The vertebral column is a series of 24 bones, muscles and ligaments that protect the nerves of spinal cord. Each bone is called a vertebra. The vertebra is about the size of a child’s toy block, only round. Behind this body of the vertebra is the spinal cord followed by a roof of bone called the lamina. The vertebral body and lamina surround and protect the spinal cord from injury (see diagram). As we age, our bones lose calcium and are more prone to fracture. This process of calcium loss is called osteoporosis and is very common in older women. In the presence of osteoporosis, the vertebral bodies can break and collapse, a process known as a compression fracture. Compression fractures most commonly take place in the mid and low back because the weight of the body is carried there. The fracture can be a source of severe pain because the bone is broken and the nerves next to the spinal cord are pinched.

Diagnosis

Patients with compression fractures complain of sudden onsets of mid and low back pain. The pain may be experienced along the course of the nerves next to the compression fracture. If the vertebrae of the lumbar spine are involved, the patient may experience leg pain. In the mid back or thoracic region, the pain may radiate to the front underneath the breast. If the doctor suspects a compression fracture, X-rays of the spine will be ordered. Compression fractures are usually readily apparent on a standard X-ray.

Treatment

The initial treatment for compression fractures is bed rest and pain medications. This gives the fracture time to heal, unfortunately however, the bone will heal in the collapsed position. Once the bone heals, it stops hurting but the nerves remain pinched, causing chronic pain. If chronic pain develops, the patient may need moderate doses of appropriate narcotic medications such as Tylenol #3, Darvocet or Vicodin. Excessive use of these drugs must be avoided because of the long-term toxic effects to the kidneys or liver. If, despite the use of appropriate medications, the patient is still experiencing significant discomfort, nerve block techniques may be able to resolve the pain. Traditionally, epidural injections are given. With this technique, powerful anti-inflammatory drugs are injected along side the nerves where they are pinched. This helps relieve swelling and inflammation, thereby resulting in pain relief. Nerve block techniques have to be used cautiously because the medication is an anti- inflammatory steroid, cortisone-type drug. Long-term use of cortisone can actually lead to osteoporosis and cause more compression fractures. The injections are usually given as a series of two or three over a period of weeks. In the event of a compression fracture, no more than two or three series should be given in the course of any one year. In addition to injections, braces can be used to help stabilize the joints. Although this may prevent further fractures, it cannot alleviate the compression of the old fracture. Compression fractures are a serious problem that can be difficult to treat. Ultimately, patients will need a combination of injections, medications and bracing to achieve a significant level of comfort.

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A headache is the most common pain complaint in our society. Tens of millions of people suffer from headaches every year. Chronic headaches can be divided into three categories:

• Migraine Headaches – are believed to originate in the blood vessels that supply the head.
• Muscle Tension Headaches – are caused from chronic contraction of the head muscles.
• Cervicogenic Headaches – are usually due to arthritis of the spine. The arthritis originates in the small joints of the neck or upper (cervical) spine called the cervical facet joints.  This type of Headache is usually seen in older patients who suffer from arthritis, but may also be present in patients who have suffered neck trauma such as whiplash.

Arthritis is a deterioration of the joint caused by low-grade inflammation. This inflammation can spread to the nerves of the neck. The occipital nerves are formed in the upper levels of the neck and ascend to the back of the head where they provide sensation. When the joints of the neck are inflamed, it spreads to the occipital nerves and the pain is experienced in the back of the head.

Diagnosis

Patients with cervicogenic headaches will have pain in the back of the head, although some patients will also experience the pain behind the eyeballs. Usually there is a history of trauma and X-rays of the neck may reveal the presence of arthritis. When the doctor examines the patient, he or she may discover the neck muscles are tender and in spasm. The only way to absolutely document the presence of cervicogenic headaches is with a diagnostic injection of the joints under X-ray. During this procedure, a specialist in joint injections can put an anti-inflammatory drug into the joint, causing reduction in the inflammation. If the headache disappears after this procedure, the doctor can be relatively certain the headache is coming from the neck, and thus diagnosed as a cervicogenic headache.

Treatment

In the event of acute flare-ups, cervicogenic headaches can be treated with a combination of ice application to the neck, oral anti-inflammatory drugs such as aspirin or Motrin, and immobilization of the neck with a neck brace or soft collar. In most cases the headache will resolve with this treatment in relatively short time. If the headache fails to improve, the patient can be prescribed physical therapy. The physical therapist will apply ice, mobilize the soft tissue and also apply gentle traction to the head and neck to relieve the pressure on the joints. If this strategy fails to improve the patient, injections of the joints with anti-inflammatory drugs can be done. These injections are the same injections that are given for diagnosis, except they may be given as a short series of two to three injections over a period of months and can lead to long term relief.

Prevention

• Sleep with your head in a neutral position.
• Use a relatively firm, non-feather pillow that keeps your neck in good alignment with the rest of your spine when you sleep on your side.
• If you sleep on your back, use a relatively narrow pillow so that your head is not thrust too far forward.
• If you pay careful attention to your sleep posture, avoid sudden neck movements and take appropriate prescribed anti-inflammatory medications, most cervicogenic headaches can be prevented or controlled.

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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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