APM Blog

Thursday, 02 November 2017 13:05

The Truth Behind Failed Back Surgery Syndrome

Back surgery doesn’t always mean the end of pain. In fact, a large portion of people still experience back and leg pain despite undergoing various types of spinal surgery, a condition universally called failed back surgery syndrome (FBSS). Fortunately, for those suffering from FBSS and for whom repeat surgery is not indicated – which is often the case – there are options to reduce the residual pain so sufferers can get back to a more normal quality of life.

Prevalence and Overview of FBSS

The true prevalence of FBSS isn’t entirely known, and estimates place the number anywhere between 5-50% of patients who undergo spinal surgery.[1] What is known is that the condition can come about from various types of surgeries and may be the result of removing bone (laminectomy or foraminotomy) or disc material (discectomy) or even a fusion of spinal segments.[2]

Failed back surgery syndrome doesn’t necessarily mean a failure on the part of the surgeon or that the pain is worse after surgery. FBSS simply refers to pain that persists after surgery – whether that pain is worse, unchanged or even slightly improved. In the case of FBSS, the outcome of the surgery just doesn’t meet the pre-surgical expectations of the provider and patient.[1]

Possible Causes

It’s thought that several factors can play into the development of FBSS.[2] Issues before surgery that can affect the outcome include spinal instability or anomalies in clinical images, in addition to preexisting conditions like diabetes, autoimmune disease and peripheral vascular disease.[3]

Psychological issues, like depression and anxiety, also play a role and patients with them are more likely to have unsatisfactory outcomes from surgery. [4]  Complications after surgery, like excessive inflammation leading to the development of fibrotic tissue, [2] can also result in unfavorable outcomes.

Treatment Options

Repeat spinal surgery is actually less likely to succeed than the primary surgery.[5]This means that oftentimes additional treatments provided by a pain management physician are needed to address the residual pain after spinal surgery.

Depending on the condition, pain management specialists have various options when it comes to managing FBSS pain. Oftentimes, they will utilize minimally invasive treatments such as epidural steroid injections, blocks or radiofrequency neuroablation. These, paired with physical therapy and other comprehensive treatments, can often lead to improved pain levels and overall quality of life.

Other times, physicians may turn to spinal cord stimulation, or SCS, a treatment that’s been proven more effective for FBSS than repeated surgery.[6] SCS delivers low voltage electricity to the spinal cord, interrupting pain signals before they reach the brain. With SCS, patients are able to try the system before permanent implantation and, once they receive the permanent version, are often able to reduce their reliance on opioids. Intrathecal pumps, which deliver medication directly to the spinal cord to block pain signals, may also be considered.

Preventing FBSS

However, as researchers note, preventing FBSS is much easier than treating it.[3] Preventing FBSS comes down, in large part, to proper patient selection for surgery,  meaning that for many, surgery may not be the right option. But for patients for whom spinal surgery is not indicated – or those who are hesitant to undergo such a serious surgery – there are other, less invasive treatment options. These may include some of the same options utilized to treat FBSS – like injections, blocks and radiofrequency – among others.

Learn More

If you’re looking for treatment options for FBSS – or are considering alternatives to spinal surgery – call (888) 901-PAIN (7246) to learn more today.

Download your free opioids and pain in-depth guide

[1] Taylor, Rod S., and Rebecca J. Taylor. “The Economic Impact of Failed Back Surgery Syndrome.” The British Journal of Pain 6, no. 4 (November 2012): 174-181.

[2] Russo, Marc. “Failed Back Surgery Syndrome: Pain That Persists after Surgery in a Subset of Patients.” International Neuromodulation Society. April 2002. Accessed August 30, 2016. http://www.neuromodulation.com/assets/documents/Fact_Sheets/fact_sheet_fbss.pdf

[3] El-Sissy, Mohamad H., Mohamad M. Abdin, and Amr M.S. Abdel-Meguid. “Failed Back Surgery Syndrome: Evaluation of 100 Cases.” The Medical Journal of Cairo University 78, no. 2 (March 2010): 137-144.

[4] Bordoni, Bruno, and Fabiola Marelli. “Failed Back Surgery Syndrome: Review and New Hypotheses.” Journal of Pain Research 2016, no. 9 (January 12, 2016): 17-22.

[5] Thomson, Simon. “Failed Back Surgery Syndrome – Definition, Epidemiology an Demographics.” British Journal of Pain 7 no. 1 (February 2013): 56-59.

[6] North, Richard B., David H. Kidd, Farrokh Farrokhi, and Steven A. Piantadosi. "Spinal Cord Stimulation versus Repeated Lumbosacral Spine Surgery for Chronic Pain: A Randomized, Controlled Trial." Neurosurgery 56, no. 1 (2005): 98-106.

So your doctor says you need a nerve block, but you’ve never even heard of this type of procedure before. You start thinking: What will this entail? Will it hurt? And, most importantly, will it really help relieve my pain? Let this in-depth look at nerve blocks answer all your most pressing questions.

Definition and Types

Nerve blocks do what the name implies: They block the pain signals traveling along a nerve or a group of nerves before they get to the brain.[1] Nerves work like sensory superhighways, transmitting sensations – like pain – from the source to the brain. Blocks involve injecting various types of medications around the nerve or nerves to stop the transmission of pain.

There are two main types of nerve blocks that may be performed at different points in the body; some nerve blocks will be diagnostic, helping doctors find the source of the pain to better determine future treatment, while other blocks may be therapeutic, providing prolonged pain relief.

  • Diagnostic blocks are utilized to determine if a specific nerve or nerves are the source of the problem. During this procedure, a doctor will inject a temporary numbing agent around the nerves, which – if the right nerves were targeted – will relieve pain for a few hours or days. You will then be told to go about your day, moving around as normal and monitoring your pain levels for signs of improvement. If you and your doctor deem the block successful, you may have another block to verify these results, or just move on to a more lasting treatment option, like radiofrequency neuroablation.
  • Therapeutic blocks aim to relieve pain for a longer period of time. This is due to the type of medication injected around the nerves, which will include an anesthetic for short-term relief and an anti-inflammatory medication for longer relief.

Procedure Overview

To begin, you may be given sedation to help you relax, but you will remain awake during the procedure. Your provider will use a local anesthetic to numb the area around the nerves that are being treated. Using a state-of-the-art X-ray device called a fluoroscope, along with contrast dye that’s been injected into the region, your physician will locate the nerve or nerves that may be causing the problem. A mixture of pain-relieving medications will then be injected around the nerves.

Following the procedure, you will usually be able to go home in about 30 minutes. After a nerve block, people may feel soreness at the site of the injection.

Therapeutic Outcomes

The ultimate goals of therapeutic nerve blocks are similar to those of many other procedures: decrease pain, increase function, decrease opioid usage and increase the ability to perform physical therapy. Yet everyone responds differently to different procedures and nerve blocks are no exception.

After the nerve block procedure, it’s possible that the pain may return after the anesthetic wears off but before the anti-inflammatory medication takes effect. This is normal and should decrease within a few days. Usually, more than one injection will be required to provide sustained relief from pain, and relief may last longer after each injection. The amount and frequency of these injections will depend on your specific condition.

Learn More

To learn more about nerve blocks, including if they may be right to help treat or diagnose your condition, please schedule a consultation with one of our experienced pain management providers by calling (888) 901-PAIN. You can also learn more on our treatment pages:

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[1] “ViewMedica Patient Engagement Videos.” Swarm Interactive 2016. Accessed October 6, 2016. http://www.viewmedica.com/.

Published in Pain-Treatment

The national numbers on opioids are clear: Opioids are a dangerous drug with concerning risks and side effects. But what’s going on beneath those numbers, among the individuals currently taking opioids for chronic pain, is equally important. Specifically, how helpful do they find opioids in treating their pain – and what drawbacks are they seeing from prolonged use? A new study presented at the America Society of Anesthesiologists’ annual meeting sought the answers to these crucial questions.

Study Overview

The study, titled “Do Patients Perceive Opioid Treatment as an Effective Way to Mange Chronic Low Back Pain?,”[1] was one of the research projects presented as part of the ANESTHESIOLOGY 2016 annual meeting.

The authors utilized data from a January 2016 survey of more 2,000 low back pain patients. They chose low back pain, in part, because these patients are more likely than patients with other types of pain to be treated with opioids. In fact, 46% of the survey respondents were currently utilizing opioids for pain.

The respondents were divided into three categories based on their opioid usage: those currently on opioids, those who were not currently on opioids but had been in the past year (28%) and those who had never been on opioid therapy (26%).

Key Findings

As part of the survey, patients were asked how successful they felt opioids were at relieving their pain levels. When taken together, only 13% of all respondents selected “very successful.” The most highly selected answer was “somewhat successful,” which was selected by 44% of people. Of the others, 31% said “moderately successful” and 12% said “not successful.” When the results were divided by opioid usage status, “somewhat successful” was still the most common answer for those currently on opioids, while those previously on opioids most commonly selected “not successful.”

The study also examined side effects and stigmas associated with opioid use. The researchers found that the vast majority – 75% – experienced side effects due to their opioid treatment. The most common of these side effects were constipation, sleepiness, cognitive issues and dependence.

On top of that, 41% of people reported feeling judged based on their usage of opioids. And, as it turns out, this feeling of being judged was unique to opioids; despite 68% of respondents also taking antidepressants, only 19% felt judged for using those.

Implications for the Future

These results put further emphasis on the dangers and inefficacy of long-term opioid treatment for chronic pain. Not only does their use create additional physical and social problems, but for most people they don’t even effectively address the pain.

Lead author Dr. Asokumar Buvanendra of Rush University in Chicago sees this as yet another reason pain patients should seek care from a multidisciplinary pain management specialist.[2] Whether it’s interventional procedures, physical therapy, alternative medications or complementary therapies, pain management providers are able to offer and coordinate a variety of services that oftentimes not only work better than opioids, but also pose far fewer side effects.

“Patients are increasingly aware that opioids are problematic, but don’t know there are alternative treatment options,” said Dr. Buvanendra in a press release regarding the research. If you want to learn more about what treatment options are available for your condition, call (888) 901-PAIN to speak to a member of our care team staff.

Download your free opioids and pain in-depth guide

[1] Buvanendran, Asokuma, Rae M. Gleason, Mario Moric, Sherry J. Robison, Jeffrey S. Kroin. “Do Patients Perceive Opioid Treatment as an Effective Way to Manage Chronic Low Back Pain? A Survey of Opioid Treatment Perception and Satisfaction.” ANESTHESIOOGY 2016 Annual Meeting (October 23, 2016). Accessed January 3, 2017, http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=431585AA0967E7E27C850BD8C99D1E06?year=2016&index=3&absnum=4614

[2] AMERICAN SOCIETY OF ANESTHESIOLOGISTS, Many Back Pain Patients Get Limited Relief From Opioids And Worry About Taking Them. 2017. Web. 9 Jan. 2017.

Published in Back Pain
Thursday, 02 November 2017 11:21

Opioids and Medication Management

Advanced Pain Management (APM) is proud to be among the growing number of providers in this country working to reduce the number of opioid prescriptions given and, in doing so, prevent as many medication-related deaths as possible.  APM’s efforts align well with the recent CDC Guideline for Prescribing Opioids for Chronic Pain, which states, “Patients with pain should receive treatment that provides the greatest benefits relative to risks.”[1]

While in a majority of cases, this means nonopioid – and even nonpharmacological – therapy for the treatment of pain, there are certain circumstances where the benefits of opioids may outweigh the considerable risks. When this is the case, it’s imperative that risk-mitigating measures are put into place to ensure continued patient safety. At APM, this is referred to as medication management.

Deciding on Opioid Therapy

When a patient enters treatment at APM, our fellowship trained, board certified physicians take a complete medical history, in addition to completing a comprehensive patient consultation. During these steps, the physician will ascertain which treatments a patient has used and how they worked, the patient’s past and present usage of opioids and other medications, how their body uses pain medications and how they tolerate opioids.

In addition, a screener and opioid assessment will help the physician determine if the patient has any additional risk factors that may make long-term opioid therapy more dangerous, such as behavioral health issues or a personal or familial tendency toward addiction. Since opioid medications affect patients in different ways, honest answers to these questions will allow APM’s providers to best assess and treat each patient’s pain.

If a decision is made that opioid therapy is the right option for a patient, the physician will work with the patient, as recommended by the CDC,[1] to establish realistic goals regarding their pain and functional ability – like being able to walk around the block or sleep through the night without pain awakening them. Together, they will also discuss how and when the therapy will be discontinued if the benefits no longer outweigh the risks – for instance, if there is no increase in pain levels or the ability to function.

Risk-Mitigating Measures

If opioid therapy is warranted, every measure will be taken to reduce the risks associated with the medication. This includes prescribing opioids at the lowest possible dose necessary to achieve both pain relief and functional restoration. This may mean that patients currently on opioids will be tapered down to a more appropriate dose.

Patients taking part in APM’s medication management program are required to sign a controlled substance agreement, which outlines their responsibilities in regard to their medication, including taking their medication only as prescribed, avoiding alcohol and illegal drugs and keeping their medication safe and away from children.

The agreement also outlines other risk-mitigating measures that APM has in place, including urine drug testing and pill counts. Drug tests are completed for new patients and several times a year after that and allow providers to verify that individuals are using their medications as prescribed and not taking other medications or drugs that could be dangerous to their health. Pill counts work in a similar manner, ensuring that patients are taking their pills as prescribed and not skipping doses or taking them too often. Pill counts may be completed during or between appointments and provide another level of safety to protect patients from addiction, overdose and other negative side effects.

APM providers also check the Prescription Drug Monitoring Program,[2] a state database that lists patients’ names and the providers who have prescribed controlled substance to them, among other information. If any of the components of the controlled substance agreement are broken (for instance, if a random urine drug test comes back positive for an illegal substance), an APM provider may discontinue opioid therapy for that patient.

Interventional and Complimentary Treatments

The goal of medication management is for you to lead a more active lifestyle – but you will need more than just medication to make this happen. Opioids alone won’t take care of your pain. The CDC notes this, as well: “If opioids are used, they should be combined with nonpharmacologic therapy.”[1]

The types of therapies used will differ from patient to patient, depending on their pain type, medical history and other medical conditions. Oftentimes treatments will include a combination of interventional procedures (like steroid injections or nerve blocks), physical therapy, cognitive and behavioral therapy, smoking cessation, home exercise programs and complementary treatments like acupuncture. This focus on multiple therapies for the treatment of pain is known as a multimodal or multidisciplinary approach, which “can help reduce pain and improve function more effectively than single modalities,” according to the CDC.[1]

If you would like to learn more about APM’s personalized, multidisciplinary approach to treatment, give us a call at (888) 901-PAIN (7246) or schedule a consultation.

Download your free opioids and pain in-depth guide

[1] Dowell, Deborah, Tamara M. Haegerich, and Roger Chou. "CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016." Morbidity and Mortality Weekly Report (MMWR) 65, no. 1 (March 18, 2016): 1-49.

[2] Wisconsin Department of Safety and Professional Services. Wisconsin Prescription Drug Monitoring Program (PDMP). Accessed June 02, 2016. http://dsps.wi.gov/pdmp/.

Published in Medication Management
Thursday, 02 November 2017 10:26

Intrathecal Pumps and Efficient Pain Relief

Oral opioids, by their very nature, are an inefficient – as well as a potentially dangerous – option for pain relief. That’s because opioids aren’t administered directly where they’re needed; after consumption, they work their way through the bloodstream before attaching to the opioid receptors in the brain, spinal cord and other organs.[1]

Fortunately, there’s a more efficient way to administer pain-relieving medications: directly where the pain signals travel. This method, called intrathecal pump implantation (or targeted drug deliver), delivers medication right to the intrathecal space, meaning pain relief can be achieved with roughly 1/300 of the dose of oral opioids.[2] For some chronic pain patients, this means more accurate pain relief with fewer of the side effects linked to oral opioids.

Overview of Intrathecal Pumps

An intrathecal pump consists of a pump, which can contain various combinations of medication, and a catheter. The device is able to provide targeted pain relief because the catheter is placed directly into the intrathecal space, the region surrounding your spinal cord. Pain signals travel along the spinal cord to the brain; the catheter delivers medication directly to that area, effectively preventing the pain signals from being perceived by the brain.[3]

The amount of medication released into the intrathecal space is controlled with an external programmer, which is pre-set with parameters and can be used by the patient to control breakthrough pain.

Intrathecal pumps are generally recommended for people with chronic pain who have utilized conservative treatments with limited success. It may also be used for people who have had surgery but are still experiencing pain, or people for whom surgery is not likely to help.[3]

Getting a Pump

The qualification process for a pump begins with a behavioral health consult for all patients. Patients who are experiencing depression, a lack of social support or a lack of motivation toward wellness do not do as well with implantable therapies. So during this mandatory step, a behavioral health professional will ensure that the patient is in the best possible position to achieve success with the implant.

After behavioral health clearance, the patient will undergo a reversible trial of the devise to ensure effectiveness of the therapy. This important step allows each patient to try the device and make sure it provides them adequate pain relief.

During the trial, the doctor administers local anesthetic then inserts a catheter through either a needle or a small incision into the intrathecal space. The catheter is then connected to an external temporary pump.[3] The patient will be able to try the system for roughly a week, and if the patient and the physician deem the trial successful, then a permanent device will be implanted.

During the permanent procedure, the patient will typically be put under local anesthetic. The temporary catheter will be removed and replaced with a permanent one. A permanent pump will be placed under the skin, usually in the abdomen, and connected to the catheter.[3]

Follow-up Care and Side Effects

After implantation, the patient will need to visit the doctor regularly so the pump can be refilled with medications. The pump itself contains a battery that will last several years. (The battery life will depend on which type of pump is utilized.)[3] After that time, a new catheter will be implanted.

There are may be some side effects related to the implant. For instance, mild discomfort and swelling at the incision site can occur after implantation. Over time, activity may move or damage the catheter, which would then require repositioning or replacement.

Learn More

For more information regarding intrathecal pumps, or to find out if one may be right for you, call (888) 901-PAIN (7246).

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[1] "What Are Opioids?" Drugabuse.gov. National Institute on Drug Abuse (NIDA), Nov. 2014. Web. 04 Aug. 2016.

[2] Lynch, Louise. “Intrathecal Drug Delivery Systems.” Continuing Education in Anaesthesia, Critical Care & Pain 14, no. 1 (September 4, 2013): 27-31.

[3] “ViewMedica Patient Engagement Videos.” Swarm Interactive. 2015. Accessed August 5, 2016. http://www.viewmedica.com/

Published in Pain-relief

Injections of pain-relieving medication are common for the treatment of back pain – but, in reality, many more painful sites throughout the body can benefit from an injection. Whether arthritis in the knee is impeding your life, neck pain is stopping you from enjoying activities or hip pain is making moving difficult, a joint injection may be just the thing you need.

How Injections Work

Injections can be utilized on various sites throughout the body to relieve pain and reduce inflammation. While inflammation is a natural part of the body’s immune response – and can therefore help us heal – the prolonged inflammation that occurs as part of many chronic conditions result in long-term pain and sensitivity.[1]

Injections for knee, neck or hip pain may contain various medications; a physician will determine which ones are appropriate based on your particular condition. Typically, a combination of a local anesthetic and steroid medication will be utilized. While the anesthetic works to reduce pain in the short-term, the steroid will work to reduce pain and inflammation in the longer-term, usually up to several months.[1]

A patient may still experience pain after the anesthetic wears off but before the steroid medication takes effect. This is normal and pain relief should occur soon. For some patients, one injection may be enough to provide adequate long-term relief; however, others may require several injections to experience the full benefits. 

The Procedure

Injections are a simple, quick and precise way to treat pain at the source. In preparation for an injection, your physician will clean the area to be treated and then inject a numbing medication. To ensure that the medication is injected at the precise area it’s needed, the physician utilizes an X-ray device called a fluoroscope and a test injection of dye. (If the dye pools around the joint’s tissue, the physician will know that the needle needs adjustment. If it doesn’t pool, that means the medication will reach the desired space inside the joint.)[1]

When the needle’s proper placement is ensured, a syringe filled with medication is attached and the medication is injected. After the needle is removed, the site may be covered with a small bandage.

More than Just Pain Relief

Injections help to both relieve pain and restore function. In doing so, they can also help an individual get more from physical therapy. And therapy, in turn, can actually help prolong and increase the pain-reliving effects gained from injections, in addition to preventing pain recurrence and re-injury.

In addition, the pain relief gained from the combination of injections and therapy can oftentimes help pain sufferers decrease their reliance on opioids. And a lower dose of opioids means a lower chance of dangerous opioid-related side effects.

Injections are a safe, low-risk way to treat pain at the source and get you moving again. To find out more about the injections APM offers, take a look these interactive animations or call (888) 901-PAIN (7246).

Get moving. Call (888) 901-PAIN (7246) or click to schedule a consultation now.

[1] "Patient Engagement Videos." ViewMedica. 2015. Accessed March 08, 2016. https://viewmedica.com/.

Published in Neck-Pain

With one online search – or a poll of your close friends and family members – you’ll get countless suggestions for relieving your pain. People are more than happy to give you the “secret” about pain, whether that’s “a supplement that will cure everything” or “a simple chemical/additive/food that’s the root of all your problems.” Myths like these are everywhere, and some are more dangerous than others. Here are a few of the most common.

  1. The truth is that pain is never normal.

    While age does bring with it nuisance aches and pains, saying that pain is normal can actually stop people from seeking the help they need. The physical wear and tear on our bodies from getting older can indeed lead to chronically painful issues, like herniated discs and joint pain, but these conditions can be treated. So when pain comes your way, don’t blame age – and don’t just suffer through it. Find real answers (and real relief).
  2. You can just push through it.

    We as humans have the tendency to think that if we simply ignore an issue, it will go away on its own. We assume we can tough it out or “grin and bear it” and that seeking help will somehow make us look weak. But ignoring pain can have serious consequences. It can impair your relationships and ability to function, cause emotional issues and, worst of all, cause you to hurt yourself further. In fact, leaving pain untreated – or trying to treat it yourself – can often make it more difficult to treat down the road. So when a health issue arises, especially if it involves long-lasting pain, suck it up and see a doctor (or you’ll pay for it later on).
  3. Rest is the best medicine.

    Conventional wisdom dictates that if you’re sick, you rest and give your body time to heal. The same is true with acute pain; laying off activities or chores after an injury can give your body time to repair itself. But chronic pain is different. While a day or two taking it easy isn’t necessarily a bad thing, more than that can actually have quite negative consequences. In fact, it’s been shown that bed rest is associated with more days off work and increased pain and disability.[1] It can result in decreased muscle conditioning and tone, cause digestive issues and put you at risk for blood clots. According to Harvard Medical School, if you must lie down, do it only for a few hours and for no longer than a day or two.[2] A better solution for addressing chronic pain is actually to get back to normal activities as soon as possible – with a little rest thrown in when absolutely needed.
  4. It must be in your head.

    To chronic pain sufferers, it can often seem like those around them don’t believe that their pain is real. After years of suffering with pain, you may still not have a concrete diagnosis and both your doctors and family members may start suggesting psychiatric help. All signs seem to suggest that they think you’re going crazy – or worse, just making it up. And sometimes you might be inclined to agree.

    But the truth is they know it’s real, just like you do. Your friends and doctors – especially if they’re trained to treat pain – know that pain is a complex issue that’s often invisible to the naked eye. And recommending behavioral health care isn’t an implication that you’re crazy or making it up. It comes from a place of caring, since chronic pain can often go hand in hand with anxiety, depression and coping difficulties. It means they want to see you get better – not just physically, but also mentally. So believe in those around you and trust that they’ll believe in you.

Download your free stretching exercises for pain reduction

[1] Wilkes, M. S. “Chronic Back Pain: Does Bed Rest Help?” Western Journal of Medicine 172, no. 2 (February 1, 2000): 121–21.

[2] Harvard Health Publications. “Bed Rest for Back Pain? A Little Bit Will Do You.” January 24, 2017. Accessed February 13, 2017. http://www.health.harvard.edu/pain/bed-rest-for-back-pain-a-little-bit-will-do-you.

Published in Pain-relief

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