Surgery - Ask Dr. P - The Pain Doc

An Often Neglected Approach to Self-Treat Disc Bulging

by Pain Doc | Aug 27, 2013 | Uncategorized

Disc bulges, or herniations, come in a variety of presentations. They usually are limited to the lower lumbar spine (L3/4 to L5/S1) and the neck (C4/5-C7/T1). In taking the medical history of patients suffering from disc bulges, there is usually a history of a sedentary office job that requires sitting long hours; a previous injury like a sports, work, or car accident injury; and in rare cases, no significant event or habit that could explain how the disc bulge occurred. In fact, there are studies that indicate that degenerative disc disease, which can include varying degrees of disc bulging, can be hereditary.

A common theoretical model for degenerative discs goes like this: something happens that causes the disc to bear excessive weight, which over time forces fluid out of the disc causing it to dessicate. The outer fibers responsible for keeping the disc intact and the nucleus in place weaken, allowing the center nucleus to bulge outwards. Chiropractors often attribute this scenario to subtle misalignments in the vertebrae caused by minor trauma, prolonged sitting and insufficient support from the abdominal muscles and lumbar muscles. Normally the disc should support 80% of the weight above it and the facet joints (the smaller joints behind the disc) about 20%. But if a physical event changes the orientation of the vertebra, it can force the disc to support 90-100% of the weight, accelerating its demise.

Other models reference calcification of the vertebral end plates,the surfaces of the vertebrae above and below the disc, which then prohibits capillaries from feeding nutrients to the disc causing it to die. Bone calcifies in response to trauma; vertebral end plates can sustain “micro-compression” injuries from activities that place a heavy, axial load (perpendicular) to the disc. Examples include basketball, gymnastics, running, and parachuting.

An acute herniated disc can be extremely debilitating, as it tends to last a lot longer than a typical sprain/strain injury. It hurts, limits movement, can make sleep difficult and restricts you from work and physical activity. If it presses on a nerve root it can send shooting pains down the buttock and leg and cause numbness and weakness. The general recommendation for most cases of non-emergency disc herniations is to manage the pain using physiotherapy (ice, heat, muscle stim, laser), do physical therapy including stretching and strengthening exercises and wait for the disc bulge to self-resolve in 2-3 weeks. Once it heals and the inflammation goes down, the pain usually goes down as well.

If your disc herniation is pressing on a nerve root, the disc may shrink as it heals, removing pressure from the nerve. This is the best scenario obviously, as you avoid surgery and get your life back. At this point, it is prudent to avoid activity that risks re-injury (heavy lifting while turning torso) and do everything you can to strengthen your core muscles and spinal muscles to guard against re-injury. Functional exercises should be emphasized, for this purpose.

The thing that can dramatically increase the chances of full recovery without surgery is healing your insides– reduce systemic inflammation by getting down to a healthy weight and maintaining it; stop smoking, avoid alcohol as best you can, reduce stress, reduce insulin levels, maintain normal blood glucose levels, ensure that your gut micro flora is in balance, and get adequate sleep every day. Eat healthy, decrease your portions, and drink enough water to stay hydrated throughout the day. Exercise consistently, 20-40 minutes each time. This is what a healthy lifestyle routine is made of.

People who are in pain usually are concerned about knocking down the pain first, and ignore the health of the rest of their body. Remember, your entire body is essentially a colony of specialized cells that are interconnected via the bloodstream, nerves, and hormones. When one area is injured, the rest can come to its aid.

If you suffer from disc herniations, joint pain or other musculoskeletal form of pain and are overweight, pay more attention to getting yourself healthy inside; it’s the often ignored self-help method to treat pain.

Article on Laser Spine Institute

by Pain Doc | Jul 12, 2011 | Uncategorized

For many individuals searching the internet for solutions to their lower back pain, Laser Spine Institute, or LSI is a familiar name. This is a network of physician-owned spinal surgery centers that rely heavily on Google and other internet search engines to obtain their clients. Their chosen niche is minimally invasive laser surgery, where the physician makes a tiny incision in the patients back and inserts a fiber optic laser and tiny camera to ablate, or burn off nerve endings around an offending spinal disc. Then, they may burn off part of the disc that is compressing nerve tissue. Through their marketing, LSI suggests that patients can be back on their feet within hours of the surgery.

However, the center is attracting a lot of attention in the malpractice arena. And, respected spinal surgeons not affiliated with LSI say that such a methodology is already available through standard medical care for spinal disc problems and cost much less; although instead of lasers, radiofrequency devices are used.

According to an article in the May 2011 edition of Bloomberg magazine, author David Armstrong reports:

Laser Spine and its competitors, part of a boom in outpatient clinics operated by entrepreneurial physicians, sell a high-tech version of procedures that have been around for years — despite a lack of independent research to show that their variations lead to better outcomes. The company commands higher prices than laser-less rivals, driving up the cost of health care. Its number of malpractice claims per 1,000 surgeries is several times the rate for all U.S. outpatient surgery centers, based on insurance industry data.

…There’s little government oversight regarding which doctors can do spine surgery — all they need is a medical license, whether their training is in orthopedics, foot surgery or pediatrics…

…Doctor-investors may lower their standards for deciding when to operate, according to researchers from the University of Michigan in a study in the journal Health Affairs last year. Looking at five common procedures at Florida surgery centers, they found that once doctors became investors, the number of surgeries they performed increased by 87 percent.

So, if you are considering spinal surgery and run across LSI, make sure to do your due diligence. Being in acute pain can make one vulnerable to lofty marketing, as there is an urgency to make a fast decision. Based on this article, it seems that there are three main problems with Laser Spine Institute:

1. There is a conflict of interest, as some doctors are investors in the parent company. Thus, there is an incentive for performing unnecessary procedures.

2. There is little if any respected research that suggests that laser surgery is superior to traditional spinal surgery methods.

3. The centers use a high volume model and rely heavily on advertising instead of professional referral. Not a good indicator for quality of service.

Can You Grow Cartilage By Eating Certain Foods or Supplements?

by Pain Doc | Feb 21, 2011 | Uncategorized

Cartilage, specifically, hyaline cartilage is the tissue that lines the articular (contacting) surfaces of bones. If the cartilage deteriorates it can lead to pain and inflammation in the weight bearing joints, mostly the knees and hips, as nerve endings in the joint get exposed to abrasive action. This can force the sufferer to elect for knee or hip replacement surgery, as well as artificial disc surgery. Smaller joints such as in the fingers can be affected as well.

Cartilage is made by special cells called chondroblasts. These cells make the extracellular matrix of cartilage, comprised of Type II collagen and ground substance, which is comprised of proteoglycans and elastin. Another important constituent is hyaluronic acid, which improves the resiliency and hydration of cartilage. Without going into too much detail, a proteoglycan is a protein molecule with a chain of sugar molecules attached called glycosaminoglycans, or GAGs. The two GAGs that are best known to the public are glucosamine sulfate and chondroitin sulfate, the key ingredients in most cartilage and bone supplements. Glucosamine sulfate is the one found in the exoskeletons of shellfish, as well as some fungi.

Persons suffering from the various forms of arthritis such as osteoarthritis and rheumatoid arthritis have cartilage tissue that is undergoing inflammation and degradation, either mechanical in nature or auto-immune.

Collagen is a group of naturally occurring proteins found mostly in animal connective tissues– tendons, ligaments, and skin. What makes collagen useful in cartilage is its ability to withstand pressure and return to its original shape (deform and rebound). This is what is necessary in joints of the human body, which are subjected to forces multiple times throughout the day. The simple act of sitting or standing places enormous pressure on the joint surfaces of the feet, knee, hip and lower back. Using one’s hands to type or grip things places pressure on the smaller joints of the fingers and wrists.

So, if your have thinning cartilage in your knees, can you grow it back simply by taking glucosamine sulfate and chondroitin supplements? Unfortunately, the latest research on their ability to reduce joint pain show minimal improvement. Why is this?

It’s because that, just because you give the body supplements through your diet, it doesn’t guarantee that your body will do things you want it to do with these nutrients. They could be going somewhere else besides you joint, which is more likely the case.

The harsh reality regarding all muscle and connective tissue building dietary supplements such as collagen, bone broth, protein powder, etc. is that they get broken down in your GI tract into their amino acid constituents, and need to be reassembled. But as mentioned, your body will not reassemble them into the desired tissue 100%. These proteins may go to your skin, hair, nails, or may be made into an enzyme or cell receptor. In other words, the amino acids in those glucosamine sulfates pills may wind up forming new hair, not cartilage.

That being said, if you hope to build cartilage through your diet, it may be more effective to eat the actual cartilage. At least it consists of the actual amino acid sequences in the proper percentage the body uses to build cartilage..

Consider consuming bone broth soup regularly if you are suffering from achey joints; or do so as a preventative measure. Most butcher shops in the grocery store will have large joints of beef or pork, usually the hips, knees and spine. And they are cheap, usually less than $2.00 a pound. They will saw them in small pieces for you if you request. What’s great about them is that they still have tendons and cartilage pieces attached. Get a large pot, add a gallon of water and bring to boil; lower temperature and boil for two hours. The broth will be rich in nutrients that your body can use to help regenerate damaged cartilage.

For preventive measures to protect the health of your joint cartilage, remember to:

do functional exercises regularly to improve whole-body muscle & joint responsiveness
avoid sitting for too long at your work
avoid activities that require repetitive trauma to the joints such as long distance running
avoid ingesting toxins like cigarette smoke, alcohol, and highly processed food
get enough daily rest to allow your body to regenerate
drink filtered water (not distilled)
get enough sun exposure for Vitamin D synthesis

What Can Be Done About Meniscal Tear?

by Pain Doc | Sep 11, 2010 | Knee Pain

Capsule of right knee-joint (distended). Poste...

Image via Wikipedia

The meniscus is a shallow bowl shaped piece of cartilage that is attached to the lower leg bone, or tibia. There is a medial meniscus (inner half of knee) and a lateral meniscus (outer half of knee).

The end of the femur (upper leg) bone has two protuberances called the femoral condyles, which rest on top of the meniscii (plural). In the standing position, the meniscii bear the full weight of the body above the knee. They serve as a cushion and shock absorber and protect both of the ends of the tibia and the femur. The meniscus also guide the action of the femoral condyles as you bend and extend your knee.

The knee is obviously a highly utilized, weight bearing joint. It has the largest suface contact area of any joint in the body as it has to bear most of the body’s weight and on top of that, absorb shock from walking, running and jumping. It is held together by several strong ligaments, the primary being the anterior and posterior cruciate ligaments (ACL, PCL), the medial and lateral collateral ligaments (MCL, LCL), and the patellar tendons. It is a synovial joint, which means it is totally encapsulated and lined with synovium, a specialized tissue that secretes synovial fluid to lubricate the joint.

The slightest alteration in the inner workings of the knee will lead to problems. A common one is a meniscal tear. The two basic types are a radial meniscal tear and a vertical meniscal tear. A radial tear that expands forms what is called a “bucket handle” tear (3rd set in the below image- top and bottom).

types of meniscal tears

Meniscal tears are caused by excessive pounding forces to the knee, which weaken the meniscii over time. Eventually a tiny tear forms, which grows in length as the individual continues to engage in the offensive activity (running on hard pavement, weight lifting, playing basketball, etc.), much like how a tiny crack in a car windshield grows into a long crack over time . If a small piece breaks free, it floats inside the knee space, suspended in the synovial fluid. Like a grain of sand in a watch, it interferes with the moving parts and can cause the knee to swell and become stiff.. Pain is felt deep inside the knee and is worse with prolonged standing and transitioning from sitting to standing.

Meniscal tears increase the chances of accelerated knee osteoarthritis, as “bone on bone” contact occurs between the ends of the femur and tibia.

TREATMENT: Diagnosis is made with a knee MRI and arthroscopy. Meniscal tears will most likely require arthroscopic surgery involving repair to the tear. If you have a gradual onset of deep, focal knee pain accompanied by knee stiffness that doesn’t go away, see your doctor.

Prevention, as always, is the key. I advise against sports that involve consistent and prolonged pounding forces to the knee. This includes long distance running and frequent hard court basketball that involves jumping. Consider doing functional exercises that combine cardio and strength instead.

Most leg exercises will strengthen the knee. Do mostly closed kinetic chain exercises where the foot is immobilized. This includes squats and lunges.

Intermittent jumping exercises are ok as long as they are controlled and are not the focus of an exercise session. Power jumps and related plyometric exercises fall into this category.

Most meniscal tears grow too large to heal on their own by the time the patient seeks medical help. This is why surgery is the only option. The surgeon stitches together the tear, but thanks to the forces the knee has to endure, the tear often returns.

Some patients do not get surgery, and let the tear become chronic. When it’s chronic, there is less acute pain, and more of a broad, dull pain in the knee. In this scenario, the knee joint will experience accelerated degeneration, leading to knee osteoarthritis. Eventually in the later years, knee replacement surgery is needed.

I made a general Knee Pain Rehab instruction video that includes things one can do to help deal with early stage knee pain.