We have had great success in treating SLAP tears and labral tears with either prolotherapy or autologous, culture expanded mesenchymal stem cell transplants. The focus of this article will be prolotherapy.
This is a case of SK, a 52 year old male who had a partial SLAP lesion tear and was told that surgery was the only option. When I first examined this patient he had severe pain with any kind of bicep use and couldn't lift anything with that arm or swim (his primary form of exercise). The patient underwent 3 injections of x-ray guided prolotherapy injections into the biceps anchor at the superior labrum. He is now able to lift 25 pound dumb-bells with that arm and has only minor intermittent pain. To understand why this would work, one needs to understand some anatomy. The biceps tendon anchors at the top of the socket of the ball and socket shoulder joint. When it gets torn partially away from that bony anchor, it's called a partial SLAP lesion. In this case the x-ray allowed us to place medication at this exact site (which wouldn't be possible without x-ray or "blind" in the office) to kick off a brief inflammatory healing cycle. This gave his body more tries at healing the site. I've attached the x-ray picture to show this unique approach, the needle shown as the dark line and the dark medication/contrast mix covering that SLAP lesion.
The moral of the story is that this gentleman didn't need surgery (with his arm in an immobilizer brace for weeks), all he needed was some injections in the exact spot to help heal the area. During this time he remained completely active, which beats sporting a blue pillow and a shoulder brace.
Wednesday, August 20, 2008
Tuesday, August 19, 2008
Chronic Thoracic Pain After a Fall
Just discharged a patient with a one year history of thoracic pain after falling on his mid back. He failed PT and was told by workman's comp doctors that he couldn't be helped. We discharged him pain-free, what did they miss?
The thoracic spine is particularly big in the ligament department. This means that ligaments hold much of it together like duct tape. There are ligaments that hold the back of the spinal bones together (supra-spinous and inter-spinous ligaments) and ligaments that hold the ribs to the spine (costo-transverse and costo-vertebral joints). In addition, there are many muscles that attach to the ribs and help guide or anchor movement like guy wires on a sail boat mast. So in a patient with chronic thoracic pain due to a fall or car crash (in many cars there is a seat stiffener in the seat that can damage upper back ligaments in a rear-ender), you think of ligaments first.
This gentleman had a ligament injury that we treated with prolotherapy. This involves injecting some substances into the ligaments to help kick off a natural healing cycle. His problem was that he got "one bite" at the apple, meaning his body had one cycle to heal his ligament injury after his fall and it was too big to heal. The prolotherapy allowed him to get a few more healing cycles in and heal the area. While this sounds simple, regrettably our medical system rarely identifies or treats sub-failure (not completely torn) ligaments. This is regrettable, as hundreds of millions are wasted annually by the medical care system as it spins it's wheels trying to help patients who aren't getting diagnosed correctly with ligament issues (especially in the spine).
This gentleman was also helped with IMS, a technique that involves getting rid of muscle knots with an acupuncture needle. Again, another easy technique which can help allow more normal motion. In the ribs this can help because there is a big muscle around where the rib connects to the spine. When this locks up, so does normal rib motion. This then causes a myriad of other problems from perceptions of shortness of breath to lack of upper back movement).
For more information on how a full spectrum of pain management procedures, click here.
The thoracic spine is particularly big in the ligament department. This means that ligaments hold much of it together like duct tape. There are ligaments that hold the back of the spinal bones together (supra-spinous and inter-spinous ligaments) and ligaments that hold the ribs to the spine (costo-transverse and costo-vertebral joints). In addition, there are many muscles that attach to the ribs and help guide or anchor movement like guy wires on a sail boat mast. So in a patient with chronic thoracic pain due to a fall or car crash (in many cars there is a seat stiffener in the seat that can damage upper back ligaments in a rear-ender), you think of ligaments first.
This gentleman had a ligament injury that we treated with prolotherapy. This involves injecting some substances into the ligaments to help kick off a natural healing cycle. His problem was that he got "one bite" at the apple, meaning his body had one cycle to heal his ligament injury after his fall and it was too big to heal. The prolotherapy allowed him to get a few more healing cycles in and heal the area. While this sounds simple, regrettably our medical system rarely identifies or treats sub-failure (not completely torn) ligaments. This is regrettable, as hundreds of millions are wasted annually by the medical care system as it spins it's wheels trying to help patients who aren't getting diagnosed correctly with ligament issues (especially in the spine).
This gentleman was also helped with IMS, a technique that involves getting rid of muscle knots with an acupuncture needle. Again, another easy technique which can help allow more normal motion. In the ribs this can help because there is a big muscle around where the rib connects to the spine. When this locks up, so does normal rib motion. This then causes a myriad of other problems from perceptions of shortness of breath to lack of upper back movement).
For more information on how a full spectrum of pain management procedures, click here.
Monday, August 27, 2007
Week 1 with My Disc
The numbness from the epidural lasted a few hours and then gradually wore off. It was abit weird to feel dense numbness down my legs. My legs gradually turned from rubber to more sure. Some stiffness returned and the sense that I could get in serious pain by moving the wrong way reared it's ugly head. However, even with those things, I was vertical again and so thankful.
Having spent my entire professional life in pain management, I knew there would be a few rules of the road:
1. No pain, no gain doesn't apply. While some bad science and superstition has led to the idea that patients with herniated or bulging discs should just return to all normal activities, I knew this was silly. For every tweak of the area (a position that caused severe pain or any sensation like cramping, weakness, tingling or even a funny feeling in my legs), I was causing a problem I would pay for by a longer recovery. The reason is that the small muscles that stabilize the back are also supplied by the same nerves I would be pissing off with these moves. This means that my ability to protect these nerves in the future (a job handled by these multifidus muscles), would be lessened. You can see these changes on MRI, as these multifidus muscles grow smaller and become less able to stabilize the spine.
2. Return to normal activities as quickly as possible. While this may sound contradictory, it isn't. In number 1 I presented the "Yin" rule, keep the area quiet. This is the Yang to rule number one's Yin. While it's true that I could piss off the nerves that hold the system together, I also had to prevent the secondary problems of muscle wasting and generalized deconditioning. This meant get moving as quickly as possible, hence the reason for my early epidural.
To summarize here, I had to allow the area healing and keep the nerve happy, while getting back in the saddle quickly. How did this work? Some examples:
-On day 3, i did 30 minutes on a StairMaster. When I noticed any sensation in my legs or the back spasm acting up (sure signs that the nerve was being irritated), I backed off.
-On day 4, I went back to a mild weight work-out and avoided carrying or lifting anything where my back was unsupported. Anytime I felt the tell tale signs of nerve irritation, I cut back.
-On day 5 I tried my usual hike/climb up a local mountain trail, but soon learned at even half speed, these climbing movements were causing some numbness in my legs. I bailed on the hike and spent an hour on my bike instead (this caused just some very light sensations).
For the first week, fatigue is my friend. I am very tired. This is likely because everything takes a bit more effort and I'm still dealing with some mild, chronic pain. I get to bed early every night.
I avoid all meds. I did take a few medications the first day, however, thanks to my epidural I don't need these. Regrettably, this is where so many of patients get hooked on narcotics. Without the luxury of prompt pain relief the first day, they take the only thing that works, narcotics.
My first week was a success, manageable pain, slow steps (I still get sharp pain if I move too fast in specific directions, sit too long, stand too long, or just stay in the same position for too long), and a rapid return to maybe 50% of my normal activities.
Having spent my entire professional life in pain management, I knew there would be a few rules of the road:
1. No pain, no gain doesn't apply. While some bad science and superstition has led to the idea that patients with herniated or bulging discs should just return to all normal activities, I knew this was silly. For every tweak of the area (a position that caused severe pain or any sensation like cramping, weakness, tingling or even a funny feeling in my legs), I was causing a problem I would pay for by a longer recovery. The reason is that the small muscles that stabilize the back are also supplied by the same nerves I would be pissing off with these moves. This means that my ability to protect these nerves in the future (a job handled by these multifidus muscles), would be lessened. You can see these changes on MRI, as these multifidus muscles grow smaller and become less able to stabilize the spine.
2. Return to normal activities as quickly as possible. While this may sound contradictory, it isn't. In number 1 I presented the "Yin" rule, keep the area quiet. This is the Yang to rule number one's Yin. While it's true that I could piss off the nerves that hold the system together, I also had to prevent the secondary problems of muscle wasting and generalized deconditioning. This meant get moving as quickly as possible, hence the reason for my early epidural.
To summarize here, I had to allow the area healing and keep the nerve happy, while getting back in the saddle quickly. How did this work? Some examples:
-On day 3, i did 30 minutes on a StairMaster. When I noticed any sensation in my legs or the back spasm acting up (sure signs that the nerve was being irritated), I backed off.
-On day 4, I went back to a mild weight work-out and avoided carrying or lifting anything where my back was unsupported. Anytime I felt the tell tale signs of nerve irritation, I cut back.
-On day 5 I tried my usual hike/climb up a local mountain trail, but soon learned at even half speed, these climbing movements were causing some numbness in my legs. I bailed on the hike and spent an hour on my bike instead (this caused just some very light sensations).
For the first week, fatigue is my friend. I am very tired. This is likely because everything takes a bit more effort and I'm still dealing with some mild, chronic pain. I get to bed early every night.
I avoid all meds. I did take a few medications the first day, however, thanks to my epidural I don't need these. Regrettably, this is where so many of patients get hooked on narcotics. Without the luxury of prompt pain relief the first day, they take the only thing that works, narcotics.
My first week was a success, manageable pain, slow steps (I still get sharp pain if I move too fast in specific directions, sit too long, stand too long, or just stay in the same position for too long), and a rapid return to maybe 50% of my normal activities.
Sunday, August 26, 2007
My Own Disc problem
A month ago I was dead lifting too much weight in the gym and felt a sudden shift in back at the base of my spine. I had severe pain and fell to my knees. I instantly knew that I had messed something up. I struggled to get up and walk and felt severe spasm. I could barely get dressed and take a shower and a few hours later I had realized that seeing patients would be impossible. I headed home and my wife found me after an unsuccessful 20 minute attempt to make it up our main staircase. I spent a few hours in bed, really unable to move without severe low back pain with cramping and knife like spasm. After a few hours like this I knew I had to do something, so I had my wife take me back to the clinic for an epidural. My partner John Schultz squeezed me in over the lunch hour where he performed a left S1 transforaminal injection of anesthesthic and anti-inflammatory (putting medicine right between the disc and the nerve root). The pain I experienced when the medication got near the nerve root was the most unbearable of my life, with cramping and spasm down my left hamstring and calf. This felt like an ultra severe a tooth ache in the leg. However, after a few minutes, it subsided as the numbing medicine kicked in. While I barely limped in to the clinic without crutches, almost aflling several times, I walked out after the epidural normally with no pain. I can say now that the decision to get a very early epidural was a great one, as I was back to the gym in a limited capacity a few days later and have since regained pretty much all activities (except dead lifts).
The helplessness and utter depression I felt when I was in severe incapacitating pain was a great lesson for me. As a pain management doctor, I have treated countless patients in similar circumstances, without ever fully understanding (at more than an intellectual level), the depth of their sorrow or the utter helplessness that they feel. I'm also a bit saddened that so few of my patients will ever get the chance for the instant relief and early intervention that I received. There are all kinds of good reasons why everyone in that situation should get an immediate epidural to control pain, reduce atrophy of key stabilizing muscles, and reduce the likelihood of other side effects caused by the pain or the pain medications. However, some doctor long ago started a myth unsupported by any science that people in that condition should "wait it out" without any intervention except medications and physical therapy. While this recommendation may be smart for those with a mild low back sprain, for those in my condition, it's lunacy. Regrettably, this is the nature of what I call modern "beer and pizza" insurance guidelines. Since there is no research data on this topic (early epidurals for patients with severe neurologic pain after a disc herniation or bulge). the insurance companies assume that they somehow have the right to pull guidelines out of thin air, or as I like to say, get a bunch of guys like me together over beer and pizza to make up some guidelines that everyone else has to follow.
I am genuinely thankful for being "vertical" as one of my patients loves to say. Here's to early intervention.
The helplessness and utter depression I felt when I was in severe incapacitating pain was a great lesson for me. As a pain management doctor, I have treated countless patients in similar circumstances, without ever fully understanding (at more than an intellectual level), the depth of their sorrow or the utter helplessness that they feel. I'm also a bit saddened that so few of my patients will ever get the chance for the instant relief and early intervention that I received. There are all kinds of good reasons why everyone in that situation should get an immediate epidural to control pain, reduce atrophy of key stabilizing muscles, and reduce the likelihood of other side effects caused by the pain or the pain medications. However, some doctor long ago started a myth unsupported by any science that people in that condition should "wait it out" without any intervention except medications and physical therapy. While this recommendation may be smart for those with a mild low back sprain, for those in my condition, it's lunacy. Regrettably, this is the nature of what I call modern "beer and pizza" insurance guidelines. Since there is no research data on this topic (early epidurals for patients with severe neurologic pain after a disc herniation or bulge). the insurance companies assume that they somehow have the right to pull guidelines out of thin air, or as I like to say, get a bunch of guys like me together over beer and pizza to make up some guidelines that everyone else has to follow.
I am genuinely thankful for being "vertical" as one of my patients loves to say. Here's to early intervention.
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