Nedal Hejazi, MD





Neurosurgical Paintherapy

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. The emotional component of pain is called suffering. Pain is familiar to everyone and yet so complex and subjective it cannot be easily described or treated.

Pain is the body's mechanism of self-preservation. It acts as a warning to indicate harm or potential danger to tissues in our bodies. However, when pain persists or reoccurs over a long period of time (more than six months), it is said to be chronic pain. Because this pain is not protective, and not a result of a continuing injury, it is "pathological" nerve injury pain and, therefore, treated as an end and not as a symptom. More than 75 million Americans suffer chronic, handicapping pain. Approximately 75 to 80 million people in the United States are estimated to suffer chronic pain, and this is generally considered a conservative estimate. Chronic low back pain, for example, affects nearly 31 million Americans and represents the most common cause of disability in persons less than 45 years of age. Persons with chronic pain fall into two groups -- those with ongoing tissue injury, as occurs with cancer-related pain; and those without ongoing tissue damage, perhaps as a result of a previous injury. Neurosurgeons can treat chronic pain by augmenting, or stimulating, functional parts of the nervous system, especially the spinal cord. Candidates for such surgery must undergo a trial consisting of temporary implantation of an electrode over the spinal dura. When successfully positioned, this electrode produces a pleasurable sensation that overlaps the regions of pain in the body. If it alleviates pain adequately, a permanent battery or "pulse generator" is connected and implanted surgically, much like a heart pacemaker. This generator can be frequently reprogrammed using a computer without resorting to further surgery. Other surgical options include a number of ablative procedures. Ablative operations involve creating an injury to the sensory portion of the central or peripheral nervous system.

Low back pain

If you are experiencing low back pain, you are not alone. More than 65 million Americans suffer from low back pain every year. Back aches are the most common reason for doctor visits, after cold and flu symptoms. Fifty percent of all patients who suffer from an episode of low back pain will have another occurrence within one year. In the vast majority of cases back pain is caused by the irritation of a nerve root near the spine, not by problems with the muscles, ligament or bone. A nerve that travels from the spinal cord through the openings between the bones of the spine gets pinched or irritated, the surrounding muscles tense up and the patient experiences low back pain. Low back pain is widespread in our society, but the good news is that in most instances the pain ends within a few days. More serious cases of back pain are treated with anti-inflammatory medication, physical therapy and muscle relaxants. Surgery, a common treatment a generation ago, is now considered necessary for only a very small percentage of back pain patients.

How Low Back Pain Occurs

A basic understanding of the spine is needed to understand back pain. The spine or spinal column is the body''s backbone, a column of cylindrical bones known as vertebrae. The spine protects the spinal cord, which begins in the brain and runs most of the way down the back.

The spinal cord controls every movement and function of the body. Motor nerves leading out of the spinal cord are responsible for controlling movement in the body, while sensory nerves entering into the spinal cord are responsible for
communicating messages from the body back to the brain. Together, the motor and sensory nerves form more than 50 nerve roots, which run through holes (foramina or windows) between the bones of the spine. Irritation of these nerve roots causes back pain.

Low Back Pain Conditions

Herniated Disc (Slipped Disc)
A herniated or slipped disc is a frequent cause of mild or moderate low back or leg pain. Soft flexible discs separate the bones in the spine. The discs, which have a rigid outside rim and a soft, gel-like center, act as shock absorbers and protect the spinal cord. Activity, stress, or a mechanical problem in the spine can cause a disc to bulge and become misshapen. The damaged or bulging disc may pinch or irritate a nerve root, causing pain.

Disc degeneration (osteoarthritis in the spine)
Another common disorder of the lower spine is disc degeneration, or osteoarthritis in the spine. As the body ages, the discs in the spine dehydrate or dry out, and lose their ability to act as shock absorbers. The bones and ligaments that make up the spine also become less flexible and thicken. Degeneration in the discs is normal and is not in itself a problem. But pain occurs when these discs or bone spurs begin to pinch and put pressure on the nearby nerve roots or spinal cord.

Sciatica The sciatic nerve, composed of several lumbar nerve roots, is one of the nerves most likely to become irritated, usually by a herniated disc. Each of the major branches of sciatic nerve travels through the pelvis and deep in the buttocks, then down the hip and along the back of the thigh to the foot. The pain of sciatica ranges from a mild tingling to a sharp ache severe enough to cause immobility.

Lumbar spinal stenosis
Degeneration of the spine also can result in lumbar spinal stenosis (LSS). This disease involves a narrowing of the canal that houses the spinal cord and nerve roots. A narrowed spinal canal may compress nerve roots in the lower back, resulting in pain and weakness in the legs and a dull pain in the lower back. Patients often find relief by sitting or standing in a hunched over position, as if leaning on a shopping cart. Symptoms of LSS usually do not occur until after the age of 50.

Degeneration in the spine also can lead to spondylolistheses, a condition characterized by the slippage of a vertebra in the spine. One vertebra slips forward over another, stretching or pinching the sciatic nerve and causing pain.

Causes of Back Pain
The causes of more than 80 percent of back pain cases are unknown. Some people have damaged or bulging discs but feel fine. Researchers do know that back pain often begins with an injury, after lifting a heavy object or moving suddenly. People who do not exercise regularly face an increased risk for back pain, as do obese people. Sciatica can be caused by blood clots, tumors and abscesses. Arthritic back pain can be the result of infections such as Lyme disease and viral arthritis. Atherosclerosis (hardening of the arteries) can cause back pain when arteries in the legs are clogged.

Wait and See
If low back pain occurs with a fever or occurs after a recent injury, such as a car accident, a fall or sports injury, patients should call their primary care physician immediately or visit the emergency room. A doctor needs to determine if a spinal fracture, infection, tumor or other serious condition is present. Patients suffering from low back pain without a fever or without recent trauma can wait to see if the pain improves for a few days before calling a physician. Patients should restrict strenuous activities, take anti-inflammatory medications such as ibuprofen (not aspirin or acetaminophen), take hot showers and try massage. Because a nerve root is often being irritated, relief comes when pressure on the nerve is relieved. Usually, a patient can find a comfortable position that relieves the pain.

If the low back pain gets worse or does not improve after two or three days of home treatment, contact a primary care physician.

Diagnosing Low Back Pain

Physicians evaluate low back pain through a medical history, a physical exam and diagnostic tests. The physical exam includes an assessment of sensation, strength and reflexes in various parts of the body to help pinpoint which nerves or parts of the spinal cord are affected. Patients are asked to sit, stand and walk on their toes, heels and flat-footed. They also are asked to bend forward, backward and sideways and to lift their legs while lying down.

A physician may order diagnostic studies. These studies may include:

X-rays: An x-ray will show the bones of the spine and determine if there is significant wear and tear or disease of the bone. It will also show whether the bones are lined up properly.

Computed Tomography (CT): A CT (also known as a CAT scan) uses an x-ray and a computer to generate images of the spine in slices. The CT shows the anatomy of the spine in great detail. It also clarifies the relationship of the disc or bone spurs to the spinal cord and nerves.

Magnetic Resonance Imaging (MRI): The MRI uses a powerful magnetic field rather than x-rays to produce a detailed anatomical picture of the spine and the structures within. It is probably the best test to see herniated discs since they are soft tissue that are invisible to x-rays.

Myelogram: A myelogram is an x-ray picture taken with a special dye injected into the spinal sac to highlight the spinal cord and nerves. The dye is usually injected into the spine with a needle and then the x-rays are obtained. Myelograms have largely been replaced by CT and MRI scans.

Electromyogram and Nerve Conduction Studies (EMG/NCS): Unlike the other tests, which help reveal anatomy and structure, these tests primarily study how the nerve and muscles are actually working together. They test for the impulse coming from the brain and/or spinal cord. If the impulse is blocked somewhere, it may be delayed or diminished enroute to its final destination (i.e., muscle, skin, toe, finger-tips). This information can assist in determining which nerves or muscles are functioning abnormally.

Discography: This is a special x-ray test that may help identify which discs are damaged and if they are a source of pain. It uses a contrast dye injected into the disc space to image the disc.

Treatment Options

Conservative treatment is the most likely course of action for back pain. Although back pain can be debilitating, the pain improves without surgery in most cases. Physicians usually recommend 6 to 12 weeks of conservative therapy before considering surgery.

Treatment usually involves relieving the inflammation around the nerve. Mild cases of back pain often respond well to rest or anti-inflammatory medication such as ibuprofen. Other conservative treatments include physical therapy, steroid injections, traction, ultrasound, electrical stimulation, acupuncture, heat/ice, massage and whirlpool.

Patients often are advised to change their lifestyle. They should lose weight, walk 30 minutes a day and do stomach-strengthening exercises such as sit-ups. Smokers need to quit. Smoking damages the structure of the spine.

Patients also need to be alert as to how they stand, sit and sleep. They should maintain good posture, avoid standing for long periods, use chairs with straight backs or low back support and sleep on a firm mattress.

If these treatment options do not provide relief within two to three months, then surgery may be needed.

When Surgery is Necessary

Surgery may be the correct course of action if conservative treatment does not work. Signs that indicate the possible need for surgery:

  • Leg or back pain limits normal activity, resulting in an unacceptable quality of life.
  • Weakness or numbness in the legs.
  • Difficulty walking or standing.
  • Medication and physical therapy are ineffective.

If a patient is in reasonably good health, neurosurgeons have a variety of surgical options available to help relieve pressure on the nerve. The most common procedure is a discectomy, which involves removing the soft gel-like material in the disc. This procedure returns the disc to a more normal shape, thereby relieving pressure on the nerve.

Neurosurgeons will sometimes remove a small piece of bone near the disc and irritated nerve to gain access to the disc or to give the area more space to expand and swell. If the nerve is being pinched as it goes through the opening between the bones on the way to or from the spinal cord, the neurosurgeon can also perform a foraminotomy, a procedure designed to expand the opening through which the nerve travels.

If several nerves and discs are causing the pain or the spinal column is unstable or degenerating, the neurosurgeon may opt to fuse the bones together with bone grafts and stabilize the vertebra with instrumentation, including metal plates, screws, rods or cages. Fusion will usually prevent the disc from bulging or herniating again.

Recovery After Surgery

A patient is usually released from a hospital two to five days after surgery and can resume physical activities such as walking almost immediately. Normal postsurgical pain will occur for a few weeks. Physical therapy may be recommended to help strengthen the muscles of the lower back and abdomen. Total recovery takes anywhere from six weeks to six months, depending on how advanced the condition was at the time of surgery and the patient''s preoperative neurological condition. Healthier patients tend to heal faster. Physical therapy may be recommended to speed healing.

The Dilemma of the Chronic Pain Sufferer

If you suffer from chronic pain, you probably have discovered that searching for effective relief can be frustrating and time consuming. You may have encountered additional difficulties in convincing others including not only health care providers but also friends and loved ones that your complaints of pain and suffering are real. Knowing when or where to turn for satisfactory treatment need not be futile, but you need to have appropriate knowledge in order to make the right decisions that meet your physical and emotional needs.

Take for example a 49-year-old female patient of ours who was extremely successful before she was involved in a motor vehicle accident that caused chronic back and neck pain. Her whole life was turned upside down, and she was unable to work or take care of her family. She spent the last 5 years going from doctor to doctor trying to find some relief but few took her complaints seriously. She had lost a great deal of self-confidence, and she doubted her own self worth as a mother, a wife, a friend, and as a person. This might sound like the story of someone you know. Perhaps it even sounds like something you are experiencing. In this article, we will relate how chronic pain sufferers such as this patient can, by becoming educated consumers, take charge of their health care, overcome barriers to effective pain management, and begin functioning again.

We have found that a major obstacle to receiving successful pain treatment is that many chronic pain sufferers lack credibility with others, including health care professionals and insurance company representatives. This is because you can't actually see pain or measure and confirm it by a test like taking your blood pressure or getting an x-ray.

A pain sufferer has to rely on his or her own word to convince others of their plight. As a result, many chronic pain sufferers are unfairly labeled as lazy whiners who exaggerate their complaints or, even worse, as malingerers who intentionally make up their pain. Some of our patients have related that because their x-rays or other tests looked "normal", a physician or a psychologist had tried to convince them that their pain was not real but rather "psychogenic", that is "in their head." Obviously, these labels can make it very difficult to access appropriate care.

Chronic versus Acute Pain

Why are medical tests often times "normal" or "non-definitive" in chronic pain patients? This is because in chronic pain there frequently is no obvious evidence of injury because the healing process has ended. This is different from acute pain, which is pain from a recent injury in which the body's attempt to heal is not yet finished. Following a recent acute injury it is easier for people to appreciate your pain and suffering and to empathize with you because there is observable proof of injury such as bruising, scabbing, swelling, the presence of blood, and bandages, splints, or casts. By the time pain becomes chronic, however, the typical signs of injury have resolved. Bruising and swelling, and bandages and casts have long since been removed. Once the visible evidence of injury is gone, most people assume that you have recovered and they expect you to go on with your life again as before. This misperception is likely because most people do not have personal experience with chronic pain and, as such, do not appreciate that chronic pain unfortunately can persist despite the body's attempt to heal itself and despite no obvious or visible evidence of injury or underlying disease. This can happen because the body cannot always fight disease effectively or repair itself successfully.

A lack of this understanding can lead health care providers to underestimate your true needs and this can result in your receiving inappropriate treatment or undertreatment. Frustration and stigmatization can erode your self-confidence and make you feel increasingly isolated from your friends and loved ones. We have seen many patients trapped in this vicious cycle of vulnerability experience degrading personal relationships and self-esteem, moodiness, loss of income, unproductive treatment, and relentlessly worsening pain and disability. A terrible irony is that this unfortunate outcome is avoidable with appropriate care.

Why Chronic Pain Management Is Often Inadequate

Modern medicine's many spectacular successes in disease control have raised our expectations about the medical care we receive generally. Unfortunately, however, many people's expectation that they should receive excellent pain management remains unfulfilled. Ironically, although modern advances in pain control can help most chronic pain sufferers enjoy satisfactory relief, there is an important reason why pain management often falls short on its promises. While teaching programs for health care professionals, including physicians, generally teach acute pain management well, very few teach anything at all about chronic pain management. Training in chronic pain management is generally provided only to the relatively few physicians who seek specialized pain management fellowship training following medical school. Unfortunately, due to this lack of training, many physicians do not appreciate the differences between acute and chronic pain and that effective treatment requires different methods. Many health care practitioners, as well as patients, are also unaware of the pain management resources available. The field of pain management is growing primarily to meet the needs of chronic pain sufferers but this growth is still in its infancy. We have a long way to go until everyone who has chronic pain does not have to experience frustration trying to obtain adequate pain management.

We believe that better pain management training can help to avoid situations where patients become undertreated with pain medications. Take for example the plight of an elderly grandmother living in a nursing home whom we encountered with uncontrolled chronic pain from cancer. She had become undermedicated because of her nurses' misunderstandings regarding the appropriate dosing of opioid pain medication prescribed by her physician. Her nurses were well meaning but felt afraid of losing their licenses by following the prescribing physician's pain medication dosage because they considered the dosage to be "too high." The nurses did not understand that you can treat chronic pain, including cancer pain, safely and effectively with higher doses of an opioid pain medication than what is oftentimes required for acute pain. On the other side of the coin, we recognize that there are well-meaning physicians who prescribe pain medications without fully understanding the nature of chronic pain and then encounter addiction problems.

The Role of Neurosurgeons

Neurosurgeons are the only physicians who routinely treat the entire spine. They can deal with problems of the spinal cord itself, nerve roots and the supporting structures of the spine. Neurosurgeons undergo six to eight years of specialized training following medical school, one of the longest training periods of any medical specialties. Because neurosurgeons spend about 70 percent of their time treating spine problems and have been extensively trained on diseases of the spine, they are familiar with all of the treatment options and can determine which option is likely to be the most effective for each patient. Surgery is one of many possible solutions the neurosurgeon may identify. A neurosurgeon will diagnose what is wrong and work with the patient to develop the optimal treatment plan.

See also:

Witzmann A, Hejazi N. Special neurosurgical paintherapy of the chronic back pain. (German)
J. Neurol. Neurochir. Psychiatr. 2001(4):23-32