General Orthopedic Questions
X-rays are a type of radiation, and when they pass through the body, dense objects such as bone block the radiation and appear white on the X-ray film, while less dense tissues appear gray and are difficult to see. X-rays are typically used to diagnose and assess bone degeneration or disease, fractures and dislocations, infections or tumors.
Organs and tissues within the body contain magnetic properties. MRI, or magnetic resonance imaging, combines a powerful magnet with radiowaves (instead of X-rays) and a computer to manipulate these magnetic elements and create highly detailed images of structures in the body. Images are viewed as cross-sections or “slices” of the body part being scanned. There is no radiation involved as with X-rays. MRI scans are frequently used to diagnose bone and joint problems.
A computed tomography (CT) scan (also known as CAT scan) is similar to an MRI in the detail and quality of image it produces, but the CT scan is actually a sophisticated, powerful X-ray that takes 360-degree pictures of internal organs, the spine and vertebrae. By combining X-rays and a computer, a CT scan, like an MRI, produces cross-sectional views of the body part being scanned. In many cases, a contrast dye is injected into the blood to make the structures more visible. CT scans show the bones of the spine much better than MRI, so they are more useful in diagnosing conditions affecting the vertebrae and other bones of the spine.
Ice should be used in the acute stage of an injury (within the first 24 to 48 hours), or whenever there is swelling. Ice helps to reduce inflammation by decreasing blood flow to the area in which cold is applied. Heat increases blood flow and may promote pain relief after swelling subsides. Heat may also be used to warm up muscles prior to exercise or physical therapy.
Physical therapy is the treatment of musculoskeletal and neurological injuries to promote a return to function and independent living. Physical therapy incorporates both exercise and functional training. Exercise restores motion and strength while functional training facilitates a return to daily activities, work or sports.
A tendon is a band of tissue that connects muscle to bone. A ligament is an elastic band of tissue that connects bone to bone and provides stability to the joint. Cartilage is a soft, gel-like padding between bones that protects joints and facilitates movement.
Cortisone is a steroid that is produced naturally in the body. Synthetically produced cortisone can also be injected into soft tissues and joints to help decrease inflammation. While cortisone is not a pain reliever, pain may diminish as a result of reduced inflammation. In orthopedics, cortisone injections are commonly used as a treatment for chronic conditions such as bursitis, tendonitis and arthritis.
An epidural is a potent steroid injection that helps decrease the inflammation of compressed spinal nerves to relieve pain in the back, neck, arms or legs. Cortisone is injected directly into the spinal canal for pain relief from conditions such as herniated discs, spinal stenosis or radiculopathy. Some patients may need only one injection, but it usually takes two or three injections, given two weeks apart, to provide significant pain relief.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are nonprescription, over-the-counter pain relievers such as aspirin, ibuprofen and naproxen sodium. They are popular treatments for muscular aches and pains as well as arthritis.
NSAIDs not only relieve pain but also help to decrease inflammation, prevent blood clots and reduce fevers. They work by blocking the actions of the cyclooxygenase (COX) enzyme. There are two forms of the COX enzyme. COX-2 is produced when joints are injured or inflamed, which NSAIDS counteract. COX-1 protects the stomach lining from acids and digestive juices and helps the kidneys function properly. This is why side effects of NSAIDs may include nausea, upset stomach, ulcers or improper kidney function.
Interventional Pain Procedures Questions
Someone from the surgery center or hospital will call you to discuss pre-procedural/operative instructions. They usually include the following:
- Clear liquids (e.g. water, gatorade) can be consumed up to 6 hours prior to your procedure and a light meal can be consumed 8 hours prior. Take your usual medications the morning of your procedure with a small sip of water with the exception of insulin or diabetic medications if you are diabetic.
- Stop taking all blood thinners (e.g. Coumadin, Plavix, aspirin) for at least 7 days prior to your procedure.
- Do not smoke for 24 hours prior to your procedure.
- Notify Dr. Glaser if there is any change in your physical condition, such as a cold, fever or flu symptoms
- If there is a chance you are pregnant, please notify Dr. Glaser immediately.
Arrive promptly at the time specified by the surgery scheduler. If you are having a procedure at an outpatient surgery center, you will usually be asked to arrive one hour before your scheduled procedure. Times may differ if you will be admitted to the hospital prior to your procedure. Most preoperative blood, lab or paperwork is performed prior to the day of your procedure.
Bathe or shower the morning of surgery but do not apply any makeup. Wear low-heeled, comfortable shoes and loose, comfortable clothing such as T-shirt, button-down shirt, sweat pants or baggy shorts that will fit over bandages or dressings following surgery. Do not wear contact lenses or jewelry.
The length of interventional pain procedures varies. Simple epidurals take 5 to 10 minutes while more complicated procedures can take up to several hours. However, most procedures take less than a half hour.
Most interventional pain procedures can be performed with a very light form of intravenous sedation, known as moderate sedation, administered by Dr. Glaser. This requires placement of an intravenous line. Some patients choose to have no intravenous sedation and therefore do not require an intravenous line. Dr. Glaser usually discusses sedation options with patients in the office prior to their procedure.
The time you spend in the hospital or surgery center will vary depending upon the type of procedrue performed, the type of anesthesia that was given and your individual needs. Most patients are discharged within one hour of their procedure.
Most patients will not encounter problems after interventional pain procedures. As with any procedure, however, there are potential risks, including but not limited to: reaction to anesthesia, infection, swelling, nerve damage, paralysis, headache, temporary nerve irritation, bleeding, epidural hematoma, epidural abscess and procedure failure.
ALL aspirin-based products (e.g. aspirin, Excedrin), Advil, Ibuprofen, Motrin, Celebrex, Mobic, Coumadin, Ticlid, Plavix, Pradaxa and other anti-coagulants/anti-inflammatories should be discontinued one week prior to your procedure to reduce the risk of complications from bleeding.
You will be taken to the recovery room and monitored for a period of time before being discharged home. If your procedure was done in a hospital and you are being admitted, you will be taken to a patient room after your recovery room stay.
If your procedure was performed in a surgery center, a nurse will review postoperative instructions with you as well as explain any special instructions provided by Dr. Glaser regarding diet, rest, medications, when to follow up with your doctor and how to use any durable medical equipment such as a neck or back brace that may have been ordered. Additionally, you will be given any postprocedural prescriptions that Dr. Glaser may have written.
When you follow up with Dr. Glaser in the office, he will discuss additional postprocedural/operative instructions.
Common Injuries & Conditions Questions
When muscles become inflamed, they can also spasm, or contract tightly, as a response to injury. While they are the body’s way of protecting itself from further injury, they often produce excruciating and often debilitating pain. Muscle spasms are common in the low back (lumbar) muscles.
The most common form of arthritis, osteoarthritis, can affect any joint in the body but most often afflicts the knees, hips and fingers. Most people will develop osteoarthritis from the normal wear and tear on the joints through the years. Joints contain cartilage, a rubbery material that cushions the ends of bones and facilitates movement. Over time, or if the joint has been injured, the cartilage wears away and the bones of the joint start rubbing together. As bones rub together, bone spurs may form and the joint becomes stiff after long periods of activity or inactivity.
A stress fracture is a microscopic crack in a bone that occurs from overuse. Muscles normally absorb the shock of physical activities, but when they become too fatigued to do so, they transfer the stress to the bones, which results in a hairline-sized fracture.
Stress fractures usually develop in the weightbearing bones of the feet and lower legs, often after a rapid increase in the duration or intensity of exercise or from wearing improper or worn-out athletic shoes.
Radiculopathy refers to a condition in which the spinal nerve roots are irritated or compressed. Many people refer to it as having a “pinched nerve.” Lumbar nerve impingement indicates that the nerve roots in the lower spine are involved, while cervical radiculopathy is associated with nerve roots in the neck. Nerve impingement is most often caused by a herniated disc or spinal stenosis.
Facet joints are found in the posterior of the spine. There are 24 vertebrae that form the human spine. There are two facet joints between the vertebrae of each spinal segment along the spinal column.
The facet joints and disc space form a three-joint complex near each vertebra. A facet joint has two bony surfaces with cartilage between them and a capsule of ligaments surrounding it. Synovial fluid lubricates the joints as is the case with any joint.
Simply put, facet arthropathy is degenerative arthritis affecting the facet joints in the spine. In the area of the spine where there are facet joints, arthritis pain can develop.
Arthritis in the facet joints can develop from:
- Wear and tear (decreases space between vertebrae causing facet joints to rub together)
- Previous back injury
- Torn ligaments
- Disc problems
Due to the additional stress caused by these circumstances on the facet joints, bone spurs can develop and cartilage can deteriorate. Pain is the main symptom associated with facet arthopathy. The pain is typically worse following sleep or rest. Pain associated with facet arthropathy may be exacerbated by twisting or bending backward. Low back pain is the most frequent complaint but it does not typically radiate down the legs or buttocks, unless spinal stenosis also is involved.
X-rays, CAT scans and magnetic resonance imaging (MRI) may be used to help diagnose facet arthropathy. Another procedure that is more specific involves performing a guided injection using a fluoroscope. Medicine and dye are injected. The dye allows the doctor to view the placement of the needle and injection. If the facet joint is injected and pain relief is the result, it serves to confirm the diagnosis of facet arthropathy.
Initially the doctor may recommend a period of rest in an effort to tame the symptoms. Sleep positions that take pressure off facet joints may be recommended (e.g. curl up to sleep or lay on back with knees up and pillow underneath).
Some oral medication may be prescribed, including:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Muscle relaxants
- Other treatment options include:
- Strengthening and aerobic exercise
- Water therapy
- Spinal manipulation
If conservative measures fail:
- Injections of an anesthetic or steroid medicine into the facet joint or nerves that go to the facet joint may be tried.
- Facet rhizotomy/radiofrequency ablation, which destroys nerves with heat energy, may be an option.
- Surgery is rarely required for facet arthropathy, but options do exist.
Surgical options to treat facet arthropathy include:
- Fusion – Fuse two or more vertebrae to eliminate movement in facet joints (sometimes facet joints are removed during spinal fusion).
Sacroiliitis is a inflammation of one or both of the sacroiliac joints, which connect the lower spine and pelvis. With sacroiliitis, even the slightest movement of your spine can be extremely uncomfortable or even painful. Sacroiliitis can be difficult to diagnose, and it may be mistaken for other causes of low back pain, including sciatica, herniated discs and strained muscles. Sacroiliitis may be associated with a group of diseases called spondyloarthropathies, which cause inflammatory arthritis of the spine.
Treatment for sacroiliitis may involve a combination of rest, physical therapy and medications.
Sacroiliitis symptoms may include:
- Pain and stiffness in the lower back, thighs or buttocks
- Pain that worsens with walking because the motion of the hips strains the sacroiliac joints
- Inflammation in one or both eyes (uveitis or iritis)
- Psoriasis, an inflammatory skin condition
- Pain radiating down the leg
- Decreased range of motion
- A fever that appears quickly
- Typically pain in the hips, low back, thighs and buttocks are presenting symptoms; pain is typically worse with sitting
Pain relievers are often prescribed to treat sacroilliitis. However, many patients do not get satisfactory relief with medications. When medication alone is not working, a diagnostic sacroiliac joint injection may be performed to confirm the diagnosis. The diagnosis is confirmed if the pain goes away for a few hours. Patients who respond well to the diagnostic block may be candidates for a radiofrequency ablation/rhizotomy of their sacroiliac joint(s).
Peripheral neuropathy risk factors include:
- Diabetes, especially if sugar levels are poorly controlled
- Alcohol abuse
- Vitamin deficiencies, particularly B vitamins
- Immune system suppression, which occurs in people who have received organ transplants and people with AIDS, among others
- Autoimmune diseases, such as rheumatoid arthritis and lupus, in which the immune system attacks a person’s own tissues
- Kidney, liver or thyroid disorders
Peripheral neuropathy isn’t a single disease but rather a symptom with many potential causes. For that reason, it can be difficult to diagnose. To help in the diagnosis, the doctor will likely take a full medical history and perform a physical and neurological exam that may include checking tendon reflexes, muscle strength and tone, ability to feel certain sensations and posture and coordination.
The doctor may also request blood tests to check the level of vitamin B-12, a urinalysis, thyroid function tests and, often, electromyography — a test that measures the electrical discharges produced in the muscles. As a part of this test, the patient will be asked to have a nerve conduction study, which measures how quickly nerves carry electrical signals. A nerve conduction study is often used to diagnose carpal tunnel syndrome and other peripheral nerve disorders.
The doctor may recommend a nerve biopsy, a procedure in which a small portion of a nerve is removed and examined for abnormalities. But even a nerve biopsy may not always reveal what’s damaging the nerves.
The first goal of treatment is to manage the condition causing the neuropathy. If the underlying cause is corrected, the neuropathy often improves on its own. The second goal of treatment is to relieve the painful symptoms.
Many types of medications can be used to relieve the pain of peripheral neuropathy:
- Pain relievers. Mild symptoms may be relieved by over-the-counter pain medications. For more severe symptoms, the doctor may recommend prescription painkillers. Drugs containing opiates, such as codeine, can lead to dependence, constipation or sedation, so these drugs are prescribed only when other treatments fail.
- Anti-seizure medications. Drugs such as gabapentin (Neurontin), topiramate (Topamax), pregabalin (Lyrica), carbamazepine (Tegretol) and phenytoin (Dilantin) were originally developed to treat epilepsy. However, doctors often also prescribe them for nerve pain. Side effects may include drowsiness and dizziness.
- Lidocaine patch. This patch contains the topical anesthetic lidocaine. It is applied to the area where the pain is most severe, and patients can use up to three patches a day to relieve pain. This treatment has almost no side effects except, for some people, a rash at the site of the patch.
- Antidepressants. Tricyclic antidepressant medications, such as amitriptyline and nortriptyline (Pamelor), were originally developed to treat depression. However, they have been found to help relieve pain by interfering with chemical processes in the brain and spinal cord that cause people to feel pain. The selective serotonin and norepinephrine reuptake inhibitor duloxetine (Cymbalta) also has proved effective for peripheral neuropathy caused by diabetes.
- Spinal cord stimulation. Peripheral neuropathy that does not get better with the treatments listed above may respond very well to spinal cord stimulation
Complex regional pain syndrome (CRPS) is an uncommon, chronic condition that usually affects the arm or leg. Rarely, CRPS can affect other parts of the body. CRPS is marked by intense burning or aching pain. People may also experience swelling, skin discoloration, altered temperature, abnormal sweating and hypersensitivity in the affected area. The cause of CRPS isn’t clearly understood, though it often follows an illness or injury. Treatment for CRPS is most effective when started early. In such cases, dramatic improvement and even remission are possible.
The main symptom of CRPS is intense pain, which gets worse over time. Additional signs and symptoms include:
- “Burning” pain in the arm, leg, hand or foot
- Skin sensitivity
- Changes in skin temperature, color and texture. At times the skin may be sweaty; at other times it may be cold. Skin color can range from white and mottled to red or blue. Skin may become tender, thin or shiny in the affected area.
- Changes in hair and nail growth
- Joint stiffness, swelling and damage
- Muscle spasms, weakness and loss (atrophy)
- Decreased ability to move the affected body part
Symptoms may change over time and vary from person to person. Most commonly, swelling, redness, noticeable changes in temperature and hypersensitivity (particularly to cold and touch) occur first. Over time, the affected limb can become cold and pale and undergo skin and nail changes as well as muscle spasms and tightening. Once these changes occur, the condition is often irreversible.
CRPS occurs in two types with similar signs and symptoms but different causes:
- Type 1. Previously known as reflex sympathetic dystrophy syndrome, this type occurs after an illness or injury that didn’t directly damage the nerves in your affected limb. About 90 percent of people with CRPS have type 1.
- Type 2. Once referred to as causalgia, this type follows a distinct nerve injury.
Many cases of CRPS occur after forceful trauma to an arm or a leg, such as a gunshot wound or shrapnel blast. Other major and minor traumas — such as surgery, heart attack, infection, fracture and even a sprained ankle — also can lead to CRPS. It’s not well-understood why these injuries can trigger CRPS. Diagnosis of CRPS is based on a physical exam and medical history.
There is no single test that can definitively diagnose CRPS, but the following procedures may provide important clues:
- Bone scan. A radioactive substance injected into one of a patient’s veins permits viewing of bones with a special camera. This procedure may show increased circulation to the joints in the affected area.
- Sympathetic nervous system tests. These tests look for disturbances in the sympathetic nervous system. For example, thermography measures the skin temperature and blood flow of affected and unaffected limbs. Other tests can measure the amount of sweat on both limbs. Dissimilar results can indicate CRPS.
- X-rays. Loss of minerals from bones may show up on an X-ray in later stages of the disease.
- Magnetic resonance imaging (MRI). Images captured by an MRI device may show a number of tissue changes.
Dramatic improvement and even remission of CRPS is possible if treatment begins within a few months of first symptoms. Often, a combination of various therapies is necessary. The doctor will tailor treatment based on each specific case.
Treatment options include:
- Doctors use various medications to treat the symptoms of CRPS. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve), may ease pain and inflammation. In some cases, doctors may recommend prescription medications. For example, antidepressants, such as amitriptyline, and anticonvulsants, such as gabapentin (Neurontin), are used to treat pain that originates from a damaged nerve (neuropathic pain). Corticosteroids, such as prednisone, may reduce inflammation.
- The doctor may suggest bone-loss medications, such as alendronate (Fosamax) and calcitonin (Miacalcin). Opioid medications may be another option. Taken in appropriate doses, they may provide acceptable control of pain. However, they may not be appropriate if the patient has a history of substance abuse or lung disease.
- Some pain medications, such as COX-2 inhibitors (Celebrex), may increase the risk of heart attack and stroke. It’s wise for patients to discuss their individual risks with their doctor.
- Applying heat and cold. Applying cold may relieve swelling and sweating. If the affected area is cool, applying heat may offer relief.
- Topical analgesics. Various creams are available that may reduce hypersensitivity, such as lidocaine or a combination of ketamine, clonidine and amitriptyline.
- Physical therapy. Gentle, guided exercising of the affected limbs may improve range of motion and strength. The earlier the disease is diagnosed, the more effective exercises may be.
- Sympathetic nerve-blocking medication. Injection of an anesthetic to block pain fibers in the affected nerves may relieve pain in some people.
- Transcutaneous electrical nerve stimulation (TENS). Chronic pain is sometimes eased by applying electrical impulses to nerve endings.
- Biofeedback. In some cases, learning biofeedback techniques may help. In biofeedback, patients learn to become more aware of their body so that they can relax their body and relieve pain.
- Spinal cord stimulation. The doctor inserts tiny electrodes along the spinal cord. A small electrical current delivered to the spinal cord results in pain relief.
Failed back syndrome (FBS), also called “failed back surgery syndrome” (FBSS), refers to chronic back and/or leg pain that occurs after back (spinal) surgery. It is characterized as a chronic pain syndrome. Multiple factors can contribute to the onset or development of FBS. Contributing factors include but are not limited to residual or recurrent disc herniation, persistent postoperative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness and spinal muscular deconditioning. An individual may be predisposed to the development of FBS due to systemic disorders such as diabetes, autoimmune disease and peripheral blood vessels (vascular) disease. Smoking is a risk for poor recovery.
Common symptoms associated with FBS include diffuse, dull and aching pain involving the back and/or legs. Abnormal sensibility may include sharp, pricking and stabbing pain in the extremities. The term “post-laminectomy syndrome” is used by some doctors to indicate the same condition as FBS.
The treatments of post-laminectomy syndrome include physical therapy, minor nerve blocks, transcutaneous electrical nerve stimulation (TENS), behavioral medicine, non-steroidal anti-inflammatory (NSAID) medications, membrane stabilizers, antidepressants, spinal cord stimulation and intracathecal morphine pump. Use of epidural steroid injections may be minimally helpful in some cases. The targeted anatomic use of a potent anti-inflammatory anti-TNF therapeutics is being investigated.
The amount of spinal surgery varies around the world. The most is performed in the United States and Holland and the least in the United Kingdom and Sweden. Recently, there have been calls for more aggressive surgical treatment in Europe. Success rates of spinal surgery vary for many reasons.
Spondylolisthesis describes the anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. It was first described in 1782 by Belgian obstetrician Dr. Herbinaux. He reported a bony prominence anterior to the sacrum that obstructed the vagina of a small number of patients. The term “spondylolisthesis” was coined in 1854, from the Greek “spondyl” for vertebrae and “olisthesis” for slip. The variant “listhesis” is sometimes applied in conjunction with scoliosis. These “slips” occur most commonly in the lumbar spine.