Research shows virtually everyone who undergoes an amputation of an extremity will describe some measure of phantom limb sensation. These are sensory illusions giving the person a sense that the missing limb is still present. The underlying cause of this disorder is not known. However, doctors suspect it may be linked to parts of the central nervous system that retain the memory of the limb before it was amputated. In many cases, the experience is not particularly troublesome and over time the sensation fades. For other patients, the phantom limb sensations become a source of severe pain that can persist for months or years. People who suffered a sudden traumatic amputation or those who have complications following a surgical amputation, are more likely to suffer from this syndrome. The intensity and quality of phantom limb pain are not the same for everybody. The patient may indicate they feel a lengthening or shortening of the phantom limb and its pain.

Diagnosis

Doctors often find during a physical examination of a patient with phantom limb pain that the stump is tender and there is deterioration of tissue around the wound at the tip of the stump. Patients with phantom limb pain may have neuromas or abnormal clusters of nerve cells at the ends of the nerves that have been cut during the amputation. Patients with significant stump pain may respond to diagnostic and therapeutic nerve blocks or injections of anesthetic medication around the painful structures. Phantom limb pain may also respond to nerve blocks used diagnostically to help reduce the irritability of the nerves that lead from the spine to the painful limb.

Treatment

The treatment of phantom limb pain should focus on correcting underlying predisposing conditions, including the development of neuromas or painful bone spurs in the stump. Some of the effects of phantom limb pain can be alleviated with the use of oral medications, which help reduce pain from nerves. The patients are usually started on a low dose and gradually given larger doses to provide the best overall results. Traditional pain medications and non-steroidal anti-inflammatory agents have a limited use when prescribed in conjunction with other therapies. Nerve block treatments can be extremely valuable for stump pain and phantom limb pain. Injections of anesthetics with anti-inflammatory medications around the painful areas of stump neuromas can provide long-term relief in selected patients. Epidural injections or sympathetic blocks containing anesthetics, sometimes in conjunction with anti-inflammatory or pain medications, can be used in the treatment of phantom limb pain. These injections are usually performed near the spine where the nerves originate. These injections are usually given in a short series over several weeks until the symptoms subside or a plateau is reached. Research shows treatment of stump pain occurring immediately after the amputation can be effective in preventing the development of long-term phantom limb pain. This treatment is often performed through a continuous epidural infusion, through a catheter placed either before or immediately after surgery. Earlier placement seems to be more effective. For some patients surgery is considered in order to remove the painful neuromas at the tip of the stump or to revise the scar at the end of the stump. Rehabilitation efforts to desensitize the painful area, including physical therapy methods, are sometimes utilized.

For patients who have severe pain affecting their ability to perform daily life activities, a combination of physical therapy and behavioral therapy can be utilized. Patients may be asked to complete broad examinations to help determine physical and mental statuses in order to determine what type of behavior modification will be most helpful. Most often patients will find counseling, biofeedback and relaxation techniques the most beneficial.

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Spinal stenosis is defined as the narrowing of the spinal column around the spinal cord or nerve roots. The spinal column is composed of a number of structures. The most delicate of these is the nerves that make up the spinal cord and branch out into nerve roots. These nerves are protected by a combination of bones, disks and ligaments. The bones have a number of joints, called the facet joints, at every level of the spine. Studies show that spinal stenosis occurs when degenerative arthritis of these facet joints leads to calcium deposits on the interior spinal ligaments. When this is coupled with a bulging disk, the result can lead to compression of a nerve root, which then causes pain and irritation. Patients may limp as a result of the pain and the reduced blood flow to the nerves. Patients may notice these symptoms occur after they walk a short distance. Resting may help relieve the symptoms. Patients will also find themselves leaning forward or flexing the lower spine to help relieve irritation of the affected nerves. Sitting for a time may also help relieve the pain. Research shows that the pain from spinal stenosis can mimic pain brought about by other spinal disorders. For most patients the condition develops slowly over time. It is quite rare for the condition to be brought about by a single incident.

Diagnosis

Doctors will often find during a physical examination that a patient with spinal stenosis will have an abnormal gait pattern. There is usually tenderness over the affected portions of the spine, with restrictions in range of motion at the waist. Doctors will often utilize X-rays, such as a CT scan, to better study the joints and bony structures in the spine. For patients who may be facing surgery, a MRI or myelogram is sometimes used to better study the nerve structures within the spine.

Treatment

Nerve block treatments or injections of anesthetic medication with anti- inflammatory medications can be quite helpful in treating the pain. These are epidural injections and are usually given in a series of three treatments over a two to three week period. If the epidural injections are not helpful, the doctors may use a nerve block designed to reduce irritation from the joints of the back that can be contributing to the symptoms. The use of oral nonsteroidal anti-inflammatory medications in conjunction with pain medications may be useful as well.

Doctors may prescribe physical therapy exercises that will initially address flexibility and proceed to strength training exercises for the surrounding muscles in order to provide support for the affected parts of the spine. For some patients with spinal stenosis, surgery is a last resort to relieve pressure on the effected nerves in the spine. This is usually reserved for patients with neurologic weakness in the affected extremities.

Behavioral interventions, including biofeedback and muscle relaxation training, in conjunction with counseling are used for patients with recurring pain when all other methods fail.  The goal is to develop coping mechanisms to live more productively with the residual pain.

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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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