Tuesday, March 22, 2011

On Car Crashes and Chronic Pain

A new study in the March 21st issue of the journal, Arthritis Care & Research found that people in car wrecks have an 84% increased risk of developing new onset chronic pain.

The study was done at the University of Aberdeen in Scotland, UK. The researchers reviewed over 2,000 patients who suffered from chronic pain. Out of these, 241 patients had new onset of chronic widespread pain after certain events such as trauma, hospitalization, surgery, etc.

What the study found was that those who said they had been in a car wreck had an 84 % increased chance of developing chronic pain--that is they didn't have chronic pain before the car wreck.

Unfortunately, the authors seem a little confounded. Many doctors will attribute this finding to a pre-existing physical or mental predisposition. Often, these poor patients will be dismissed as trying to game the system and trying to get a large insurance settlement from personal injury tort lawsuits.

However, I see these patients all the time. Most commonly, they have undiagnosed fractures. They have a fracture that is mistaken as a normal variant, just because it doesn't 'light up' on MRI. They have all of the other obvious clinical features, such as midline and/or radiating pain, pain worse with standing or lifting, and tenderness to palpation of the spinous process at the involved vertebrae.

What's more is these patients are often on narcotics. The doctors they have seen before have said that there is nothing that can be done. I hear that from patients so many times that it makes me angry. I just don't understand why other doctors insist on ignoring these clinically obvious fractures and choose to sentence their patients to a lifetime of narcotics which don't help. Often, this choice to do nothing leads to unnecessary loss of productivity and income, but also robs the patients of enjoying life.

Years ago, there was nothing that could be done for fractures. I understand why people have been suffering for years from a car wreck 20 years ago. However, now there are effective, non-operative, solutions for fractures that are effective in up to 95% of patients with back pain.

So, if your doctor has told you or a loved one that there is nothing that can be done, especially if you've been in a car wreck, please--get a second opinion. As an expert, board-certified radiologist, I am available to review films and do this for patients outside of Oklahoma.

Monday, March 21, 2011

Why I Love My Job

Some days it's just incredible how life sets gifts on your door.

Today I had a patient in his forties who has been suffering from back pain since a motorcycle wreck 17 years ago. We all know people who were hurt in a wreck or other accident when we were in high school. This still young man had been living with back pain for two decades. He had had three back surgeries, one of which didn't take.

He came to my clinic, able to walk, but in severe, activity-limiting daily pain. He has fractures that were overlooked by other doctors. There are two main reasons why.

First, they were very mild fractures on x-ray and MRI. Most of the spine surgeons I work with would blow them off. Yes, they are subtle and they are mild, but they do not look like normal vertebrae. Personally, I used to blow them off too, because that is the standard of care and that is how I was trained. However, that is not the right thing for the patient--we'll come back to that.

The other problem that these types of patients encounter is that their fracture is remote. I heard from self-proclaimed expert spine surgeons all the time that fractures don't respond to vertebroplasty after 6 months. Really? These opinions are usually most vehemently held by the surgeons that don't even perform vertebroplasty. So they have zero clinical experience with a procedure that cures pain from vertebral compression fractures in 95% of patients.

I guess if I had trained in 1970s or 80s, that I might be in the same boat. However, doctors are supposed to be patient advocates. We have to do the best thing for our patients. And because I perform hundreds of vertebral fractures each year, I see those who were blown off by other docs. True, some of them aren't painful. But most of the ones are. Sometimes it is the subtle finding that is the only imaging indication of a big problem.

So, the young man in question. When I see him in clinic, I spend 20 minutes going over the subtleties of his situation and why other doctors haven't been able to help him. I also tell him that he has a greater than 80% chance of being pain free after vertebroplasty.

Today we fixed the fracture. Afterwards, he got up, went through all the range of motion exercises that usually cause him pain. He said his pain was gone.

It makes me very sad to think that this young man had to suffer for all of those years. Granted, vertebroplasty has only been around in Tulsa for about 10 years. But even 10 years is too long to suffer when it isn't necessary.

I really feel for those patients out there who suffer from back pain day to day and haven't found the solution, because sometimes it is that easy. But it really gives me indescribable joy when I can help another human like this end decades of suffering. Giving hope to the hopeless is what I love doing--and I am lucky to be able to do it everyday.

Wednesday, March 9, 2011

"I Don't Want Spine Surgery"

This is one of the most common 'chief complaints' I hear from patients with back pain. Often they have seen several doctors and lumbar fusion has been recommended.

Often, lumbar fusion surgery is contemplated in patients who have spinal stenosis with 'neurogenic claudication'. This occurs when you have pain that is worse with standing and/or walking and relieved by sitting. Fortunately, in cases like this, then the Vertos MILD (minimally invasive lumbar decompression)procedure is usually helpful.

With MILD ~70% patients have complete or significant pain relief. Although not perfect, it is about a 2/3 response rate, better than most things in modern medicine. Better yet, if it doesn't work, there are no implants and it doesn't preclude you from having something else done if you're in that unlucky 1/3. Here are the main advantages of this procedure over a fusion:

outpatient procedure - go home after 1-2 hours.
procedure time only 1, maybe 2 hours
light sedation (rather than anesthesia)
return to usual activities next day (as opposed to months)
no surgical incision - done through a needle hole about the size of a pencil
no implants
does not affect spine stability
I've yet to have a patient who was WORSE after the MILD procedure
you can always have a fusion after a MILD if it is really needed
no blood transfusions or dural tears reported to date in the US (vs. ~10% in open surgery)

In addition, the MILD procedure can provide relief in patients who are 'poor surgical candidates' for spine surgery, such as the elderly, those with heart disease or other medical conditions.

The other option to think about if your pain is mainly in your lower back and not into your legs is a facet block--works well typically for lower back pain that doesn't radiate.

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