Putting Out The Pain Fire

I see many patients that come to me every day with pain and lots of it. Often they have pain in several similar global areas. These seem to occur in groups like neck, upper back and shoulder pain some with arm pain some without; or low back, sacrum and hip pain as a group some with leg and some without leg involvement just to name a few. I have talked in the past to Drs. Spurlock, Matz and Hadley of the UAB Dept of Neurosurgery, as well as our doctors about this phenomena. They too have seen this in their practices. Over the years I have concluded that Pain is often not of a single source genesis or origin. Meaning that pain often comes from more than one cause. Further pain seems to begot pain. In that once the body is in pain the second or third pain seems to combine with the other pains to make the global area painful.

We the patients, want our pain to be from a single origin or cause as we feel that in someway it might be easier to stop or turn off the pain. However, I now believe in the multi genesis pain origin theory. This theory says that pain is often cumulative in the body. I often compare this to lighting a book of matches. If one were to light one match, one would have a small fire. Light the whole book and you get a much bigger fire composed of many smaller fires.

I find the same is true for the body. Let us take the low back pain for example. The origin of low back pain can often be traced to several pain generators. Say for example, a patient presents with low back pain radiating into the hip. How many times have we found that the patient did indeed have a disc problem, a same side facet problem, sacroiliacs, and bursitis of the hip or similar findings. This perhaps, is part of the reason for so many failed low back surgeries. Yes the surgeon dutifully decompresses the disc but does nothing to treat the co-concomitant conditions(other problems).

I often tell my doctors that if you can't find the problems you can't fix the problems. This can only be done through examination, treatment, re-examination and continued treatment. I often find it necessary to bring in other doctors or specialist in their respective areas to confirm diagnosis or treat. I find by accurately diagnosing the multi genesis pain and its several pain generators we can often separate and treat the overall pain putting out several of the pain fires and then determining the extent of the core problem. Kind of like turn off the background noise and see what is left.

Patients like this kind of treatment as they feel the progress. This progress gives them hope that their pain may be treatable. Surprisingly it is. Often the average doctor does not take the time or have the inclination to tease out the many pain generators. It is far easier to just say you have a bulging or herniated disc and treat only that problem. We encourage our doctors to look globally at our patients, diagnosing multi genesis pain generators and then treat them all.
Dr Greg


Copyright 2009 Millar Chiropractic Associates, Inc. All rights reserved. The contents of this website including all links to other pages or websites herein including but not limited to text, graphics, images, comments, statements, or information from doctors, host or guest, and other material contained therein (Content) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. You should not use this Content for diagnosing or treating a health problem or disease. Never disregard professional medical advice or delay in seeking it because of Content you have seen, read or heard.

Stenosis and Degenerative Facet Disease

Problem: Today I had a 62 year old man present with severe low back and leg pain. On taking his history, he stated that his low back hurt worse first thing in the morning and again late at night. He also stated that his pain was increased with slightly bending over say the sink to wash dishes or shaving. He also stated that his low back and leg pain was decreased by sitting down. On questioning, he stated that when he shops he needs to lean over a shopping cart. And while shopping his pain can be relieved if he sits down for a few minutes. I ask him if his pain immediately goes away while sitting or does it take a few minutes to historically differentially separate vascular claudication from stenosis. He has a past history of MRI study showing 2 bulging disc and has had 2 lumbar epidural injections with little success. You know God gives you the right to have more than one thing going on at a time an I think this patient has taken him up on that idea. After taking his history, I have a theory that he had two primary problems 1) lumbar stenosis and 2) degenerative facet syndrome. I feel that his bulging disc may in fact be a red herring and not causing his problems. I did a complete and thorough examination including posture exam, orthopedic test, neurological test, palpatory exam, spinal exam, range of motion and digital muscle weakness exam. Next I completed a surface NCV and EMG of his spine and lower extremities. I ordered X-rays of his lumbar with obliques at the hospital and compared them to his recent MRI films. Discussion: On imaging he in fact does have both soft tissue and bony stenosis. The lumbar canal was narrowed to 9mm at L4 and L5. Since he did not have any pain with a straight leg raiser or well leg raiser and was able to tandom walk heel/toe with no other neurological deficits, I concluded that his bulging disc were red herrings. Spinal stenosis, a narrowing of the spinal canal, which places pressure on the spinal cord or nerve roots. If the stenosis is located on the lower part of the spinal cord it is called lumbar spinal stenosis. Stenosis in the upper part of the spinal cord is called cervical spinal stenosis. While spinal stenosis can be found in any part of the spine, the lumbar and cervical areas are the most commonly affected. Patients with lumbar spinal stenosis may feel pain, weakness, or numbness in the legs, calves or buttocks. In the lumbar spine, symptoms often increase when walking short distances and decrease when the patient sits, bends forward or lies down. Cervical spinal stenosis may cause similar symptoms in the shoulders and arms. In some patients the pain starts in the legs and moves upward to the buttocks; in other patients the pain begins higher in the body and moves downward. Treatment: I started him on phisotherapy including Interferrential current (IFC) for 15 minutes along with hot pads. I also started him on ultrasound over the lumbar paraspinal muscles and facets. I started him on DTS Decompression Traction; Cox Flexion/Distraction; and chiropractic manipulative therapy. If he does not improve in two weeks then I will send him for lumbar facet injections. I feel he will ultimately need the facet injections. However if he needs facet injections I want them to be done under floro guidance at the hospital or surgery center. I am also talking to him regarding his overall health and his future health goals and life expectancy. If he develops neurological deficits then I will immediately refer him back to the neurosurgeon for surgical decompression.
Dr Greg Millar

Copyright 2009 Millar Chiropractic Associates, Inc. All rights reserved. The contents of this website including all links to other pages or websites herein including but not limited to text, graphics, images, comments, statements, or information from doctors, host or guest, and other material contained therein (Content) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. You should not use this Content for diagnosing or treating a health problem or disease. Never disregard professional medical advice or delay in seeking it because of Content you have seen, read or heard.

Leg Pain & Groin Pain with NO Back Pain

Problem: Today I had a man present with groin pain and leg pain to the foot worse on sitting and lying down and better with standing and walking. He has had similar groin pain in the past over the years but he has had no similar leg pain. He thinks he hurt himself lifting something heavy a week ago. Today, he had no back pain to speak of. In fact on examination, the low back had very little tenderness or spasms. He had a little edema over the sacrum. His groin and leg pain however he rated at a 9. During the exam his pain was so intense he could hardly carry on a conversation. My exam revealed several things. First, I could make the pain worse by having him sit on the table and raise a leg to 90 degrees. Secondly, with him lying on the table, when I lifted his uninvolved leg up to 35 degrees, pain shot down his leg and into the groin. Third when I tested his lower extremity sensory nerves (dermatomes) he had moderate hypersensitivity (too much) in one area of the involved leg followed by moderate hyposensitivity (too little) of the along the outside of the foot (S1) dermatome. Forth, his muscle strengths were somewhat diminished with some loss of strength at the involved leg quad and hamstring muscles both rated a 4/5. He had a negative heel walk and toe walk and denied any change to bowel. Finally he had a negative braggard's ruling out simple sciatica. Treatment: He had a defibrillator so e-stimulation was out. So I went with moist heat followed by laser to the sacrum and lateral/posterior leg along the nerve route and ultrasound to the upper lumbar para spinal muscles at T12 -L3 on the side of involvement. I did some manual therapy on his low back and sent him for X-rays at the local hospital as I want a radiologist to read these films. I think he has two things going on. First I think he has stenosis (narrowing of the central spinal canal) and secondly I think he has superimposed a bulging disc at L5. He also may have one at L4. I think he has neuroforaminal encroachment (disc pressing on the nerve root) causing inflammation. I will order an MRI after I get the x-rays back. I talked to him about anti inflammatory meds but he was already on Mobic. Discussion: Diagnosis is the key. If a doctor does not know what is causing the problem he can't fix it. God gives us the right to have more than one thing going on at a time. Most people have multiple pain generators. I talk everyday to patients that tell me that the doctor did not touch them in the examination. That means the doctor is guessing and that's why we have so many failures in low back pain treatment. Greg Millar DC CCEP




Copyright 2009 Millar Chiropractic Associates, Inc. All rights reserved. The contents of this website including all links to other pages or websites herein including but not limited to text, graphics, images, comments, statements, or information from doctors, host or guest, and other material contained therein (Content) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. You should not use this Content for diagnosing or treating a health problem or disease. Never disregard professional medical advice or delay in seeking it because of Content you have seen, read or heard.