Back & Neck Pain

Last month, I blogged about new guidelines issued this spring by The Congress of Neurological Surgeons and the American Association of Neurological Surgeons on the use of the steroid methylprednisolone immediately after spinal cord injury.

That same document reviewed a broad scope of other medical to-dos including surgical techniques, management protocols for specific cervical spine conditions and much more.

Advancements in medical technology was the main reason behind the update for one of those topics, namely vertebral artery injury, or VAI. Vertebral artery injury is perhaps best known as the (rare) instance of stroke following a neck adjustment by a chiropractor. I say rare because it's actually more common in situations where a patient is having neck surgery (although it's rare then, too). But when a stroke follows a chiropractic adjustment, it tends to attract more media attention.

Related: Vertebral Artery Injury

Up until this latest issue of the guidelines, the recommended way to diagnose VAI was by angiogram. This involved inserting a catheter (with dye) into a major blood vessel, and was risky, says Dr. Daniel Resnick, Professor of Neurological Surgery at the University of Wisconsin School of Medicine and Public Health, and President-Elect of the Congress of Neurological Surgeons.

Resnick goes on to say that the Congress of Neurological Surgeons now recommends CT Angiograms. "With a CT angiogram you no longer have to inject dye into a blood vessel," he informs me. "Instead, this is done through an IV."

"The risk for complication with a CT angiogram is much lower than with an angiogram," Resnick explains. "Radiation is the biggest risk."

It's a very reliable test, too.

The Real VAI Issue

But the real issue with VAI is that doctors don't actually know what to do when it occurs without symptoms, Resnick says. That is one reason why testing is currently being debated. "We need prospective studies that looks at treated VAI and compares the outcomes with untreated VAI to determine if treatment is, in fact, needed."

Resnick is not currently aware of any such studies.

Photo: click

If you're down for the count - i.e. you have a neck or back injury that's keeping you laid up as the weather gets good - don't fret!   I've got list of strategies and things you can do so that this time of healing and mending does not become wasted time.    Check it out:   Back Injury - Recovery Time, Yes.   But Not Lost Time.

If you take amitriptyline or other tricyclic antidepressant for your chronic back pain, as prescribed by your doctor, you are using this medication "off-label".  In other words, the FDA has approved your medication for a purpose other than spine pain management.  Even so, your doctor has  prescribed it (in a lower dose) to you because of your back.   The FDA has not approved the use of these drugs for back pain.

MDs are the only people allowed by the FDA to prescribe the use of a medication for off label purposes. But a recent lawsuit that invoked the 1st Amendment (Free Speech) may have begun to set a precedence allowing drug company sales reps to speak persuasively to doctors about off label use of their products. Another recent lawsuit, again invoking the First Amendment, now allows companies to obtain prescriber information from pharmacies, then turn around and sell those names to big drug companies for their marketing purposes.

Where does this leave you?

Sometimes off label use of a drug is substantiated by medical research, but often it is not.  If you take or are considering taking off-label medications, it's best to be as informed as you can about the drug - before you start taking it, if possible. Consumer Reports covers all the basics on how to do this in their short video called Off-label drug prescribing: What does it mean for you? Check it out; it's for your safety.

_Sources:

_{Consumer Reports. Off-label drug prescribing: What does it mean for you?. Consumer Reports. Website Last Updated Dec 2012.http://www.consumerreports.org/cro/2012/05/off-label-drug-prescribing-what-does-it-mean-for-you/index.htm}

_{Marcia M. Boumil, J.D., LL.M. Off-Label Marketing and the First Amendment. Perspective. N Engl J Med 2013; 368:103-105January 10, 2013DOI: 10.1056/NEJMp1214926 http://www.nejm.org/doi/full/10.1056/NEJMp1214926}

Photo: FDA

If your doctor is suggesting a total disc replacement surgery, you may want to ask the hard questions before signing on.  Things like: how effective is this procedure overall, and what are the potential complications and/or risks of having it done?

Related: Spine Surgery:  Risk for Infection

Other things to research about a disc replacement procedure include how long your chosen surgeon has been performing it, and if disc replacement is their specialization.

Does Your Doctor Go by Guidelines?

Also, please be aware that there are guidelines for when a disc replacement is safe and when it isn't. For example, is this your first back surgery?  If not, you are not an "ideal candidate" for a disc replacement procedure, according to the American Academy of Orthopedic Surgeons.  (The AAOS lists several other things to watch out for, as well.)   I've heard many stories from people whose doctors neither told them about this kind of "ideal candidate" criteria, nor heeded them. Post surgically, the results were not pretty.

The following articles may be helpful as you research disc replacement surgery (vs spinal fusion).

1. Total Disc Replacement or Spinal Fusion?
2. Motion Sparing Surgery
3. When Shopping for Disc Surgery

_Source:

_{Artificial disk replacement in the lumbar spine.  AAOS Website.  Last Updated:  March 2010.   http://orthoinfo.aaos.org/topic.cfm?topic=A00502}

I recently read a USA Today article (What Surgeons Leave Behind Costs Some Patients Dearly March 8, 2013) about how surgical tools, quite often sponges, are increasingly left inside of patients.  Spine surgery is no exception to this trend in my observation.  This iatrogenic mistake can lead to a life of chronic pain.  Two terms describe a sponge left inside a surgical patient.  They are:  gossypiboma and texiloma.

Photo: Yahquinn

The average person or family doesn't buy a new mattress very often.  If you have a bad back, you'll likely need to research not only brands, costs, construction, materials, warranties and the usual fare, but also how well the mattress can support your spine.  You may need to consider things like:

• Will the proposed mattress provide the support you need for your lumbar or cervical curves?
• Will it create uncomfortable pressure points?

I interviewed Dr. Michael Perry, Medical Director of the Laser Spine Institute in Tampa, Fla. for some shopping tips geared specifically for people with back problems.  Check it out:  How to Buy a Mattress for a Bad Back.

Photo: Adam Ciesielski

I meet a lot of people who are "candidates" for discectomy - i.e. they've sustained a herniated disc, they've gone through 6 weeks of physical therapy, and the nerve pain and disruption to their daily activities persists.

If this is you, what should you do?  Should you tough it out or submit to going under the knife?  The good news is that generally speaking, discectomy, the surgery most often given for herniated disc, has a good track record for success.  Just the same, studies show that after about a year, pain relief and other outcomes from surgery and those resulting from a commitment to physical therapy tend to equal out.  Get the full scoop and make your decision:  Discectomy.

If you've experienced instability at your sacroiliac joint (as I have), you know that this joint is a tricky one to deal with.  One reason may be that there are no muscles that cross over this joint, so you have to rely on the balance of all the bones in your kinetic chain to keep it in tact.   Another reason may be that it is a key joint in weight transfer between your spine and your pelvis and legs.  Learn more about the sacroiliac joint.

Photo: Tadija Savic

If tax season has resulted in a royal crick in your  neck, you're likely not alone. Here's some things you can do in lieu of seeing a doctor.  If your crick symptoms last longer than a week, though, you should actually get some medical attention for it.

Going forward, consider about your ergonomics.  For example, does your chair support you?  Is your desk at the right height?  How about your monitor?  And don't forget you need to take regular, frequent breaks from the computer to keep your neck healthy.

Photo: kzenon

Here's a tip if you're seeing a physical therapist for your spine:  Do your exercises!  Most likely your therapist has given you a home exercise program as part of your treatment.  You won't get significantly better unless you take this program seriously and commit to doing it daily (or as often as your therapist prescribes.)

I know that  physical therapy modalities such as massage, traction, ultrasound, etc. feel good.  It can be rejuvenating to stop what your doing and let yourself be cared for.  I get it.

But you need strong, flexible muscles to help support your spine in posture and through movement.  Got that?  No excuses - do the work!  Here are some resources that may help propel you to success:

• Core Strengthening Work
• Posture Exercise Series
• Strengthening Exercises for Low Back Arthritis