Failed Spinal Pain Management
What are the causes of Spinal Failed Pain Management?
Patients with degeneration of the spine are very frequently referred for Chronic Pain Management because their surgeon may not be able to identify the cause of the pain or the risk of conventional surgery outweighs the likely benefit. Since 1990 we have used Aware State Surgery to diagnose and precisely target treatment for such patients. This has taught us a great deal about the true sources of such pain. Chronic Pain Management centres use MRI /CAT scans and clinical examination to attempt to source the pain and then inject a number of structures to reduce the presumed inflammation and localise the pain source. Treatment takes the form of repeat injections, nerve ablations or instillation of irritants to thicken ligaments in the expectation that these will stabilise a joint. The number of repeat injections feasible is limited and have side effects. The cause of failures in patients seen in the Spinal Foundation is that the source of the pain has not been adequately or definitively treated.
What are the symptoms?
These include significant back or neck pain, arm or sacral, buttock or leg pain, weakness, numbness, spasm, Piriformis syndrome, boiling water or oil or iced water passing down the limb. These symptoms are so severe that patients state that massive doses of pain killers, antidepressants and anti-epileptic agents fail to do more that “take the top off the pain”
What actually causes the pain?
The perceived wisdom is that back pain in particular arises from the disc itself. Therefore it is thought that over time, the pain will gradually decreases as the degenerating disc stops causing pain. However aware state endoscopy allows us to see where the pain is arising. This shows us that only 11% of patients have symptoms arising from the disc itself. The medial border of the nerve when palpated is the actual cause of the back pain and the core of the nerve is the cause of the referred pain down the arm or leg.
The pain may arise from multiple origins. The pain may derive from damage, irritation or pressure upon nerves within and around the spinal area. There are actually few nerves in the disc itself, but any injury to the disc can cause these nerves or those in the Posterior Longitudinal Ligament to become sensitised and cause pain. In addition, the disc in some patients may contain inflammatory proteins which can leak and irritate the exiting nerve in the foramen or the descending nerves in the spinal canal at that level causing pain for the sufferer. Moreover, when the disc becomes damaged or worn down loosing tension and height, it can permit micro-movements of the vertebrae which can lead to painful reflex muscle spasms because the facet joints and ligaments in the foramen impact upon the nerve and irritate or compress the nerve causing back and leg pain.
How is the condition conventionally diagnosed?
MRI & CAT scans enable the Pain Management Consultant to image good anatomical detail and definition of pathological changes. But because pathology becomes prevalent with increasing age even in patients without symptoms MRI images cannot be used as the sole diagnostic tool. This means that clinical examination and consideration of the patient’s history must also be taken into account. However the loss of disc height and dehydration which results from disc degeneration can result in exiting nerve roots becoming nipped by the vertebrae and so causing irritation and pain such changes may be evident at several disc levels in the same patient. The distribution of the pain is supposed to guide the Pain Management Consultant as to the disc level causing the symptoms but these distribution patterns may be in error for instance in the lumbar spine in excess of 15% of patients. So a more accurate method of diagnosis is called for hence our development of aware state diagnosis.
What is wrong with conventional diagnosis?
Clinical examination as a means of identifying the causal segment is unreliable, although the use of weight bearing X-rays in flexion and extension, both standing and sitting, does demonstrate the way in which each patient individually moves their back. MRI and CAT scans demonstrate the presence of pathology e.g. degenerate disc bulges etc, as well as overgrown facet joints, bone spurs and swelling of the nerve. However this can grossly underestimate the presence of the essential tethering of the nerve which is causal.
How is the condition treated by Pain Management Consultants?
In many cases management of the condition is encouraged using pain medications, physiotherapy, osteopathy and chiropractic techniques including ultrasound and electrical stimulation. The use of these thus enables the sufferer to engage in exercise regimes and rehabilitation. The aim of the treatment is to re-train the body to adopt better posture and optimised intersegmental load transmission. Overall, management of the condition seeks to minimise or prevent the application of excessive stress upon the disc through better ergonomics and posture.
As symptoms persist then increased medication and injections of steroid are employed to reduce pain and inflammation of the nerve using facet joint injections, root blocks or epidural injections. On occasions the Pain Management Consultant attempts to stabilise the joint by using irritant sugar like injections to cause scarring around the joints and so reduce their movements and lessen the patient’s pain.
Over recent years there has been a fashion to refer patients to coping courses and Cognitive Behavioural Therapy. To enter such a course the patient has to deem that they have no interest in finding a definitive solution to their problems. (Where else in joint degeneration for instance, where we clearly know the cause of the pain, do we employ such an approach.)
Where all else fails then certain patients will be referred for a Dorsal Column Stimulator to block the upward migration of pain stimuli to the brain. This system only works in 50% of carefully selected cases and begins to fail after about 5 years.
Why is aware state diagnosis better?
Conventionally the cause of the pain is diagnosed from the pattern of the pain and MRI scans but these techniques are inaccurate. However, the causal pain sources can now be accurately defined through aware state surgical examination, during which the surgeon seeks to replicate the pain by spinal probing. When this provokes a response, the patient, who is protected by circulating intravenous pain killers, offers feedback to the surgeon regarding the type and distribution of the pain produced. Sometimes, when the response is only partially akin to the presenting symptoms or when the response is at more than one spinal level, additional techniques are used to determine the relative importance of each site in the totality of the patient’s pain and condition. This defines whether the operated disc or an additional disc level is the cause of the pain
Can the diagnosis be confirmed?
This can be achieved by the use of spinal probing of the nerve, contents of the foramen and epidural space to determine contributory levels. Hydraulic discography to re-tension the disc and ligaments and restore disc height at the suspected level can be used to determine levels causing compression of the nerve in the epidural space or foramen. These techniques which include the injection of an X-ray visible liquid into the disc, open up the ‘Foramen’ or spinal spaces and effectively liberate the nerve. If this temporarily reverses the symptoms, then the specific causal segment has been identified without having to open the back at several levels. This will demonstrate whether original surgery addressed the causal segment in the first instance or whether it failed to correct the effects of the pathology at the operated level. Where pain rather than compression is the predominant symptoms then insertion of anaesthetic or steroid in to the disc (Differential Discography) can be used to distinguish the role played by each level in the symptom complex.
Is there a better alternative treatment to Chronic Pain Management?
Having determined the causal level, Transforaminal Endoscopic Lumbar Decompression & Foraminoplasty (ELDF) enables the surgeon to ‘walk up’ the exiting nerve root, make space in the foramen and the spine, ‘liberate’ the nerve and remove the factors causing the pain. The great benefit of ELDF is that it enables the surgeon to treat the condition specifically, precisely and with minimum collateral damage to tissues, reduced risk to the patient and enhanced long-term outcome.
Are there additional benefits?
After liberating the exiting nerve, the water jacket and nerves within the spinal canal as necessary, Laser, RF or other high energy sources can be used to remove scarring sufficiently to allow the nerve to recover its natural mobility and avoid further irritation. This also seals the operative bed and reduces clotting around the nerve so that the patient is mobilised within a few hours, minimising the risk of re-tethering. In cases following segmental fusion or total disc replacement where the implant is causing the posterior wall of the disc to bulge and compress the nerve, the nerve can first be mobilised and displaced, the false bulge can then be removed and the nerve restored to its natural position.
What proof is there of successful treatment?
Aware State Diagnosis and ELDF Surgery are delivering encouraging results in well over 80% of cases treated when reviewed 2-4 years later, and 70% at 10 years later. In a current study of Failed Fusion Surgery the success rate has been 80% at three years.