Category: Painful Conditions

The piriformis, located deep within the buttocks, is a large muscle with two large sections. The sciatic nerve is a large nerve running from the base of the spine down through the back of the leg and passes through the two piriformis muscle bundles. If the muscular tissue or the connective tissue around this muscle becomes inflamed or swollen, it can irritate the sciatic nerve and cause pain that reaches from the buttocks down through the leg. Some patients will complain of lower back pain as well. Typically pain is worse while sitting and especially while driving a car.

Diagnosis

During a physical examination the piriformis muscle is tender. Stretching the muscle will often cause a painful reaction. The neurologic exam is usually normal.  Symptoms of piriformis syndrome can be similar to symptoms for spinal disorders that affect the sciatic nerve such as a ruptured disk. X-ray studies of the spine such as a CT scan and a MRI are used to insure there is not a spinal pathology causing the pain. MRI scanning of the piriformis area itself can sometimes show enlargement of the piriformis muscle with compression of the sciatic nerve. An injection of anesthetic medications around the piriformis muscle and sciatic nerve helps confirm the diagnosis. A biomechanical screen performed by the physical therapist can also help confirm the diagnosis.

Treatment

Many patients will find relief  from  the pain with injection therapy around the piriformis muscle and sciatic nerve. Physical therapy is also very important in treating this syndrome. Patients with piriformis syndrome will be asked to perform exercises to stretch and condition the large muscles in the gluteal region. This will help reduce the number of muscle spasms and irritation of the connective tissue around the sciatic nerve. For some patients the use of behavioral therapy, including biofeedback techniques, helps control some of the excess muscle irritability and reduces the pain. This permits the patient to progress more efficiently through their course of physical therapy. In extreme cases of piriformis syndrome, surgery is considered, but only after conservative measures have failed.

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The spinal column is composed of a series of 24 bones called vertebrae that are separated from each other by a disk. These disks help absorb the shock from every day wear and tear. The disks are about the size of four silver dollars stacked on one another. Their consistency is like a jelly donut and is surrounded by tough ligaments. The jelly center is called a nucleus.  This nucleus will flatten out and bulge depending on the stress applied to the back. If the force is too much, the nucleus can rupture and break through the surrounding ligament. When this happens a nerve is pinched causing pain.

Diagnosis

A ruptured disk does not produce low back pain, but instead causes pain at the end of the pinched nerve at the arm or leg into the hand or foot. It can be associated with tingling, numbness or weakness in the extremity. The onset may have been associated with excessive physical activity or a traumatic incident such as a car accident. When the doctor examines the patient, he or she will look for signs of nerve involvement through a careful neurologic exam, checking sensation, strength and reflexes. To confirm the presence of a ruptured disk, the doctor will order a myelogram, CAT scan or a magnetic resonance test (MRI) to visualize the spinal column.

Treatment

Depending on the pain and potential for nerve damage, there are a number of ways to treat a herniated disk. In some patients, the nerves can be severely injured, causing loss of bowel or bladder function. If this is the case, it is an emergency and the disk must be surgically removed. Fortunately, in most patients, this rarely occurs. Patients usually present with pain and minimal loss of nerve function. Conservative treatment consists of a combination of physical therapy, medications, and injections. Physical therapy is useful for reducing a bulging disc and taking pressure off the nerve. A specific set of exercises, called the McKenzie program, is usually used. Medications can be given over a short-term basis to allow the patient to sleep more comfortably and to increase his or her level of function. These medications consist of anti-inflammatory drugs, muscle relaxants and a reasonable dose of narcotics like Tylenol with codeine, Darvocet 100’s, or vicodin. Under no circumstances should more than three to four doses of narcotics be consumed in a 24-hour period because of potential injury to the liver or kidneys. If physical therapy and medications are inadequate for control of pain, injections can be given to ease the discomfort. Epidural steroid injections apply powerful anti- inflammatory drugs to the involved nerve root, easing pain and swelling secondary to disc irritation. The injections are usually given as a series of two to four over a period of weeks. Relief can begin within 72 hours of the first injection. Patients experiencing severe pain despite medications, physical therapy and injections may decide to have surgery. Surgery is advised only if a ruptured disk is confirmed with the CT scan, MRI or myelogram along with severe pain in the foot or hand.

Prevention

• The best way to treat a ruptured disk is to prevent it from happening.
• Spine care
• Stop/avoid smoking
• Maintain ideal body weight
• Proper strength training
• Proper posture

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Osteoarthritis is a disorder affecting our joints; causing pain and gradual deterioration of function. Every joint is composed of two bones with a gap between them. Lining the bone on either side of the gap is a smooth material called cartilage that allows the joint to move freely. In the gap between the two cartilage surfaces is joint fluid. Around the joint is a capsule called the synovium. It contains the joint fluid. Overlying the synovium are ligaments and muscles keeping the joint intact and the bones in place.

In osteoarthritis there is a progressive loss of the smooth cartilage, exposing the rough bone underneath. The bone will compensate by increasing its growth. This causes spur formation where the ligaments and capsule attach to the bone. This combination of exposed bone and spurs make the joint stiff and painful. The causes of osteoarthritis are:

• Joint overuse
• Obesity
• Fractures
• Trauma to the soft tissues (cartilage)
• Genetics

Diagnosis

The primary symptom of osteoarthritis is joint pain and stiffness. Sometimes the pain can be directed to some other area of the body that has a nerve connection with the joint. Patients with osteoarthritis of the hip may actually feel pain in their groin or knee. Patients with osteoarthritis of the spine may feel pain in the hip. If these symptoms are present, the doctor will order an X-ray, test the joint fluid and order blood tests to make sure there is no other disease present.

Treatment

Treatment of osteoarthritis should include medications, strength training, weight loss, minimal joint impact and surgical replacement of certain joints when necessary. Strength training is extremely important in patients with osteoarthritis. Avoiding physical activity causes the muscles around the joint to decrease in size or atrophy. As the muscles atrophy, the joint becomes less stable and that can have a negative effect on osteoarthritis. It is important to keep our body weight at ideal levels. Excessive body weight puts additional stress on the joint causing more pain. Using a walker or cane can make the joint feel better.

Your doctor may prescribe certain medications. There are over 17 different drugs, called non-steroidal anti-inflammatory agents (NSAID) that are useful in the treatment of osteoarthritis. These drugs include medications such as ibuprofen, aspirin and Naprosyn. It is important to realize these drugs have significant side effects such as ulcer formation, water retention, increased blood pressure and increased stress on the kidneys and liver. Your doctor will want to monitor your response to these drugs very closely.

Depending on the location of the arthritis, injections can sometimes be given into the joint or adjacent nerve to help relieve the pain associated with a sudden flare up. The injection may require the use of an X-ray machine for accurate placement. If the injection is painful to administer, a light intravenous sedative such as Valium can be used to make the procedure comfortable. In some patients the joint function deteriorates so badly that surgery is the best option. Surgery is commonly used to replace the joints of the knees, hips and fingers. Other joint replacement surgeries such as the shoulder are being developed and with time may be as successful as hip and knee replacement.

It is important to remember to stay very active despite the osteoarthritis. Non-impact exercises such as bicycling and swimming are ideal. Strength training is very beneficial when done appropriately.

Prevention

• Maintain ideal body weight
• Low-impact activities
• Proper strength training

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Spinal arthritis is a very common disorder affecting millions of Americans. When it occurs in the neck it is called cervical spinal arthritis. When it involves the low back it is called lumbar spinal arthritis. It begins to affect many people in their 30’s. By the age of 40, 50% of people will have evidence of spinal arthritis on an X-ray or CT scan. By the age of 50, that number rises to 100 percent.

Arthritis begins as a low-grade inflammation of the soft tissues surrounding the joints. The joints are composed of a delicate tissue called articular cartilage. It is a very smooth surface and allows the two bones composing the joint to glide over one another easily. Around the articular cartilage is a capsule of soft tissue called synovium. This capsule contains the joint fluid that lubricates the articular cartilage. Inflammation first begins in the capsules. Because the capsules are composed of soft tissue, they cannot be visualized on x-ray. As the arthritis progresses, the surface of the joints becomes pitted and gradually deteriorates. As the articular cartilage erodes, the bones underneath respond to the stress by forming spurs. This erosion and spur formation is a later finding that can be viewed on X-rays.

Diagnosis

Patients with spinal arthritis will develop pain in the neck or low back. That pain can spread to the arms or legs as the inflammation from the joints begins to affect the spinal nerves next to the joints. The pain may be worse in the morning because the joint stiffens during the night. As the day progresses, the joint gradually loosens up and symptoms get better. As the pain progresses, the patient will frequently go to the doctor to see what is wrong. The doctor will conduct a history and physical exam and may order blood tests and X-rays to confirm the diagnosis. The most sensitive test is the CT scan. This is capable of picking up arthritis at a relatively early stage. However, in most symptomatic patients, a simple X-ray will suffice.

Treatment

Many patients can find meaningful relief with a combination of therapies. The initial approach to early arthritis should involve a modest exercise program to keep the joints flexible; usually non-weight bearing exercises such as water aerobics to put the spine through a gentle range of motion and to enhance its flexibility. As arthritis progresses, medications such as aspirin may be necessary. There are now over 17 different types of compounds resembling aspirin on the market. These include drugs like Motrin or Naprosyn. Many patients with spinal arthritis find excellent relief with these anti-inflammatories, however there are some troublesome side effects such as stomach ulcer formation, high blood pressure, and deterioration of the liver or kidneys. Patients on these drugs have to be monitored by their doctor with blood tests taken at least once a year.

If gentle exercises and oral medications fail to control the discomfort, the patient can try a back or neck brace to inhibit the joint’s movement and to allow it to rest for a short period of time. Wearing a brace long term is controversial because it will cause weakening of the spinal muscles, which can worsen symptoms.

In severe cases of spinal arthritis, the patient may be a candidate for nerve block techniques. With nerve blocks, anti-inflammatory medications are injected directly into the joints or nerves. Once the inflammation decreases, the pain decreases. These steroid drugs are generally given as a short series of injections, usually two or three, over a period of weeks. If the patient gets relief lasting at least a few months, the drugs can be used again if the symptoms recur.

It is important to realize spinal surgery cannot relieve the pain of spinal arthritis. Even if a surgeon removes an arthritic joint, the tendency to form arthritis is still present in all the other elements of the spine so the pain will continue. Only if there is pressure being placed on the nerve by a single spur, can surgery be beneficial. The surgeon can remove the spur, alleviating the pressure and pain associated with nerve compression. Nonetheless, the tendency to form arthritis still remains and another spur may develop in a matter of years.

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