Myths About Slipped Disc

 

Tags >> Back Pain Treatment In Gurgaon, myths about slipped disc, Pain Management in Gurgaon

Bouts of back pain are common with up to 80% of people worldwide experiencing back pain at some point in their life. Most episodes are a result of minor problems such as a strained muscle, ligament and usually resolve soon. Less than 1 in 20 cases of sudden onset back pain are due to a slip disc and are often inappropriately managed. Here are some myths about slipped disc.

Myth #1: Discs slip out of place

The name slipped disc is a misnomer as the disc does not slip out of place. It is firmly supported in its place surrounded by strong ligaments on both sides. The discs have a tough outer layer that surrounds a jelly-like material in the centre. Slipped disc is used to refer to a condition where the disc looses its shape and/or consistency and either the central jelly-like material of the disc leaks or bulges out. In medical terminology other terms such as degeneration, bulging, protrusion, extrusion and sequestration are used to refer to varying magnitudes of the problem.

Myth #2: Slipped discs are always caused by injury

Slipped disc results from a magnitude of factors causing weakening of the disc such as genetic factors, age related wear and tear, lifestyle including physical activity, body weight, smoking etc. They may however come to light after a sudden movement/ injury but the predisposition is already present and sometimes even trivial activities can trigger the symptoms.

Myth #3: Slipped discs always cause excruciating pain

Whilst slipped discs can be quite painful, this is not the case always as the severity of pain can vary. It is possible for a person to have a slipped disc and feel no pain or show no symptoms. For most people, a slipped disc will cause some pain and discomfort, and this generally reduces with time.

The pain from a slipped disc may be felt in the back and/ or the arms/legs. This may be accompanied by other symptoms such as numbness, tingling and muscle weakness.

Myth #4: My x-ray is fine so I cannot have a slipped disc

X-rays of the spine are not good at looking at discs. Although they may show problems such as reduced disc height, they are not good for evaluating slipped discs. MRI scans are better at looking at the spine anatomy in detail. X-rays are used more for evaluation of bones.

Myth #5 : MRI imaging will show the cause of my back pain

Technological advancements have enabled us to identify minute changes in disc structure using investigations such as the MRI. A significant number of normal individuals with no symptoms, when scanned will show disc abnormalities on the MRI. This emphasises the point that not every slipped disc causes pain and the findings need to be interpreted in relation to your history and examination findings. Discs normally wear down as we age, so just because the MRI showed a disc problem doesn’t mean that it is the cause of your pain.

Myth #6: Slipped discs require Surgery Sooner Or Later

In an overwhelming majority of cases the problem will NOT require surgery and can be managed conservatively. Disc bulges are NOT forever. A recent study revealed that spontaneous regression of disc injury can occur with conservative care.

Understandably the idea of being under the knife can be terrifying for most people and this option is required only for severe/ non resolving cases. Experienced, knowledgeable medical professionals always try less invasive treatments first. Non surgical interventions, such as medications, physical therapy and injections, can help in reducing the symptoms. Spinal injections such as nerve root block can sometimes play a key role in controlling symptoms and speeding up recovery. Such injections are administered under x -ray guidance to ensure accuracy.

Myth #7: Movement will make my disc problem worse

Whilst extreme pain episodes may require rest, continued activity is generally advised. Simple activities (such as walking, mild stretches) as recommended by your specialist, can reduce the loss of muscle strength and endurance. It can reduce deconditioning of muscles which in itself can be a source of pain. It may be sensible to avoid certain types of activities such as heavy lifting, impact sports etc whilst the body attempts to repair itself. Movement can plan an essential role in the healing process.

Myth #8: Slipped disc is a permanently disabling condition

Many believe that once they get a slipped disc it’s a lifetime problem and they will never be able to return to normal activity. I have seen patients with normal spine who have not bent forwards for years as they were advised not to do that during a back pain episode. Such strongly embedded negative beliefs are disabling and dealing with them can be challenging. With patience, correct knowledge and timely treatment most individuals can return to 100% prior level of function without pain.

Walking on a Pebble or a Crumpled Sock?

 

What is Morton’s Neuroma?

Morton’s neuroma is painful swelling, irritation or damage of the nerves leading to the toes. Irritation of the nerves generates sharp burning pain in the ball of foot and a sensation as if one is standing on a pebble or a fold in the sock. Most commonly the nerve running between the third and fourth toe (third interdigital nerve) is involved. In as many as 28% of cases adjacent nerves may also be involved (commonly the second interdigital nerve and rarely the first and fourth interdigital nerves).

This condition is addressed by many other names including Morton’s metatarsalgia, Morton’s entrapment, interdigital neuralgia/ neuritis/ neuroma and interdigital nerve compression syndrome.

What are The Symptoms of Morton’s Neuroma?

This condition is most commonly seen in middle aged women. Women are 5-10 times more likely to be affected as compared to men. Common symptoms of Morton’s Neuralgia include

• Burning or sharp forefoot pain in between the toes. Initially the pain may be present only when wearing tight/heeled shoes and on prolonged walking or standing. Chronic cases may develop constant rest pain and night pain. The pain can radiate to toes or occasionally to the dorsal aspect of the foot or even the lower leg.
• Feeling like there is a “bunched-up sock” or a pebble under the ball of the foot is present in more than 50% of patients
• Numbness and/or tingling in the third and fourth digits or in between the toes
• Local tenderness and clicking sensation

Why Does it Occur?

This condition is linked to

• Wearing tight, pointy or high-heeled shoes as this can place extra pressure on the forefoot.
• People with flat feet, high arches, or abnormal toe position as seen with deformities such as bunions, hammer toes.
• High-impact athletic activities such as jogging, running, tennis and other racquet sports, rock climbing, snow skiing may subject feet to repetitive trauma.

A combination of anatomical and biomechanical factors is thought to contribute to the development of Morton’s Neuroma. Third interspace is commonly affected as this a narrower space with greater mobility of the 4th metatarsal relative to the 3rd metatarsal, producing a greater shearing force and trauma. The third digital nerve has increased thickness and is tethered in the third web space making it more susceptible. The compression and repetitive trauma to the nerve results in blood supply changes, nerve oedema/ degeneration, and excessive fibrosis (scarring) around the nerve.

Biomechanically wearing pointed, high- heeled shoes raises the body’s centre of gravity, reduces the support base of the weight bearing foot and produces extension at some of the foot joints predisposing the nerves to compression.

How is Morton’s Neuroma Diagnosed?

Diagnosis is usually made through history, clinical examination and is aided by imaging (ultrasonography, magnetic resonance imaging). Presentation features have already been discussed in the previous section. Examination involves specific tests such as the thumb index finger squeeze test (pain on applying pressure in the intermetatarsal space with thumb placed on the dorsal aspect whereas index finger is kept on the plantar aspect), Mulder’s click test and foot squeeze test.

Ultrasound and magnetic resonance imaging can help in confirming the diagnosis and give information about the location, number, and size of neuroma. A neuroma of >5mm size on MRI is generally significant. An x ray may show outward deviation of the toe (Sullivan’s sign) and a faint shadow in case of a large Morton’s neuroma.

How is Morton’s Neuroma Treated?

The treatment options for Morton’s Neuroma include

Footwear Modification

Wearing a wide, soft-soled, laced shoe with a low heel is helpful in relieving pressure on the nerve. Modifications to footwear have been shown to improve symptoms in up to 41% of patients but are associated with lower satisfaction rates when compared with steroid injections.

Orthotics

Metatarsal bar or a soft metatarsal support spread across the metatarsal heads. This insole relieves pressure on the neuroma and thus improves symptoms.

Medications

A combination of different types of medications, including Anti-inflammatory and neuropathic agents is used to reduce pain.

Ultrasound Guided Steroid Injections

Steroid injections are one of the most commonly used methods of nonoperative treatment. Several studies have purported that ultrasound (US) added accuracy to the injection procedure and one study demonstrated more pain reduction with ultrasound guided injections compared to the unguided injections. One study indicated at least 9 month relief in combination with physical therapy and these injections are more effective if used within one year of onset of symptoms. A dorsal approach (from the top of the foot) to the injection is associated with better outcomes and a lower risk of plantar fat pad atrophy and associated pain and gait disturbances. Some individuals may require multiple injections although a satisfactory outcome can be achieved in a majority (up to 82.4%). Some studies indicate that the size of neuroma may have an effect on the outcome of injections whereas others found no such relationship.

Given the actual problem and the mechanism of generation of neuroma PRP treatment is less likely to work in this condition and hence I do not offer this in Morton’s neuroma.

The treatment of the concomitant anatomical and functional disorders is important in the prevention of recurrence.

Cryotherapy

Cryotherapy or freezing of nerves can help reduce the pain in this condition. The treatment involves creating a freezer burn on the outer layer of the nerve to interrupt the pain signal being sent to the brain. A probe is placed next to the affected nerve and the temperature of the probe is then dropped to freeze the irritated nerve. The freezing inactivates the nerve producing pain relief.

Cryotherapy is a relatively safe and effective means of treating localized nerve irritation. In one study 4 out of 5 patients improved with this treatment.

Alcohol Nerve Injections

Alcohol and other similar chemicals are used to impair the nerve structure and functioning. One study reported complete symptom resolution in up to 89% of patients although multiple treatments are often required, and the effects diminish with time. The procedure complications may include peri-procedural pain (16.8%), allergic reaction (1.1%), and failure with up to 20% progressing to surgery. In one study approximately a third of patients experienced complications including burning pain (can sometimes last for weeks). The fibrosis associated with the treatment can make any subsequent surgery challenging.

Radiofrequency Ablation of Nerve

This procedure involves creating a heat lesion of the nerve to reduce the symptoms. It involves placing a special needle near the nerve under ultrasound guidance followed by creating heat lesion using the radiofrequency waves.

Physical Therapy

Intrinsic and extrinsic foot muscle strengthening to improve transverse arch and control foot pronation can help in addressing the biomechanical problems thereby reducing the chances of recurrences.

Surgery

It has been found to be effective and to elicit positive results in 80% to 90% of cases. One study however found the failure rate following surgical excision to be up to 30%. There are multiple reasons for this such as incomplete resection, multiple neuromas, recurrence or incorrect diagnosis.

References/ Further Reading

• Bhatia, M., & Thomson, L. (2020). Morton’s neuroma – Current concepts review. Journal of Clinical Orthopaedics and Trauma. Volume 11, Issue 3, May–June 2020, Pages 406-409 doi:10.1016/j.jcot.2020.03.024
• Munir U, Tafti D, Morgan S. Morton Neuroma. [Updated 2020 Jun 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470249/
• Di Caprio, F., Meringolo, R., Shehab Eddine, M., & Ponziani, L. (2018). Morton’s interdigital neuroma of the foot: A literature review. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons, 24(2), 92–98
• Ata, A. M., Onat, Ş. Ş., & Özçakar, L. (2016). Ultrasound-Guided Diagnosis and Treatment of Morton’s Neuroma. Pain physician, 19(2), E355–E358.
• Morgan, P., Monaghan, W., & Richards, S. (2014). A Systematic Review of Ultrasound-Guided and Non–Ultrasound-Guided Therapeutic Injections to Treat Morton’s Neuroma. Journal of the American Podiatric Medical Association, 104(4), 337–348.
• Friedman T, Richman D, Adler R. Sonographically guided cryoneurolysis: preliminary experience and clinical outcomes. J Ultrasound Med 2012;31(12):2025–34.

Hughes, R. J., Ali, K., Jones, H., Kendall, S., & Connell, D. A. (2007). Treatment of Morton’s neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. AJR. American journal of roentgenology, 188(6), 1535–1539.

Tags >> Morton's Neuroma

Lower Back Pain Due To Spinal Arthritis Non-Surgical Pain Management Options

 Tags >> Lower Back Pain Treatment In Delhi, Non Surgical Pain Management, Pain management specialists, Pain Specialist in Gurgaon

The lockdown due to coronavirus created a never before situation where a number of us were unable to pursue our routine physical activities. Some were forced to performunaccustomedactivities like household chores, shifting/lifting heavy objects whereas others had to compromise on their routine exercises or gym visits. Having treated both type of patients with back pain during the lockdown, I can confirm that both situations can initiate andaggravating low back pain.

Low back pain (LBP), in simple words, is any pain in the bottom region of spine, between lower margins of ribs and the gluteal folds (end of buttocks). It is a leading cause of disability with lifetime prevalence estimated at 70–80%. In otherwords, 70- 80 % of us will be troubled by back pain at some point in our life. The pain may vary in severity from a mild discomfort or distraction to severe pain bringing life to a standstill. Common causes of LBP include muscle or ligament strain, arthritis of the spine, disc bulges/ rupture (slipped disc in common language) and pinched nerves. Other causes include degenerative discs, abnormal curvature or alignment of spine, narrowing of the spinal canal and referred pain from nearby areas.Fortunately, serious causes such as fracture, infection, cancer etc. are not so common. The pain may remain localised to the back or spread to the legs. Pain radiating to the legs accompanied bynumbness, tingling and weakness is addressed as sciatica. When dealing with BP pain generators are sometimes tricky to identify. It is better to control this pain sooner than later as persisting untreated pain not only leads to distress/agony but also has harmful effects on most body systems including mental, emotional well-being and quality of life.

Back Pain Secondary Arthritis Of Spinal Joints

One of the causes of back pain is arthritis of the spinal joints. Spine is made up of a number of vertebrae stacked one above the other. The vertebrae join with each other at joints called the facet joints. These joints provide stability while allowing some degree of movement. As one ages, they can become painful and stiff as a result of wear and tear or inflammation. This condition is called facet joint arthritis or simply arthritis of the joints of the spine.

Symptoms

Pain originating from facet joint arthritis generally presents as a dull ache, heaviness sensation accompanied by back stiffness. Some individuals experience difficulty in straightening their back especially in the morning or after a period of rest. It is not uncommon for the pain to travelto the buttocks and thigh. Many bear the pain, accepting it as a part of aging thinking that there is no solution, but is that so? as thereare that can provide relief, improving the quality of life. After all, it’s all about quality of life. For someone, quality of life may mean to be able to play a few rounds of golf and for someone else it may to all about attending a work meeting without being distracted by pain. Your goals are your goals and they are important.

Investigations such as x-rays and MRI are often requested to evaluate the source of pain. These may or may not show joint changes. Even if these investigations show wear and tear/arthritis, not every arthritic joint is painful so investigations alone cannot be relied on todiagnose this problem. It required a skilled pain physician to put all findings together (history, examination, Investigations) to identify the source of pain.

Prevention

This is a common question on everyone’s mind – What can one do to minimise the chances of developing this problem?Prevention involves combining healthy lifestyle with regular exercises to strengthen the core muscles. Healthy lifestyle includes eating healthy, maintaining a healthy weight, good posture, smart lifting using current technique and not smoking.

Treatment

The fact that surgery or pills cannot resolve all pain issues has been long recognised. Understanding and treating pain is challenging as we all experience and process pain differently. Pain management specialists focus on holistic management, using a combination of modalities such as education, medications, physiotherapy, ergonomics & posture advice, psychology, complementary and alternative therapies and interventions such as injections.

Injections for this pain issue are safe, effective, non-surgical interventions routinely performed as day cases under local anaesthesia. The options include

Facet Joint Injections

Facet joints injections can help to identify the pain source and they generally provide good relief. The procedure revolves placing needles at precise location in the bodyunder x-ray guidance followed by injection of a mixture of medicines to relieve pain.

Radiofrequency Treatment

This procedure can provide prolonged pain relief for back pain originating from spinal joints. It involves placing special needles under x-ray guidance, close to the nerves carrying pain sensation from the affected facet joints. Using specialised equipment, a small area of these nerves is heated using the electric current produced by radio waves. This reduces the pain signals being transmitted by the nerves to the brain resulting in pain relief.

This procedure offers many advantages including no requirement for hospital stay or prolonged rehabilitation and one can return to normal activities soon after the procedure. The pain reduction can help in improving and reducing medication requirements and provide lasting pain relief.

Persisting Pain After Knee Replacement Treatment In Delhi

 Tags >> Knee Pain After Knee Replacement Surgery, knee pain treatment in delhi

How Common Is Persisting Pain After Knee Replacement And Why Is It Important ?

Pain is the most important indication for joint replacement surgery and although surgery is successful in a vast majority of patients, some continue to have persisting pain. As per research evidence, approximately 9% after hip and 20% after knee replacement have an unfavourable pain outcome. 20% implies 1 in 5 patients, a significant number. Despite the high prevalence, the condition remains under acknowledged and can be rightly addressed as a silent epidemic.

Persistent pain not only has an adverse impact on the quality of life but often leaves patients confused or blaming themselves for the pain or the decision to go ahead with surgery. It can have an impact on mobility, general health, mood, sleep and lead to functional limitation with social isolation. When no obvious cause is found, the problem may be downplayed leading to the dissatisfaction, frustration, anger, tension or breakdown of the doctor–patient relationship, promoting doctor shopping. Somewhat ironically, persisting pain can sometimes be a consequence of surgery that was performed to alleviate pain.

Risk Factors For Persisting Pain After Knee Replacement

Persisting pain may have more than one reason, with a wide range of factors influencing the outcomes. It is important to know about these as some of them are modifiable. 

Some of the known risk factors include

• Poor mental Health including major depression, anxiety
• Catastrophization (Constant worrying and exaggerated negative orientation towards pain experience)
• Presence of other chronic pain conditions
• Surgical factors include infection, instability, implant loosening or failure, alignment problems with the implant (misalignment), soft-tissue impingement, nerve injury and extensor mechanism problems (patellar maltracking and non-resurfaced patella) 
• Severe preoperative pain. Some studies have linked poorly controlled pain after the operation to increased chance of developing chronic pain whereas other studies have found insufficient evidence. 
• High number of comorbidities (other medical problems). Pre-existing heart disease has been found to be an independent risk factor for pain at 5 years after knee replacement. The peripheral edema(swelling), sedentary lifestyle/ reduced engagement with physical therapy may contribute to increased pain levels. 
• Young age and female gender 

Pain Assessment

Most patients with persisting pain after the replacement surgery would return to the operating surgeon for a reassessment. Sometimes a second opinion from another surgeon is sought. Careful assessment in required to identify the problem and this involves detailed history, clinical examination (including the spine, hip and knee), psychological exploration, review of preoperative images & operative records, new investigations (serological, radiological and microbiological), assessing response to treatments and joint aspiration/ diagnostic injections if indicated. Sometimes despite extensive evaluation and best attempts using all modern technology at our disposal, the cause of pain cannot be identified. In such cases a trial of conservative therapy including pain relieving medications and physical therapy is often suggested. 

Management Of Persisting Knee Pain After Knee Replacement Surgery

Treatment of chronic pain after knee replacement is challenging. It requires a multidisciplinary team approach with input from orthopaedic surgeon, pain physician, physiotherapist, psychologist and many others. The aim is generally improvement in function and quality of life. Once the cause of persisting pain is known the treatment can be directed accordingly. 

Anatomically the cause of pain may be located 

• Extra articular (outside the knee joint at a distant site such as spine)
• Peri articular (around the joint) such as tendinitis (tenon problem), bursitis (inflammation of bursa) 
• Intra articular (inside the joint) such as joint instability, loosening of implant, issues related to size/type of implant, infection, osteolysis (loss of bone), kneecap problems 

How Can A Pain Physician Help ?

A pain specialist plays an important role in management of persistent pain and this includes

• Identifying the type /source of pain. This is especially relevant when issues with implant have been excluded and surgery is not required/not possible. Diagnostic joint injections can help differentiate whether the pain is coming from inside the joint or from an external source. If required, some joint fluid can be aspirated (removed) at the same time to evaluate for infection. Similar injections can be used to identify pain sources around the joint by trigger point injections, nerve blocks etc.
• Regulating pain medications. This is an essential component of overall management, best performed by professionals who are aware of all options and their limitations. Pain physicians are more familiar with use of stronger pain killers and some options such as capsaicin & Lidocaine patches as they use it more often. Sometimes small changes in medications can make a huge difference in the pain levels.
• Treating nerve pain. Nerve pain after knee replacement often goes unrecognized and may be responsible for persisting pain in approximately 6%-13% of patients. Typically, it presents with electrical shock like or burning sensation, numbness or altered sensitivity, although it can also present as an aching sensation associated with stiffness. Sometimes thickening of the nerve (neuromas) can be a source of persistent pain. 

Infrapatellar branch of the saphenous nerve. This is a small nerve running from the inner to the outer side of the knee below the kneecap. An injury to this nerve or a neuroma can be a common cause of persistent knee pain. Pain physicians can treat this successfully in an overwhelming majority of patients with nerve blocks, radiofrequency or cryoablation procedures. 

• Nerve blocks are offered if nerves are suspected to be the pain generator. A simple OPD performed procedure can often help identify the pain source and provide prolonged relief. 
• Pulsed Radiofrequency can be performed as a day case in an attempt to prolong the pain relief, in case the effect of the nerve block is short lasting. This is similar to nerve block but uses special needles and a radiofrequency machine to interfere with the pain signals being transmitted to the brain. 
• Cryoablation. This specialised technique involves application of cold to cause temporary disruption of the nerves ability to transmit pain signals without causing permanent nerve damage. 

• Other specialist interventions used to provide pain relief include

• Radiofrequency Ablation of Genicular nerves. Knee joint is supplied by many nerves and these are collectively addressed as genicular nerves. This procedure involves an initial diagnostic test whereby a small amount of local anaesthetic is injected close to these nerves. If this produces effective pain relief then one proceeds with the radiofrequency ablation. In radiofrequency ablation special types of radio waves are used to create a heat lesion around the nerves interrupting the transmission of pain signals to the brain. These nerves are approached with help of needles placed under x-ray and ultrasound guidance with no requirement for any surgical incisions. This is a safe, non-surgical procedure performed as a day case under local anaesthesia.
• Cooled Radiofrequency Ablation. Cooled Radiofrequency treatment is a minimally invasive treatment performed on a day care basis under local anaesthesia. The treatment aims to deactivate the nerves responsible for transmitting pain signals from the painful knee. It involves placing needles close to these nerves under x-ray or ultrasound guidance followed by heating of nerves to reduce the pain signals being transmitted. It differs from conventional Radiofrequency (described earlier) as it has water circulating through the device and can create a larger treatment area increasing the chances of success. Normal activities can generally be resumed soon after the procedure. 

• Spinal Injections – All nerves supplying the knee joint originate from the spine and interventions targeted on these (such as pulsed radio frequency of dorsal root ganglion) can help reduce the pain.
• Identifying your needs and directing you to other experienced professionals (such as physiotherapists, occupational therapists, psychologists) as required.