There he got to help test participants’ balance and grip strength. The tests were part of an interactive display developed by the NASS Exercise Committee to demonstrate how functional tests like these can be used to objectively assess patients with back and neck pain.

Pain can be highly subjective and clinicians strive to use objective measures in order to understand how to best treat their patients. The results can also be used as bench marks to show improvement. As decreased balance has been associated with chronic low back pain and decreased grip strength has been associated with chronic neck pain, these are two useful tests.

Balance was tested by timing participants for up to 30 seconds as they stood on one foot with their arms crossed over their chest. Participants were graded based on how many seconds they could remain on one foot. If they could stand the whole 30 seconds they were then asked to repeat the test with their eyes closed.

Grip strength was tested using a hand held dynomometer. This is a portable hand-held device that can measure strength in Newtons, pounds, or kilograms. The test is performed with the elbow bent to 90 degrees and held close to the body. The results can then be compared to established norms.

Evan says, “People learned a little something new and had a lot of fun trying to out do each other.  We even gave out prizes.”

Learn more about the 2011 annual meeting of the North American Spine Society. 

Dr. Christopher Winfree

Dr. Christopher Winfree from the Pain Center and Peripheral Nerve Center became Chairman of the Joint Section on Pain at the recent meeting of the American Association of Neurological Surgeons (AANS).

He was also active in three separate sessions during the annual meeting:

1. Faculty at a Practical Clinic on Peripheral Nerve Injuries entitled, where he spoke about the Evaluation of Entrapments and Tumors.
2. Moderator at a Breakfast Seminar on Neuromodulation for Chronic Pain.
3. Moderator during the joint Session of the AANS/CNS Section on Pain.

Congratulations Dr. Winfree on your new post!

MRI showing Donna's Giant Aneurysm. Photo courtesy of Ms. Ainsworth.

Donna Ainsworth doesn’t take anything for granted anymore.  Not after surviving a Giant Aneurysm that first caused unbearable pain, then nearly blinded her in one eye, and finally almost killed her.  She is grateful for every moment.

Dr. Sean D. Lavine from the Cerebrovascular Center and Endovascular Center was her surgeon and he got to her just in time.

For some time Donna had been having intermittent bouts of double vision but she didn’t think anything of it.  Then the headache started.  ”It was just behind my right eye,” Donna says. “It kept getting worse but I didn’t want to go to the hospital for a headache.  That seemed silly. But finally my family made me.”

Donna eventually got to St. Vincent’s Hospital near her home in Connecticut where an MRI was performed.  ”I had already been to two hospitals and seen a few doctors by the time I got there.  I had pretty bad double vision, I was vomiting and I could hardly walk,” says Donna.

After the MRI, Donna says, “The doctor came to me and said, ‘The bad news is that you have a giant aneurysm. The good news is that it is not in your brain.  It is behind your right eye, below your skull’.”  They couldn’t perform the surgery she needed there so they sent her by ambulance to Columbia Presbyterian where she saw Dr. Lavine.

Donna says, “When I met Dr. Lavine, I hit the lottery. The whole team was amazing.”

The first thing Dr. Lavine had to do before he could operate on the aneurysm was to see if the operation itself would be too dangerous.  He did this by performing a balloon test occlusion. In this procedure, using endovascular techniques, a deflated balloon is brought through an artery in the groin all the way up to the main artery feeding Donna’s aneurysm (in this case, the right internal carotid artery).  There, Dr. Lavine inflated the balloon temporarily to make sure that if this artery was blocked, as it would be during the surgery, there would be enough blood flow to Donna’s brain.  She passed this test.

The only problem that remained was Donna’s high blood pressure.  Donna says, “My pressure has always been a little high but when I got to Columbia they told me it was sky high.  They said they had to get it down before they could safely operate on me.”

Five days later, her pressure was still high but her symptoms were rapidly getting worse.  Donna says, “I was in such pain, despite the medicine they gave me.  I could hardly sleep and I couldn’t see at all through my right eye. I kept crying, ‘Just get this thing out of my head’.”  Dr. Lavine worried that Donna could suffer permanent blindness and the aneurysm could fatally burst, so he decided he had to operate immediately.

Donna says, “Everyone got really busy. Dr. Lavine held my hand.  He was so warm and personable. He had my heart and I knew I was in good hands.”

He performed a two-step endovascular procedure on Donna called a stent-assisted coiled embolization.  (To learn more about endovascular surgery see our featured article, Endovascular Neuroradiology; The New Frontier)

The first step was to place a stent, or mesh liner, at the base of the huge aneurysm.  Lavine did this because the aneurysm was so big and irregularly shaped that a physical barrier needed to be created between the aneurysm and the artery from which it stemmed.

Next, he performed the embolization, by placing a number of tiny flexibly coils within the aneurysm.  These coils collective take up space in the body of the aneurysm giving it a solid structure that prevents it from bursting.

Dr. Lavine had gotten to the aneurysm in time.  Donna’s symptoms immediately began to abate.  She says, “My vision was back in 2 months and I don’t have any headaches anymore. Now I get to see my first grandchild and I appreciate every day.”

About her experience at Columbia, Donna says, “Every time I go there, they treat me so professionally.   They care,  right down to the people who carry you on the gurney.  This one lady who cleaned the room; We got to talking and she came over and gave me a big hug.  I am just so glad I ended up at Columbia.”

Imagine one day you stub your toe and the pain that would usually go away after a day or so, just keeps getting worse. Then the pain spreads to your whole foot which turns red and starts to swell. After a while your whole lower leg gets involved, you are having trouble walking and you can’t even put a sock on because your foot is so sensitive.

This kind of runaway pain response, called Complex Regional Pain Syndrome (CRPS), is rare but does actually happen. Dr. Christopher J. Winfree who heads both our Centers for Pain and Peripheral Nerve Surgery spoke at this year’s annual meeting of the American Association of Neurological Surgeons (AANS) and outlined a number of state of the art Neuromodulation techniques that can help people with this extreme condition.

If left untreated, CRPS can lead to irreversible changes in the soft tissue of the leg and even the bone can become more porous. While the exact cause is unknown, it is theorized that either the nervous system or the immune system get a sort of glitch in them and go haywire. No matter the cause, the pain can be unrelenting and treatment essential.

The first lines of treatment for CRPS are usually pain medications and antidepressants. Physical therapy can be prescribed to help with desensitization training and to mitigate any loss of strength, motion, and function. In more extreme cases, the patient is sent to a pain specialist like Dr. Winfree. As a pain specialist who is also a neurosurgeon, he employs a variety of neuromodulation techniques.

Neuromodulation is the process whereby an implantable device is used to reversibly alter the activity of the nervous system. This may be accomplished using small doses of medications or a weak electrical current. By altering the activity of certain pathways in the nervous system, pain may be immediately and dramatically relieved. Pain Center Website

In particular, Dr. Winfree spoke at this year’s AANS meeting about the individual or combined use of three types of neuromodulation: Spinal Nerve Root Stimulation, Peripheral Nerve Stimulation, and Subcutaneous Peripheral Nerve Stimulation. While there are many factors that determine which procedure is used it is largely based on where exactly the pain is. “Sometimes”, says Dr. Winfree, “CRPS is largely within the confines of a single peripheral nerve or nerve root distribution.” When this is the case, that nerve can be targeted either where it comes out of the spinal cord using Spinal Nerve Root Stimulation or closer to the area of pain using Peripheral Nerve Stimulation.

Dr. Winfree says however, that “CRPS typically exceeds the confines of a single peripheral nerve or nerve root distribution” in which case a combination of one or more of these techniques along with Subcutaneous Peripheral Nerve Stimulation can give the most pain relief. The word subcutaneous means “just under the skin” and that is exactly where they put the stimulator with this technique, right where the pain is. Sometimes this method is used alone but only a small area can be targeted at a time so might not be enough.

See previous blog Turn up the static when Pain Won’t Stop Calling for more about nerve stimulation

Harry was sent to see Dr. Christopher J. Winfree at the Center for Peripheral Nerve Surgery. With stubborn nerve pain like Harry’s, neurosurgeons like Dr. Winfree consider implanting an electrical nerve stimulating device (ENSD) in the spine for pain relief. Because of the very specific pattern of Harry’s symptoms his doctors could trace the irritated nerves in his feet back to a specific spinal segment where these nerves emerged from the spinal cord.

Dr. Winfree felt that placing the ENSD in the foramen or tunnel where the nerve emerged from the spine would give Harry the most targeted pain relief. An ENSD has a battery powered unit similar to it’s cousin, the pacemaker, that is placed just under the skin. This unit generates electrical impulses that travel through a wire to an electrode that is implanted next to the offending nerve. Using a remote control, the patient can control the intensity of the stimulation and thus his pain. Where and how these electrodes were placed in Harry’s spine was the subject of a paper Dr. Winfree and his colleague Raqeeb Haque, MD published in the July, 2009 issue of the journal Neuromodulation.

They used a new technique called, Transforaminal (meaning through the tunnel on the side of the spine where the nerve comes out) Nerve root (the name for the nerve when it first comes out of the spinal cord) Stimulation. It can be tricky to implant an electrode in this area because the nerve’s exit tunnel or foramen is small and narrow and as a person gets older and the spine degenerates it gets even harder to access.

Dr. Winfree has found a clever way to sequentially use three different shaped probes to guide the electrode into the narrow space. He says it is actually faster, easier, and requires less radiation from guiding X-Rays to access the foramen from the inside out. Here is how he did it.

He started by making a small incision in the skin above the level of the spine where the troublesome nerve was located. He then cut a small segment of bone out of the back to access the spinal canal. Using a slightly curved probe, Dr. Winfree threaded the electrode down the canal and over to the side where the foramen is. Once at the foramen entrance he switched to a highly curved probe to guide the electrode around the corner and into the narrow passage. Then, he switched again to a straight probe that wouldn’t get hung up on the nerve root and pushed the electrode into place. In the end, four electrodes where placed at two levels of the spine to target both Harry’s feet.

To learn more about this case, see the July 2009 Issue of Neuromodulation and look for Dr. Winfree and Dr. Haque’s paper, Transforaminal Nerve Root Stimulation: A Technical Report.

]]> http://www.columbianeurosurgery.org/2009/12/a-new-way-to-give-an-old-vet-relief-2/feed/ 0 http://www.columbianeurosurgery.org/conditions/lower-back-pain/ http://www.columbianeurosurgery.org/conditions/lower-back-pain/#comments Fri, 06 Nov 2009 19:43:35 +0000 Neurosurgery Webmaster http://beta.columbianeurosurgery.org/?page_id=2559 Low back pain is a common disorder affecting millions of individuals annually. Back pain is the single most common cause for lost workdays in the United States and one of the most common reasons for patients to visit their primary care physician. It is estimated that approximately 50 to 80% of the adult population suffers from a memorable episode of low back pain each year. In the vast majority of cases no specific diagnosis is made and the symptoms resolve spontaneously. Only a minority of patients present with symptoms specific to an irritated nerve root or have identifiable pathology on radiographic studies. The overall prognosis of low back pain is good, with improvement occurring in the majority of cases without aggressive medical intervention.

Anatomy of The Low Back

In order to understand the principles of low back pain a basic knowledge of spinal anatomy is helpful. The spine is made up of 24 to 25 separate bones known as the “vertebrae”. The basic functioning unit of the spine is known as the “spinal motion segment,” composed of two adjacent vertebral bodies, the intervening intervertebral disc, and surrounding ligaments (Figure – “Spine Motion Segment”). The portion of the spine that is equivalent to the lower back is referred to as the Lumbar Spine.

The vertebral bones articulate through three joints, two “facet joints” along the back of the spine and the intervertebral disc. The intervertebral disc and facet joints are densely supplied by nerve fibers that play an important part in the various clinical manifestations of back pain.

The vertebral bodies form a bony canal that runs the entire length of the spine and contains the spinal cord and associated nerves. The spinal cord acts as a relay, transmitting information between the brain and remainder of the body. At each spinal motion segment a pair of “spinal nerves” exit to supply various parts of the body. These nerves are in close proximity to both the intervertebral disc and facet joints. Degenerative changes involving these structures can irritate the exiting nerves and produce symptoms within the area supplied by the nerve, known as a “Radiculopathy.” When the nerves of the lower back are involved these symptoms are referred to the legs and are commonly referred to as “Sciatica.”

The intervertebral disc plays an important role in the degenerative cascade that can eventually lead to low back symptoms. The normal disc is composed of a fibrous ring of tissue containing a gelatinous center that acts to cushion the vertebral bones and limit the degree of normal motion. As a result of the aging process, the fluid content within the disc interior decreases, leading to a transformation from a gelatinous central core to one composed of dry, stiff, fibrous tissue. The outer fibrous ring also deteriorates with age, developing tears and allowing migration of the internal tissues beyond the normal confines of the disc space. These changes all contribute to structural changes that eventually lead to mechanical incompetence of the disc.

Over time, degenerative changes to the spinal motion segment, compounded by any additional stresses and trauma, can lead to an abnormal transfer of stress across the degenerated spinal segment and produce “Mechanical Pain”. Collectively these degenerative changes are referred to as “Spondylosis”, the medical term for arthritic spinal disease.

Causes and Treatments of Low Back Pain

MRI Spondylosis: Spondylosis of the Lumbar Spine (multiple level disc bulging and degeneration)

Any anatomical element of the spine may be a source for pain. The intervertebral disc, facet joints, surrounding ligaments, and muscles adjacent to the spine are all innervated by nerve fibers that relay pain information and can individually or collectively contribute to the generation of low back pain. Attempts have been made to characterize specific pain patterns produced by abnormalities of these structures, however to date there is no standardized method of categorizing, diagnosing, or treating many of the pain syndromes described.

Pain originating from the ligaments and muscles surrounding the spine has been categorized as Myofascial Pain. This type of pain is usually caused by excessive strain to the ligaments or muscles and is prolonged through mechanical factors. The pain is typically in an ill-defined area but can usually be reproduced in individual patients with specific maneuvers of the lower back. These patients are typically treated with activity modification, physical therapy, and a course of non-steroidal anti-inflammatory drugs (NSAIDS).

Abnormalities of the spine, either the vertebrae, intervertebral disc, or associated joints, are thought to produce pain referred to as Mechanical Back Pain. The pain is thought to originate from stress or strain placed on a degenerative joint. Various syndromes have been named in an attempt to define the origin of pain including the “Facet Syndrome,” for pain originating from the facet joints, and “Discogenic Back Pain,” for pain originating from the intervertebral disc. Despite the different syndromes described, there are no specific diagnostic tests to make this distinction. The pain produced is often described as a dull ache that originates in the midline and radiates into the hip, buttocks and/or thighs. The pain is typically exacerbated by activity, hyperextension, or prolonged standing and relieved with rest or lying flat. Typically there are no sensory changes or muscle weakness associated with mechanical back pain. Treatment options include conservative maneuvers, such as physical therapy and NSAIDS. Surgery is reserved for symptoms that do not respond to conservative therapy and produce debilitating pain (see treatment of low back pain).

The patient, we’ll call “Mildred”, suffered for years with plantar fasciitis.  This causes pain on the bottom of the foot, especially the heel.  She had extensive physical therapy and two foot surgeries and nothing helped relieve her pain.  When all else fails with a patient like this, Neurosurgeons can place an electrical nerve stimulation (ENS) device in the spine to block the pain.

ENS devices work, essentially by introducing pressure and vibration to mask pain. You are doing the same thing when, after bumping into a coffee table, you rub your shin to make it feel better.  When this kind of stimulation is effective, permanent implantation can be an option.

A neurosurgeon can map which nerve is associated with the pain and place an ENS device on it.  All the nerves in our arms and legs travel to and from our brain. They travel from our brain, like electrical wires coming from a main frame, through our spinal cord and out to their assigned locations. The brain and spinal cord make up what is called the central nervous system, and all the nerves once they exit the spine are called the peripheral nervous system. The central nervous system is more delicate so surgeons prefer to work with peripheral nerves.  The most common place to put an ENS device is in the patient’s back where the peripheral nerve starts.

Mildred had this procedure done four times and it failed four times because of infection.  Surgeons at The Center for Peripheral Nerve Surgery knew they had to find a location further along the nerve pathway.  The perfect location was in the back of her knee.

Typically, surgical placement of an ENS unit there involves opening up the back of the knee, treading through muscles, arteries and veins to find the nerve they are looking for.  At this point in Mildred’s ordeal, however, doctors wanted to limit the amount of trauma they had to put her through so they used an innovative technique using ultrasound.

Most of us know what an ultrasound is; something doctors use to see a baby.  Instead of using it on Mildred’s belly however, they used it on her knee.  Ultrasound images were used like a camera and required only a tiny incision and a hollow needle.  Doctors threaded the ENS unit through the needle and attached it right where they wanted it.  It didn’t take Mildred long to recover and she finally got the relief she needed.

Look for Dr. Winfree and his colleagues’ paper, Ultrasound-Guided, Percutaneous Peripheral Nerve Stimulation: A Technical Note in an upcoming issue of Neurosurgery

For many years, Atypical Facial Pain (AFP) represented a group of disorders that included most of the facial pain disorders that did not fit into the category of classic trigeminal neuralgia. As our understanding of the pathophysiology of the many facial pain disorders increased, a new classification for facial pain was developed that reflected this new knowledge. Thus, terms that were unnecessarily general were abandoned in favor of terminology that was more specific. Currently, AFP is reserved for facial pain of psychogenic origin.

Possible Causes

Patients with AFP are thought to have psychological origins of their pain. Depression, unresolved conflicts, behavioral problems, or other psychological issues may result in AFP.

Symptoms

The symptoms of AFP can be quite variable. Patients may describe burning, aching, cramping, pinching, or pulling sensations. Commonly, symptoms exceed the confines of the trigeminal nerve distribution, or are bilateral in nature.

Diagnosis

The diagnosis of AFP is made following a formal psychological evaluation, including a battery of psychometric tests. Additionally, other causes of facial pain, such as injuries to the trigeminal nerve or trigeminal neuralgia, must be excluded.

Treatments

Since the pain from AFP is psychogenic in origin, psychological support, to include ongoing counseling if necessary, is the appropriate treatment. It is important for both patients as well as the treating physician(s) to realize that surgery is completely inappropriate for the treatment of this condition.