Frequently Asked Questions

Frequently Asked Questions in Neurosurgery and Pain Management will be updated periodically and additional questions answered.

Disclaimer: The opinions expressed here are for general information and based on my own professional experience. They are not intended to replace the advice of your health care provider on your particular condition.

1. Question: I did 6 weeks of physical therapy and they really helped my back pain, but every now and then I have a dull ache in my lower back. The physical therapist gave me a paper and said I should do the exercises at home to strengthen my core. What does that have to do with my back?

Answer: Mechanical pressure on the lower back is one of the consequences of our evolution to walking on 2 legs. The structures that keep us upright include the vertebrae, discs, ligaments, back and abdominal muscles. Of course our legs and ankles also play an important role. Weak core muscles or bad posture, result in more stress, wear and tear on the structures and joints of the lower back, arthritis, and pain. Strengthening the core muscles can alleviate or prevent back pain.

2. Question: I am 55 years old and I have worked in construction for 35 years and never missed a day of work. I pulled my back at work 6 months ago. I did PT but it did not help. I had cortisone injections at a pain clinic in New Hampshire, and they burned the nerves, but it only eased my pain for 2 months. I am taking Ibuprofen 3 times a day, and I use CBD oil but my back still hurts. I asked my doctor to fill out my disability papers but she said that I should get another test. Why do I need another test if I say that I cannot go back to work?

Answer:  With a few exceptions such as complex regional pain syndrome (commonly known as RSD) which is often associated with characteristic changes in the skin, and affected limb, determination of functional impairment and disability cannot be based on subjective symptoms of pain alone. Most people in your age group have degenerative arthritis changes in the spine that do not necessarily reflect the degree of chronic pain. Testing such as functional capacity evaluation can provide objective evidence to assist your doctor determine your level of impairment, readiness to return to work, and possibility for gainful employment.

3. Question: I have had back pain off and on for 5 years. The pain started to go into my right leg just before Christmas last year, and I was limping and really in bad shape. My surgeon performed a laminectomy in my back in March of this year. He said that he removed a bone spur from my nerve. My leg pain is gone, and I am walking fine, but why does my back still hurt?

Answer: A variety of arthritic changes occur in the structures of spine from wear and tear, and can result in back pain. The usual treatment includes exercise, good posture and ergonomics, physical therapy, proper diet, and weight control. When arthritic bone spurs develop or the intervertebral disc herniates, the back pain may travel to the leg. If conservative measures and steroid injections do not control the leg pain, some patients may require surgical decompression to take the pressure off the nerve root and relieve the leg symptoms. The primary goal of such surgery is to treat the leg pain and related nerve symptoms, and not to alleviate the back pain. We have described the ongoing back pain as part of the “Post-surgical spine syndrome.” [ADDITIONAL INFORMATION]

4. Question: My 82 year old grandmother has fractures in her spine and she is taking 2 Oxycodone 5mg tablets a day. Her helper puts the pills in a daily pill organizer for her. When I came with her to the pain clinic last month she was told to take a urine drug test. Do they think that she is a drug abuser?

Answer: No. There are several reasons to do periodic urine drug screen (UDS) and the most important is patient safety. It is reassuring to find prescribed medications in the test. Failure to find the Oxycodone may indicate that she is taking it but her body is not absorbing it, or that she is not taking it. It is possible that her helper loaded the organizer with a different medication. UDS also helps to alert the prescriber if your grandmother is taking another prescribed or over the counter medication which may have an adverse interaction with Oxycodone.

5. Question: I had an epidural injection in my back in Florida during the winter and I no longer have pain in right leg. A few months later I was having pain in my right hip. I sent the reports from Florida and I wanted to get another epidural, but the Nurse Practitioner said I had to come in to be examined. She said that I had bursitis, and I am glad to say that I had the bursa injection, and after 3 days I was pain free. Why didn’t they do the bursa injection in Florida?

Answer: You said that the epidural injection took care of your leg pain. The likelihood is that you had a “pinched nerve” and that the inflammation of the nerve subsided with the epidural steroid injection. A bursa is a fluid filled cushion that is close to the muscles and ligaments of joints. Bursitis is the term used to describe inflammation of the bursa, and it often manifests with pain in the proximity of the joint.

6. Question: I have diabetes and take insulin. I started to have severe burning pain in my feet and legs 6 months ago. The pain wakes me up every two hours. I take Ibuprofen and it’s starting to hurt my stomach, but it does nothing to the pain. My primary got an MRI of my spine and sent me for cortisone injection. I went to the clinic and the doctor looked at the MRI, showed me the pictures of the disc degeneration and said that he did not see the cause of my pain, and ordered a nerve test. Am I missing something? I thought an MRI is to show what is causing my pain.

Answer: MRI does not show pain. The purpose of an MRI of the spine is to show the structures, identify any abnormalities such as arthritis, bone spurs, disc degeneration or herniation, fracture, tumor, or infection of the spine. The information provided may help your provider to determine which of the findings may be causing your pain or other findings on examining you. MRI does not identify neuropathy which is a possibility with the burning pain that you describe. The nerve test may confirm the diagnosis, though the test may be normal in some types of neuropathy. Cortisone injection is not the usual treatment for neuropathy. Diabetes is one of the common causes of neuropathy, but there are other causes such as chemotherapy, toxins, vitamin deficiency. Initial treatment may include medications such as Gabapentin, Pregabalin.

7. Question: My chiropractor treated my back for 12 weeks and my back pain is better but I am still having pain going into my legs. He ordered MRI and told me that I have a herniated disc, and that I should go to the Pain Clinic for an epidural injection. What is the next step and how do I know if my insurance will pay for it?

Answer: The first thing is for you to be seen in consultation, obtain a history of your pain and your general medical condition, examine you, and review the MRI scan. If it is determined that epidural steroid is best for you, the procedure, potential risks, and other treatment options, are explained to you, and you are given the opportunity to ask questions.  If you decide to proceed, the office will check and let you know if it is covered by your insurance, and any co-pay that the insurance has determined. Some insurance companies may require prior authorizations and it may take a few days to make a decision. Worker’s Comp may take a week or more to complete their review.

8. Question: I pulled a muscle in my back 2 weeks ago while lifting heavy machinery at work. I saw the company doctor and she said that I should go for PT. I asked for an MRI but she wouldn’t order one. Isn’t it just a band-aid and waste of time going to PT?

Answer: Most “pulled back”, muscle or back strain, are soft tissue injuries and often resolve within a few weeks with PT or other conservative management. In the absence of significant neurological deficits, an MRI is not likely to change the initial treatment.

9. Question: I had spinal fusion 3 years ago and I have scar tissue in my back and I take Vicodin and Gabapentin. I recently started smoking marijuana to help me sleep. My doctor did a urine test and warned me not to smoke marijuana otherwise the office will stop prescribing Vicodin. But marijuana is no longer illegal in Massachusetts, so what’s the problem?

Answer: There is some evidence that marijuana may have some therapeutic benefit in some conditions such as pain, anxiety, nausea, sleep disorder, seizures, and multiple sclerosis. However, the adverse reactions include short-term memory disturbance, paranoia, psychosis, impairment of motor co-ordination and increased risk of driving a vehicle. Andrew H. Rogers, and colleagues studied the outcome of opioid use alone versus combined use of opioid and cannabis, for chronic pain. They concluded “Potential clinical implications of these findings include that it may be important for clinicians to assess cannabis use prior to initiating opioids for the treatment of chronic pain. The results from this study suggest that cannabis use in the context of opioid use for chronic pain is associated with significantly worse mental health and substance use out-comes.”  [ADDITIONAL INFORMATION]

10. Question: I got a series of 3 epidural steroid injections at the Pain Clinic 2 years ago and the pain in my right leg went away. Now I am having back pain and it goes into the left leg. My PCP said that I should come back for another injection. I thought that I could only get 3 steroid injections in my life time?

Answer: Steroids have potential side effects with frequent or prolonged use, and they include elevation of blood sugar making it difficult to control diabetes, suppression of immune system and increased risk of infection, osteoporosis and risk of fractures, reduction of adrenal gland hormone production, weight gain, muscle weakness, poor wound healing, erectile dysfunction and loss of libido . In order to avoid these unwanted effects, the amount of steroid that is administered in epidural steroid injections is monitored and recorded. The number of injections is often limited to not more than about 3 every 6 months. Your thought that it is 3 injections in a lifetime is incorrect.

11. Question: My friend popped a disc in his back and couldn’t walk, and PT was too painful. He got an epidural and 3 days later he said that his back felt much better and the leg pain was gone. When I hurt my back I asked for an epidural; why did the doctor tell me that trigger point injection would be better for me?

Answer: Not all back injury is the same. It is likely that your friend’s injury resulted in a “pinched nerve,” hence the leg pain. In your case, if you sustained back strain and muscle spasm, then trigger point injection of local anesthetic into the muscles would be more appropriate.

12. Question: I crushed my leg 3 years ago and they put screws, but it always felt as if my leg was on fire. Gabapentin was working great but I am now taking 600 mg three times a day, and it doesn’t touch my pain, and I get dizzy. I asked my doctor, but he wouldn’t give me pain medication. He prescribed Nortriptyline. I read on the internet that it is used to treat depression. Does he think that the pain is in my head?

Answer: A number of medications have dual actions and are used to treat more than one condition. One that comes readily to mind is Acetaminophen (Tylenol) which has both analgesic (pain reliever) and antipyretic (fever reducer) properties. Nortriptyline (Pamelor) is both a tricyclic antidepressant, and is also used to treat neuropathic or nerve pain. Gabapentin (Neurontin) that was working so well for you is used as an anticonvulsant (to treat seizure), and also for treatment of neuropathic pain.

13. Question: I was playing football and I threw out my back. I did 4 weeks of PT and the pain is somewhat better, but I still get sharp pain in my left butt and it is very painful to sit for more than 10 minutes. My ortho doctor examined me, looked at X-rays of my spine and she said that the pain is in my SI joint and that I should see you for an injection. Don’t you always get an MRI before you give an epidural?

Answer: An epidural injection refers to introduction of medication (usually steroid) to the surface of the nerve. MRI or CT scan is often obtained to determine which nerve roots may be “pinched” or inflamed, and to determine the optimal target for the injection. The sacroiliac (SI) joint is the joint between the sacrum and the iliac bone, is lined by cartilage, and connected by fibrous ligament.  The nerve roots send tiny branches to the joint. They are often not seen on CT or MRI. X-ray study alone will suffice if the diagnosis is back strain. However, if there is suspicion for other risk factors such as fracture, infection, or tumor, then more advanced imaging studies may be considered.

14. Question: I am presently in Triple-A baseball and my ambition is to make it to the Major League. I ruptured a disc in my back and my doctor wants me to get a steroid injection. Won’t it make me fail a drug test and ruin my career?

Answer: There are different types of steroids. Corticosteroids have anti-inflammatory properties, are commonly used for joint and spinal injections. Their medical use is legitimate and will not get you in trouble. What you are concerned about are the anabolic steroids. These are structurally similar to the male hormone testosterone, and are illegally used by some athletes to build up muscles and enhance performance; better known as doping. Anabolic steroids have serious long term risks to your health.

15. Question: My doctor recommended epidural steroid injection because I have a herniated disc which is pinching my nerve and giving me terrible leg pain. Why wouldn’t they do an ablation?

Answer: Epidural steroid injection is more appropriate for your pinched nerve. Radiofrequency ablation (RFA), also called rhizotomy, is the use of an electric current to heat a portion of a nerve to block the transmission of pain signals. It is commonly used to treat some types of arthritic chronic pain in the spine, knee, and hip. Cardiac specialists also use ablation to block certain areas of the heart from generating and transmitting abnormal heart rhythm such as atrial fibrillation.

16. Question: I often hear you say that laughter is the best medicine. Can you explain what you mean?

Answer: There is an abundance of scientific evidence that laughter increases the release of endorphins (endogenous morphine) in the brain. They are part of nature’s mechanism for coping with pain and stress. By decreasing the heart rate and blood pressure and relaxing the muscles, laughter can reduce your stress level, boost the immune system, and be beneficial to the overall psychological and physical well-being. Some of the benefits derived can be long-term. [ADDITIONAL INFORMATION].

17. Question: It is interesting that laughter can make my pain better. Are there other things that I can do to increase my natural endorphin level that does not involve taking medication?

Answer: Laughter is the best medicine. Other activities that have been shown to boost the release of endorphins in the brain and decrease pain and stress include exercising, yoga, meditation, and singing. Complementary therapies such as acupuncture, and massage have been shown to trigger the release of endorphins.

18. Question: I hurt my back 2 months ago and the pain was traveling from my back to my leg, and the foot was numb. My doctor said that I had a herniated disc. She gave me an exercise program to do at home. The pain was gone in 3 weeks and I was back to normal. How did the exercise make the disc go back inside?

Answer: When a disc herniates, the central gel-like nucleus pushes out the weakened outer fibrous ring known as the annulus. It can sometimes rupture through the annulus. A herniated disc may affect the nearby nerve root in 2 ways. First is by mechanical compression, secondly chemical irritation by inflammatory substances that are released by the nucleus. The herniated disc does not actually work its way back in, but over time, it shrinks as it loses water and is absorbed by the inflammatory chemicals. It can take several weeks or months for the process to complete. When this happens, the limb pain and other symptoms of a “pinched nerve” also called radiculopathy, often improve or resolve. This is one major reason why, more often than not, conservative management is warranted before surgical consideration for the treatment of a disc herniation.

19. Question: My dad was helping me to replace the flat tire in my car 6 months ago and he felt a pop in his back. He had excruciating pain down to his left leg and he could barely lift the foot which was also numb. I drove him to the ER and the doctor said that he had a foot drop. They put an intravenous and gave him steroid through it. He had MRI of the spine and the doctor said that there was a large herniation. Dad was admitted to the hospital, and the spine surgeon was consulted. He had surgery the following day. His pain went away almost immediately, but he still has some numbness. He completed 3 weeks of PT and he has regained some strength in the foot, but not complete. The surgeon explained it but dad does not remember why he went for surgery and did not try epidural injection first. Can you enlighten me about the reason?

Answer: Many herniated discs can shrink over time, and surgery can be avoided. However, there are certain “red flags” which are indications for thorough diagnostic workup and possible urgent surgery to prevent significant long-term neurological deficit. Given that your dad had a foot-drop, early surgery was a reasonable consideration. Aside from significant motor weakness, other “red flags” include loss of bladder or bowel control, numbness in the saddle area of the buttocks, and suspected spinal infection or malignant tumor. In these circumstances, surgery may be considered to prevent progressive or devastating neurological loss. As with any other condition, patient’s overall medical status, respiratory, cardiovascular, BP, immune system, and glucose control, are important factors that are taken into account in the surgical decision making process.

20. Question: My neurosurgeon removed a tumor from my brain a few weeks ago. Thank God, I am doing very well. He said that it was a benign meningioma. He was unable to remove all of it and he is going to send me to get radiation therapy. I thought that radiation was only used to treat cancers. Am I missing something?

Answer: I don’t think that you are missing something. Complete removal of a non-cancerous meningioma may not be wise or possible if the location is difficult to access, if it is encasing a major nerve, artery or vein, or is in close proximity to other vital structures in the brain. In such circumstances radiation therapy may be recommended after recovery from surgery. The goal is to utilize precisely focused beam of radiation to shrink the residual tumor and prevent or slow it from growing over time.

21. Question: I have been working in construction for more than 20 years. I get pain in my back off and on. I heard that the spine is similar to the frame of a house. I don’t get it. Could you explain it to me?

Answer: The spine consists of a number of bony structures called vertebrae which house and protect the spinal cord and nerve roots. When viewed in a transverse plane, the strong bony foundation in front is the cylindrical vertebral body. A pillar, called the pedicle extends backwards on either side and connects to the triangular roof, or lamina. The chimney represents the spinous process. A bony wing called the transverse process projects from each side of the pedicle and provides attachment for muscles which play a role in maintaining posture. Between the pedicle and the lamina, a pair of processes called the facets extend upwards and downwards. The vertebrae form a chain, and the vertebral bodies are cushioned by discs which have a central gel that acts as a shock absorber, and an outer ring of strong fibrous tissue. The synovial joints of the facets allow for various motions. The ligamentum flavum (yellow ligament) is the thick ceiling which connects adjacent laminae and also attaches to the facet joints. The spine has 3 primary functions. i. Protection of the spinal cord and nerve roots from the base of the skull to the tailbone. ii. Maintenance of Posture. iii. Facilitate Movements of the head, neck, back, and hips. Wear and tear, arthritis, or injury to any of the structures may cause back pain.

22. Question: I get pain, cramping and numbness in my legs when I walk. I have to lean on a cart when I go to the supermarket. The PA (Physician’s Assistant) said that I have narrowing of the spine, and that when I lean on the cart it opens it up and that’s why I get better. How does the bone open up?

Answer: In the overview of the anatomy, I explained that the spine houses and protects the spinal cord and nerve roots. Narrowing of the spine, is referred to as “spinal stenosis.” It is often caused by wear and tear, resulting in arthritis which involves most of the structures of the spine. The outer ring of the disc degenerates and bulges out. The central gel becomes dry, shrinks, and is less effective as a shock absorber. There is loss of bone mass and development of bone spurs in the vertebral bodies, and enlargement of the facet joints. The ligamentum flavum loses elastin fibers and its elasticity, and there is thickening and buckling of the collagen component into the spinal canal. The result is spinal stenosis with compression of the spinal cord and nerve roots. When you bend or lean forward, the ligamentum flavum unfolds, flattens out and there is less compression. That is what is responsible for the temporary relief of your symptoms which are collectively known as neurogenic claudication.

23. Question: My grandmother lives in Arizona. Her neurosurgeon said that she has spinal stenosis in her back and recommended laminectomy under general anesthesia. Her primary care would not clear her for anesthesia because she has heart and breathing problems. She can hardly walk and she really wants something to be done. Epidural steroid injections helped her for a couple of years but not anymore. Are there other options?

Answer: Decompressive lumbar laminectomy involves removal of the lamina, ligamentum flavum, and thickened facet joint to take pressure off from the nerves. A fusion may be done as well if the spine is noted to be unstable from the primary arthritis or expected to be so after an extensive decompression. Minimally invasive options that often do not require general anesthesia may be considered especially in cases where thickening of the ligamentum flavum is the predominant cause of the stenosis. 1. Interspinous Spacer Procedure: A device is implanted between adjacent spinous processes to provide some flexion, and limit extension. This results in unfolding and flattening of the ligamentum flavum and relief of pressure on the nerves. 2. Minimally Invasive Lumbar Decompression (MILD): A less than 1 cm long incision is made, and with fluoroscopic guidance, a small tubular port is directed to the ligamentum flavum between the laminae. Special instruments are passed through the port to remove pieces of the ligament. Injection of contrast material in the spine during the procedure will give a good idea as to how well the canal has been decompressed.

24. Question: Back problem is common in my family, and many have had lumbar laminectomy. My nephew has had back pain for many years. He eats healthy, there is no ounce of fat in his body, he attends PT and goes to the gym at least 3 times a week. His low back pain has been getting worse recently, and his spine surgeon said that he has discogenic pain, not sciatica. We are confused. What is discogenic pain?

Answer: In one of our earlier discussions, I likened the vertebrae to a chain which provides protection to the spinal cord and nerve roots, supports posture, and allows for body movements. The discs are the cushions and shock absorbers between the bony vertebrae. They are innervated by sinuvertebral nerves which are mostly present in the outer fibrous ring called the annulus. These nerves are different from the nerve roots that supply the muscles and skin of the extremities. Annular disruption and disc degeneration can occur from wear and tear related to repetitive movement of the back. Irritation of the sinuvertebral nerves results in the type of back pain known as “discogenic pain.” Unlike sciatica, which arises from “pinching” of the nerve roots, discogenic pain is mostly confined to the back, but can be referred to the thigh or leg. The initial treatment often includes measures such as activity modification, home exercise program, PT, anti-inflammatory medication, chiropractic, and acupuncture.

25. Question: I told you about my nephew, and you provided an explanation of discogenic pain, the diagnosis which his spine surgeon made. He went on a brief visit to Newfoundland in Canada, and the cold weather wasn’t kind to his back. He has spent the better part of the past 6 months doing all those things you mentioned, PT, chiropractic, injections, you name it. He had a discogram last week, and his surgeon wants to remove the disc and replace it with some type of an artificial disc device. The surgery will be done from the front, and a vascular surgeon will be assisting him. None of us has ever heard about artificial disc. Can you explain anything about the surgery?

Answer: If discogenic back pain persists despite standard treatments and significantly impacts quality of life, disrupting everyday activities, it may require closer examination.  Your interventional pain physician or spine surgeon may perform a minimally invasive provocation test called discography to pinpoint the specific disc that is responsible for the pain. Following confirmation, more advanced treatment options can be considered. One minimally invasive approach is radiofrequency ablation of the sinuvertebral nerves. Surgical options include discectomy and spinal fusion. One drawback is that more motion occurs at the vertebral levels adjacent to the fusion, making them vulnerable to developing progressive arthritic changes. For some patients, total disc replacement with an FDA-approved prosthetic disc may be a better choice over a fusion.  The surgery requires an exposure through the abdomen and navigation between several blood vessels. The services of a vascular surgeon who is more familiar with that environment are crucial for this aspect of the operation. With disc replacement, range of motion is preserved, and the stress on adjacent levels is minimized.

26. Question: I thought that Botox was only used to remove wrinkles, but I was speaking with a friend the other day and she told me that it is also used to treat pain. Please tell me more about it.

Answer: Botulinum toxin comes in various brands. It is a medical grade toxin that is derived from the bacteria Clostridium botulinum. The clinical application is based on its ability to cause muscle relaxation by blocking the release of acetylcholine at the junction between the nerve and the muscle. Acetylcholine is a chemical which triggers muscle contraction. When a relatively small amount of botulinum toxin is injected into specific muscles, acetylcholine is blocked, the muscles relax as they are temporarily paralyzed, and the wrinkles flatten out. Botulinum toxin has medical uses other than cosmetic. It may be considered to treat certain myofascial pain and muscle spasms that have failed to respond to conservative measures such as home exercise program, physical therapy, massage, acupuncture, chiropractic, oral muscle relaxant, and injection with local anesthetic. The more common conditions include neck spasm, torticollis, migraine, back spasm, localized limb spasticity from trauma, stroke, or multiple sclerosis, and overactive bladder. Only individuals who have received specialized training should administer the injection. The specific targets in the taut muscles are called trigger points. Some can be identified by manual palpation, but the use of ultrasound or electrical stimulation may improve the accuracy. In the case of the urinary bladder, the detrusor muscle in the inside is visualized through a cystoscope. The potential risks of botulinum toxin injection include muscle weakness, drooping of the eyelids, slurred speech, difficulty swallowing and breathing, and loss of bladder control.

27. Question: Are there any virus products that have a medical application?

Answer: One that comes readily to mind is the Johnson & Johnson COVID-19 vaccine which uses a modified and harmless adenovirus to deliver genetic material to trigger an immune response to the virus.  Another one that is showing promise in clinical trials is the use of genetically modified poliovirus for the treatment of a very aggressive type of brain tumor known as glioblastoma. With conventional treatments such as surgery followed by chemotherapy and radiotherapy, the average life expectancy is 12 to 18 months after the diagnosis. However, some people have survived for more than five years.  The rationale behind the research is that since poliovirus naturally attacks cells in the nervous system, it could be modified and injected into the tumor to trigger an immune response to destroy the tumor cells while sparing normal brain cells. The results of the trials are encouraging. There is hope.

28. Question: I read about the tragedy that occurred decades ago when Thalidomide was used to treat nausea during pregnancy. Many children were born with birth defects, and the drug was taken off the market. Is it true that it is now used to treat some types of cancer?

Answer: Thalidomide, which was a widely used sedative in the 1950s and 1960s for pregnancy-related nausea, led to tragic outcomes. Its use resulted in numerous cases of congenital malformations, often involving underdeveloped or missing limbs in newborns. Consequently, it was removed from the market by the early 1960s. Notably, while it was extensively used in several countries, it did not receive commercial approval for use in the United States. Thanks to the U.S. Food and Drug Administration (FDA) who played a pivotal role by expressing apprehensions about its safety profile. More recently the ability of thalidomide to inhibit the growth of blood vessels (antiangiogenesis) that tumor cells need to survive, has been exploited to develop new cancer treatments. It is presently approved to be used in combination with the steroid dexamethasone, for the treatment of multiple myeloma, a type of blood cancer. There is ongoing research in the use of thalidomide in brain cancer treatment but it is by no means an established therapy. The focus of the research is the potential benefit when thalidomide is combined with chemotherapy or other antitumor agent in the treatment of glioblastoma which is a very vascular and aggressive tumor.

29. Question: Are there any differences between degenerative arthritis and rheumatoid arthritis?

Answer: There are significant differences. Degenerative arthritis which I referred to as being one of the common causes of back pain is also called osteoarthritis. It is caused primarily by wear and tear on the cartilage of various joints in the body, and the intervertebral discs by repetitive motion. On the other hand, rheumatoid arthritis is an autoimmune condition in which the immune system mistakenly attacks the synovium of joints and other organs resulting in inflammation, pain, stiffness, and structural damage. Systemic symptoms such as fever and weight loss are common. Rheumatoid arthritis can cause skin nodules, vasculitis, dry eyes, and bone marrow involvement resulting in anemia. Similar to what I said about discogenic pain, both types of arthritis may benefit from activity modification, home exercise program, PT, anti-inflammatory medication, chiropractic, and acupuncture. However, one important tool in the treatment of rheumatoid arthritis is the use of immunosuppressive medication, commonly referred to as disease-modifying antirheumatic drugs (DMARDs).

30. Question: What are some of the highlights in the history of pain medicine?

Answer: The word “Pain” is derived from the Greek “Poine” the Greek goddess of revenge. The ancient view of pain was that it was divine punishment for some wrongdoing. Treatments included prayers, intervention by priests, and making sacrifices to the gods. Fast forward to 1644 when French philosopher René Descartes proposed that pain is due to impulses that are produced by an injury and are transmitted directly along a nerve to a center in the brain where it is perceived. More than one hundred years later in 1775 Benjamin Franklin used static electricity to stimulate the nerve and treat pain. In 1965, Canadian psychologist Ronald Melzack and British anatomist Patrick Wall introduced a groundbreaking theory of pain mechanism, challenging Rene Descartes’ idea after 400 years. They proposed The Gate Control Theory of Pain which suggested that parts of the spinal cord act like a gatekeeper capable of inhibiting or facilitating the transmission of signals from the body to the brain. New treatments for pain emerged focusing on the chemical or electrical stimulation of descending inhibitory pain pathways or modulation and suppression of ascending pain signals at the level of the spinal cord. I would like to conclude with the current definition of pain by the International Association for the Study of Pain (IASP).  Pain is “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

31. Question: I had dinner with my friend the other day, and she told me that she heard that the hot pepper habanero is used to treat some types of pain. Is this something that we do in the U.S.? Gracias doctor.

Answer: Gracias Senora. Thank you Ma’am. Habanero is the Spanish name for one of the hottest varieties of chili pepper. Because of its intense flavor it is a staple in spicy cuisine. It contains the chemical called capsaicin which can relieve neuropathic pain, muscle pain, and arthritis or joint pain when applied topically to the skin. It binds to the nerve endings initially causing a burning sensation, then it desensitizes nerve and blocks the transmission of pain. Therapeutic capsaicin preparations are presently available in two forms, creams and patches. The cream has a maximum concentration of 0.1% and can be obtained over the counter. Contact with the eyes, or open wounds should be avoided as it can cause serious irritation, burning, and pain. The hands must be thoroughly washed after application. The prescription-only 8% patch is indicated for the treatment of postherpetic neuralgia which can follow an attack of shingles, and diabetic neuropathy of the feet. It is to be administered only by a trained healthcare professional using appropriate gloves and eye protection. Given that the patch can be very painful, the skin is pretreated with a local anesthetic cream such as lidocaine, or lidocaine-prilocaine (EMLA). The therapy may not be appropriate for you if your blood pressure is uncontrollably high. The treating professional removes the patch targeting postherpetic pain after 60 minutes, while that for diabetic neuropathy is removed after 30 minutes.  If the treatment is successful and provides some pain relief, the application can be repeated every 3 months if clinically indicated.

32. Question: What brain related problems are associated with poor oral hygiene?

Answer: Poor oral hygiene resulting in tooth decay and dental caries poses a risk for potential brain-related problems from the entry of oral bacteria into the bloodstream potentially reaching the brain and other organs. The migration of bacteria to the membranes covering the brain can result in meningitis, or it can extend further to the brain itself, leading to the formation of a brain abscess. Various forms of spinal abscesses can also occur. The entry of bacteria into the bloodstream increases the likelihood of blood clot formation, cerebral embolism, and stroke. Individuals with dementia and Alzheimer’s disease frequently exhibit poor oral hygiene, often characterized by gum disease also referred to as periodontitis, and tooth loss. This condition arises from inconsistent brushing habits and inadequate oral care practices. Attending to the oral care requirements of these individuals will not only enhance dental hygiene but also mitigate associated risk factors, consequently enhancing their overall health and well-being.

33. Question: Are there dietary supplements that can help alleviate pain?

Answer: Turmeric belongs to the ginger family and has anti-inflammatory properties that aid in reducing pain. It is available as a spice, tea, pastille, or as a capsule. Its active compound is Curcumin. Ginger can also reduce muscle pain. The anti-inflammatory attributes of Omega-3 Fatty Acids and Fish Oil supplements have the potential to reduce pain. Vitamin B12 deficiency is a known cause of peripheral neuropathy which can be painful. Calcium, Vitamin D, Magnesium, and Zinc, all play a role in supporting bone metabolism and strength. Adequate amounts in a balanced diet, or as supplements, might offer protection against osteoporosis and painful vertebral compression fractures, which can significantly impact one’s quality of life. Avoidance of unhealthy diet, over processed food, obesity, and smoking, can also lead to a reduction in inflammatory pain. A false sense of security may arise that dietary supplements are universally safe because they are not generally regulated. It is advisable to discuss with your healthcare professional before starting a dietary supplement, as there may be potential adverse reactions, or interaction with other medications. It is important to keep in mind that regular exercise plays a vital role in maintaining overall well-being and reducing pain.

34. Question: What are the differences between acute and chronic pain?

Answer: Acute Pain is typically triggered by a specific injury, surgery, or event. It often responds well to treatment, the intensity diminishes as healing occurs, and the duration is relatively short-term. It can be considered as serving as a warning signal to protect the body from further harm. Common causes of acute pain include muscle strain, skin bruise or burn, bone fracture. Chronic Pain can originate from a particular injury but it persists after the injury has healed, typically lasting longer than 3 months or even years. It involves sensitization of the nervous system leading to potential occurrence of spontaneous pain at rest, pain from normally painless stimuli (allodynia), or increase in intensity of a painful stimulus (hyperalgesia). The conditions which can progress to chronic pain include back pain, arthritis, fibromyalgia, nerve injury, spinal cord injury, and stroke. Chronic pain serves no clear protective function, and it can have a negative impact on the quality of life. It is estimated that 20 percent of adults in the U.S. live with chronic pain. The treatment can be challenging, usually requiring a multidisciplinary approach. Chronic pain often leads to issues like depression, anxiety, insomnia, and chronic fatigue, so that psychological support is essential.

35. Question: What tissues in the body are responsible for causing pain?

Answer: Pain can be divided into two categories based on the tissue of origin, neuropathic and nociceptive. Neuropathic pain results from injury or damage to the nerves. Examples include sciatica, neuropathy, carpal tunnel syndrome, and spinal cord injury. The pain is often described as tingling, burning, shooting, electric-shock, and stabbing.  Nociceptive pain arises from an injury or disorder of tissue outside the nervous system that activates pain receptors called nociceptors. Such receptors in the skin, muscles, bone, and joints, are capable of producing somatic pain which is described as aching, throbbing, less often, sharp.  This type of pain can occur from arthritis, osteoporosis, and poor leg circulation. Pain that arises from nociceptive receptors in internal organs is also known as visceral pain. It tends to be poorly localized, and is commonly described as deep, dull, pressure, or cramping. Examples include peptic ulcer, gastroesophageal reflux disease (GERD), menstrual pain, urinary bladder infection, and kidney stones. Mixed pain is a combination of neuropathic and nociceptive pain.  This may be seen in migraine, sickle cell disease, or cancer. The acute pain of sickle cell disease is thought to be mostly nociceptive and related to vaso-occlusion resulting in tissue injury. However, patients with sickle cell disease also have chronic pain and there is evidence that a component of such pain is neuropathic. Effective pain management requires attention to both pain mechanisms. Regrettably, studies suggest that approximately 70% of individuals with advanced cancer experience pain, and about 25% of them pass away without receiving adequate relief.

36. Question: I am familiar with the use of ultrasound tests for examining the abdomen. Can ultrasound be utilized to look at structures in pain management or neurosurgery practice?

Answer: While x-ray is the best known of the radiological techniques, and is outstanding for demonstrating bones, fractures and osseous abnormalities, it does not show soft tissues very well. Ultrasound is a very useful tool in the diagnostic imaging of soft tissues. Portable units can be used for real time image guided navigation in interventional pain management and in cranial and spinal neurosurgery. Image guidance allows the surgeon to reach the target safely while avoiding injury to vital structures and blood vessels along the way. When removing a tumor, it can be beneficial to differentiate between normal tissue for preservation and abnormal tissue for removal. Some studies have indicated fewer complications when brain tumor resection is done utilizing ultrasound guidance. A new technology known as functional ultrasound imaging can offer real-time high resolution images of the spinal cord during surgery. A secondary benefit of ultrasound in the operating room is that no radiation is involved, so that the surgeon does not have to wear an often heavy lead apron during the surgery.

37. Question: Did you say that ultrasound can also be used for treatment in neurosurgery?

Answer: Within the nervous system, a dynamic balance is maintained between facilitatory and inhibitory mechanisms, often mediated by various natural chemicals known as neurotransmitters. Imbalance may be corrected by stimulation of the underactive pathway, or by suppression or ablation of the overactive system. Let us take Parkinson’s disease as one example. Parkinson’s disease is a neurological disorder caused by degeneration of nerve cells in the part of the brain known as the basal ganglia which facilitate movement. The four characteristic symptoms of Parkinson’s disease are tremor, muscle stiffness (also called rigidity), slow movements (also known as bradykinesia), and an unstable posture. Tremor is seen in about 75% of patients with Parkinson’s disease. It often affects the upper extremity on one side, occurs mostly at rest, and can result in significant functional impairment. Parkinson’s disease tremor is mostly related to a deficiency of the neurotransmitter known as dopamine which is produced in the part of the basal ganglia known as the substantia nigra. Dopaminergic medications may be effective, but for those who are dopamine-resistant other treatment options may need to be explored.

38. Question: Wow, this is getting more interesting. How is the ultrasound focused at the target in the brain to treat Parkinson’s disease?

Answer: Focused ultrasound is an FDA approved minimally invasive treatment of tremors associated with Parkinson’s disease, and also for essential tremors. The procedure takes about 2 to 3 hours. It is usual to place an intravenous line, and a urinary bladder catheter, so that the procedure is not interrupted by a full bladder. The head is shaved because hair can obstruct the transmission of sound waves. The procedure is done in an MRI room with the patient lying on their back on the MRI table.  It is important for the treatment team to communicate with the patient who may even be asked to write some words, or draw figures during the procedure. Intravenous sedation may be provided for comfort but no general anesthesia is required, and there is no scalp incision or drilling of the skull. A stereotactic frame is secured to the head with four pins after injection of local anesthetic to the scalp. A silicone cap containing cold water is placed around the head and the frame is attached to the MRI bed to keep the head still as any motion can degrade the quality of the images and precision of the treatment. Under MRI guidance and temperature measurement, increasing pulses of sound waves are directed to the target usually in the area known as the globus pallidus to heat and disrupt the nerves that are responsible for generating the tremors. Only one side of the brain can be treated at a time. The Food and Drug Administration (FDA) approved the second side to be treated at least 9 months after the first. The results are good in about 70% of patients, but may not be permanent. There are potential side effects and risks which are best discussed with the healthcare providers before signing a consent for the procedure.

39. Question: You mentioned that the potential risks are best discussed with the healthcare providers before undergoing the procedure. Can you briefly touch on some of the more common side effects with focused ultrasound treatment of Parkinson’s disease?

Answer: During the treatment itself, some patients have reported headache, sharp or burning head pain, nausea, and vomiting. Typically, the majority resolve within one or two days. A number of potential side effects can occur after the procedure. They include scalp irritation, muscle weakness, and unsteadiness of gait, dizziness, numbness and tingling in the fingers or around the mouth, or other parts of the body, loss of taste, slurred speech, and difficulty swallowing. Your healthcare provider can go into more detail, and also answer any questions.

40. Question: I read about someone who had deep brain stimulation surgery to treat their Parkinson’s disease and they did very well. What is the difference between deep brain stimulation and focused ultrasound?

Answer: There are important differences between deep brain stimulation, also known as DBS, and focused ultrasound treatment, for Parkinson’s disease. Earlier, I pointed out that restoring balance in the nervous system could involve either stimulating the underactive pathway or suppressing the overactive system. DBS takes the first approach, which is to apply electrical energy to stimulate specific targets in the brain which in turn will interrupt the signals that are responsible for the tremors. DBS is more invasive than focused ultrasound treatment. A stereotactic head frame is applied similar to focused ultrasound treatment, but the stimulation device consisting of electrodes and a generator have to be implanted. A scalp incision is made, and a small hole is drilled in the skull through which the electrodes are guided to the target which is deep in the brain. The electrode wires are tunneled under the scalp and connected to a small generator which is implanted under the skin of the upper chest wall. Some surgeons will bury the ends of the wires under the scalp, and return a day or several days later to connect them to the generator and complete the implantation. The electrodes are implanted under mild sedation to allow for intraoperative stimulation to get the optimal placement for tremor cessation, and to be certain that there are no undesired effects such as tingling and discomfort. The implanted stimulator is turned on and off, and programmed with an external hand-held patient controller, which is about the size of a mobile phone.

41. Question: I know very little about a topic that has featured in the news lately. Perhaps you can help me to understand it better. What exactly is climate change?

Answer: Climate change is often referred to as “Global Warming” because it is mainly characterized by rising environmental temperatures and an increase in the frequency and intensity of heat events due to shifting climate patterns. The United States Centers for Disease Control (CDC) estimates that there were approximately 1,602 heat-related deaths in 2021, 1,722 in 2022, and it increased to 2,302 in 2023. [ADDITIONAL INFORMATION]

42. Question: That was what I thought but I wasn’t sure. Are there any medical consequences of climate change?

Answer: The increased heat from climate change can have direct and indirect adverse effect on one’s health. Dehydration, heat exhaustion, heat stroke, are direct consequences. The elderly, outdoor workers such as those in construction, and agriculture, are particularly vulnerable. Wild fires can cause burns, contaminate the air and water and contribute to respiratory and waterborne diseases. More widespread and community disruptions can occur from extreme weather events due to climate change. The impact of storms, hurricanes, and flooding, can include injuries that cause lasting brain, spinal, orthopedic challenges, and chronic pain. Severe climatic events can also result in loss of property, livelihood, and death.

43. Question: I read that in recent years there has been a steady rise in the number of cases of malaria in tropical countries due to climate change. Can you explain it?

Answer: Diseases which are caused by insect bites are referred to as vector-borne diseases. Malaria is one of the best known, but others include dengue fever, Zika virus, and Lyme disease. As warm weather spreads to new regions, mosquitos, which are the vectors for malaria, broaden their habitat, not only in the tropics, but on a global scale. There is some optimism that the recent introduction of malaria vaccines may stem the rising tide of malaria in some of the most vulnerable tropical countries.

44. Question: Is climate change driven by natural forces or is it caused by human activity?

Answer: Scientific evidence indicates that climate change is largely driven by human activity. However, natural forces also play a role that is too small to account for the rapid warming that has been observed in recent decades. The Earth’s surface absorbs energy from the sun and typically emits this energy as infrared radiation and heat into outer space, thereby keeping the surface relatively cool. However, human activities release greenhouse gases such as carbon dioxide, methane, and nitrous oxide which absorb the heat and infrared radiation and re-emit them towards the Earth’s surface, leading to increased atmospheric warming. The burning of fossil fuels such as coal, oil and natural gas for energy and transportation is the largest source of carbon dioxide which is the most abundant of the greenhouse gasses. Trees absorb carbon dioxide_, and deforestation removes an important source of clearing it from the atmosphere. The natural forces which contribute to climate change include solar radiation, and volcanic activity. Variations occur in the sun’s energy but they have no significant effect on global warming. Volcanic eruptions release gases and particles into the atmosphere that can reflect sunlight away from the Earth, actually resulting temporary atmospheric cooling, rather than warming.

45. Question: Thank you for the clear explanation. It seems to me that the solution to the problem of global warming rests squarely in our hands. Do you agree or should we be waiting for divine intervention?

Answer: As the name implies, global warming is a worldwide problem that requires international cooperation for a successful response. The world is a functional system of interdependencies where the action of one nation can affect the whole system. Countries should base their actions on scientific facts, and reputable sources of information, and act in good faith and genuine commitment. Overwhelming scientific evidence implicates human activity as the leading cause of global warming. A crucial step to counter this dangerous trend is to reduce the production of greenhouse gasses, particularly carbon dioxide. As I alluded to earlier, the burning of fossil fuels such as coal, oil, and natural gas for energy and transportation is the largest source of carbon dioxide_. Alternative sources of energy which are more environmentally friendly need to be explored. Renewable energy sources such as solar energy, wind energy, and hydroelectric power can produce abundant energy without causing global warming. Major economies might consider offering incentives to encourage low-income countries to embrace renewable energy and energy efficiency. Deforestation, which eliminates a crucial carbon dioxide sink, can be mitigated by strict control of both legal and illegal logging activities, and improving infrastructure development to protect the environment. On an individual level, we can reduce paper usage by opting for electronic statements where possible, filing applications digitally, reusing grocery bags, and supporting local recycling initiatives. During weather emergencies, it is important to pay attention to finding safety shelters, maintain hydration, and utilizing cooling, and relief centers.

46. Question: A dear friend of mine has smoked cigarettes for many years. She began to experience shortness of breath, and I’m very proud of her that she chose to quit and has not smoked for over three months. How does smoking cigarettes affect breathing?

Answer: I join you in congratulating your friend for making the right decision and following through with it. Cigarette smoking is associated with a wide range of serious health hazards, involving the respiratory, cardiovascular, and other systems. Smoking irritates the airways and lungs, leading to inflammation, increased mucus production, swelling and narrowing of the air passages. The symptoms can include shortness of breath, wheezing, chronic cough, and fatigue. Long term effects include Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, and emphysema. Tobacco is carcinogenic, and there is strong scientific evidence that cigarette smoking is the leading cause of lung cancer, accounting for about 80% [ADDITIONAL INFORMATION].  Smoking is also closely linked to cancers of the mouth, throat, esophagus, kidney, cervix, liver, urinary bladder, pancreas, stomach, colon, and rectum.

47. Question: How does cigarette smoking affect the cardiovascular system?

Answer: Smoking damages blood vessels because the nicotine in tobacco causes narrowing of the arteries which results in loss of elasticity, a buildup of plaque, otherwise known as atherosclerosis. Narrowing of the coronary, cerebral, and peripheral arteries increases the risk of heart attack, stroke, and poor arterial supply to the legs and arms.

48. Question: In your discussion of the Covid-19 emergency on your website, you said that not all heroes wear capes, and that some wear helmets. You will be pleased to hear that I have a friend who is a retired firefighter and a true hero. I recently drove him to a meeting of a patient support group at a spine clinic, and nearly every speaker highlighted the harmful impact of smoking. What are the effects of smoking on the spine?

Answer: I salute your friend, and other firefighters who bravely confront fires and other dangers to rescue and save others.  In my previous answer, I mentioned that nicotine damages and narrows blood vessels. Decreased blood flow to the spine can lead to the development or worsening of disc degeneration, osteoporosis, back pain, and even nerve compression. For patients who are undergoing spinal surgery, impaired blood and oxygen supply increases the risk of poor healing of bone and wound. Smokers are more likely to develop postoperative complications such as pneumonia, and blood clot in the leg (deep venous thrombosis). Some spinal fusion surgeries are not ideal for smokers given the high rate of non-union. Patients are typically advised to stop using smoking, vaping, and other nicotine products, including patches and gums, for 4 to 6 weeks before undergoing non-emergency surgery. Some centers will conduct a urine analysis to confirm that the body is free of nicotine before proceeding with surgery. While abstaining from nicotine for at least 4 weeks after surgery is beneficial, some providers advise at least 3 months. In my opinion, the best course of action is to quit permanently.

49. Question: Does cigarette smoking have any effect on pain?

Answer: Yes. The active ingredient in cigarette, nicotine, binds with the area of the brain known as the limbic system, and triggers the release of dopamine. This neurotransmitter promotes the production of endogenous opioids, has analgesic effects and may provide some short term pain relief, euphoria, and a false sense of feeling good. However, chronic cigarette smoking has numerous adverse effects on the causation, perception, and treatment of pain. Long term exposure to nicotine can cause tolerance, desensitization in the pain pathways and increased sensitivity to pain, a condition known as hyperalgesia syndrome. Smokers often report higher intensity of chronic pain compared to non-smokers. Impairment of blood supply to the spine, and the resulting degenerative disc disease and osteoporosis can cause back pain. Pain management is generally more challenging because smokers may require higher doses of pain medications to achieve the same level of pain relief as non-smokers.

50. Question: What resources are available to people who have a hard time quitting cigarette smoking?

Answer: Cigarette smoking can be addictive, and people who are looking to quit often require counseling, support, and assistance. Some people choose to begin with self-effort. They might find the addition of one or more of the following resources to be beneficial. 1. Telephone line 1-800-QUIT-NOW. 2. Mobile App QuitSTART. 3. Online site https://smokefree.gov/. Others prefer counseling, either individually, in a local group setting, or by attending Nicotine Anonymous meetings. Regardless of the option chosen, it is advisable to consult with the healthcare provider to receive personalized advice and guidance. Exploring additional options such as Nicotine Replacement Therapy to reduce craving and withdrawal symptoms, may be beneficial. Quitting smoking provides numerous immediate and long-term health benefits with significant improvement in overall well-being and quality of life. The life expectancy of non-smokers or those who quit smoking is about 10 years longer than those who continue to smoke. I don’t want to be philosophical, but I call your attention to the famous quotation “If at first you don’t succeed, try, try again.”  The expression is a call for perseverance and persistence. The quote “You never fail until you stop trying” is often attributed to Albert Einstein, and is a powerful reminder that with persistence and relentless effort, we can achieve our highest goals. Please, don’t give up your efforts to quit. Every stride you take is a step towards a healthier life for you and for others who may be exposed to second hand smoke. Extinguish your cigarette and light up a brighter future.

51. Question: I know that sickle cell affects the blood. Can one get it from a blood transfusion?

Answer: No, it is not transmissible through blood transfusion. Sickle cell disease refers to a group of inherited disorders characterized by the presence of crescent shaped (sickle) red blood cells (HbS). It is one of the most common genetic disorders in the world, impacting over 20 million people. It primarily affects people of African, Mediterranean, Middle Eastern, Asian, and Latin American descent.  The most common form is sickle cell anemia. When only one sickle cell gene is inherited, the condition is called sickle cell trait (HbAS), which rarely causes any symptoms. Two sickle cell genes have to be inherited, one from each parent, for a child to have sickle cell anemia (HbSS), which has the most severe symptoms.  Other forms of sickle cell disease include sickle hemoglobin-C disease (HbSC), and sickle cell beta thalassemia (HbS/ß-Th).

52. Question: What medical challenges are faced by individuals with sickle cell disease?

Answer: Red blood cells contain hemoglobin which is rich in iron, and is involved in the transportation of oxygen from the lungs to the tissues of the body. Normal red blood cells are round in shape. In sickle cell disease some of the red blood cells become sickle or crescent shaped and rigid, and cannot efficiently transport oxygen. Healthy red blood cells have a lifespan of about 120 days. The abnormally shaped sickle cells are fragile and they frequently breakdown in 10 to 20 days, leading to a deficiency in red blood cell count, and anemia which is an inadequate amount of red blood cells or hemoglobin. Symptoms usually begin to appear between the ages of 4 and 6 months, and the child can look pale, tired, and less playful. The liver is unable to quickly filter out the rapidly disintegrating sickle cells which release bilirubin into the system, resulting in yellow discoloration of the skin, eyes, and the urine. Under normal circumstances, bilirubin is excreted in the bile and urine. When the sticky red cells block the flow of blood in small blood vessels, the consequences can include pain, both acute and chronic, swelling of the hands and feet, infections, growth retardation, problems with vision, and stroke.

53. Question: How does the blockage of blood flow cause pain?

Answer: Periodic episodes of acute pain, sometimes referred to as vaso-occlusive crisis, occur when sickle-shaped cells block the blood flow to the spleen, abdomen, chest, bones, and joints, thereby depriving the tissues of oxygen. The body reacts by producing more lactic acid which activates the pain receptors called nociceptors. The acute, severe pain of sickle cell disease is thought to be mostly nociceptive. The severe pain often requires hospitalization. Witnessing an innocent child suffer through the pain of a sickle cell crisis is heart-wrenching, not only for the parents and family, but also for the doctors, nurses, and other healthcare providers. It can last from one day to about one week. Some children will bounce back with so much bravery and begin to play and interact with others shortly after the acute pain is over. Patients also have chronic pain from persistent or ongoing tissue and bone damage, and leg ulcers. There is evidence that a component of the chronic pain is neuropathic. In an earlier discussion, I explained that pain can be divided into two categories based on the tissue of origin, neuropathic and nociceptive. Neuropathic pain results from injury or damage to nerves. Both mechanisms have to be taken into account for effective pain management. There is an important takeaway that cannot be emphasized enough. Please, listen. When a child frequently complains of pain and is found to be anemic or jaundiced, a diagnosis of malaria alone is not sufficient. Proper laboratory investigation is required to explore the possibility of sickle cell disease. It is absolutely acceptable for a parent or guardian to ask the pediatrician, “Do you think that it could be sickle cell?” In the United States, newborns are routinely screened for sickle cell disease through a blood test.

54. Question:  Knowing the significant challenges of sickle cell disease, are there any preventive measures available?

Answer: There is presently no way to fully prevent the symptoms of sickle cell disease in individuals who already have the condition. However, various measures can be taken to prevent factors that trigger acute attacks, thereby alleviating symptoms and reducing complications and sickle cell crises. Good hydration should be maintained to avoid the death of red blood cells. The acute pain can be exacerbated by cold weather, so a warm but not hot temperature is ideal. High altitudes are associated with low atmospheric oxygen, and should be avoided because of the risk of further tissue damage. Exercising should be done with moderation to avoid depriving the tissues of oxygen. Good hygiene is essential to ward off infection. Antibiotics may be used for prophylaxis or to treat an infection. Vaccinations, and blood transfusions are often important tools. An oral medication called hydroxyurea can reduce frequency of pain episodes by about half. It promotes the production of fetal hemoglobin (HbF), which helps to prevent red blood cells from sickling, leading to a reduction in the need for blood transfusions, and other complications. It is approved by the Food and Drug Administration (FDA) for use in severe sickle cell disease. [ADDITIONAL INFORMATION]

55. Question: I have heard you say that blood type B-positive resonates with you. Is there something to “B” positive about sickle cell disease in the near future?

Answer: Blood type B positive always reminds me to be positive. While there is currently no cure for sickle cell disease and many challenges remain, some ongoing research is starting to show promising results. Red blood cells are produced in the bone marrow. In sickle cell disease, the bone marrow cannot produce enough red blood cells to compensate for the rapid breakdown of the defective ones. One area of research is bone marrow transplant as a potential cure. It is also known as stem cell transplant because it involves replacing abnormal stem cells in the bone marrow with normal cells from a compatible donor. Research in gene therapy is still in its infancy. It aims at modifying the gene of the individual so that there can be more production of fetal hemoglobin (HbF) which has more oxygen carrying power than sickle red blood cells (HbS). There is also gene editing which is a cutting-edge biotechnological technique designed to modify the genetic code inside the cells to correct the problem in the gene that causes the production of hemoglobin S (HbS). Many studies are in their early stages, and are beginning to yield encouraging outcomes with less pain crises, and improved quality of life. I am positive that with more funding and research, there is hope in the horizon.

56. Question: There is a lot in the news about the staggering number of deaths in the U.S. from drug addiction, especially fentanyl. What exactly is addiction?

Answer: Addiction is a chronic brain disorder characterized by the compulsive urge to use a substance or engage in a behavior, even when it results in harmful consequences. The most severe manifestation of substance use disorder is substance addiction. Examples include alcohol, nicotine usually from cigarette smoking, and drugs such as opioids like morphine, heroine, and fentanyl. Behavioral addiction can involve gambling, and excessive social media use.

57. Question: What drives people into addiction?

Answer: I want to start by correcting a common misconception. Consider the example of a baby exposed to drugs in the womb and is born addicted. This situation strongly illustrates that drug addiction is not always by choice. Addiction is similar to other medical conditions such as hypertension, and diabetes. The causes of addiction can be categorized into biological, social and environmental, and psychological factors. Biological factors include genetics, and chemical imbalances in the brain. Social and environmental factors typically involve issues like food and financial insecurity, neglect by family or society, difficult relationships, social media and peer pressure, and exposure to addictive substances. Psychological factors primarily consist of emotional trauma, stress, anxiety, and depression.

58. Question: How do addictive substances and behavior affect the brain?

Answer: A potentially addictive substance or behavior triggers the release of large amounts of the neurotransmitter dopamine in the area of the brain known as the limbic system which serves as a “reward center.” The limbic system plays a role in the regulation of movement, motivation, emotions, pleasure, and euphoria. The “happiness” and euphoria from the dopamine rush is short lived, as the reward network of the brain reduces the number of dopamine receptors that are responsive to the agent. Repeat or long term exposure can cause tolerance, in which a larger amount of the substance or behavior is required to give the same pleasure. The result is an uncontrollable craving for more, with a disregard for the consequences. This is the essence of addiction. Elevated dopamine levels have also been linked to behavioral effects such as irritability, anxiety, and aggression. Failure to get more of the addicting agent leads to withdrawal symptoms characterized by nausea, vomiting, headache, anxiety, depression sweating, agitation, tremors, and seizures.

59. Question: Why is it that many people who are struggling with addiction and have committed no crime end up in jail if their problem is a disorder of the brain?

Answer: I have been asking the same question for a long time and have even written about it. In the 1960s, some scientists, including psychiatrists, began the anti-psychiatry movement in Europe and North America. Their main argument was that most mental illnesses lacked an organic cause. Thus, they believed that it was not people who were ill, rather it was society that was sick. They were against the medical treatment of most mental illnesses, and believed that suicidal patients had a right to destroy themselves. They saw mental institutions as instruments of government control and advocated that they should be closed. Their views were enhanced by the movie One Flew Over the Cuckoo’s Nest which was released in 1975. By the mid 1970s significant numbers of state psychiatric hospitals had been closed. In their chapter in the book titled, Current Controversies in Neurosurgery, published in 1976, Dr. Mark and Dr. Ordia warned that those actions “would precipitously dismantle our mental hospitals and discharge mentally ill patients into an unprepared community.” We strongly advocated that they should be provided access to proper medical care. While the anti-psychiatry movement is now only a shadow of itself, the aftermath of closing mental institutions continues to impact society. This has led to prisons being sometimes inappropriately utilized as substitutes for medical facilities. Functional MRI studies can reveal specific brain abnormalities in individuals with addiction. MR spectroscopy (MRS) can detect changes in the levels of the neurotransmitter dopamine and serotonin during addiction, and recovery. However, some people continue to deny these findings, similar to those who still believe that Covid-19 is a hoax.

60. Question: What steps can we take to reduce the problem of addiction?

Answer: It requires the combined efforts of the entire community to successfully combat addiction.  Let’s begin with Parents. The brains of children and adolescents are still developing, and are more susceptible to behavioral influences. A safe and loving home and protective school environment can promote good mental health. When exposed to peer pressure, they should be reminded that you don’t have to put your hand in fire to know that fire burns. Any decline in school performance should be investigated so that it can be promptly remedied. Providers are trained to practice safe and responsible prescribing and monitoring. Pain management often begins with non-opioid options such as physical therapy, chiropractic, acupuncture, non-steroidal anti-inflammatory drugs (NSAID), psychological support and cognitive behavioral therapy, and interventional procedures. Patient education and the establishment of realistic goals is essential before prescribing opioid. The ultimate goal is functional restoration and not necessarily to eliminate all the pain. Patients should use all medications responsibly and according to the given instructions. Safe storage of controlled substances is important to protect those around you. Don’t drive under the influence, avoid aggressive behavior towards others, and avoid actions that might attract the attention of law enforcement. When you are feeling down, turn to your faith and you will find hope. You should not have a feeling of shame or guilt. Take advantage of support groups. If you are struggling and are unable to reach your healthcare giver or local emergency services, consider calling the Substance Abuse and Mental Health Services Administration at 800-622-4357 for free treatment referral information. Public policy must ensure that addiction is not stigmatized, acknowledging it as a medical condition, not a moral failing. Prisons are not appropriate substitutes for healthcare facilities. Punishment alone, without serious attention to rehabilitation, will inevitably lead to failure and relapse.

61. Question: How was pain treated in ancient times?

Answer: Ancient cultures dating to around 3000 BC, including African, European, Oriental, and the Americas believed that pain was a form of punishment or possession by demons for moral transgressions and wrongdoing. Treatment primarily involved rituals, offerings to appease angry gods, and the use of herbs. The poppy seed was used by the Samarians of Mesopotamia mainly for its euphoric effect. Acupuncture was introduced in the Far East to balance the philosophical forces of Yin (darkness and passivity) and Yang (light and activity). A deficiency in Yin was linked to chronic, dull pain and insomnia, while an excess of Yang was associated with acute, sharp pain, fever, inflammation, and anxiety.

The beginnings of pain management are commonly traced to ancient Greece, around 2000 BC. The word “Pain” originates from “Poine,” the name of the Greek goddess of revenge. This was rooted in the ancient belief that pain was divine punishment for moral transgressions and wrongdoing. In Greek mythology, the god of medicine, and pain relief was Asclepius, the son of Apollo, the god of healing. The Romans referred to him as Aesculapius. He is often depicted holding a staff with a serpent wrapped around it, which has been used as the symbol of medicine since 800 BC. It should not be confused with the Caduceus which features two serpents intertwined around a staff with a pair of wings at the top. In 1902, it was adopted as the insignia of the United States Army Medical Corps. Temples dedicated to Asclepius were frequently visited by people who were seeking treatment for chronic pain or other ailments, and treatments were guided by priests.

62. Question: How did those earlier beliefs about pain change to a more scientific explanation?

Answer: Hippocrates (460-370 BC), is considered as the father of Western Medicine, and a descendant of Asclepius. He wrote the original Hippocratic Oath which begins with “I swear by Apollo, the Healer, by Asclepius ….” and includes “I will use those dietary regimens which will benefit my patients— and I will do no harm or injustice to them.” He argued that the origins of diseases were natural, and dismissed the belief that they were inflicted by gods in response to sin. He proposed the theory that an imbalance in the humors of blood, phlegm, yellow bile, and black bile, resulted in inflammation, disease, and pain. He promoted a holistic approach to treatment, emphasizing the importance of rest, hygiene, diet, mental well-being, and herbal remedies. His famous saying “If you want to learn about the health of a population, look at the air they breathe, the water they drink, and the places where they live” is just as pertinent today. Hippocrates and his followers used opium, the juice of the poppy plant, to treat pain, and to control diarrhea and cough.

I also wish to say “Efharisto” (meaning “Thank you”) to Hippocrates for his invaluable role in shaping the definition of the mission and ethics of medicine.

There was a prolonged era during which scientific medicine remained stagnant. Even as organized religions took a foothold in various nations in the late BCs through early ADs, the notion that pain, suffering, and illness were divine retribution for sins remained deeply rooted. Treatments continued to be centered on faith, prayers, rituals, and exorcism.

63. Question: Who carried on the mantle of medicine after Hippocrates?

Answer: Claudius Galen (129-216 AD) was a Greek-Roman physician and one of the leading physicians in ancient Rome. He promoted the humoral theory of Hippocrates. However, most of his work was devoted to the dissection of primate and mammals and study of the anatomy which he regarded as the foundation of medical knowledge. He identified pain as an indicator of disease, and that three conditions were necessary for its perception: a receptor of the stimulus, a connecting nerve pathway, an a central processing center in the brain where it is perceived.

64. Question: What other significant breakthroughs followed Galen’s contributions to the understanding of the anatomy of pain?

Answer: French philosopher and scientist Rene Descartes (1596-1650) proposed the theory of dualism, asserting that the body and mind exist separately. He described pain as a physical sensation that occurs in the body but is perceived in the mind, paving the way for the understanding that pain has both physical and psychological dimensions. He introduced the theory of a pain pathway, suggesting that a pain signal travels from the injury site through a nerve directly to a brain center where it is perceived.

Between 1880 and 1940, many scientists worked tirelessly to understand the anatomy of neurons and synapses, and the physiology of chemical neurotransmitters.

The discovery of ether as an anesthetic gas deserves mention. The first public display occurred on October 16, 1846 at the Massachusetts General Hospital, Boston, in an amphitheater that is now known as the “Ether Dome.” A dentist, Dr. William Morton anesthetized a patient with ether, and a surgeon, Dr. John Warren, successfully removed a tumor from the patient’s neck. This breakthrough changed surgery from a distressing and painful ordeal to a more humane experience. The use of ether as a general anesthetic spread widely around the world. Ether was replaced by newer and safer inhalation agents in the 1960s. Attending a meeting at the Ether Dome was always special for me given its historical significance. I was a senior resident in neurosurgery when I gave my first presentation at the Ether Dome, and the subject was the history of pain management. In attendance was Dr. William Sweet, one of my professors, and a pioneer of neurosurgical pain management and education. Dr. James White and Dr. William Sweet co-authored a book, “Pain and the Neurosurgeon: A Forty-Year Experience” which was published in 1969.

Dr. John Bonica, an anesthesiologist at the University of Washington in Seattle, was a pioneer of interdisciplinary pain management, and he championed the creation of specialized pain clinics. In 1947, he established the first multidisciplinary pain clinic at his hospital with services from anesthesiologists, neurologists, psychologists, and other healthcare professionals. He also introduced innovative interventional techniques. In 1953, he published the groundbreaking book “The Management of Pain.”

65. Question: You pointed out that after Rene Descartes, scientists focused on the study of neurons and neurotransmitters. Did their work help in shaping current pain medicine?

Answer: Yes it certainly did. After 400 years, a significant milestone in the understanding of pain emerged in 1965 when Canadian psychologist Ronald Melzack and British anatomist Patrick Wall presented the Gate Control Theory of Pain. They challenged the view of Rene Descartes that a pain signal travels from the injury site through a nerve directly to a brain center where it is perceived.

The Gate Control Theory of Pain proposes that a mechanism in the spinal cord acts like a gate which inhibits or facilitates the transmission of a stimulus from a site of injury to the brain where it is processed and can be influenced by psychological factors before the sensation is perceived as pain. Descending messages from higher centers of the brain to the spinal cord can also close the gate. Researchers used this theory and its adaptations as a foundation for developing various treatments. The psychological factors that can modulate pain perception include anxiety, stress, and depression. Psychological counseling, and cognitive behavioral therapy were introduced. Medications were produced either to block the message from reaching or passing through the gate or to activate the inhibition from the higher centers in the cortex of the brain. Nerve ablation, and various types of electrical stimulation of the nerve, spinal cord, and brain, were developed to activate the inhibitory pathways or suppress those that facilitate the transmission of pain.

66. Question: I know that many people have back pain because of problems with their discs. What exactly is a disc?

Answer: The spine plays a vital role in the structure and function of the back, and consists of a chain of 33 bony vertebrae, each separated by a disc, except for the first two vertebrae in the neck. The bony vertebral bodies are cushioned by discs which have a soft central gel called the nucleus pulposus that acts as a shock absorber, and an outer ring of strong fibrous tissue, the annulus fibrosus, which keeps the nucleus in place. By cushioning the spine, the discs enable flexible and stable movements of the head, neck, back, and hips, while also preventing bone rubbing on bone, reducing wear and tear and the risk of arthritis, and injury to spinal structures.

67. Question: What is a herniated disc?

Answer: A herniated disc occurs when the soft central gel-like nucleus pulposus protrudes through a weakness or tear in the outer layer, the annulus fibrosus. The classification is based on the location and characteristics of the herniation:

68. Question: What are the common causes of herniated disc?

Answer: The causes of herniated disc are numerous, and range from gradual wear and tear to an acute injury. There are also genetic predispositions. In the course of daily living and movement, over time the outer ring of the disc, the annulus fibrosus, can be weakened by small tears. Injuries from repetitive bad posture, overuse, overweight, or acute injury such as from lifting, twisting or a fall, can cause annular tears of different sizes. Disc degeneration is a natural part of aging. It is marked by loss of water in the nucleus of the disc, which leads to loss of disc height, diminished cushioning effect, weakness of the annulus, and increased risk of disc herniation.

69. Question: You said that discs can be classified based on the location and characteristics of the herniation. What are the types of herniated disc?

Answer: A Protrusion is when the disc bulges outward but the outer ring, the annulus fibrosus, remains intact. It is called an Extrusion when the nucleus pulposus breaks through the annulus but remains connected to the disc. A Sequestration occurs when a fragment of the nucleus breaks out of the annulus, completely detaching from the disc and migrating into the spinal canal or foramina. It is sometimes called a “free fragment.”

70. Question: What problems can be caused by a herniated disc?

Answer: The discs are located near the spinal cord and nerve roots that exit through openings between the vertebrae (foramina). Healthy discs help protect these nerves by maintaining proper spacing between the vertebrae. When a disc is damaged or herniated, it can protrude into the spinal canal or foramina, which can result in chemical irritation and mechanical compression of the spinal cord, and nerves.  The symptoms often include pain in the neck or back, and weakness, numbness and tingling in the extremities. Sudden loss of bladder or bowel control, or weakness with foot drop, are “red flags” warning of a potentially serious condition that requires prompt medical attention to prevent potentially irreversible loss of neurological function. Please seek medical attention right away by notifying your healthcare provider or going to Urgent Care or the Emergency Room if you encounter any of these “red flags.”

71. Question: In our previous session you described some of the causes. What can I do to reduce my risk of developing a herniated disc?

Answer: Your commitment to preventive care is commendable as it is often a better approach than focusing solely on treatment. Preventive strategies include regular exercises and stretching. Eating a balanced diet and keeping a healthy weight can alleviate stresses on the spine, while avoiding smoking enhances blood flow and nourishment to the vertebrae and discs. Practice good posture, use supportive shoes, and follow correct lifting practices. Choosing a firm mattress supports spinal alignment and promotes restful sleep.

72. Question: A friend of mine recently arrived in the U.S. as an exchange school teacher from Europe. She developed problems with sciatica and she did PT for 4 weeks but the pain did not improve. Her primary care physician referred her to a spine specialist, and she was surprised to be asked nearly the same questions she had already answered for her PCP. She wanted me to ask you why the specialist did not copy the information from the computer to their record to save time.

Answer: Having a discussion with her specialist serves to establish a professional patient-provider relationship, and opens up a channel of communication where she also has the opportunity to ask questions. The standard of care calls for the specialist to obtain an independent history, rather than relying on notes that could contain some error. In addition, based on the answers to targeted questions, the specialist can more effectively zero in on detecting any specific nerve roots that could be involved, and to look for potential causes outside the vertebrae. Medical knowledge is constantly evolving with new discoveries that enhance diagnostic tools and surgical techniques. Evidence-based guidelines are frequently updated as clinical data emerge. The specialist is more likely to be familiar with new breakthroughs related to her condition. Applying this knowledge effectively requires a deep understanding of her unique circumstances and making individualized decisions.

Comment: I certainly get it, and I will convey your response to her. Merci beaucoup docteur.

73. Question: Can you explain how a herniated disc is diagnosed?

Answer: Making a diagnosis often begins with a detailed medical history which can provide insight into the present symptoms and form a basis for understanding previous and present illnesses, treatments, medications, and other health related issues. Some patients have mentioned to me that they were embarrassed to discuss certain symptoms when speaking with a provider of the opposite gender. A medical condition reflects neither personal failing nor fault; it calls for empathy and compassionate care, not judgment. Withholding important information can hinder the ability to receive optimal care. The history is followed by a physical examination which primarily focuses on the musculoskeletal and nervous systems, but the cardiorespiratory and other systems are evaluated as well. Even when the history and physical examination point to a herniated disc, an imaging test may not be ordered at the outset, given that herniated discs often shrink over time, with 85% to 90% resolving within 6 to 12 weeks [ADDITIONAL INFORMATION]. However, uncontrollable pain, or the presence of any red flag symptom, such as loss of bladder or bowel control, loss of sensation around the rectum and buttocks, foot drop, infection, cancer, or acute fracture, may require blood tests, and prompt imaging. X-rays are excellent for visualizing bones, but not soft tissues like acute herniated discs which are better seen on MRI. CT scan may be used if the patient has an implanted device that is not MRI compatible or conditional, or that may create an artifact.

Patients who have failed to respond to physical therapy, a home exercise program, or appropriate pain medications may also be candidates for MRI or CT, to assist in guiding further treatment. If questions remain about which nerves may be contributing to the symptoms, Electromyography (EMG) and Nerve Conduction Studies (NCS) may provide information about the electrophysiological activity of the nerves.

74. Question: What are the treatments for a herniated disc?

Answer: I explained earlier that herniated discs frequently shrink, with most resolving within 6 to 12 weeks. In the absence of any red flag symptoms, this timeframe is a good opportunity to focus on conservative management. Measures include a home exercise program, physical therapy, pain medications which may include non-steroidal anti-inflammatory medication, oral steroid, and Gabapentin which is often used to treat neuropathic or nerve pain. Referral may also be made for acupuncture, or chiropractic treatment. If there is no sustained response, or the symptoms worsen after 6 weeks of conservative management, MRI or CT scan may be obtained to confirm the diagnosis. Identifying a herniated disc with nerve compression can open up additional treatment options. Epidural steroid injection delivers a small amount of an anti-inflammatory steroid directly on the nerve using image guidance, aiming to reduce inflammation caused by mechanical compression and inflammatory chemicals that are released by the disc.

Surgery is considered if reasonable conservative treatments prove to be ineffective. In the lumbar spine, the primary objective is to remove the herniated portion of the disc to alleviate compression on the affected nerve. There are different approaches to the disc, some are minimally invasive, while others are open. To reduce the risk of reherniation, some surgeons use an annular closure device to close the opening in the outer ring through which the disc herniated. When recurrent herniation occurs at a site of a previous discectomy, repeat discectomy along with lumbar interbody fusion is considered to reduce the risk of yet another herniation in the affected area. For certain spinal conditions, an anterior approach through the abdomen to the spine can be the preferred method. A vascular surgeon may be needed to safely navigate through the blood vessels and provide surgical exposure for the spine surgeon. The surgeon will explain the type of surgery that is best for your particular condition, the potential risks, and realistic expectations. While the leg pain and abnormal sensations may gradually improve, removal of the disc does not directly target relief of back pain. The key here is to maintain stretching, exercises, ergonomics, and the other preventive measures that we talked about.

75. Question: So, what types of surgery are performed for a cervical herniated disc?

Answer: The surgical approach to a cervical herniated disc is largely determined by the type, size, and location of the herniation relative to the spinal cord. Unlike the nerve roots in the lumbar area which can withstand gentle retraction to reach the disc, retraction of the cervical spinal cord carries risks including reduced blood flow called ischemia, swelling, and potential paralysis. If a disc extrusion or sequestered fragment is at the side of the spinal cord and is compressing the nerve root, a posterior surgical approach may allow for removal of the herniated section without retraction of the spinal cord. On the other hand, if the disc is compressing the spinal cord anteriorly, it is often safer to approach it from the front of the neck. The entire disc is removed, and the surgeon can choose to either perform a fusion or, alternatively, a Cervical Disc Replacement (CDR) using a device that allows for some motion at the joint. Anterior Cervical Discectomy and Fusion (ACDF) of two vertebrae causes more motion and increased stress at the adjacent discs and joints. A few years later some patients develop degenerative disc disease and arthritis in the joints, a condition known as Adjacent Segment Disease (ASD). The changes can result in nerve root or spinal cord compression, and require further surgery. To be eligible for cervical disc replacement (CDR), the conditions that have to be met include, healthy, mature bones, absence of severe arthritis, osteoporosis or other metabolic bone disease. Your surgeon can discuss the options for your particular condition and the potential risks.

76. Question: What is spinal cord stimulation?

Answer: Spinal cord stimulation is the use of a medical device to deliver controlled electrical impulses to targeted areas of the spinal cord. In our context, the objective would be to provide pain relief.

77. Question: I recall you mentioned spinal cord stimulation in relation to the gate control theory of pain. Please elaborate on the connection?

Answer: In 1965, Canadian psychologist Ronald Melzack and British anatomist Patrick Wall proposed The Gate Control Theory of Pain which suggested that parts of the spinal cord act like a gatekeeper capable of inhibiting or facilitating the transmission of signals from the body to the brain. The back or dorsal aspect of the spinal cord is the target area. Stimulating the large nerve fibers transmits touch, pressure, and tingling sensations to the brain and activates inhibitory interneurons to “close” the gate to pain signals from smaller, slower nerve fibers. The tingling sensation, also referred to as paresthesia, masks the pain. When your foot hurts and you rub it, you feel better because the pain signals are blocked from reaching the brain.

78. Question: Which patients are suitable candidates for spinal cord stimulation?

Answer: Spinal cord stimulation is not a first line treatment for pain. It may be considered for patients with chronic neuropathic pain who have failed medical and interventional management. It is mostly beneficial for persistent spinal pain syndrome involving the upper or lower extremity and back following surgery, painful diabetic neuropathy, and complex regional pain syndrome (CRPS). An individual whose cognitive impairment hinders their ability to provide meaningful feedback during the trial, or use the patient remote control may not be suitable. Contraindications to surgery include active infection, bleeding disorder, or uncontrolled diabetes. An MRI or CT scan of the spine is obtained to identify abnormalities that might interfere with the precise placement of the epidural lead. Psychological screening is required, because managing the psychological stress caused by chronic pain maximizes the benefits of spinal cord stimulation. A patient with a cardiac pacemaker should consider a spinal cord stimulator from the same manufacturer, if available, for easier access to technical support.

79. Question: If the MRI is good, and psychological clearance has been given, what is the next step?

Answer: The next step is a trial phase to assess the effectiveness of the therapy before deciding on permanent implantation. The patient should receive a thorough explanation of the potential risks, and their questions clearly answered. The percutaneous technique is often used. The percutaneous lead is composed of wires insulated with polyurethane, and featuring an array of cylindrical electrodes typically made of platinum-iridium, titanium, or gold, at the distal end. A connector at the proximal end connects to the generator.

The trial can be done with a single or dual leads. Under mild sedation and local anesthesia, a special spinal needle is passed into the appropriate level of the spine, and using fluoroscopic image guidance, the lead is advanced into the epidural space. Dual leads are placed parallel, one on each side of the midline. The connectors are attached to a handheld trial stimulator via a trial cable. Intraoperative stimulation testing involves using various electrode combinations. Patient feedback helps to fine-tune the optimal placement. The goal is paresthesia covering the affected areas of pain. The cable is discarded. The proximal ends of the leads are secured to the skin, a sterile dressing is applied, and the leads are connected to a trial stimulator.

A paddle lead trial might be an option if spinal abnormalities present challenges for percutaneous lead placement. Unlike the thin cylindrical percutaneous lead, the distal end of the paddle lead is flat and is usually made of silicone. The array of electrodes are only on one surface. The placement of the paddle lead is more invasive and requires a back incision and a laminotomy, which can also be done under sedation and local anesthesia. A temporary paddle trial is otherwise similar to a percutaneous trial. After direct epidural lead placement under fluoroscopy, and satisfactory testing, the proximal lead wires are externalized, secured, and a dressing is placed. A drawback is that, following the trial, the lead has to be removed in the operating room. With a permanent paddle trial, the epidural lead is fully implanted, and anchored. It is connected to a lead extension which is the only part that is externalized and connected to a trial stimulator. If later proceeding with a permanent implant, the extension is discarded, and the existing lead is connected to an implantable pulse generator (IPG).

In the recovery room, a company representative will add several programs to the stimulator, and teach the patient how to use the remote control. Many patients like low frequency tonic stimulation which masks the pain with paresthesia, during the day. The high frequency (HF) mode is favored by some at night as it targets inhibitory interneurons to alleviate pain while avoiding the large dorsal column nerves, ensuring pain relief without paresthesia. Percutaneous trial is usually day surgery, while those who undergo a laminotomy may be observed overnight. The length of the trial is variable but commonly around 3 to 7 days. Pain reduction of at least 50% is considered to be a successful response. Percutaneous leads are pulled out at the office. A temporary paddle trial requires surgery for removal. With a permanent paddle trial, the extension is removed in the operating room, and if the trial was successful the pulse generator can be implanted simultaneously.

80. Question: What does permanent implantation involve?

Answer: If the trial is successful, permanent implantation is done under mild sedation and local anesthesia. To implant percutaneous leads, an incision is made in the back, a spinal needle is introduced, and under fluoroscopy, the epidural leads are advanced to mirror their positions during the trial. Test stimulation is performed to confirm that paresthesia covers the painful areas. The lead wires are anchored to the ligament or fascia, and lead extensions are added if more length is needed. They are tunneled under the skin to a second incision and subcutaneous pocket in the upper buttock chest, or abdominal wall, and connected to the generator, which is about the size of a pacemaker. Impedances are measured to ensure proper connections between the leads and the generator. The generator is placed in the pocket, and both incisions are closed and dressings are applied. The generator typically contains a battery and a computer chip enclosed in a titanium or plastic case. A rechargeable generator with lithium-ion battery has a lifespan of ten years or longer. A non-rechargeable model with lithium battery last around five years, however, with light use or low-energy burst stimulation, some may last up to ten years.

Following a temporary paddle trial, the previous spinal incision is reopened, and a new paddle lead is advanced into the epidural space under fluoroscopy. After satisfactory test stimulation the lead wires are anchored to the fascial or ligament. Lead extensions may be added before they are tunneled to a subcutaneous pocket and connected to the generator, and impedances are verified. The generator is placed in the pocket, the wounds are closed and dressings are applied. The surgery is similar if the trial was with a permanent paddle. However, the externalized extension is discarded, and the existing paddle wires with or without new extensions are tunneled to the pocket and connected to the generator. Impedances are checked, wounds are closed, and dressings are applied.

Prior to discharge, the patient is taught how to use the remote control. Charging guidelines are included if the generator is rechargeable. Further reprogramming may be done during follow-up office visits. Reaching overhead, bending, twisting, and heavy lifting should be avoided for several weeks to prevent displacement of the lead.

Please remember these safety tips. Always have the remote control readily available. Turn off the stimulator while driving or operating machinery to avoid distraction from the stimulation. Airport and security metal detectors can trigger the generator, so opt for a manual screening. Be prepared to show an identification card (ID) which you will receive from the manufacturer with information about your devices. Inform your healthcare provider about the stimulator before scheduling any MRI scan, as specific safety conditions have to be followed. Your surgeon should use bipolar electrocautery during surgery instead of monopolar.