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Pain Conditions

 Sciatica

Overview of sciatica causes and symptoms Sciatica—pain along the large sciatic nerve that runs from the lower back down the back of each leg—is a relatively common form of low back pain and leg pain. This pain along the sciatic nerve can be caused when a root that helps form the sciatic nerve is pinched or irritated.

Sciatica is usually caused by pressure on the sciatic nerve from a herniated disc (also referred to as a ruptured disc, pinched nerve, slipped disk, etc.). The problem is often diagnosed as a "radiculopathy", meaning that a disc has protruded from its normal position in the vertebral column and is putting pressure on the radicular nerve (nerve root) in the lower back, which forms part of the sciatic nerve.

Sciatica occurs most frequently in people between 30 and 50 years of age. Often a particular event or injury does not cause sciatica, but rather it may develop as a result of general wear and tear on the structures of the lower spine. The vast majority of people who experience sciatica get better with time (usually a few weeks or months) and find pain relief with non-surgical treatments.

For some people, the pain from sciatica can be severe and debilitating. For others, the pain from sciatica might be infrequent and irritating, but has the potential to get worse. Usually, sciatica only affects one side of the lower body, and the pain often radiates 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 radiate to the foot or toes.

Typical sciatica treatments Nerve pain is caused by a combination of pressure and inflammation on the nerve root, and treatment is centered on relieving both of these factors. Typical sciatica treatments include:

 Manual treatments for sciatica, including physical therapy and specific stretching and strengthening exercises, and manual manipulation (e.g. osteopathic or chiropractic manipulation) to help relieve the pressure on the nerve root, which is the cause of the pain.  Medical treatments for sciatica, including medications such as non-steroidal anti-inflammatory drugs (NSAIDs), oral steroids, or epidural steroid injections to help relieve the inflammation, which is usually a component of the pain.  Surgery for sciatica, such as microdiscectomy or lumbar laminectomy and discectomy, to remove the portion of the disc that is irritating the nerve root. This surgery is designed to help relieve both the pressure and inflammation and may be warranted if the sciatic nerve pain is severe and has not been relieved with appropriate manual or medical treatments.  Trigeminal (trifacial) Neuralgia (TIC)

Trigeminal neuralgia (TN), also called tic douloureux, is a condition that is characterized by intermittent, shooting pain in the face.

Trigeminal neuralgia affects the trigeminal nerve, one of the largest nerves in the head. The trigeminal nerve sends impulses of touch, pain, pressure, and temperature to the brain from the face, jaw, gums, forehead, and around the eyes.

What Causes Trigeminal Neuralgia?

The most frequent cause of trigeminal neuralgia is a blood vessel pressing on the nerve near the brain stem. Over time, changes in the blood vessels of the brain can result in a blood vessels rubbing against the trigeminal nerve root. The constant rubbing with each heartbeat wears away the insulating membrane of the nerve, resulting in nerve irritation.

What Are the Symptoms of Trigeminal Neuralgia?

Trigeminal neuralgia causes a sudden, severe, electric shock-like, or stabbing pain that lasts several seconds. The pain can be felt on the face and around the lips, eyes, nose, scalp, and forehead. Symptoms can be brought on when a person is brushing the teeth, putting on makeup, touching the face, swallowing, or even feeling a slight breeze.

Trigeminal neuralgia is often considered one of the most painful conditions seen in medicine. Usually, the pain is felt on one side of the jaw or cheek, but some people experience pain at different times on both sides. The attacks of pain may be repeated one after the other. They may come and go throughout the day and last for days, weeks, or months at a time. At times, the attacks can disappear for months or years. The disorder is more common in women than in men and rarely affects anyone younger than 50.

Treatment

Trigeminal neuralgia can be treated with antiseizure medications such as Tegretol or Neurontin. The medications Klonapin and Depakote may also be effective and may be used in combination with other drugs to achieve pain relief. Some antidepressant drugs also have significant pain relieving effects.

If medications are ineffective or if they produce undesirable side effects, neurosurgical procedures are available to relieve pressure on the nerve or to reduce nerve sensitivity.

 Fibromyalgia

The condition called “fibromyalgia” is a myofascial pain syndrome (a muscular pain syndrome) that can result in generalized back pain and muscle pain, a feeling of general fatigue, and specific tender areas. The patient will have a normal neurological exam, but may have multiple spots that are tender to palpation, called "tender points". These tender points are specific places on the neck, shoulders, back, hips, arms, and legs. These points hurt when pressure is put on them.

Fibromyalgia most commonly affects middle-age women who are otherwise healthy. However, the condition can affect women of all ages, as well as men and children.

While there is no known anatomical reason for the syndrome, it is suspected that there are underlying biochemical causes.

Fibromyalgia symptoms People with fibromyalgia often have other symptoms in addition to specific tender points, and common symptoms may include one or some combination of the following:

 Difficulty sleeping  Feeling tired after waking from sleep, instead of feeling refreshed  Stiff joints in the morning that usually feel better as the day goes on  Headaches  Tingling or numbness in hands and feet  Depression

Fibromyalgia treatments Physicians who treat fibromyalgia typically include family physicians, general internists, or rheumatologists (who specialize in treating painful conditions that involve the joints, muscles, tendons and ligaments). Often a team of healthcare professionals is the best option to treat the diverse symptoms of fibromyalgia. For example, treatment for fibromyalgia may include one or a combination of the following options:

 Massage or injections of lidocaine may be used to help relieve the pain in tender spots  Non-narcotic pain medications (e.g. acetaminophen)  Low-impact aerobic conditioning  Antidepressants (e.g. Amytriptiline), both for help with sleeping and to alleviate the pain

 Lumbar Spinal Stenosis

Facet joints tend to get larger as they degenerate. This process is the body’s attempt to decrease the stress per unit area across a degenerated joint. Unfortunately, as the joint enlarges, it can place pressure on the nerves as they exit the spine (see Figure 1). Standing upright further decreases the space available for the nerve roots, and can block the outflow of blood from around the nerve. Congested blood then irritates the nerve and the pain travels into the legs.

Generally, patients with spinal stenosis are comfortable if they are sitting, but have more pain down their legs when they walk and the pain increases with more walking ("neurogenic claudication"). Walking while leaning over a supporting object (such as a walker or shopping cart) can help ease the pain, and sitting down will cause the pain to recede.

Treatment options Options for conservative treatment for spinal stenosis include activity modification and epidural injections.

 Activity modification. Since patients are more comfortable when they are flexed forward, they can concentrate their activity in that position and exercise can include stationary biking and using a cane or walker for walking while flexed forward.  Epidurals. Approximately 50% of patients will experience good relief after an epidural injection, although the results tend to be temporary. If the injection is helpful it can be done up to three times annually. The action of the injection is not clearly known, but is probably a combination of the anti-inflammatory effect of the steroid and a flushing effect due to injecting a volume of fluid.

Spine surgery (an open decompression or laminectomy) is the only way to change the anatomy of the spine and give the nerves more room. Decompressing the nerves by removing a portion of the enlarged facet joint prevents the nerve pinching when the patient stands up. It is effective in approximately 80% of cases, although over a 5-year period of time the results tend to deteriorate. Part of this deterioration is due to the progressive nature of osteoarthritis, and part is due to the overall aging process.

It should be noted that lumbar spinal stenosis rarely causes nerve damage, and surgery is almost always elective. The results seem to be as good if the surgery is done early or delayed, even for years.

 Shingles (Herpes Zoster)

Shingles is a reactivation of the herpes zoster virus, the virus which causes chickenpox. With shingles, the first thing you may notice is a tingling sensation or pain on one side of your body or face. Painful skin blisters then erupt on only one side of your face or body along the distribution of nerves on the skin. Typically, this occurs along your chest, abdomen, back or face, but it may also affect your neck, limbs or lower back. The area can be excruciatingly painful, itchy and tender. After one to two weeks the blisters heal and form scabs, although the pain often continues. The deep pain that follows after the infection has run its course is known as postherpetic neuralgia. It can continue for months or even years, especially in older people. The incidence of shingles and of resulting PHN rises with increasing age. More than 50 percent of cases occur in people over 60. Shingles usually occurs only once, although it has been known to recur in some people.

What Causes It?

Shingles arises from the same virus, herpes zoster, that causes chickenpox. Following a bout of chickenpox, the virus becomes dormant in the spinal nerve cells, but it can be reactivated years later at a time when the immune system is suppressed -- by physical or emotional trauma or a serious illness, or by medications which suppress the immune system. Medical science doesn't understand why the virus becomes reactivated in some people and not in others.

Treatment

Because shingles comes on suddenly, with scarcely any warning, there is little you can do in the way of prevention, but your doctor may be able to avert some of the pain that follows. Some pain experts have had success using a nerve block during the acute phase of the disease. Administered on an outpatient basis in a hospital to deaden pain and shrink inflammation at the nerve root, a nerve block may act as a preemptive strike against later development of postherpetic neuralgia.

 Sacroiliac Joint Dysfunction

The sacroiliac joint connects the sacrum (triangular bone at the bottom of the spine) with the pelvis (iliac bone). It transmits all the forces of the upper body to the pelvis and legs. There is not a lot of motion in the joint and it is very strong.

It is not clearly understood why this joint sometimes becomes painful, although some believe it is due to a limitation in its normal motion patterns. It typically results in pain on one side very low in the back or in the buttocks, and is more common in young or middle age women.

Conservative treatments for sacroiliac joint dysfunction Conservative treatment for sacroiliac joint dysfunction generally centers around trying to restore motion in the joint, and can include:

 Physical therapy and exercise  Chiropractic or osteopathic manipulations of the sacroiliac joint  Injections to the sacroiliac joint

 Facet Syndrome Facet joints are in almost constant motion with the spine and quite commonly simply wear out or become degenerated in many patients. When facet joints become worn or torn the cartilage may become thin or disappear and there may be a reaction of the bone of the joint underneath producing overgrowth of bone spurs and an enlargement of the joints. The joint is then said to have arthritic (literally, joint inflammation-degeneration) changes, or osteoarthritis, that can produce considerable back pain on motion. This condition may also be referred to as “facet joint disease” or “facet joint syndrome”.

A protective reflex arrangement arises when the facets are inflamed which causes the nearby muscles that parallel the spine to go into spasm. We therefore see inflamed facets causing crooking and out-of posture of the back, along with powerful muscle spasm. Manually ‘correcting’ this spinal curvature actually depends on relaxing the spastic muscles and not a rearrangement of bony structures.

Treatment

To break up a cycle of recurring, acute facet joint pain, a number of treatments can be used successfully. Many of these treatments give some or even a lot of temporary relief but all too often, little long-term help.

There are a number of conservative care treatment options that can be tried to alleviate the pain and rehabilitate the back, such as:

 Successful long-term treatment involves proper exercises, with instruction by a trained physical therapist or other healthcare provider.  Good posture (maintaining a normal curvature of the spine such as pulling the car seat quite forward or when standing at a sink, putting one foot up on a ledge, bending that knee a bit), support to the low back when seated or riding in a car (particularly in the acute phase). A very useful posture when standing or sitting is the pelvic tilt - where one pinches together the buttocks and rotates forward the lower pelvis - and holding that position for several seconds, done several times per day.  Heat (e.g. heat wraps, a hot water bottle, hot showers) or cold (e.g. cold pad applications) may help alleviate painful episodes  Changes in daily activities (e.g. shortening or eliminating a long daily commute), and adding frequent rest breaks  The use of anti-inflammatory medication, such as various non-steroidal anti- inflammatories, called NSAID’s (e.g. ibuprofen) and the more recent Cox-2 inhibitors (e.g. Celebrex)  Chiropractic manipulations or osteopathic manipulations may provide pain relief  For the neck, a restraining collar may bring temporary relief, as may also cervical traction. A suitable supportive neck pillow is often essential and abnormal nighttime flexion positioning of the neck, such as when using a pile of pillows, is to be avoided. More lasting relief of the facet joint problem can be obtained by destroying some of the tiny nerve endings serving the joints. This can be accomplished by a tip freezing or an electrified hot probe technique (also known as a facet rhizotomy) performed under careful x-ray control, (or for a lesser time by a carefully controlled injection of botox toxin which treats the muscle spasm).

In unusually severe and persistent problems, degeneration of the adjoining disc is nearly always present so the segment may require a bone fusion surgery to stop both the associated disc and facet joint problems. Such surgery may be considered radical, but an untreated persistent, episodic, severely disabling back pain problem can easily ruin the active life of a patient and surgery can therefore be a reasonable choice in selected cases.

Fortunately, for the vast majority of patients, a combination of change in life style, medication and proper exercise and posture will reduce the problem to a manageable level.

 Low Back Pain In the US, low back pain is one of the most common conditions and one of the leading causes of physician visits. In fact, at least four out of five adults will experience low back pain at some point in their lives.

Ironically, the severity of the pain is often unrelated to the extent of physical damage. Muscle spasm from a simple back strain can cause excruciating back pain that can make it difficult to walk or even stand, whereas a large herniated disc or completely degenerated disc can be completely painless.

The causes of low back pain can be very complex, and there are many structures in the low back that can cause pain. The following parts of spinal anatomy can cause pain:

 The large nerve roots in the low back that go to the legs and arms may be irritated  The smaller nerves that innervate the spine in the low back may be irritated  The large paired lower back muscles (erector spinae) may be strained  The bones, ligaments or joints may be injured  The intervertebral disc may be injured

It is important to note that many types of low back pain have no known anatomical cause, but the pain is still real and needs to be treated. However, usually low back pain can be linked to a general cause (such as muscle strain) or a specific and diagnosable condition (such as degenerative disc disease or a lumbar herniated disc).

 Herniated Spinal Discs

Spinal disc pain terminology varies There are many different terms to describe spinal disc pathology and associated pain, such as “herniated disc”, “pinched nerve”, and “bulging disc”, and all are used differently by different healthcare practitioners. Unfortunately, there is no agreement in the healthcare field as to the precise definition of any of these terms. Often the patient hears his or her diagnosis referred to in different terms by different practitioners and is left wondering if there is any consensus on what is wrong.

Some examples of terms used to describe spinal disc abnormalities include:

 Pinched nerve  Sciatica  Herniated disc (or herniated disk)  Bulging disc  Ruptured disc  Slipped disc  Disc protrusion  Disc degeneration  Degenerative disc disease  Disc disease  Black disc

Rather than focus on the terminology referring to spinal anatomy, it's most helpful for patients to focus on understanding the medical diagnosis, which identifies the actual source of the patient’s low back pain, leg pain, or other symptoms.

Conservative treatments for a lumbar herniated disk There’s a wide variety of conservative treatment options for patients to try for treatment of a lumbar herniated disk. The primary goals of treatment are to provide relief of pain and to allow return to a normal functional level.

The most common conservative treatment options for a lumbar herniated disk include:

 Rest, followed by slow mobilization  Pain medications  Chiropractic/osteopathic manipulations  Physical therapy  Epidural steroid injections

The recommended amount of conservative treatment for the herniated disk needs to be individualized for each patient. For those patients who are not in severe pain and can function well, a longer period of conservative treatment is reasonable (e.g. 12 weeks). For those patients with severe pain that is not responsive to conservative treatment, surgery to decompress the nerve is a reasonable option to treat the lumbar herniated disk.

Surgery for a lumbar herniated disk If a patient does not feel better after 6 to 12 weeks of conservative care, then surgery may be considered to treat the lumbar herniated disk. The goal of surgery is to help alleviate the pain faster. If a patient has severe pain and is unable to function at a satisfactory level, surgery may be a good option even before six weeks of symptoms.

Any patient who has progressive neurological deficits, or develops the sudden onset of bowel or bladder dysfunction, should have an immediate surgical evaluation as these conditions may represent a surgical emergency. Fortunately, both of these conditions are very rare, and most surgery for a lumbar herniated disk is an elective procedure.

In recent years, the morbidity (such as post-operative pain) of surgery for a lumbar herniated disk has decreased and the results have improved, so surgery is generally considered a very reasonable option to get better quicker.

Surgical treatment options for the lumbar herniated disk include:

 Microdiscectomy (the most common procedure)  Lumbar laminectomy  Chymopapain injections  Arthroscopic lumbar discectomy  Microendoscopic surgery

A lumbar microdiscectomy (also called a lumbar micro-decompression) is considered the gold standard and is the most common surgery to alleviate pain from a lumbar herniated disk

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