Category Archives: Treatments

Treatments

Laminectomy

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A lumbar laminectomy, or lumbar decompression, is performed to treat spinal stenosis, a narrowing of the spinal canal that puts pressure on the nerves in the lower back, which causes symptoms in nearly 500,000 Americans over the age of 50. Used to manage related conditions involving deformities of the vertebrae, such as spondylolisthesis or scoliosis, a transforaminal lumbar interbody fusion (TLIF) is an innovative, sometimes safer, more efficient alternative to other anterior and posterior-approach fusion procedures. Both conditions cause pain and weakness in the lower back and legs, leading to walking difficulty in many patients. The conditions occur as people age because ligaments around the spine thicken and the discs, or cushions, between the vertebrae start to deteriorate.

During the surgery, an incision will be made in the patient’s back, but surgeons will approach the spine from the side, minimizing the nerve manipulation required to access the vertebrae, discs and nerves. They will remove bone and ligament from the spine to open the spinal canal and relieve pressure on the nerve roots which has been caused by stenosis.

Next, the surgeons will perform a TLIF to fuse the spine where one vertebra has slipped forward onto the vertebra below it. (This generally occurs with spondylolisthesis, but in the case of the webcast patient it has been caused by complications from scoliosis.) Some vertebral bone will be removed to reduce nerve exposure, and then the pain-causing disc will be taken out. A spacer and bone from the patient’s extracted vertebra will then be manipulated to fuse the two surrounding vertebrae together. Finally, rods and screws will be put in place to support the spine over the next several months as bone generates and connects to the vertebra.

Most patients are out of bed and walking the morning after surgery, and typically spend three to five days in the hospital. After discharge, they require three to six months of outpatient rehabilitation, but are able to care for themselves at home with the exception of heavy lifting. Generally after six months, patients are able to do any type of activity excluding those that pose high physical risk

Treatments

Nutrition important in the care of patients with chronic pain

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Nutrition important in the care of patients with chronic pain, and recommended they take essential fatty acids (omega-3 and omega-6 fatty acids) and use olive oil in cooking.

Best avoided, are inflammation-inducing fats such as corn oil and margarine.

Some patients may benefit from switching from coffee to green tea, and avoidance of any food allergens such as wheat, corn, dairy products, and red meat.

Also recommended nonpharmacologic approaches for chronic pain such as cognitive therapy and mind-body approaches — meditation and yoga — as well as exercise and physical therapy.

Treatments

Prolotherapy

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Nonsurgical reconstructive therapy ó also referred to as “prolotherapy” or “proliferative therapy” ó evolved out of a treatment pioneered by H. I. Biegeleisen called “sclerotherapy,” which was originally (and still is) used to treat varicose veins. Prolotherapy involves the injection of an “irritant” solution into the area where ligaments are weak and/or damaged. Over the next few days, cells called “macrophages,” literally big eaters, are attracted into the area by the presence of this irritant solution. Once they arrive, these macrophages pick up the irritant solution and carry it away for disposal (they are the garbage men of the body). As the macrophages are finishing their job, the body sends in “fibroblasts,” literally connective tissue builders, to lay down fibrous tissue wherever they detect damage to connective tissue such as ligaments.

Of course, prolotherapy can be used on any weakened ligament or tendon in the body. The determining factor is the doctor’s skill in introducing the needle to exactly the right locaiton. Knees, hips, elbows, shoulders, in fact every joint in the body can develop problems which can be addressed with prolotherapy.

The doctor’s job is to introduce the irritant solution into the places where ligaments are weak or damaged. If properly placed, this causes the repair of ligaments. This new supporting structure pulls the vertebrae back into close relationship with each other correcting instability and therefore putting an end to inflammation. When inflammation disappears, so does pain! Stability is restored along with mobility.

A single treatment with prolotherapy will cost around $200. Usually not more than ten to fifteen treatments are necessary to bring a typical back pain or neck pain syndrome under control.

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The term “prolotherapy” is a derivation of “proliferative injection therapy” and is also known as sclerotherapy. The practice of prolotherapy is used by doctors of osteopathy and other physicians to treat a number of different types of chronic pain. Prolotherapy consists of a series of intraligamentous and intratendinous injections of solutions in trigger points near the pained area to induce the proliferation of new cells.

Proponents of this treatment suggest that looseness in the supporting ligaments and tendons around the joints causes the pain, inducing the muscles to contract against the ligament and irritate the nerve endings. The physicians using this treatment method for low back pain believe the ligament laxity to be concentrated in the sacroiliac joint. During a physical examination a physician will identify trigger points generally in the muscles overlying the sacroiliac joint. The physician then may inject proliferant substances into the supporting ligament and tendon tissue.

The practice of sclerotherapy or prolotherapy to produce dense fibrous tissue in an effort to strengthen the attachment of ligaments and tendons is not new. Forms of this therapy apparently date back to Hippocrates, however, prolotherapy recently found favor with osteopaths following the teachings of George Hackett, MD, who in 1939 began using a local injectable irritant to initiate the healing process. It was Dr. Hackett who coined the term “prolotherapy” because sclerotherapy implied scar formation, which, according to Dr. Hackett, did not occur with prolotherapy. Nevertheless, both processes use trigger point injections to form new cells in an effort to support weakened muscles. Although the method has been in use for some time, to date there is no strong clinical evidence to support the efficacy of the treatment.

Prolotherapy injections are intended to mimic the natural healing process by causing an influx of fibroblasts that synthesize collagen at the injection site, leading to the formation of new ligament and tendon tissue. The newly produced collagen is intended to support the injured or loosened ligaments, creating a more stable and strong muscle base, in the process, alleviating pain.

There are three classes of proliferant solutions used to initiate inflammation: chemical irritants (e.g. phenol), osmotic shock agents (e.g. hypertonic dextrose and glycerin), and chemotactic agents (e.g. morrhuate sodium, a fatty acid derivative of cod liver oil). The two studies supplied by the requestor used a dextrose-glycerine-phenol solution.

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What is known about prolotherapy outcomes for back pain?
Reported success rates range from 80%-90% when performed by a physician trained in the prolotherapy procedure. Many of these reports are based on anecdotal evidence from the physicians themselves. Studies have not yet connected positive outcomes for back pain and healing to prolotherapy.

The anecdotal reports suggest improvements such as:

* Reduction or elimination of back pain
* Increased strength of the ligament, tendon or joint capsule
* Reduced recurrence of injury to the treated site
* Improved or return to normal function

Factors that may be key for a successful outcome include:

* Proper diagnosis of the location of the sprain or strain
* Willingness of the patient to complete follow-up therapy
* Clinical skill of the physician in performing the injection

Finally, it is important to note that nobody knows exactly what happens in prolotherapy. There is no objective medical evidence, and no histology has been published as to what goes on when injection is placed into the painful soft tissues.

Treatments

Non-Surgical Ligament Reconstruction

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Is it impossible to have a healthcare system that is driven by profits to also be focused on inexpensive and permanent solutions?

When reports on ESPN this week revealed that some US Olympic Ski Team members left the country and went where they could use what is considered ìalternativeî treatments for relief of their injuries and pains, it once again elevated the question of why Medical insurance and workmans comp in the U.S. wonít cover procedures like that.

In many cases, these treatments prove markedly more effective than traditional therapies. The treatment called prolotherapy, used to strengthen weakened ligaments, is widely accepted and used in other countries with national health care systems, including Canada.
Prolotherapy has been considered ìinvestigationalî for 70 years by the Medicare board; insurance companies will cover it when Medicare decides to cover it.

The practice of prolotherapy is used by both medical doctors (MDís) and osteopathic physicians (DOís), such as Dr. Jo Ann Douglas of Colorado Osteopathic & Sports Medicine, to treat several different types of chronic pain. It may be the latest alternative therapy to hit the sports medicine scene.

Doctors are using the treatment successfully for tennis elbow, Achilles tendonitis, patellar tendonitis, back problems, and other common sports injuries. Prolotherapy is also effective in cases of arthritis, fibromyalgia, whiplash, and chronic pain in the neck, back, shoulder, ankle, and sciatica. It relieves disk problems unresponsive to more conservative treatment.

According to Dr. Douglas, there are approximately 600 licensed physicians in the U.S. that perform this procedure. ìProlotherapy treats the cause of the problem; that is, instability. We inject a solution into the ligament or tendon where it attaches to the bone, which stimulates the bodyís own healing response by creating blood flow to the area, recruiting immune system cells that clean the area, and construction cells (fibroblasts) that rebuild the tissues.

ìThis is the exact opposite of the current standard of care, which treats pain and inflammation with anti-inflammatories. Prolotherapy promotes the bodyís inflammatory process so that the body can heal itself. In most cases, commonly prescribed anti-inflammatory medications and drastic measures like surgery or joint replacement may not help, and often hinder or even prevent the healing process.î

According to Dr. Douglas, ìmany patients do not understand why insurance companies will not reimburse for this technique. In many cases it may save the patient from chronic pain management or surgery, which would save money for insurance companies and Medicare as well as treat the cause of the problem for the patient.î

The federal government hears issues from large special interest groups loud and clear. The drug companies, surgeons and chiropractors are heard; whereby the 600 doctors who perform prolotherapy are a very small voice in the healthcare system. In fact, they were not heard at all until Olympic Athletes went to Mexico to get prolotherapy.
Vioxx was covered by insurance, even though it had risks. Surgeons continually change their methods and the new surgery techniques are covered by Medicare and insurances. Secondly, surgeons use cortisone for temporary relief even though cortisone has been proven to cause ligament and tendon deterioration, which may only lead to surgery.
X-rays and MRIís do not always reveal injuries. The number of qualified doctors specifically trained to administer prolotherapy is growing. There are training programs at medical schools now that teach this technique, including how to properly diagnose these injuries.

Although medical doctors who do prolotherapy will continue to be few until more evidence accumulates, osteopaths like Dr. Douglas have a long track record with the procedure.

Each injection treatment varies in cost, ranging from less than $100 for smaller joints to several hundred dollars for larger or more complex joints such as those in the neck and back. Most people need 4-6 treatments ó usually administered in a series of injections three weeks apart ó to stabilize the joint

WHY ISN’T PROLOTHERAPY COVERED BY MEDICAL INSURERS?
Modern allopathic medical research demands that therapies be proven by double-blind methods. This means that neither the patient nor the physician know which therapy is used. For medications, the pills can easily be made to look alike, and a sugar pill used as a placebo is presumed to have no therapeutic value.

For procedures like prolotherapy and most surgeries, there is no adequate placebo. Cortisone cannot be used as a placebo because cortisone can only be injected 3 times a year; typically, prolotherapy requires 4-6 treatments.

The Medicare board wants more data to show the effectiveness of prolotherapy. Drug companies pay for research when it is profitable. They are unlikely to pay for research on prolotherapy because this would not be a profitable venture. In fact, drug companies and surgeons would profit less if prolotherapy would be more widely used, since fewer people would need pain medication and they could avoid expensive surgeries or complications from surgeries.

Dr. Douglas can be contacted through her Website (www.mycodo.com) which further explains this procedure.

Jo Ann Douglas, M.S,D.O.
Board Certified by the American Osteopathic Board of Neuromusculoskeletal Medicine
Colorado Osteopathic & Sports Medicine

Medications, Treatments

Botulinum Toxin A

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In another study exploring nonsystemic treatment modalities, Jabbari B. found that patients with chronic low back pain may respond to injections of botulinum toxin A. In a prospective study involving 75 patients, patients received paraspinal intramuscular injections at baseline and then at recurrence of pain, typically at 4, 8, and 12 months after the initial therapy. Although a modest number of patients reported significant improvement, 56% at 3 weeks and 54% at 2 months, the investigators did note that among initial responders, 90% responded to subsequent treatments. Among the patients overall, there were 3 adverse events — 2 transient flulike reactions and 1 episode of acute root pain after the injection.

Treatments

Intrathecal Pump

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An Intrathecal Pump (“Spinal Morphine Pump”)? is a specialized device, which delivers concentrated amounts of medication(s) into spinal cord area via a small catheter (tubing).

Am I a candidate for Intrathecal Pump Implant

Currently at TPM, Intrathecal Pump is offered to patients with :

Chronic and severe pain, who have not adequately responded to other treatment modalities. Some of the examples are failed back syndrome, cancer pain, RSD. These patients receive infusion of painkillers such as Morphine or Dilaudid.

Spastic disorders such as Multiple Sclerosis, Spinal Cord Injury – associated with muscle spasms. These patients receive infusion of an antispasmodic medication called Baclofen.

What is the purpose of it?

This device delivers concentrated amounts of medication into spinal cord area allowing the patient to decrease or eliminate the need for oral medications. It delivers medication around the clock, thus eliminating or minimizing breakthrough pain and/or other symptoms.

How long does the procedure take?

It is done in two stages. In the first stage, a single injection is made to assess effectiveness and screen for unwanted side effects. If this trial is successful in relieving symptoms, then the permanent device is placed under the skin. The patients have to meet certain other screening criteria before implanting the pump.

Will the procedure hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

Will I be “put out” for this procedure?

The placement of the tubing is done under local anesthesia with patients mildly sedated. The amount of sedation given generally depends upon the patient tolerance.

For the pump placement, patients are given stronger intravenous sedation and analgesia.

How is the procedure performed?

It is done with the patient lying on the side. Sometimes the tubing is placed with the patient sitting up. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needle for inserting the tubing.

Where is the tubing inserted? Where is the pump placed?

Tubing is inserted in the midline at the lower back. The pump is then placed on the side of the abdomen.

What should I expect after the procedure?

If the procedure is successful, you may feel that your pain may be controlled or quite less. The pump is adjusted electronically to deliver adequate amount of medication.

What should I do after the procedure?

This procedure is normally a day-procedure and patients are kept overnight for observation and pump adjustment.

How long will the pumps last?

The medication contained within the pump will last about 1 to 3 months depending upon the concentration and amount infused. It is then refilled via a tiny needle inserted into the pump chamber. This is done in the office or at your home and it takes only a few minutes.

The batteries in the pump may last 3 to 5 years depending upon the usage. The batteries can not be replaced or recharged. The pump is replaced at that time.

Will the Intrathecal Pump Implant (“Spinal Morphine Pump”) help me?

It is very difficult to predict if the procedure will indeed help you or not. For that reason a trial is carried out to determine if a permanent device (pump) will be effective to relieve your pain or not.

What are the risks and side effects?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. Please discuss your concerns with your physician.

Who should not have this procedure?

If you are on a blood thinning medication (e.g. CoumadinÆ), or if you have an active infection going on, you should not have the procedure. The patients also have to meet certain other screening criteria before implanting the pump.

Additional information?

More detailed information is available from the manufacturer of this device. At the time of consultation you will receive a Synchromed™ Infusion System Patient Education Booklet. Additional information is also available at the Medtronics™ Web Site @ www.medtronics.com/neuro/apt/faq.html.

Treatments

Lethal injections

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While I sympatize greatly for Carol Weihrer’s pain and suffering during surgery, I hope she will not pursue a totally different concern for any ‘pain’ possibly involved with death sentences. The pain of the condemned, if any, is their dues to pay for their crime. The concern for the two situations is totally opposite.