Frequently Asked Questions

The FAQ 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.

FAQ 1-5

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.” [MORE 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.

FAQ 6-10

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.”  [MORE 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.

FAQ 11-15

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.

FAQ 16-20

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. [MORE 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.

FAQ 21-25

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.

FAQ 26-30

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.”

FAQ 31-35

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.

FAQ 36-40

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.

FAQ 41-45

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. [MORE 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 themost 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.