Chronic Back Pain: When Surgery is Not the Answer

For patients suffering from chronic back pain, surgery isn't always an option because of other health problems, previous surgery or a specific characteristic of their pain. However, neurosurgeons have other solutions besides surgery for eliminating chronic pain from everyday life.

Low back and related leg pain are the most common manifestations of chronic pain seen by neurosurgeons, who can also provide relief to patients suffering from cancer pain, phantom limb pain, complex regional pain syndromes, vascular pain in the arms and legs, pain caused by nerve damage as a result of trauma, and more. The feeling of pain is transferred throughout the body by nerves and the pain message originates in the spinal cord and the brain.

"Patients suffering from chronic pain often have damage to a nerve and that nerve is in a constant state of aggravation sending pain messages up and down its entire length," said Kim J. Burchiel, MD, an Oregon neurosurgeon who specializes in pain management. "Many times, the sciatic nerve in the lower back is damaged and causes chronic pain in the legs because that's where the nerve travels. Nerves can be damaged by injury, cancer treatment or a circulatory problem."

In some cases, painful nerve damage cannot be repaired. However, neurosurgeons currently have two techniques available to stop the pain message before it even leaves the spinal cord.

Spinal Cord Stimulation

Spinal cord stimulation is a pain management strategy that blocks pain messages by sending an electrical impulse to selected nerves in the spinal cord. Small electrodes are implanted in the spine and a generator is placed just under the patient's skin. A programmable transmitter is worn by the patient and communicates with the receiver via radio waves. The generator is programmed to allow a certain number, type and pattern of electrical impulses to be fired by the electrodes within a specific time frame. Patients can turn off the system throughout the day by turning off the power source and a neurosurgeon can adjust the amount, type and pattern of impulses by adjusting the generator.

Pain relief with a spinal cord stimulation system is almost instantaneous and patients normally experience a 50 to 70 percent reduction in pain. This often allows patients to significantly reduce the amount of pain medication they take, reducing side effects. The system can be removed if needed.

Intrathecal Pump Therapy

If pain is limited to the spine, an intrathecal pump can be used to deliver medication directly into the spinal fluid. Normally, for pain medication to reach the spinal fluid, it must be given in great quantities, causing significant side effects. An intrathecal pump, can be implanted under the skin in the side of the abdomen. The medication is delivered directly to the site of the pain and in much larger quantities than would be tolerated if taken orally.

The pump is refilled with medication through a syringe every four to 12 weeks and is programmed to deliver specific amounts of medication throughout the day. Neurosurgeons can reprogram the amount of medication that flows through the catheter using radio telemetry from a computer and electronic wand.

Approximately 65 percent of patients experience significant pain relief with intrathecal pumps. The pump can also be easily removed.

"These two techniques are not the first option for patients suffering from back pain because we are not 'fixing' the problem, just stopping the feeling of pain. A neurosurgeon needs to determine which option is best for each individual patient," said Kenneth A. Follett, MD, a neurosurgeon in Iowa and a specialist in pain management. "The advantage is that they can be tested in a trial mode, they are non-destructive to the tissue and they are reversible."

Pain Management Treatments for Arachnoiditis

Question: I just finished reading the and am left with another question. If this procedure "cooks" the nerves to gain pain relief, would it be a viable option for patients with arachnoiditis? And if not, is there a treatment for this horrific condition?
—Nashville, TN

Answer: Thanks for your question about arachnoiditis, which is a very painful condition that affects your spinal nerve roots. In my, I did say that it "cooks" the nerves. However, RF is used to treat joint pain, and arachnoiditis is a problem inside the spinal canal. That area and the nerves in the spinal canal can't be treated by RF, unfortunately.

Here's why radiofrequency rhizotomy won't work for arachnoiditis…
Arachnoiditis is an inflammation of one of the protective layers around the spinal canal. You can think of it as scar tissue that develops in the arachnoid lining. The lining can become inflamed due to repeated intervention on the spine: many surgeries can lead to scarring, for example. It can also develop because of certain spinal infections and perhaps because of chemicals in epidural steroid injections, especially if those chemicals get into the spinal fluid.

Arachnoiditis causes the nerve roots to clump together; this clumping can cause nerve pain, numbness, and tingling. Patients with arachnoiditis tend to have pain no matter what position they're in or what they're doing. Moving around or avoiding some movements won't bring pain relief because the pain is from the arachnoid lining inflammation, not from a joint.

Radiofrequency rhizotomy is most effective on joint pain. Patients who are good candidates for RF have pain when they're doing activities that stress the spine. RF blocks the nerves around the joint from sending pain signals to the brain, and that pain-free period usually lasts around one year. In that time, patients should learn postural correction and good body mechanics. RF gives patients the opportunity to get back their mobility and learn how to go about their daily lives with less pain.

Here's what may help with arachnoiditis…
Patients with arachnoiditis do have some pain management treatment options available, although there is no cure for this condition. Patients may try medications to find pain relief. Some options are:

• NSAIDs (non-steroidal anti-inflammatory drugs)
• anti-spasm drugs
• anti-convulsant drugs
• narcotic pain relievers

Some of these medications may be given with a That's a small device implanted under the skin that delivers medication directly to the inflamed area.

Patients may also try spinal cord stimulation. My colleague, Dr. Kowlowitz, has an here on SpineUniverse.

What is Degenerative Disc Disease?

(DDD) is typically associated with aging. As you age, your discs, like other joints in the body, can degenerate (break down) and become problematic: that's a natural part of growing older as your body deals with years of strain, overuse, and maybe even misuse. However, DDD can occur in people as young as 20, so sadly, youth doesn't always protect you from this disc-related condition. In fact, some patients may inherit a prematurely aging spine.

involves the intervertebral discs. Those are the pillow-like cushions between your vertebrae in your spine. They help your back carry weight and allow complex motions of the spine while maintaining stability. As you age, the discs can lose flexibility, elasticity, and shock absorbing characteristics. They also become thinner as they dehydrate. When all that happens, the discs change from a supple state that allows fluid movement to a stiff and rigid state that restricts your movement and causes pain.

If you have chronic back or , you may have . It commonly occurs in your low back (lumbar spine) or neck (cervical spine). Developing degenerative disc disease is a gradual process. As you can see in the illustration, there are even many stages and states your discs can go through as part of DDD. They can bulge, herniate, or thin. Because of disc changes, your vertebrae can be affected-you can see this in the illustration, too. For example, (osteophytes) can form as your spine tries to adjust to the intervertebral disc changes.

Osteoporosis, Low Back Pain, and Other Bone Disorders

he human skeleton is an intricate framework of 206 bones that give the body its structure and shape. These bones serve as armor for vital organs and soft tissue, a storehouse for minerals, and a birthplace for blood cells. Together, the bones act in concert with the muscles, ligaments, tendons, and other connective tissue to give humans an amazing range of movement. Most bone diseases are rare, but a few pose serious health problems. Osteoporosis, for example, is a progressive loss of bone substance that affects about 25 million Americans, mostly postmenopausal caucasian women. Osteoarthritis, the most common form of arthritis, is widespread among people over 40. (See Chapter 3, "Coping with Arthritis.") which often results from slipped vertebrae or disks, is the second most frequent cause of lost work for adults under 45 years of age. How Bones Are Structured Bones are made of inorganic salts--including calcium and phosphate--imbedded in collagen fibers. Though solid and seemingly completely formed, bones undergo constant renewal and change. The marrow, or soft center, of certain bones serves as a spawning ground for the many different cells that make up the blood. There are three types of bones--long, short, and flat or irregular. Long bones include the humerus, radius, and ulna of the arm; the femur, tibia, and fibula of the leg; and the phalanges, metacarpals, and metatarsals of the hand and foot. The tarsal in the foot and the carpal in the wrist are short bones. Flat bones can be found in the head and also include the ribs, breastbone, and collarbone. Irregular bones are located mostly in the spine; certain others are situated in the head.

Liver disease and diabetes mellitus.

Division of Gastroenterology and Hepatology, Jefferson Medical College, Philadelphia, Pennsylvania, USA.

The liver plays an important role in the pathogenesis of NIDDM. More importantly to the clinician is the myriad of situations in which the care of the patient with diabetes is affected by or causes an effect to the liver. Patients with underlying diabetes can present with abnormal liver chemistries, which can represent findings as benign as hepatic steatosis or as severe as cirrhosis of the liver. The medications used to treat diabetes can be potent hepatotoxins. Several primary liver diseases are associated with increased risk of the development of diabetes. Epidemiologically, there seems to be a correlation between diabetes mellitus, the most common endocrinologic disease, and hepatitis C, the leading cause of chronic liver disease in the United States. In the management of end-stage liver disease, both cirrhosis and orthotopic liver transplantation promote glucose intolerance and diabetes in a number of patients through various mechanisms including insulin resistance and impaired insulin secretion. These relationships highlight both the importance of the liver as an endocrine organ and the multisystem aspects of the patient with diabetes mellitus.

The multifaceted associations of hepatobiliary disease and diabetes.

Southside Endocrinology, Birmingham, Alabama 35205, USA.

OBJECTIVE: To investigate the association of diabetes and hepatobiliary disease. METHODS: We performed a MEDLINE search of the English-language literature published between January 1980 and January 2007 for studies in which diabetes was associated with liver diseases. RESULTS: Through its association with the insulin resistance syndrome, type 2 diabetes is associated with nonalcoholic fatty liver disease, nonalcoholic steatohepatitis (NASH), NASH-cirrhosis, and NASH-cirrhosis-related hepatocellular carcinoma. Because of the association with insulin resistance, insulin sensitizers may slow or even arrest the progress of these diseases. Type 2 but not type 1 diabetes is associated with hepatitis C virus but not hepatitis B viral infection. This association is likely due to hepatitis C viral infection of the pancreatic beta-cells. Early detection and antiviral therapy can decelerate the development of diabetes. Type 1 diabetes is associated with hemochromatosis and autoimmune hepatitis. Because of the presence of autonomic neuropathy, cholelithiasis but not cholecystitis is more common in patients with diabetes than in the general population. Therefore, asymptomatic cholelithiasis in patients with diabetes no longer warrants a cholecystectomy. In patients with advanced liver disease of any cause, insulin resistance and diabetes have an increased frequency of occurrence and can be reversed with liver transplantation. Rarely, medications used to treat type 2 diabetes have been associated with drug-induced hepatitis. CONCLUSION: The prevalence of hepatobiliary diseases is increased in patients with diabetes. Early recognition and treatment of these conditions can prevent, stabilize, or even reverse hepatic damage and prevent the development of hepatic carcinoma and liver failure.

Hepatobiliary Disease in Type 2 Diabetes Mellitus

Diabetes mellitus is the fifth leading cause of death in the United States; 17 million people are affected. Liver disease is one of the leading causes of death in persons with type 2 diabetes. The standardized mortality rate for death from liver disease is greater than that for cardiovascular disease. The spectrum of liver disease in type 2 diabetes ranges from nonalcoholic fatty liver disease to cirrhosis and hepatocellular carcinoma. The incidence of hepatitis C and acute liver failure is also increased. Nonalcoholic fatty liver disease is now considered part of the metabolic syndrome, and, with alcohol and hepatitis C, is the most common cause of chronic liver disease in the United States. Weight reduction and exercise are the mainstays of treatment for nonalcoholic fatty liver disease, but there are promising results with the new thiazolidinediones (pioglitazone and rosiglitazone) as well as metformin and 3-hydroxy-3-methylglutaryl coenzyme A inhibitors.

Diabetes Mellitus, Type 2

Diabetes mellitus is a chronic disease that requires long-term medical attention both to limit the development of its devastating complications and to manage them when they do occur. It is a disproportionately expensive disease; in 2002, the per-capita cost of healthcare was $13,243 for people with diabetes, while it was $2560 for those without diabetes.

This article focuses on the ED evaluation and treatment of the acute and chronic complications of diabetes other than those directly associated with hypoglycemia and severe metabolic disturbances such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). (Please see , , and for more information on these disorders.)

Pathophysiology

The 2 basic types of diabetes mellitus are type 1 and type 2. Type 1 diabetes mellitus is reviewed more fully in a separate eMedicine article (see).

Type 2 diabetes mellitus was once called adult-onset diabetes. Now, because of the epidemic of obesity and inactivity in children, type 2 diabetes mellitus is occurring at younger and younger ages. Although type 2 diabetes mellitus typically affects individuals older than 40 years, it has been diagnosed in children as young as 2 years of age who have a family history of diabetes.

Type 2 diabetes is characterized by peripheral insulin resistance with an insulin-secretory defect that varies in severity. For type 2 diabetes mellitus to develop, both defects must exist: all overweight individuals have insulin resistance, but only those with an inability to increase beta-cell production of insulin develop diabetes. In the progression from normal glucose tolerance to abnormal glucose tolerance, postprandial glucose levels first increase. Eventually, fasting hyperglycemia develops as inhibition of hepatic gluconeogenesis declines.

About 90% of patients who develop type 2 diabetes mellitus are obese. Because patients with type 2 diabetes mellitus retain the ability to secrete some endogenous insulin, those who are taking insulin generally do not develop DKA if it is stopped. Therefore, they are considered to require insulin but not to depend on insulin. Moreover, patients with type 2 diabetes mellitus often do not need treatment with oral antidiabetic medication or insulin if they lose weight or stop eating.

Maturity-onset diabetes of the young (MODY) is a form of type 2 diabetes mellitus that affects many generations in the same family with an onset in individuals younger than 25 years. Several types exist. Some of the genes responsible can be detected by using commercially available assays.

(GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. GDM is a complication in approximately 4% of all pregnancies in the United States, though the rates may be 1-14% depending on the population studied. Untreated GDM can lead to fetal macrosomia, hypoglycemia, hypocalcemia, and hyperbilirubinemia. In addition, mothers with GDM have increased rates of cesarean delivery and chronic hypertension. To screen for GDM, a 50-g glucose screening test should be done at 24-28 weeks of gestation. This is followed by a 100-g, 3-hour oral glucose tolerance test if the patient's plasma glucose concentration at 1 hour after screening is greater than 140 mg/dL.

Analyse the Size of the World's Breast Cancer Disease and Therapy Market.

Disease and Therapy Reviews were developed to provide a basic understanding of the key facts about a disease and market in a quick, easy-to-read format. These reports are prepared by the senior market research team of Timely Data Resources. Each Disease and Therapy Review provides a concise analysis of the most important information about a particular disease, its treatment, and the market opportunities. Reports begin with an overview of the condition, and also contain tables that the available worldwide incidence and prevalence data for the condition, a review of current diagnosis strategies and treatment options, general information about the market size, and information about important market trends.

The data contained in these reports comes from key industry secondary data sources, such as the Incidence and Prevalence Database, and Lange's Current Medical Diagnosis and Treatment. This information is supplemented by reviews of analyst reports, company reports, and medical websites. Sources and references are provided.

Breast Cancer with von Recklinghausen's Disease. Review of the Literature in Japan.

Accession number;02A0544546

Title;Breast Cancer with von Recklinghausen's Disease. Review of the Literature in Japan.

Author;ONO TAKU(Mie Univ.) IRIYAMA TAKUHEI(Mie Univ.) KOIDE AKIRA(Mie Univ.) TONOUCHI HITOSHI(Mie Univ.) MIKI CHIKAO(Mie Univ.) KUSUNOKI MASATO(Mie Univ.) SHIRAISHI TAIZO(Mie Univ., Sch. of Med.)

Journal Title;Japanese Journal of Cancer Clinics

Journal Code:Z0928A

ISSN:0021-4949

VOL.48;NO.5;PAGE.275-278(2002)

Figure&Table&Reference;FIG.4, TBL.1, REF.6

Pub. Country;Japan

Language;Japanese

Abstract;A 71-year-old woman was admitted to our hospital for diagnosis of her left breast mass. She had a history of multiple neurofibromas and cafe-au-lait spots over the whole body since 30 years of age. On admission, the tumor was located at the upper outer quadrant of her left breast. Mammography, ultrasonography and MRI were consistent with a diagnosis of breast cancer. An excisional biopsy revealed the tumor to be breast cancer and left modified radical mastectomy (Bt+Ax) was performed. Histopathologically the breast tumor was invasive ductal carcinoma (scirrhous) without lymph node involvement. Postoperative staging was pT1cN0M0, stage I, according to the TNM classification. The tumor was negative for estrogen receptor and positive for progesterone receptor. The postoperative course was uneventful, and she is currently healthy without recurrent disease. (author abst.)