Tag Archives: back pain

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Nerve ablation

Would I do this? A nerve ablation for chronic pain?

https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.nerve-ablation-for-chronic-pain.zx3505

Two people mentioned nerve ablation to me this week: one in the back and one in the knee. Would I do this?

Holy denervation, Batman. I’d like to think that I wouldn’t, but pain does suck.

The problem is that pain is information, even chronic pain. The current thinking in medicine is that chronic pain is some sort of glitch in the wiring or the brain where something keeps hurting even if we can’t see much of an injury.

Like grief or a broken heart or the death of a loved one.

Those pains can soften, but do they entirely go away? The death of loved ones doesn’t. It’s been a decade since my sister died of cancer and I still think of things that would make her howl with laughter. She understood me in a way that no one in the world does: ok, except for my children. My children are adults now and out in the world and observing other parenting and non-parenting and disastrous young adult choices. My son now has a high school classmate dead of opioid overdose. A topic for another essay.

Back to chronic pain. Medicine in the United States does patients a terrible disservice by talking about the spinal discs all the time. 99 times out of 100, the pain is NOT a disc. The back is very complicated, with 6 layers of muscles, and some of those muscles are only an inch long. They all have to work together in a fluid way. Often, we forget this. Our muscles try to obey us and we lock them into a terrible position and they try and try and try: and then tear and hurt.

Lock them? Yes. We have three main types of muscle: fast twitch fatigable, fast twitch non-fatigable and slow twitch. Slow twitch don’t get much attention in the United States MORE AND FASTER dysfunctional ADHD culture. Slow twitch muscles are the posture muscles. If you lock them in one position, they will stay there. Even when you get up from the computer or desk or bent over picking strawberries.

When the muscles lock, remember that they are all attached to bones. Every muscle attaches to at least two sites. Picture a muscle that crosses the knee joint locking into a shortened position. Now, do you think the knee moves normally? NO, it doesn’t. And if the muscle is tight and locked, the knee joint can be damaged by not being able to move freely.

Now, think about your back. You have seven cervical vertebrae, 12 thoracic and five lumbar. So 24 separate bones, and then other bones, like ribs, attached by tendons and ligaments and muscles. You pull a muscle in your lower back playing pickleball. It hurts. When the muscle is injured, it tightens up to protect itself. The surrounding muscles can tighten as well, and then that area doesn’t move right. The other muscles and joints have to attempt to take up the slack! They can’t move normally either! All too often I ask what people did when their back started hurting and all they did was take something to mask the pain and keep going.

Pretty dysfunctional.

So what do I want you to do with a new injury? RICE. Rest, ice, compression, elevation. Rest the muscle. It’s hurt. Ice for ten minute intervals in the first 48 hours, not heat. Heat increases bleeding and swelling. Muscles can bleed if they are torn. You have had a bruise sometime in your life, right? You won’t see a deep muscle bruise, and personally I have trouble looking at my own back. You may add heat after the first 48 hours. Usually the peak of swelling and bleeding is by 48 hours. Compression: if it is an ankle or an elbow, an ace wrap holds the joint still and reduces swelling. You can press ice on your back, or lie on an ice pack. Go ahead and shower but not super hot at first. Elevation for arms and legs: gravity helps reduce swelling and pain.

What if it’s been hurting for a year? Your blog was too late!

Check your posture first. If you have been avoiding moving a part of your body, you need help. If your posture is terrible, you really need help. Take breaks at the computer! Get up and walk! And see your primary care person. Physical therapy, occupational therapy, massage therapy. Pay attention to what makes the pain worse and what makes it better. Alcohol or pot might make if hurt less, but that’s not fixing the problem and could make it worse. Muscle relaxants are not great either. The muscle tightened up to keep from tearing, remember? And scar tissue can form in muscle. You need to work with someone to gently break down that scar tissue without tearing the muscle again. So muscle memory is for injuries too. If a muscle has been traumatized, it has scarring and it remembers. It may tear more easily and will tighten up more easily. Listen to your muscles. They do not just tighten with trauma, they also tighten with stress and are more at risk for injury. Learn how to reduce your stress, go into a parasympathetic relaxed mode, and help your muscles.

For long term chronic pain, I think of present injury, old injury and then brain and emotional injury. We are often afraid of injury, that we will be hurt, that it will hurt forever, that we will be disabled and be alone and starve. Our culture for the most part celebrates the young and strong and the survivors. I don’t think we have a “chronic pain day” where the whole country thanks the people who have chronic pain and work anyhow, to take care of each other and their families. Maybe we should have that. The emotional part of chronic pain must be addressed too.

I would be very cautious about having a nerve cut, or ablated. The exception for me is the abnormal heart pathways that cause arrythmias. Yes, I think ablating them is a good treatment, but we still try other things first. There can be complications of any surgery.

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The photograph is me and my ex dancing at our wedding in 1989. Swing dancing is a delight and you have to not injure your partner or yourself! We noticed that even one drink would affect our dancing and our favorite place to dance was at Cabin John Park, which had no alcohol at all. Posture is important. I think the photographer on this one was my ex’s uncle but we also had a dance friend who took wonderful photographs.

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what would YOU choose?

Here is a story of a choice about an abortion, a theraputic abortion, where a mother has to make a difficult choice. I have seen Family Medicine patients since 1991, so this will not identify a particular person. No HIPAA problem.

I see a new patient in clinic, a woman, who already has children. She has back pain. All is routine until she says, “Sometimes my leg goes numb from the knee down.” I stop. This is NOT normal. “Completely numb?” I say. “Not patchy?” “Yes.” “How often?” I ask. She shrugs. “Not very.” “If it happens again, call me and I want to see you right away.”

Why? This is unusual because most numbness follows dermatomes if it is from back pain. The dermatomes on the skin wrap from the back down the leg all the way to the toes. When someone describes numbness or the pain of shingles in that distribution, we know which nerve is affected. Numbness from the knee down can come from diabetes and other causes, but it is not on one side and it doesn’t come and go. So the unusual stands out for me.

“Anything else weird?”

“I had vision problems in my last pregnancy. They sent me to specialists, even a neuro opthamologist. He couldn’t find anything.”

“Ok.” I shrug. We move on.

She calls two days later. “Both legs are numb from the knee down.”

“Come in today,” I say.

Both legs ARE numb from the knee down. She also can’t lift her feet. The muscles from the knees down are weak. I get neurology on the phone. “MRI her from the top of her head to the base of her spine.” I call the hospital and set it up. That day.

She has seven brain lesions suspicious for multiple sclerosis. She did have an MRI in the previous pregnancy, which was negative. I do not remember how old the child was, 2-4 years or more when I saw mother.

I call her back in for results, we talk about specialists, and I call a neurologist in the nearest big city, three hours by car from where she lives. We start medications and my patient is scheduled.

She has multiple sclerosis. The flare improves. The visual symptoms were MS in the previous pregnancy, but it was not yet visible on brain MRI.

Then she gets pregnant again. Her symptoms immediately flare. She comes to me and I call the neurologist.

The symptoms are not a little worse. Much worse. “I suggest she terminate the pregnancy.”

My patient is horrified. Until the neurologist’s next words. “She needs to terminate if she wants to be able to walk for the children she has.”

My patient chooses an abortion, to terminate the pregnancy. Because she has a bad version of MS*, she remembers the symptoms in the last pregnancy, she is young, she is clearly progressing and she wants to take care of the children she already has.

What would YOU choose? For yourself, for your sister, for your wife. If you are male, do you have any right to make that choice? Now picture yourself pregnant with that choice. And thank you for reading this.

*Addendum: present evidence says that multiple sclerosis does NOT worsen with pregnancy. However, another illness, NMO (neuromyelitis optica) instead tends to become more active in pregnancy. It previously was lumped in with MS until the antibodies (anti-NMO) were identified and it was realized it’s a different subtype of demyelination disease, with its own treatment options. Medicine changes over time and the woman, the neurologist and I were working with the information available at that time.

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Does back pain mean a disc?

Does back pain mean a disc?

Does sciatica, pain down the sciatic nerve, all the way down the leg, mean a lumbar disc is out of position and you need back surgery?

Ninety nine times out of one hundred: No.

No? What? Really? Doesn’t back pain and sciatic pain mean a disc is pressing on the nerve?

Nope.

Sciatica means that the nerve is annoyed. It is sending pain signals. It can be irritated and inflamed anywhere along the entire path of the nerve. When the nerve is inflammed or there is surrounding inflamation, the nerve sends pain signals.

But… if it is not a disc, WHAT IS IT?

Muscles that are injured, inflamed, irritated, contracted or torn, that in turn put pressure on or inflame the nerve.

The sciatic nerve is made up of multiple nerve roots coming from the spinal cord: L3, L4, L5, S1, S2, S3. And then variants. The nerve roots bundle together and then dive through a group of muscles and go down the back of the leg: deep in the muscles. Why deep? To protect this very big, very important, bundle of nerves. Branches veer off and innervate muscles and bone and tendon and fascia, all the way down to the toes. There is not a spinal column in the leg, to protect this nerve.

It dives in between the superior gemellus and the piriformes muscle, deep in the buttock. Under the gluteus maximus and the gluteus minimus. Then it goes down the leg, under the semitendonosus muscle and the biceps femoris muuscle, the big hamstrings.

Now, let’s go back up to the low back. Why does it hurt? With or without sciatica? There are six layers of muscles in the back, all way smaller than those hamstrings. The top is the latissimus dorsi, down 5 more layers to the small longus and brevis rotares muscles, which connect each vertebral bone and allow subtle and complex movements of the spine.

What happens when a muscle is torn or injured? People look blank in clinic when I ask. I say, “Think of a piece of steak, what happens when you cut it?” They still look blank. “It BLEEDS, right?” When a muscle is torn or injured and bleeds, it and the surrounding muscles cramp up as much as they can, to try to prevent further bleeding and tearing. If it is an extremity, ace wrap, elevate and ice, as soon as possible, to slow the swelling and bleeding and pain. If it is the lower back muscles, ice as soon as possible and applying pressure won’t hurt. No heat for 48 hours since muscle bleeding and swelling and inflammation usually peak at 48 hours. After 48 hours apply heat, then gently stretch, then ice after stretching.

Think of the muscle fibers as torn. They take about 6 to 8 weeks to fully heal. You want to stretch them and rehabilitate them without tearing them in that 6-8 weeks. You want every muscle to be fully functional, to be the right length, to not heal shortened or scarred. Get those fibers working again…

….or….

But doctor, my back has been hurting for FIVE YEARS!

Then it will take longer than 6 to 8 weeks to rehabilitate, retrain the muscles, gently break down the scar tissue, get it all functioning. Your muscles are doing their best. They told you they were hurt and you need to listen to them.

Covering it up with ibuprofen or alcohol or any number of substances or trying to ignore what your muscles are trying to tell you is a bit counter productive, don’t you think? Pain is information. An advil can help with the pain, but it does NOT fix the problem. “Drug me so that I can go on ignoring it.”…. uh, no. That is not ethical and it also doesn’t work.

And just think, if those back muscles continue tighter and tighter… they are constricting and pulling on the spinal bones.  They pull on those bones and then a disc might be thinned or crushed and might protrude and then press on a nerve. And then for surgery, what do they do to get to the disc? Cut through the six layers of muscle….