Got Pain?

SI Joint Pain

2010-03-18T08:32:00.000-07:00

Pain in the Butt…

A source of controversy for many physicians, the diagnosis and treatment of the sacroiliac joint (SIJ) as a source of pain is often overlooked. Although it can be a significant percent of those suffering with low back and buttock pain, many physicians refuse to recognize its connection to low back pain. This unfortunately subjects patients to pain that perpetuates and forces them to continue to suffer without relief.

As observed in a report from Schwarzer et al. in 1995 the prevalence of SIJ pain can be at least 13 percent and possibly as high as 30 percent in patients with low back and buttock pain. To provide a better understanding of why SIJ can be controversial, I will discuss the anatomy of the SIJ, evaluation, and treatment of the SIJ pain.

The SIJ is a diarthrodial joint, between the sacrum and ilium on the right and left of the posterior pelvis region. The joint is a variably shaped capsule with synovial fluid and hyaline cartilage on the sacral side and fibro cartilage on the iliac side. There are a multitude of ligaments and muscles that support it. The SIJ is more mobile in youth than later in life. The upper two thirds of the joint become more fibrotic in adulthood. Although the female pelvis is more mobile to accommodate pregnancy and parturition the prevalence of SIJ pain seems to be equal among males and females.

The pain that arises from a dysfunctional SI joint can vary among patients but for the most part there are basic similarities. The pains are usually located over the joint itself which is in the upper buttock areas. The pain can be described as sharp, aching, dull, numbing and even a combination of those symptoms is sometimes seen. The pains can radiate down the buttock and even mimic sciatic pains. Their pain can be intense enough to cause patients to limp and sit in awkward positions.

Diagnosing SIJ pains can be very challenging which is why many doctors refuse to recognize it as the cause of the pain. There is a wide array of physical exam maneuvers to detect SIJ pain. Most can be performed simply during the regular examination and verified by provocation. The Fortin’s Finger test, Fabere maneuver, Gaenslen’s test, Compression test, Gillet test, and Patrick’s test are some of the most commonly employed test. A major problem with these tests however is their poor inter tester reliability and false positive rate of 20 to 30 percent in asymptomatic individuals. No single maneuver is ideally diagnostic for SIJ syndrome but having multiple positive SIJ provocation tests can be somewhat reassuring and would suggest at least that SIJ pain should be part of the differential diagnosis.

Of course as with all patients but especially in these cases a thorough history must be taken to check for pre existing disease or injury, or new trauma and to evaluate the patient’s general health. The physical examination also has to be thorough and should include a Full Neurological examination, motor strength, sensory exam, and reflexes in the lower extremities. When exams are thoroughly performed, inspections can often reveal an asymmetrical pelvis with one crest higher than the other. Other important exams to keep in mind are the measurement of limbs to look for irregularity or detect scoliosis.

Laboratory studies are useful to rule out inflammatory disorders. Radiological studies such as plain film x-rays, are reasonable. Imaging with CT Scans and MRI’s is controversial because it is uncertain whether normal and abnormal radiographic studies can definitively differentiate symptomatic vs. non-symptomatic patients. This is in part to the great variability that exists in SIJ anatomy among patients. A comparison between CT Scan and MRI results on patients with sacroilitis revealed that their diagnostic sensitivity was similar. The MRI, though, did provide distinct information about the disease process in sacroilitis.

Once the diagnosis is established, controlling conditions for mechanical mal positioning can start with pain control, followed by education, modalities, and exercises. Educating patients on proper ergonomic training for bending, lifting and stretching can prevent repeated injury. Deep heat can soften and relax the muscles around the joint and electricity can relax muscle spasms. Mobilization is helpful in restoring SIJ alignment and sacral position. Physicians should keep in mind that injections may be the best option for quickly reducing inflammation along the joint line. These injections contain analgesic and corticosteroids that are placed in the lower third of the joint under fluoroscopic guidance or CT guidance. “Blind” injections with similar drugs can also be effective at reducing pains by decreasing ligament irritation.

Other treatments such as percutaneous radiofrequency neurotomy of the SIJ innervation have been performed with reports of long term relief. Reports though are from case series. Some authors have concluded that in patients with SIJ pain who respond to L4-5 dorsal rami and S1-3 lateral branch blocks, radiofrequency denervation of these nerves appears to be an effective treatment. Unfortunately, these studies consist of a very small test group which currently prevents endorsement of this approach.

Another treatment option is a proliferant injection. This injection instills an irritant such as dextrose along the joint line with the desired result being the thickening of the ligaments or muscle attachments to stabilize the hyper mobile joints. Surgery is only considered when pain is intractable and disabling and the patient has failed to respond to conservative treatments. The surgical treatment would consist of screw fixation.

Complications are minimal with the conservative treatments. Potential complications can include infection, hematoma formation, nerve damage, vascular particulate embolism, and complications related to drug administration.

In conclusion SIJ dysfunction continues to be a pain in the butt to physicians. Until studies with adequate methodology and experimental design are completed, physicians will have to use their best guesses as to the best interventions or treatments to use.

Raul G. Martinez, MD is a diplomat of the American Board of Anesthesiology. He completed his post-doctorate Fellowship in Pain Medicine from the University of Texas Health Science Center and has been in private practice since 1999. His offices are located in the Medical Center, Stone Oak, Alamo Heights and Southeast San Antonio. For an appointment call (210) 447-6333. Visit www.cipm.com for more information.

Facial Pain (Trigeminal Neuralgia)

2010-01-29T13:23:00.000-08:00

Pain is a tricky thing. It can be reflective or site specific. It can occur in every inch of our bodies and feel radically different in different areas. Commonly we think of PAIN as something affecting our backs and jointed areas or perhaps even more commonly our heads but from internal organs to our skin pain can manifest itself EVERYWHERE. In this blog we are reviewing facial pain, specifically trigeminal neuralgia.

Have you ever experienced facial pain that seemed sudden and probably brought on by a daily activity such as brushing your teeth or eating? If the pain didn’t last very long but came back frequently and is or was sever enough to cause you distress you might have visited a dentist in hopes of alleviating it. However, if you or someone you know has had dental procedures such as root canals and still find the pain returning you should consider that it could be something else. Perhaps you know the pain and have not yet visited your dentist. Either way, consider that when it comes to facial pain there might be more to it than you might think.

Trigeminal Neuralgia

By Dr. Raul G. Martinez

Trigeminal Neuralgia or “tic douloureux” is one of the most severe types of facial pain. It is pain so severe that it renders a patient’s life unbearable and in some instances suicide is not an uncommon occurrence. Unfortunately many patients go undiagnosed for months because their physician is not familiar with this painful syndrome.

Patients with this disorder have similar and unique type of symptoms. A diagnosis can be made on the history itself because of the uniqueness of the symptoms. Patients can present with intense facial pain that can last up to two minutes. In fact, the pain attacks can last only a few seconds but can recur within short periods. Some patients may have multiple episodes per day while others can have only a few episodes per year and the intensities can vary between the attacks.

An attack can occur by stimulating a trigger zone which can be located within the distribution of the trigeminal nerve. Stimuli like brushing teeth, eating, drinking, talking, laughing, light touch, can cause an attack to occur. The attacks can occur over a few weeks to months and there can be episodes of remission lasting a few months or longer.

The criteria for diagnosis of Trigeminal Neuralgia as per the International Headache Society is: facial pain lasting less than two minutes; pain that has at least four characteristics such as: a distribution along one or more divisions of the trigeminal nerve; sudden, intense, sharp, stabbing, or burning pain; lancinating pain; initiation of pain from trigger areas or by daily activities such as brushing teeth, eating, talking; no symptom between attacks; no neurological deficit; attacks are stereotyped in individual patients, exclusion of other causes of facial pain.

The trigeminal nerve is the largest and most complex of cranial nerves. It contains sensory and motor nerve fibers. The trigeminal nerve consists of three sensory divisions, the ophthalmic (V1), maxillary (V2), and mandibular (V3). Somatic afferent impulses carried by the trigeminal nerve can transmit pain, light touch, and temperature sensation. Information is transmitted to the central nervous system via the trigeminal nerve from the skin of the face, the mucosal lining of the nose and mouth, the teeth, and the anterior two thirds of the tongue. In addition to sensory innervation, the trigeminal nerve innervates a variety of muscles of facial expression, tensor tympani and some muscles of mastication.

Trigeminal neuralgia is caused by demyelination of the sensory fibers within the trigeminal nerve root. This could be in part from compression by an overlying artery or vein. Other causes where demyelination is involved include multiple sclerosis and compressive space occupying tumors. Ectopic generation of spontaneous nerve impulses and their conduction to adjacent fibers is likely increased by the buckling associated with pulsatile vascular indentation. Decompression of the nerve root from the vessel rapidly relieves symptoms. Other compressive type lesions can cause trigeminal neuralgia such as vestibular schwannomas, epidermoid cysts, and tumors.

Patients with multiple sclerosis have a higher incidence of trigeminal neuralgia. Since multiple sclerosis has plaques of demyelination, one of these plaques can affect the trigeminal dorsal root entry zone. Patients with peripheral nerve demyelination due to Charcot-Marie-Tooth disease also are prone to develop trigeminal neuralgia. Infiltrative disorders of the trigeminal nerve root such as carcinomatous deposit can occur causing the neuralgia.

When the symptoms develop at the onset of trigeminal neuralgia, many patients think it is due to dental problems. They usually seek dental treatment first. Sometimes these patients may undergo procedures such as root canals and extractions in trying to obtain pain relief. Unfortunately patients arrive at pain clinics after several failed attempts at fixing a dental problem that does not exist.

Patients undergoing medical management of trigeminal neuralgia should have baseline blood studies and biochemical studies to determine if side effects are related to treatment. Imaging studies can include x-rays of upper/lower jaws if patient is suspect of having dental pain. More importantly, an MRI scan can be used to detect benign or malignant lesions or multiple sclerosis plaques. Also the presence or absence of vessels in contact with the trigeminal nerve can be seen.

Treatment for trigeminal neuralgia consists of pharmacotherapy and/or surgical intervention. The anti convulsant drug such as carbamezapine has shown to decrease pain in this disorder. Baclofen and lamotrigine have helped in decreasing pain. Uncontrolled observations with other drugs such as phenytoin, clonazepam, sodium valproate, gabapentin, and lidocaine can decrease pain in trigeminal neuralgia. In some instances, multi drug use has been utilized with some beneficial results. Carbamezapine should be considered the mainstay of pharmacotherapy for trigeminal neuralgia. Baclofen, lamotrigine, oxcarbazepine, and gabapentin should be used as secondary drug choices.

Neurosurgical interventions include retrogasserian percutaneous radio frequency thermocoagulation, glycerol rhizolysis, balloon compression of the gasserion ganglion, and sterotactic radiosurgery. No randomized controlled trials have been found but are needed to see which procedure(s) have significant positive outcomes.

A typical patient with trigeminal neuralgia is often misdiagnosed and mistreated, with many undergoing unnecessary dental or medical procedures that bring no relief. It is important that doctors, dentists, and other health care professionals be familiar with trigeminal neuralgia, its diagnosis and treatment options. This in turn will bring proper treatment to patients sooner and minimize suffering.

Raul G. Martinez, MD is a diplomat of the American Board of Anesthesiology with a subspecialty certification in Pain Management. He completed his post-doctorate Fellowship in Pain Medicine from the University of Texas Health Science Center and has been in private practice since 1999. With offices in the Quarry Area, Medical Center, Stone Oak and Southeast he can be reached for an appointment at (210) 447-6333 or for more information about our practice visit us at http://www.cipm.com/. You can also follow us on twitter @sapaindocs or read our other blog Got Pain at MySA.com

Back Pain!!!

2009-10-28T10:03:00.000-07:00

Pain comes in many forms and intensities and it can affect just about every part of your body but some pain is more common than others. Frequently it has been my experience that almost everyone I know has suffered from back pain at some point. For this reason I spoke with Dr. Raul G. Martinez about back pain and am sharing his insights.

Q: What are the most common causes of back painA: Some of the most common causes of back pain include: muscle strain, disc herniation, failed back surgery, shingles, and fractures of the spine.?

Q: These sound serious. Is there a way to prevent back pain?
A: Prevention is very possible in some cases, like in muscle strain, but not in others. To prevent back pain people need to make sure to use proper techniques for lifting, keep a strong core through exercise and use stretching exercises of the lower back and abdominal area. Weight loss is also crucial if you're overweight. Of course fractures are hard to prevent if they're caused by accidents but if they are caused by osteoporosis they can be prevented by having regular check-ups and a bone density scan so that treatment can begin if bone loss is detected before it becomes sever.

Q: What kinds of treatments are available?
A: There are many different treatment options available for low back pain. Some of the most common and less invasive include physical therapy, epidural steroid injections, and trigger point injections. In other cases there are also advanced pain therapies available which include spinal cord stimulation.

Q: If my primary care physician is treating my pain why or when should I see a specialist?
A: Your primary care doctor may be treating your pain with medication. If medication management is not helping or if you have a disc herniation and would like to pursue conservative treatments prior to considering surgery then this would be a good time to ask your physician for a referral to a pain specialist.

Q: Don't most people live with some pain? If that's the case can't I just manage pain with OTC drugs like ibuprofen or acetaminophen?
A: Yes. We all live with some pain to varying degrees but if your pain is to the point of causing an interruption in your daily activities and you find you require more than the daily recommended amount of over the counter medications; then you may want to consider further options for care such as a referral to a specialist. The point you have to remember is that we don't have to live with prolonged sever pain. There are many treatments available that can help.

Q: If someone has surgery for back pain won't this solve it?
A: Surgery is not a guarantee for complete pain resolution. Many times patients do very well after surgery and they will never require further treatments but other times surgery corrects the problem assumed to be causing the pain yet the pain is still present, hence the diagnosis of Failed Back Surgery. A patient should always seek the least invasive procedure and escalate to surgery after other options have been exhausted. If they do, or have had, surgery and are still experiencing pain seeing a pain management physician is a good option as they can offer other treatments which are non invasive, or minimally invasive, as treatment for patients who continue with pain after surgery.

If you'd like more info you can visit www.cipm.com or call our office at (210) 447-6333 to schedule an appointment for an evaluation.