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1. Treating pain
2. How we treat pain
3. Basic types of pain
4. Back, Leg and Arm Pain-Radicular or Somatic?
5. Other Pain Sources
1. Treating Pain
Treating pain can be simple or it can be complex. An example of
simple pain would be nerve root irritation from a herniated disc,
with pain going down the leg. This type of problem can often be
taken care of by simply providing an epidural steroid injection
and physical therapy. Oftentimes, however, the pain does not go
away. In these cases, a wide variety of skills and techniques may
be necessary to treat the pain. These skills and techniques include:
- Interventional procedures
- Medication management
- Physical therapy or chiropractic therapy
- Psychological counseling and support
- Acupuncture and other alternative therapies; and
- Referral to other medical specialists
We need all of these skills and services because pain can be an
experience of the whole person. Efforts to treat just part of you
will not succeed. We need to look at you and your life with the
goal of reducing your pain; improving your function and helping
you get over this temporary period of disability. At Pacific Coast
Pain Management Center, we tailor the treatment to meet your needs,
using as few or as many modalities as you require.
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2. How we treat pain
The underlying idea behind most interventional procedures is that
there is a structure in the body, with a nerve supply, which is
generating pain. Our goal is to precisely inject medication or perform
therapies so that we can:
• Diagnose or identify the source of the problem and then
• Treat the problem.
To make the injection precisely where we want to, we use fluoroscopy.
The use of fluoroscopy ensures that the needle is placed exactly
where we want it to be, so that the medication reaches the appropriate
spot and only the appropriate spot. In this way, with the use of
precision, minimally invasive procedures, we are able to maximize
the success of your procedures.
In order for a structure to cause pain, it must meet several criteria:
• It must have a nerve supply;
• Stimulation of the structure should cause pain; and
• The structure should be susceptible to injury.
By following these criteria, we are able to limit our injections
to those injections which have a reasonable, understandable basis
for helping diagnose and treat your pain.
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3. Basic Types of Pain
There are many sources of pain. One way of dividing these sources
of pain is to divide them into two groups, nociceptive pain and
neuropathic pain. How we treat pain depends in large part upon what
type of pain it is.
a. Nociceptive pain
Your body’s nervous system is working properly. There is a
source of pain, such as a cut, a broken bone or a problem with your
spine. The body’s system of telling the brain that there is
an injury starts working. This information is passed on to the brain
and you become aware that you are hurting.
b. Neuropathic pain
Your body’s nervous system is not working properly. There
is no obvious source of pain, but the body nonetheless tells your
brain that injury is present.
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4. Back, Leg and Arm Pain-Radicular or Somatic?
Most back, leg and arm pain is nociceptive pain. Nociceptive pain
can be divided into two parts, radicular or somatic.
Radicular pain is pain that stems from irritation of the nerve
roots, for example, from a disc herniation. It goes down the leg
in the distribution of the nerve root. Associated with radicular
pain is radiculopathy, which is weakness, numbness, tingling or
loss of reflexes in the distribution of the nerve.
Somatic pain is pain limited to the back or thighs. The problem
that doctors and patients face with back pain is that, after you
go to the doctor and have a good history taken, a physical exam
performed and appropriate imaging studies, such as X-rays, MRIs
or CT scans taken, the doctor can only come up with a diagnosis
as to why you are having pain only about 15% of the time. We don’t
believe that 85% of the people coming through our door are making
up their pain!
Careful research has shown that most back pain which does not go
away after conservative treatment comes from one of three structures
in the back:
The facet
joints (small joints in the back of the spine which
provide stability and which limit how far you can bend back or twist);
The discs
(the “shock absorber” which stands between each of your
vertebral bodies (bones of the spine) ;
Or
The sacroiliac joint, a joint in your pelvis which
helps you walk and which helps transfer weight from your torso and
head down onto the legs.
By using fluoroscopically (x-ray) guided injections, we can determine,
about 80% of the time, where your pain is coming from. In this way,
using interventional techniques, we can help most of the 85% of
people with low back pain of unknown origin determine where that
pain is coming from.
Once we have diagnosed your pain, we can then treat it.
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5. Other Pain Sources:
There many other sources of pain, such as:
a. Neuropathic Pain, including:
- Complex Regional Pain Syndrome (CRPS), also called Reflex Sympathetic
Dystrophy;
- Sympathetically Maintained Pain;
- Fibromyalgia;
- Interstial Cystitis; and
- Irritable bowel syndrome.
b. Treatment of Neuropathic Pain
The various neuropathic pains are a complex collection
of disorders that can be difficult to treat. However, with careful
diagnosis and the marshalling of diverse resources, we stand an
excellent chance of improving your life. Our favorite phrase here
is, “you have given me my life back.”
One of the most powerful tools in treating neuropathic pain is
the spinal cord stimulator, which delivers tiny amounts of electrical
energy directly onto the spine. The effect of this stimulation of
the spinal cord is to allow, via a variety of mechanisms, the spinal
cord to function normally and to stop sending inappropriate pain
information up to the brain.
C. There are also other sources of pain, such as
i. Headaches and Facial pain, including atypical facial
pain and trigeminal neuralgia.
Headaches are a major source of discomfort and lost
productivity. Multiple effective treatments exist for refractory
headaches, including medication, biofeedback, injections and implants,
depending upon the precise type of headache.
Botox also provides a useful means of effectively and safely treating
headaches.
Atypical facial pain can be debilitating. Often times it can be
treated by injections of the sphenopalatine ganglion.
ii. Peripheral Nerve Pain
Peripheral nerve pain is an under appreciated source
of pain which is often misdiagnosed and under treated. While not
common, they can be debilitating. They can respond well to simple
treatments such a trigger point injections and cryoablation, an
office based procedure which involves freezing the nerves.
Examples of peripheral nerve pain include intercostal neuralgia,
ilioinguinal neuroma, hypogastric neuroma, lateral femoral cutaneous
nerve entrapment, interdigital neuroma and related nerve entrapments.
iii. Coccyxdynia
Coccyxdynia is simply pain in the region on the
tailbone, or coccyx. It can result from trauma or arise without
apparent cause.
The initial treatment is conservative, with oral analgesics. Oftentimes,
the pain is sympathetically mediated and can respond to either a
local anesthetic injection of the Ganglion Impar, which is located
by the coccyx or by ablating the Ganglion Impar, usually using radiofrequency.
iv .Compression Fractures
Compression
fractures of the vertebral bodies are common in the
elderly and commonly arise as a result of osteoporosis, or loss
of calcium in the bone. With less calcium, the bone becomes weak
and can break. Like any fracture, compression fractures hurt. Like
any fracture, they are treated by stabilization, in this case, by
injecting cement into the bone in a procedure known as a vertebroplasty.
Vertebroplasty is an effective way to treat the pain of compression
fractures.
v. Post Herpetic Neuralgia
Post herpetic neuralgia (PHN) is a painful
condition occurring after a bout of shingles. When we are young,
we are almost all exposed to chicken pox, caused by the Herpes Zoster
virus. Our immune system controls the virus, but it goes to live
in the spinal cord. When we get old, sick or stressed, the virus
can again attack us. However, in this second attack, the body usually
recognizes the Herpes Zoster virus and contains the pain to a localized
area, along the course of one nerve root (cervical,
lumbar).
You have the characteristic blisters, which normally heal. Sometimes,
however, the Herpes Zoster virus damages the nerve, causing ongoing
neuropathic pain which persists after the lesions from the shingles
have healed.
The best way to treat the PHN is to treat it before it sets in.
Medications such as Acyclovir (Zovirax), steroids and injections,
such as sympathetic
injections, can help prevent the onset of PHN.
After the pain is present, injections, local anesthetics and pain
medications can be useful.
vi. Myofasciitis and Torticollis
Myofasciitis (pain in the muscles, whether in the neck
or back) often responds to conservative physical therapy treatments,
massage and exercise. If the pain persists, trigger points can be
used. If the trigger points provide temporary relief, our preference
is to proceed to Botox injections. Botox, which is botulinium toxin,
can relax the muscles for six or more months, with long-term relief
of pain. It provides a safe, effective treatment for what can otherwise
be a difficult, ongoing problem.
Torticollis is spasm of the muscles in the neck, forcing the sufferer
to hold his or her neck tilted or rotated to the side. Botox is
approved by the Federal Drug Administration for treatment of this
problem.
vii. Piriformis Syndrome
The Piriformis muscle goes from the hip to sacrum (tailbone).
It is important in that the sciatic nerve passes through it.
Piriformis syndrome is a spasm of the Piriformis muscle. When the
muscle goes into spasm, it can squeeze the sciatic nerve, causing
pain going down the leg.
Piriformis syndrome will usually respond to physical therapy. In
persistent cases, one can inject local anesthetic and steroid into
the muscle. If the pain persists, injecting Botox or Myobloc, which
are both botulinium toxins, into the musce provides effective, safe
treatment.
viii. Plantar fasciitis and Lateral epicondylitis
Plantar fasciitis (heel pain) and lateral epicondylitis (tennis
elbow) are two common pain problems. Treatment starts with conservative
options, such as rest, non-steroidal anti-inflammatory medications,
steroid injections, over-the counter pain medications, physical
therapy and, for heel pain, shoe inserts.
If the pain lasts for more than six months, Extracorporeal Shockwave
treatment is an effective, FDA approved treatment.
Extracorporeal Shockwave treatment is not recommended for pregnant
women, children, anyone with a pacemaker, anyone on anti-coagulant
therapy or anyone with a history of bleeding problems.
ix. The many types of Cancer Pain
Cancer pain can arise from many different causes,
including the cancer itself, compression of a nerve or other body
part, fractures or treatment of the cancer. We have multiple techniques
to assist with treating the various pains from cancer, including
medications and injections. In particular, we offer ablative therapies
and the use of pumps to deliver pain medication to the subarachnoid
space, so that the medication is targeted to pain receptors on the
spinal cord. The advantage to the cancer patient is better pain
control with decreased side effects.
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