Spinal Cord Injuries
Spinal cord injury
Spinal cord injuries are associated with damage to the spinal cord, typically traumatically induced, although these may be related to other events. Spinal cord injuries are typically associated with spasticity and a variety of other problems. A team approach is required for the care of these patients (please see section on spasticity).
Groin pain can follow a variety of different abdominal or hernia operations and in these cases is frequently related to injury or scarring around a peripheral nerve or nerves within the abdominal wall. Groin pain can also be the result of referred pain from a variety of other injuries including sacroiliac injuries and degeneration of the hip joint. In order to treat groin pain properly, a precise determination as to the cause of the symptoms is required.
Medial and Lateral Collateral Ligament Injury
Medial and lateral collateral ligament injuries are often associated with injury of the respective medial or lateral meniscus. These injuries can often effectively be treated with regenerative medicine therapy using PRP (as long as the tears are partial and not associated with retraction).
Neck or cervical pain can be caused by a variety of different injuries and degenerative conditions. Neck pain frequently follows motor vehicle accidents, slip and falls, and other trauma. The mechanism of injury is important and can help the doctor determine which structures were damaged. An extremely common injury occurs related to something referred to as the whiplash phenomena. This happens when the neck is traumatically and rapidly moved forward and backward. This motion can injure discs, joints, muscles, and ligaments in the cervical region. Treatment must be directed at those structure(s) in order to successfully control this type of traumatic pain.
Some patients will have pain simply related to degeneration of their disc or other spinal structures. Neck pain is frequently associated with headaches. This can be the result of normal wear and tear or the development of arthritis in an area that was previously injured. The neck is comprised of a variety of different structures including discs, joints, and muscles, and any one (or more than one) of these structures can cause pain. It is important to identify which of these structures is (are) causing symptoms and then appropriately direct care to those specific problems. It is important to note that some patients will need surgery to try and control their cervical pain or to repair a damaged structure in the neck. While cervical spine surgery is often successful and, in fact more frequently than lumbar surgery, there is a small group of patients who will have persistent pain following surgery. There are many treatment options available for patients with persistent pain following cervical spine surgery.
Shoulder pain is one of the most common sports injuries seen today amongst athletes but it can affect anyone. Typically the patient will know when they injured their shoulder, either with a specific motion (lifting a heavy object or hyper extending one’s arm) or trauma (fall, motor vehicle accident, etc). Careful examination can often determine the specific portion of the rotator cuff or other shoulder structure that is injured. This can be confirmed with imaging such as ultrasound or MRI. Many shoulder injuries can be treated conservatively with regenerative medicine therapies, others require open surgical treatment. Dr. Kloth will help you to understand whether you have a conservative option for treatment of your symptoms. Regenerative medicine techniques can be used to repair partial tears of the rotator cuff, labrum, and other such structures with little risk. Failure of these therapies does not eliminate the possibility of surgical intervention. Regenerative medicine techniques are associated with a much shorter recovery time and less pain during the acute post-procedure period, although both open surgery and regenerative medicine techniques for the shoulder require a significant postoperative exercise/therapy program.
Heel Pain- Plantar Fasciitis
Heel Pain- Plantar Fasciitis
Heel pain is frequently related to plantar fasciitis. While previously heel spurs were described as the primary cause of pain, it is now felt that the spur is formed in response to the strain placed on the calcaneus or heel. Treatment of the primary plantar fasciitis will help to control the symptoms. PRP injections (with possible fat grafts) may be very helpful for plantar fasciitis and other foot and ankle injuries (please see foot and ankle for other related injuries).
Foot and Ankle Pain
Foot and Ankle Pain
Ankle sprains and fractures frequently result in chronic pain. Treatment for these injuries will be determined by the location of the fracture, the extent of healing, and previous treatment of the injury (i.e. – was surgery performed and if so did the surgery heal as expected). Other types of injuries to this area include ligament tears, Achilles tendonitis and partial Achilles tendon tears; these conditions are often responsive to PRP therapy. Nerve injuries in the foot can result in severe pain and in the some cases can cause the patient to develop a complex regional pain syndrome (see sympathetic pain syndromes)
Unfortunately cancer is often associated with significant pain as adjacent tissue is destroyed by the cancerous tumor. Specific treatments for cancer are directed at the underlying cause of symptoms. When a nerve is being compressed by the direct growth of a tumor, treatment of that nerve injury may be helpful. For instance, radiation or chemotherapy may help shrink the tumor and therefore may help to control the pain. When this does not help or is not an option (i.e. – too much radiation already), then direct injection of the compressed nervous structure or of the nerves innervating that tissue, may be helpful. In extreme cases the nerve can be permanently destroyed, chemically (most commonly with the injection of alcohol or phenol). Pancreatic cancer, which is associated with severe abdominal pain, is often well treated with a neurolytic injection of the celiac plexus (a group of nerves within the abdomen that innervate the pancreas). When the tumor is causing fracture of the bone, or other soft tissue injury, the use of narcotic or opioid medications may be helpful. These may be delivered orally or intrathecally, through an implanted pump. This latter option is a more sophisticated interventional pain technique which is effective for more severe and recalcitrant cases. At least one study has shown that the better pain control which can be achieved with implanted spinal drug delivery devices has been associated with improved survival and prolonged life. This is believed to be due to the body’s ability to then concentrate its energy on fighting the disease rather than the pain. We are happy to explore with cancer patients the various treatment options that are available to them.
Post Stroke Syndromes
Post Stroke Syndromes
Patients who have a cerebral vascular accident or stroke may be left with a variety of different long term problems. Stroke involves neurologic changes and damage to specific structures of the brain. Patients can lose motor function, sensation, speech, vision, and a variety of other primary functions. Some patients develop severe pain following a stroke, usually this is in a specific area associated with the area of the brain that has been damaged.. These are often some of the most complex and challenging conditions to treat.
Arm/leg pain can be due to a variety of different problems including nerve pain from disc injuries in the cervical or lumbar region, nerve injuries in the extremity itself, joint related problems including shoulder, elbow, wrist, hand, hip, knee, and ankle, as well as other musculoskeletal injuries. Patients may develop pain following surgery with a small number of patients developing a neuropathic pain condition called Complex Regional Pain Syndrome (please see sympathetic pain). As with all painful conditions it is important to determine the precise cause of symptoms in order to design appropriate therapy.
This term refers to pain radiating into an extremity (arm or leg) that is caused by compression or irritation of a spinal nerve. This can occur from acute compression as with a disc herniation or it can occur more chronically from the slow overgrowth of bone. Chronic radiculopathy occurs when the pain is longstanding and not responsive to basic treatments; it can follow open surgery when scar tissue develops and chronically irritates the encased nerve.
Spasticity Related Pain
Spasticity Related Pain
Spasticity related pain describes symptoms associated with spinal cord injury or spinal cord damage. This can occur following traumatic spinal injuries with subsequent paraplegia or quadriplegia, and also can occur following various spinal cord diseases such as multiple sclerosis or transverse myelitis. Treatment of patients with spinal cord injuries is complex and requires a team of experts. In some patients control of the spasticity is mandatory in order to progress with rehabilitative therapies. In these patients, when oral agents do not adequately control the spasticity, intrathecal anti-spasmodic medications may be appropriate. Connecticut Pain Care can assist in the placement and management of spinal drug delivery systems used to treat spasticity.
A spinal headache can occur following a spinal tap, lumbar puncture, a spinal anesthetic, or rarely following an epidural injection. When a needle is inserted into the spinal fluid, it can cause a chronic or persistent leak of spinal fluid through this needle puncture hole. This leakage of spinal fluid causes a spinal headache. This is commonly repaired by taking blood from a patient’s arm and inserting it in the location of the hole or leak and “patching” the epidural space. Spinal headaches may follow an epidural injection (which is not theoretically an intrathecal or spinal injection) when there is an inadvertent puncture or nicking of the dura (or lining of the spinal fluid).
Failed Back Syndrome
Failed Back Syndrome
Failed back syndrome describes the patient who has undergone spinal surgery one or more times, but yet still has persistent pain significantly interfering with their normal daily activities. This pain can come from joints, muscles, and/or nerve damage. Pain can also occur from the hardware, which is the rigid metal that was placed in the spine during surgery to provide the injured spinal area with stability. This hard metal then interacts with the much softer bone and muscle in the area, causing pain. Patients who have had prior back surgery and who have hardware and instrumentation will frequently tell us that there pain is worse when it is cold and when it rains (in fact most painful conditions increase with these factors).
Treatment options for failed back syndrome are directed at the specific cause of the persistent injury. Treatments may be conservative in the form of Physical Therapy, medications, and/or injections. Alternatively this pain may require more sophisticated interventions such as implantable therapies including spinal cord stimulation or spinal drug delivery systems. Treatment of failed back syndrome should progress from less invasive interventions to more invasive treatments. In some patients the use of chronic medications may be appropriate as an adjunct to other treatment directed at the specific cause of symptoms.
Radiculopathy describes nerve pain which travels or radiates into the extremity from a nerve which is compressed or irritated in the spine. This nerve can be compressed by disc, bone, or other structures. Many patients refer to leg pain associated with a radiculopathy as sciatica. Although this is not an accurate term for this condition, it has become overused in popular culture and many people still confuse the two problems. Radiculopathy can occur at any spinal level (cervical, thoracic, and lumbar), which means that pain radiating into your arms or your legs can be considered radicular if the source of that pain occurs in the spine.
Chronic Post-Surgical Pain
Chronic Post-Surgical Pain
Almost all surgery is painful. The most common type of pain experienced after surgery is called acute pain. This is the pain that patients feel related to the incision and direct surgical trauma and it should resolve as their body begins to heal. Once the recuperative period is over, many people have little to no residual pain. Unfortunately, some patients develop chronic pain following surgery. This is pain that continues past the normal recuperative period and almost any surgical intervention can be associated with postoperative pain on a prolonged basis. This pain frequently occurs as a direct result of the scar tissue or injury to structures adjacent to the area where surgery was performed. These structures can include nerves, joints, muscles, or ligaments. Sometimes this irritation or damage to surrounding structures can also cause secondary muscular spasm. Treatment of a post-surgical condition requires that we determine the precise cause of the pain and more specifically, to which of these potential causes can the pain be attributed. Once the specific cause of the symptoms can be determined, appropriate medical intervention can be directed to treat the symptoms. It is likely that you will undergo certain injections to determine the precise cause of your symptoms. These injections will be diagnostic, but also hopefully therapeutic.
Motor Vehicle Accident Related Injuries
Motor Vehicle Accident Related Injuries
Motor vehicle accidents can be associated with a number of different injuries including injuries to the neck, back, head, spine, and extremities. The mechanism of injury, specifically the type of impact and whether the patient was the driver, a passenger, or riding a motorcycle can help determine the cause of the patient’s symptoms. . As an example, the shoulder which the seatbelt crosses is much more likely to be injured than the shoulder which is not restrained. If the patient was the driver in the accident and presents with shoulder pain, it is likely that it will be the left shoulder which is painful. Dr. Kloth will carefully look at the specific mechanism of injury and use this knowledge to help determine the precise structures which are injured. This will help him to properly direct your care and provide treatments that are most likely to result in a positive outcome.
Spinal stenosis describes a condition where the spinal canal is narrowed. The spinal canal can be narrowed by disc herniations, bony overgrowth, ligamentous overgrowth (ligamentum flavum), and/or spondylolisthesis (a condition where one bone of the spine slips forward or backward in relation to the bone below). Spinal stenosis can occur centrally or in the foramen where the nerve exits. Placement of medication in close proximity to the area of narrowing provides the greatest degree of relief. Spinal stenosis may be effectively treated with intermittent injections, however if this does not provide lasting relief, surgical decompression may need to be considered; this can be performed with a minimally invasive technique in certain patients.
Diabetic and other Peripheral Neuropathy
Diabetic neuropathy occurs in patients who typically have longstanding diabetes. It often is associated with poor control of blood sugars which has been associated with damage to the peripheral nerves. This damage is typically irreversible but can be treated with a variety of medications, as well as some interventional pain management techniques
Spondylolisthesis describes the situation where one vertebral body or spinal bone moves forward or backward on top of the adjacent vertebral body (spinal bone). Spondylolisthesis is frequently associated with back pain, but may also be associated with nerve compression causing radiating pain into the lower extremity.
Phantom Limb Pain
Phantom Limb Pain
Phantom limb pain occurs following amputation of an extremity. Patients experience pain in the limb that is no longer present. This has a central cause, at the level of the brain and/or spinal cord, and is often very difficult to treat. There are a number of medication options. One of the most beneficial therapeutic interventions is ‘mirror therapy’ and it is completely non-invasive. Other options include invasive interventional pain management therapies which may have a role in the treatment of this condition when it does not respond to non-invasive measures.
Myofascial pain describes a condition involving muscular spasm or tightness, typically to a specific group of muscles. Myofascial pain may be primary problem or secondary to another underlying injury. When myofascial pain is the primary problem it typically responds to stretching and physical therapy, but may require trigger point injections for additional relief. Myofascial pain that continues to recur or that is present for an extended period of time is typically secondary to other underlying injury. For instance, a disc herniation can cause secondary spasm in the muscle that the compressed nerve innervates. Treatment of myofascial pain requires active patient involvement in order to perform the appropriate stretching exercises. These will be provided and discussed with you at your visit.
Post Herpetic Neuralgia/Shingles
Once you have had Chicken Pox, the virus remains dormant in your body. Shingles is the reemergence of the Chicken Pox virus in your body and is typically associated with a painful rash. Post-herpetic neuralgia occurs following an acute episode of shingles when the pain does not improve as the rash resolves. .
When these viral particles, which live dormant in the cells of your nervous system, reactivate, they travel down a specific nerve and cause inflammation and damage to that nerve. If this is not treated early the damage becomes permanent and irreversible. The best treatment for post-herpetic neuralgia is prevention, meaning to treat those high-risk patients with acute shingles early and aggressively to prevent the development of post-herpetic neuralgia. Vaccines also exist today and help decrease the incidence of shingles outbreaks. Patients over the age of 65 are at particularly high risk due to the associated vascular disease at that age (the nerve injury is caused in part by reduced blood flow). There are many treatments available for acute herpes zoster to try to prevent it from progressing to a post-herpetic neuralgia. There are some treatments that are effective for treatment of post-herpetic neuralgia after it has been present for an extended period of time.
Sympathetic Pain (RSD, CRPS, Causalgia, Intercostal Neuralgia)
Sympathetic pain refers to a broad category of pain syndromes involving the sympathetic nervous system. These conditions can actually be either sympathetic dependent or sympathetic independent, and this describes how they respond to specific treatment interventions. Other names for this condition are Reflex Sympathetic Dystrophy or RSD, Complex Regional Pain Syndrome or CRPS, Causalgia, and Sudeck’s Atrophy, which is an older name for this condition. Today the proper terminology is to call these conditions Complex Regional Pain Syndromes Type I and Type II. CRPS Type I refers to a situation when there is no documentable nerve injury and is synonymous with RSD. CRPS Type II, AKA causalgia, is associated with the presence of a nerve injury. Treatments for these conditions are similar, except when a triggering, peripheral nerve injury can be identified. In these cases it may be possible to turn off the CRPS by directing care at the specific peripheral nerve injury.
CRPS, Type I
Complex Regional Pain Syndrome Type I is synonymous with Reflex Sympathetic Dystrophy. This nomenclature was changed in the mid-90’s. CRPS Type I describes the situation when CRPS or RSD occurs in the absence of a documentable nerve injury.
CRPS, Type II
Complex Regional Pain Syndrome Type II is synonymous with Causalgia and represents a sympathetic pain syndrome associated with a peripheral nerve injury. This nomenclature was changed in the mid-90’s (see sympathetic pain).
Joint pain can involve any joint in the body from knees, hips, and shoulders to the small joints of the fingers. Even the spine has joints which exist between each vertebral body, these are called facet joints. There are many different treatments available for joint injuries. Joint pain can be associated with arthritis, damage to the ligaments, meniscus, labrum, or other internal structure. In order to determine the appropriate treatment the specific etiology or damage within the joint must be determined. There are many situations where joint pain can be treated non-surgically. In some cases the damage is severe enough to warrant surgical intervention.
Degenerative osteoarthritis of a joint has been traditionally treated in this country with joint replacement. Stem cell therapy, as well as other regenerative medicine therapy techniques, have shown some benefit for the pain and can theoretically result in reversal of some of the damage found within osteoarthritic joints; in many patients a total joint replacement can be avoided. Ongoing research continues in this area. We have found a high success rate with the use of regenerative therapy techniques for the treatment of joint injuries and arthritis.
Headaches are one of the most common complaints that patients make to their physicians. Headaches can be mild and intermittent or severe, chronic, and daily, and anywhere in between. Headaches can be debilitating as they can interfere significantly with normal activities of daily living. Serious causes of headaches must be first evaluated and ruled out and are typically done by your Primary Care Physician and/or a neurologist. It is important to first assess whether there is an underlying cause for the headaches. When a serious or life threatening cause for headaches cannot be found, less serious causes should be investigated. Headaches can also be caused by cervical (neck) problems (cervicogenic headaches) and occasionally by shoulder injuries. When headache symptoms persist there are a number of different treatment options available; these are typically directed at the underlying cause of symptoms. For instance, if the pain is coming from the neck, treatment directed at the neck will cause secondary improvement of the headaches. In other situations the headaches are the primary problem and may be treated with therapeutic interventions such as occipital nerve blocks, Botox injections, and in more recalcitrant cases occipital nerve stimulation.
Joint hypermobility describes a situation where a joint has more motion than normal. This can be seen in certain types of genetic conditions such as Ehlers-Danlos Syndrome or may occur following injury or damage to a joint when ligament and tendinous structures that help support the joint become damaged or torn. Treatment of hypermobility syndromes with regenerative medicine techniques has shown significant promise. When specific structures attributing or causing the hypermobility can be identified, regenerative medicine techniques may be a useful treatment option.
Many other causes of pain
Musculoskeletal pain describes symptoms that are related to a muscle, bone, joint, ligament, or tendinous structure of the body. This is a general description of a variety of different types of painful conditions.
Back pain is one of the most common disorders affecting Americans today. Statistics show that 80% of Americans will develop back pain at some point in their life. While it is true that the vast majority of lower back pain episodes are self-limiting and will resolve spontaneously, unfortunately there is still a group of individuals who will suffer from chronic lower back pain. There are many different types of treatment which range from conservative treatments such as physical therapy and medications, to more invasive interventions which include surgical intervention. What is most important is to make an accurate diagnosis first which allows treatments to be more appropriately applied. Treatment directed at a misdiagnosis can only fail long term.
It is extremely important with back conditions to also recognize that the pain may be multifactorial, which means that more than one structure may be injured, and therefore need to be treated, for an optimal outcome. That being said, one of my guiding principles is ‘less is more’. This means that simple, less invasive treatments should be tried first for back pain. If chiropractic treatment or physical therapy resolves the symptoms, then that is all that is necessary. If injections are required and they resolve the pain adequately so that it allows the person to function and return to their normal daily routine, than that may be sufficient. Surgical intervention should usually be reserved for cases which have failed to respond to more conservative, less invasive approaches. It is important to note that a small percentage of patients have conditions that need to be treated emergently with a surgical intervention. In these cases the patient will have physical signs of neurologic damage (such as weakness in an extremity or incontinence) and urgent repair of the underlying cause must be undertaken to prevent permanent damage. There will also be patients who will require surgery for back pain that does not respond to less invasive approaches but even for these patients it is crucial to determine which spinal level or levels are causing the symptoms to properly plan surgery. If open surgical treatment is required we will also help the patient identify the appropriate physician for their particular condition.
Some patients may benefit from minimally invasive spine surgery. Minimally invasive procedures are typically performed through very small incisions measuring less than 1 cm and are associated with more rapid recovery. Only certain types of spinal damage are amenable to this less invasive approach. Connecticut Pain Care is one of the few practices to offer these therapies in the CT area and will help you determine if you may be a candidate for these less invasive approaches.
Unfortunately, some patients who undergo open surgical intervention will (despite the best intentions of the surgeon) still have insufficient relief or even worse, sometimes worsening of their pain. Postoperative pain syndromes, also known as a failed back syndrome or post-laminectomy syndrome, require careful evaluation to determine the precise cause of the on-going symptoms. This will often allow a painful and injured structure to be treated conservatively without the need for further surgery. For patients who do not respond to less invasive interventions and for whom further surgery is not warranted, advanced implantable pain therapies may be helpful at treating more severe pain conditions (please see treatment sections on spinal cord stimulation and implanted spinal drug delivery systems).
Sciatica is a generic term used by patients to describe pain radiating into their legs. In its truest definition sciatica refers to irritation of the sciatic nerve. This is rarely the cause of pain in the lower extremity. Sciatica is often misapplied to a situation where a disc herniation or other damage is causing compression of a nerve in the spinal canal. This is more correctly called a radiculopathy.