Dr. Mosallaie Interviewed by Phoenix Magazine for Pain Management article
The Problem of Pain: From conservative treatments to surgery, options abound for patients in pain
The American Academy of Pain Medicine reports that 100 million Americans suffer from chronic pain – which is more than diabetes, cancer and heart disease combined.
Not surprisingly, back pain tops the list, afflicting 27 percent of U.S. adults. Severe headaches or migraines, neck pain and facial pain also are top culprits. “It’s really head-to-toe,” says Abram Burgher, M.D., a fellowship-trained pain management physician with The Pain Center of Arizona. “We take everyone and try to figure out what is the best therapy.”
Read on as Valley physicians discuss some of the therapies that are helping patients reclaim active lifestyles with less pain or no pain.
Medication and physical therapy are still the first line of treatment for pain. While physical therapy works on the functional side of getting people better, medications can play a role in calming inflammation, relaxing muscles and reducing pain. These can range from over-the-counter anti-inflammatories to prescription painkillers and muscle relaxants.
“The most important thing for patients who have musculoskeletal pain is doing physical therapy and exercises,” says Farhad Mosallaie, D.O., a board-certified pain management specialist with Sonoran Spine. “That’s really low-tech, and often patients try to bypass it, but I can’t emphasize enough how important that really is.”
Patients with acute, severe pain also may be prescribed narcotics, or prescription painkillers. While narcotics can play a role in managing pain, Dr. Mosallaie says they should be used in conjunction with other conservative therapies and their use should be quickly tapered down due to the risk of addiction.
While narcotics get a bad rap – and rightly so, as enough painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month – the long-term use of over-the-counter anti-inflammatories has risks, too. “One of the most dangerous medicines we use are non-steroidal anti-inflammatory drugs (NSAID), such as Alleve, Advil or Celebrex,” says Eric Feldman, M.D., a fellowship-trained pain management and interventional spine specialist with The CORE Institute. “Most people think because these are over-the-counter, they are safe, but high-dose daily NSAID use is bad.” He notes that long-term or high-dose NSAID use can cause gastric ulcers, internal bleeding and deteriorating kidney function.
Tory McJunkin, M.D., a double-board-certified interventional pain medicine physician and co-founder of Arizona Pain Specialists, likens pain management physicians to quarterbacks for patients in pain – helping them coordinate physical therapy, chiropractic care, acupuncture, muscle or tissue work, traction, disc decompression and bracing.
Sometimes, it takes a bit of sleuthing to diagnose the source of pain. “If you take 100 people without pain, 70 percent of them will have findings on an MRI. That’s why you don’t treat purely based on an MRI,” explains Anthony Lee, M.D., a board-certified pain management physician with Southwest Spine & Sports. “You could have the classic herniated disc in your lower back, but that’s not what’s causing the pain,” he says, noting that bones, ligaments, hip or pelvis, a hernia, arthritic joints or even kidney problems could be the culprit.
“As good as medicine has become, it’s a process of finding the right diagnosis and using the right tools to correct a problem. Unfortunately, it’s not always a simple, single solution,” Dr. Lee adds.
Sometimes, targeted treatments such as epidural injections offer relief. Injections can deliver anti-inflammatory medication near the problem disc, nerve or joint.
In patients whose pain stems from medial branch nerves (the small nerves that carry pain signals from facet joints in the spine to the brain), Dr. Mosallaie says a next step can be the medial branch block. “If we get 80 percent or better relief, the facet joint is pinpointed as the source of pain,” he says.
For some of those patients, especially those who have chronic nerve- related pain and arthritis pain in the neck and lower back, radiofrequency ablation can heat the troublesome nerve. “By destroying a small sensory nerve, you’re blocking the pain signal,” Dr. Feldman says. Relief typically lasts about a year.
Dr. McJunkin says RF ablation is showing new promise for peripheral nerves, especially for knee pain before or after knee replacement surgery. “A year ago, most practices weren’t treating chronic knee pain with RF,” he says, noting that this treatment allows physicians to steer away from overuse of cortisone, which can be effective but also can have side effects.
SPINAL CORD STIMULATION
Spinal cord stimulation delivers low-level electrical pulses to interrupt pain signals. It can help with chronic back pain, cancer pain, nerve injuries and complex regional pain syndrome. The North American Neuromodulation Society reports that nearly half of patients who received spinal cord stimulation reported pain relief of 50 percent or more.
How does spinal cord stimulation work? Experts themselves aren’t even entirely sure. However, the prevailing belief is called the “gate theory.” Dr. Feldman explains: “If you bombard the spinal cord with signals that are carried by large nerves, it basically closes the gate to the nerves that carry pain signals. You’re tricking the brain into seeing one signal and not another.”
Dr. Mosallaie likens spinal cord stimulators, which are implanted under the skin, to a “pacemaker for the nerves.” He says patients describe a soothing, tingling sensation that occurs in place of pain. “It simply controls the nerve signals before they reach the brain,” he notes.
“We can make the spinal cord feel what we want it to feel,” Dr. Burgher adds. In fact, he says, studies show that up to 50 percent of patients who use spinal cord stimulators are able to decrease pain medicine dosages or discontinue medication completely.
The stimulator can be worn externally before being surgically implanted to see if it reduces pain.
An emerging field called regenerative therapy basically tries to coax the body into healing itself by giving it a boost.
Dr. Feldman cites prolotherapy as one option. The therapy involves the insertion of needles into different tendons and ligaments. “We’re basically trying to create inflammation to get the body to heal itself,” he says.
The use of platelet-rich plasma, or PRP, involves drawing a patient’s blood, centrifuging it, and inserting the growth factors back in order to jumpstart healing. “It’s prominent for chronic tendon and ligament injuries,” says Dr. Lee, noting that Tiger Woods and Peyton Manning had PRP following sports-related injuries. While PRP holds tremendous promise, Dr. Lee says clinical trials are needed to test its effectiveness for other applications, such as muscle tears or arthritic discs.
Stem cells for treatment of degenerative disc disease also hold promise. Dr. McJunkin cites a study out of Australia in which patients with degenerative disc disease showed normal disc health after insertion of stem cells. “Inject stem cells and maybe they can regenerate and repair the underlying problem,” he suggests.
"One day, hopefully we'll be able to treat chronic painful conditions with these types of injections," adds Dr. Feldman. "They are very safe. You're injecting your body's fluids back into the body at a higher concentration to stimulate growth or repair of damaged tissues."
The downside? Regenerative techniques are not proven and not approved by insurance companies.
Mohamed Abdulhamid, M.D., a neurosurgeon with Arizona Brain & Spine Center, says nine out of 10 patients with acute back pain will not need surgery. For some patients, however, surgery is the best option.
Before surgery, it is critical to pinpoint the source of pain. “For example, with pain that shoots down the arm or leg, surgery may take the pressure off a pinched nerve. When it’s a nerve-pinch pain, typically the pain relief with surgery is immediate,” he says.
For patients with herniated or degenerated discs, artificial disc replacement may be an option. Dr. Abdulhamid says the best candidates are young patients who have just a single bad disc. The upside? Compared to fusion, artificial disc replacement might reduce stress on the discs above and below the replaced disc. The downside? Disc replacement is relatively new, so there is no long-term data.
One of the surgical advancements that Dr. Abdulhamid is excited about is the use of a “GPS”-like technology in spine surgery. Used in place of fluoroscopy – a kind of continuous X-ray that exposes the patient to radiation – the new GPS-like navigation system aids spinal fusions, trauma surgeries and other procedures by increasing accuracy of screw and instrumentation placement. “This technology has made a huge difference in minimally invasive surgery,” Dr. Abdulhamid comments.
Dr. Burgher says rapid advances in technology have indeed taken surgical options to a new level. “For back pain, we have gone from taking the whole disc out to taking a portion of the disc out through microdiscectomy. Patients not only recover faster, but pain relief is the same or better,” he says, noting that smaller incisions, smaller cameras and smaller instruments are used.
GETTING BACK IN THE GAME
In the end, if you’re suffering from chronic pain, it’s important to know that skilled clinicians right here in the Valley offer the latest in pain management therapies.
“My job is not to get rid of 100 percent of patients’ pain, but I can get them back to a level of functionality with hopefully very little pain,” Dr. Feldman says. “When patients come to me, they are distraught. They think their old life is over. Most of the time, I can get them back to a level where they are functioning well. I’m not curing cancer. I’m not fixing hearts. I’m not saving lives – but I am saving peoples’ quality of lives.”