Wednesday, February 2, 2011

Help and Hope When Other Doctors Have Failed

I am often asked what I can do for patients in chronic pain that have seen multiple physicians. Often these patients are on chronic narcotics for pain and their doctors have given up on finding a solution for their pain. As an aside, for chronic pain, opiate narcotics such as lortab really just exacerbate the problem.

We frequently see patients who come to us who have seen other doctors, had injections and are still in pain. Most of these patients we can help by trying a different approach that the other doctors have overlooked. Most commonly this is done by addressing facet pain, spinal stenosis or fractures.

I am continually AMAZED at the number of patients who come in with no hope that have an UNTREATED FRACTURE. If it's a vertebral fracture, we can almost always take away or significantly reduce the pain. Even with other causes of pain, we have great results.

Main Pain Causes
My systematic approach considers the most common causes of pain. For example, the most common causes of back pain that I see are:
1. Muscle strain or other soft tissue injury (usually self-limited).
2. Disc disease (annular tears, bulges, herniations, intervertebral osteochondrosis, etc.)
3. Facet osteoarthritis
4. Vertebral fractures, painful hemangiomas and similar conditions.
5. Sacroiliac joint arthritis.

Typically, when a patient sees a pain doctor, they are past the phase where #1 is usually a factor. Most commonly, patients will progress on to epidural injections. If there is no help, and the patient has disk disease, often the patients are sent to surgery or placed on chronic pain medications.

Why Repeat Epidurals
Lastly, even though a patient may have had an epidural injection before, I will usually repeat this because about 1/2 of these patients will get significant sustained relief when I do the injection. I can't always explain why, but frequently when the I do an epidural and the patient gets excellent relief for months, it suggests that the previous injection may have been in the wrong place.

For example, we always use x-ray guidance. A recent study showed that even the most experienced pain doctors injected in the wrong place 25% of the time if they didn't use x-ray guidance.

Also, often people had a steroid shot in the hip muscles, but not an epidural injection. These are two completely different procedures. It's hard for me to know which a patient had unless I have the operative report. An intramuscular steroid injection is no more effective that taking oral steroids and has all the same side effects as systemic steroid administration.

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