain, but may make your condition worse. Discogenic pain can cause significant chronic pain in the neck, shoulders, arms, back and legs. Some degenerated discs in the uppermost neck may cause or contribute to headaches.
Many cases of discogenic pain resolve within two months – the tear in the annulus heals. (Refer toDiscogenic Pain Procedures section for the treatment of spine-related pain.)
I treat cases of trigeminal neuralgia (a painful disorder affecting the fifth cranial nerve), other facial neuralgias, and atypical facial pain using medication with excellent results. When treatment beyond medication is warranted, I may treat trigeminal neuralgia with radiofrequency lesions directed at the ganglion of the fifth cranial or trigeminal nerve. Alternatively, I refer patients with this condition either for gamma knife radiation, a very focused form or radiotherapy, or for a neurosurgical procedure calledposterior fossa decompression. This procedure involves opening up the back of the skull, exposing the underside of the brain, and placing a small piece of Teflon to keep a small artery from pulsating against (and irritating part of) the trigeminal nerve.
Up to 250,00 factures of the bones of the spine – vertebra – occur each year in the U.S. Most of these are compression fractures in which a vertebra collapses due to osteoporosis. Most fractures occur in normal activities or minor incidents, such as a misstep or minor fall. The vertebra break if they are too weak to withstand the forces exerted on them. About half of vertebral fractures occur without symptoms of pain – they are silent. Others can be excruciating, but the majority of these heal spontaneously on their own in about 6-8 weeks with excellent result. Moreover, fracture induced pain should begin to improve significantly within two weeks. In the healing period, standard therapy includes pain medication (including narcotics) progressive activity in rehabilitation, and a brace as needed. Once healed the risk of renewed fracture is high and patients must follow a medical regimen to aggressively treat underlying osteoporosis.
For the relatively few fractures due to osteoporosis which do not heal, or those fractures resulting from uncontrolled cancerous tumors or benign blood vessel abnormalities with the vertebra, vertebroplastyor kyphoplasty may be used. (See Vertebroplasty and Khyphoplasty for more information)
Approximately 20-50% of cancer patients are in some pain at the time of their diagnosis, with 55-95% experiencing moderate-to-severe pain at advanced stages of cancer. Yet in at least 75-85% of cancer patients, pain can be adequately controlled through pain-relieving medication given by mouth or skin patches. Up to 20% of cancer patients whose pain is not relieved with the above means of medication delivery will respond well to intravenous or subcutaneous (under the skin) narcotics. Only 10% or less of cancer patients will require “high-tech” means of pain control, such as delivering narcotics into the spinal canal or, when all else fails, destroying nerves which carry pain impulses to or in the brain.
Cancerous tumors cause pain by invading tissues, thus causing pressure on nerves, destroying and breaking bones, and obstructing hollow organs like intestines. Cancer treatment also causes pain. Chemotherapy may damage nerves resulting in disturbing tingling in the feet and hands, a condition known as neuropathy. Radiation and surgery can cause scarring of skin and muscles, restricting motion and making it painful. Radiation and surgery can also cause nervous system damage causing pain as well as weakness and abnormal sensation in areas served by the damaged nerves. It is obvious that treating cancer pain requires diagnosing and treating musculoskeletal, visceral, and neuropathic pain, often in combination. Different types of pain may require different medication and other analgesic remedies.
Fortunately, cancer treatment is more successful – and less toxic – than in years past. Patients are living better and longer, with their cancer increasingly being treated over many years like other chronic diseases. It follows that the major goal in treating pain in the cancer patient is to relieve pain while maximizing the patient’s alertness and quality of life – over years.
Cancer pain is better treated today than 27 years ago when I was a fellow at Memorial Sloan Kettering. At that time, outside of prestigious, specialized centers like Memorial, or large university medical school-affiliated cancer centers, cancer pain was not treated uniformly well. However, there is still room for improvement. All too often pain in the cancer patient is treated mainly with high doses of narcotics, with pain relief complicated by sedation. In such cases, combining other non-narcotic pain relievers to the treatment regime (see below) may result in better pain control and less side effects. Also, there are now a host of medications that can combat sedation from analgesics. On the other hand, in some patients, cancer pain continues to be treated inadequately with insufficient narcotics and other medications, with the patient suffering needlessly. Not all pain in a patient with a history of cancer is due to cancer or its treatment. Cancer patients also have pain due to arthritis, osteoporosis (not all fractures are due to cancer), diabetes, spinal stenosis, disc ulcers, irritable bowel syndrome, and myofascial pain due to overuse. The key to pain relief is diagnosis and appropriate treatment. Recurrent cancer needs anti-cancer therapy as well as pain management. Non-cancer related, or benign pain, needs the usual combination of pain management, medical and (where needed) surgical treatment appropriate to the painful condition.
While narcotics are the safest and most effective pain killers for moderate-to-severe pain, they cause constipation in all patients, nausea in some, and also may cause sedation. Tramadol – or Ultram – is not a narcotic but acts like one and is about as strong as codeine and causes some narcotic side effects. Many drugs which help control neuropathic pain (due to damaged nerves) cause sedation and some cause other nervous system side effects like balance difficulties. These medications include some, but not all, anti-depressants and many seizure medications. Advanced age of the patient may increase the likelihood of some of these side effects as may higher doses of the drugs used. Some drugs used for musculoskeletal pain (arthritis, bone pain, tendonitis, bursitis) such as non-steroidal medication, may not be advised in cancer patients on active treatment. These medications can cause ulcers, liver and kidney damage, and increased bleeding. Cancer therapy may also cause some of these problems. Therefore, it may be best to avoid complicating the drug side effect picture while receiving cancer therapy. The latter is needed for survival while the non-steroidals may be substituted by less toxic pain relievers.
Steroids themselves play a role both in treatment of certain cancers as well as cancer pain treatment. They reduce bone pain due to certain cancers and lessen swelling in nerves compressed by tumors, lessening pain and restoring neurological function. They also stimulate appetite and transiently give some patients a sense of vitality. Their side effects include weight gain due to fat and water retention, elevated blood sugar, ulcers, muscle weakness, insomnia, and mood disturbance, to name a few. Most of these side effects are totally reversible, over time, when off the medication.
I have helped a large number of cancer patients lead a very comfortable life, living as actively and richly as their overall condition permits, in many cases for long enough that their major complaints were due to old age and not cancer or its treatment. That is a gratifying accomplishment of which I am very proud.
The most common cause of neuropathic pain in the world is leprosy. However, for those of you in the Americas and Europe, the most common form of neuropathic pain is diabetic neuropathy, and this is usually associated with damaged nerves in the legs (and eventually the arms) due to the effect of diabetes on the small blood vessels within the nerves. This is associated with numbness (worse in the legs), burning and tingling (also worse in the legs), and at times quite painful . The pain is usually worse at night and, at times, there is a vice-like feeling in the legs. Other non-diabetic neuropathies also cause pain. At times they may improve if an underlying cause is found and corrected. Usually, however, there is no treatable cause and these painful neuropathies must be treated with medication for neuropathic pain (Refer to “Cancer” above).
Failed back surgery syndrome is continued pain, often neuropathic pain, due to spinal nerve damage from the surgery. This complicated condition, usually lumbar, was discussed under surgery.
The arachnoid is a saran wrap like covering of the brain, spinal cord, and spinal nerve roots. It becomes inflamed and scarred locally following spinal surgery. However, this scarring is temporary, causing little pain, and resolves over months without any side effects. Another form of this condition was seen in patients who underwent myelograms, a specialized spinal radiological study in which contrast material is injected into the spinal fluid with a radiological dye that proved to be toxic in certain patients. It caused a reaction in some patients–they developed progressive, irreversible scarring of the covering of the spinal nerves with progressive damage to them. This resulted in neuropathic pain, numbness, weakness, and bowel, bladder, and sexual disturbance. It also affected the nerves in the lower back. The dye in question is no longer used and hasn’t been for years. As a result, this condition is rarely seen today and no more cases are expected to appear.
The only treatment for the painful form of this condition due to the dye is pain management, with appropriate medication (narcotics and medication for neuropathic pain) and, at times, a spinal cord stimulator, a sort of implanted TENS unit. This device causes vibratory sensations to be felt in the painful area. The brain pain processing system spends time processing the vibrations, as opposed to the pain from the scared nerves. The net result is that 75% of well-selected patients in whom the device is implanted obtain 50% pain relief. (This device may be used for controlling other forms of pain due to damaged spinal roots such as some cases of failed back surgery as well.)
Shingles is due to a reactivation of the chicken pox virus (varicella zoster) with which a patient was infected previously. Another name for this virus reactivation with the skin outbreak called shingles isherpes zoster. Sometimes (in patients with poor immunity) shingles may occur without a rash. In 20% of patients with shingles, a painful condition called post herpetic neuralgia develops. It lasts a month or more after an attack of shingles. It is one of the most common forms of neuropathic pain, occurring in 10% of adults forty or older and about half of the people over sixty who develop shingles. Most people recover from postherpetic neuralgia, although the recovery rate diminishes with age. At one year, pain from post-herpetic neuralgia resolves in about 80 percent of those over fifty-five, but only 50 percent of people over seventy. The pain of postherpetic neuralgia is described variably as spasms of shooting, stabbing or burning pain, or as a deep aching sensation in the affected area (most commonly on the thorax). There may also be a loss of feeling in the affected area or such extreme skin sensitivity that brushing a piece of clothing against the skin can cause terrible pain. Pain often can occur spontaneously and this is a psychologically debilitating aspect of all neuropathic pain. It seems to worsen and resolve spontaneously. There is little you can do to prevent an episode of pain or make it resolve. However, medication for neuropathic pain and narcotics help. “Novocaine” patches (Lidoderm) also help and some patients benefit from capsaicin (chili pepper) cream (Zostrix). The good news is that there is now a safe and effective vaccine which should be given to patients 60 and over who have not had shingles. This increases immunity, protecting against reactivation of the varicella zoster virus. It is quite safe and effective and all patients who fulfill the requirements to receive it should avail themselves of it.
Other viral illnesses can damage nerves causing painful conditions akin to shingles. However, some of these conditions not only cause pain and sensory loss, or abnormal sensitivity of the skin supplied by affected nerves, but may also cause weakness, loss of muscle, and restricted range of motion of the affected area. There are several viruses implicated in some of these conditions including Coxakie andEcho virus which can damage the nerves leaving the neck at the level of the collar bone and neck-shoulder junction, before they course down to the arm, shoulder, and shoulder blade area. This condition may take two years to fully resolve and, in some cases, permanent pain and some deficit remains. It must be treated with medication, including narcotics and medication for neuropathic pain, and physical and occupational therapy, when tolerated and appropriate. There is no vaccine against the viruses involved in these disorders.
Nerves (referring to either spinal roots or peripheral nerves, outside the spine, like the sciatic nerve or medial nerve of carpal tunnel fame) are complicated structures akin to fiber optic cables. They can withstand external pressure, especially if it is applied slowly over time (i.e., a slowly increasingly protruding spinal disc), and continue to function normally or, in some cases, once compressed begin emitting pain signals and malfunction. In the latter case, the nerves do not process nerve impulses that allow you to feel and move properly. The result of this damaged nerve is pain, numbness, abnormal sensitivity to touch, weakness, loss of muscle mass in the distribution of the nerve–any or all of the above. After pressure on a nerve is relieved, it may return to normal function quickly or over months. Alternatively, when nerves are internally damaged and scarred due to external pressure or actually being severed, nerves may form neuromas, or a tangled mass of the internal fibers. These produce persistent pain and numbness or excessive painful sensitivity and act like a short-circuited wire discharging or sparking when moved or compressed by surrounding muscles, or pressing on it directly.
Following hernia surgery, about 10% of men may have some element of chronic pain. Those who have had a laparoscopic procedure and a mesh implanted are at higher risk to have this problem. Usually, there is a focus of point tenderness in the groin under the incision. This is typically due to a small nerve trapped under the mesh, or over sewn with a suture, or one that has been damaged during surgery or either of the above scenarios. In these cases, re-operating on the affected area may alleviate the pain if the nerve was not permanently damaged and scarred. Other surgical scars may also contain painful zones that can become truly debilitating. Imagine a one half inch squared zone, just under the skin, which can destroy your life due to exquisite pain provoked by anything which presses on the area or contractions of the muscles surrounding the nerve.
Laparoscopy is on the increase due to the decreased costs of care associated with this form of surgery—and earlier return to work. However, nerve damage occurs more frequently in laparoscopic procedures than in open surgery, probably due to less adequate visualization of small nerves in the operating field. Nerves, once damaged, may produce neuromas, cause permanent sensory abnormalities, and pain.
One cause of stump pain in amputees are neuromas due either to nerve trauma occurring during the surgical amputation or, more commonly, associated with traumatic amputation outside the medical environment.
Neuroma related pain must be treated with medication (see below under Cancer Pain). Injections do not effectively control this type of pain. On some occasions, radiofrequency lesions of the ganglion or “volume control” regulating the passage of pain impulses from the periphery to the spinal cord and brain, is useful in diminishing pain due to nerve entrapment. However, this can only be used if there is no numbness or abnormal sensitivity of the skin in the area supplied by the nerve in question.
Pain due to surgical nerve damage and neuromas were discussed above as well as the neuropathic pain following surgery or non-surgical trauma. Pain due to non-surgical nerve damage should be treated identically as that due to surgery. (Refer above under “Painful Scars.”)
The musical-chairs list of names in the title to this section reflects the confusion surrounding the causes and treatment of this serious but enigmatic, neuropathic painful disorder or group of disorders. The details underlying the confusion are beyond the scope of this website. Suffice it to say that this disorder (or constellation of disorders) involves neuropathic pain. There are two types of this painful disorder. Type I does not involve obvious injury to peripheral nerves. Its pain is brought on by infection, inflammation, surgery, heart attack, stroke, arthritis, burns, prolonged nerve compression from casting, to name a few of purported causes. Type II (formerly called causalgia) results from obvious peripheral nerve injury. In this form of CRPS, the hand and foot are most often affected, but pain can spread to involve the entire limb as well as unrelated structures.
Pain in both cases is often continuous, with episodic flare-ups, and usually affects the extremities, although other parts of the torso and abdomen may be affected. The pain in both types is intense burning, occasionally combined with acute stabbing pain. Some people describe knife-like piercing, and throbbing pain, as well as deep aching. The flare-ups are out of proportion to the most innocuous of stimuli, such as a stiff cold breeze, moving the arm connected to an affected hand, putting on a shirt over an affected arm, or feeling anxious. A quick touch can set off a 30 minute episode of intense burning pain.
This disorder is usually over diagnosed. True CRPS must exhibit four characteristics. First, the involved skin is supersensitive. Second, there is weakness of the affected limb or tremor, or abnormal posturing, or decreased range of motion, or the development of dry, cracked nails and shiny skin devoid of hair and usual wrinkles. Third, there is also swelling of the affected area, or differences in sweat production between an affected limb and a normal one. Fourth, skin color changes, or temperature differences between an affected and a normal area are also characteristic.
CRPS often slowly disappears over several years but may flare up again from time to time. It is more common in women than men. Psychological factors may help bring it on after trauma. I suspect that it is in fact a host of poorly understood disorders – akin to “madness” in a nineteenth century asylum. At that time, patients referred to as “mad” included those suffering from schizophrenia, depression, epilepsy, brain tumors, brain damage from trauma or infection or vitamin deficiency or exposure to toxic substances, for example. In a hundred years, what today is called CRPS may be reclassified as several other better understood disorders, each with different treatments.
Treatment for this painful disorder includes drugs for neuropathic pain, narcotics, trials of oral steroids, and physical therapy. In some cases, blocks of the sympathetic nerves supplying an affected limb may give relief and, at times, after one or several of these blocks, the condition may improve significantly and begin to resolve. Intentional damage or lesioning of these sympathetic nerves, in a procedure called a sympathectomy, may give long term benefits to a select few of patients with CRPS. In my opinion, these procedures are overused treating this disorder, but in some patients they appear to have a very beneficial role. (Refer to “Procedures” section.)
These conditions can cause burning pain in the affected parts of the body and it can be excruciating at times. This kind of pain requires treatment with drugs for neuropathic pain as well as possible narcotics.
Phantom pain is seen in amputees as they perceive pain in the no longer existent amputated limb or portion of the limb. It is different from phantom limb sensation which is not painful. Phantom pain is probably due to dysfunctional nerve circuitry in the brain that evolved weeks or even years after an amputation. I have had success in helping patients with this condition. However, as a rule, this complicated challenge to treatment should be treated in specialized centers.
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