Download Medical Sonography Minimally Invasive Spine Surgery

C RE INK
SPRING 2012
A
P U B L I C A T I O N
O F
T H E
C O R E
I N S T I T U T E®
Medical Sonography
PG 14
Minimally Invasive
Spine Surgery
PG 19
The CORE Institute® Spine Division
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LETTER FR
1.866.974.2673
Central Phoenix
1820 W. Maryland Ave., Ste. 2
Phoenix, AZ 85015
Gilbert
3420 S. Mercy Rd., Ste. 200
Gilbert, AZ 85297
North Phoenix
2730 W. Agua Fria Freeway, Ste. 100
Phoenix, AZ 85027
Peoria
10494 W. Thunderbird Blvd., Ste. 102
Sun City, AZ 85351
Spine Center
10494 W. Thunderbird Blvd., Ste. 102
Sun City, AZ 85351
Volume 3 • Issue 3
Sun City West
14520 W. Granite Valley Dr., Ste. 200
Sun City West, AZ 85375
Clinical Faculty
Joshua Abrams, DO
Damon Adamany, MD
Krystle Alexander, PT, DPT
Ali Araghi, DO
Arash Araghi, DO
Clifford Baker, MD
Melissa Barrett, PA-C
Robert Beckenbaugh, MD
David A. Ben-Aviv, MD
Kyle Brooks, PA-C
John A. Brown, MD
Mark D. Campbell, MD
Robert M. Cercek, MD
Aaron Clare, PA-C
Lise Cote, ARNP-BC
Amalia M. De Comas, MD
Pamela Dillenbeck, PTA
Summer Dehnert, PA-C
Hilary Delis, PA-C
Eric Feldman, MD
Nathan Franke, MEd, PA-C
Matthew L. Hansen, MD
Jamie Hartzell, PT, DPT
David J. Jacofsky, MD
Marc Jacofsky, PhD
John A. Kearney Jr., MD
Sarah Kocisky, PA-C
Bethany Larsen
Rene A. Lucas, MD
David Martineau, MD
Jason McKown, PA-C
Haley Meyer, PTA
Mona Mhatre, DO
Leonor Moncloa, PT, MPT, COMT
Andrew Morchower, MD
Olivia E. Morris, DO
Steven L. Myerthall, MD
Danial A. Neal, PT, MSPT
Tony Nguyen, MD
Janet Orozco, PA-C
Frank J. Raia, MD
Vimala Ramachandran, MD
Nathan D. Richardson, MD
Eric Robinson, MD
Turk Satterly, DO
Jason J. Scalise, MD
Jennifer Schaeffer, RN, FNP-BC
Lavon Schaffner, PTA
Scott W. Siverhus, MD, MS
Sylvia Spillett, PTA
Peter Strang, PA-C
Geoffrey Streeter, PA-C
Mark Suchsland, PTA
Brad Tenney, PA-C
John Thompson, DO
David Tom, MD
Bryan Wall, MD
Jennifer R. Watry, MMS, PA-C
Matthew T. Weichbrodt, DO
Stephanie Williams, PT, MPT
Christina Wooldridge, PA-C, MPAS
Nick Zastrow, PA-C, MPAS
Michael Zwanziger, PT, DPT, CSCS
M THE CHAIRMAN
For The CORE Institute, 2011 has brought about many important
changes — maybe most importantly, the growth of our Comprehensive
Spine Division. That’s why we have dedicated this issue and the cover
of CORE Ink to the spine surgeons who joined us this year, as well
as our growing interventional spine division. This year marked the
opening of our first-ever Spine Center as well. This fully equipped
facility now makes it easier for our patients to undergo interventional
spine procedures in our high-quality outpatient facility.
Celebrating our spine division, we are pleased to welcome Dr. Ali
Araghi, a board-certified and fellowship-trained orthopedic spine
surgeon with more than 13 years of clinical experience. A familiar David J. Jacofsky, MD
name to many in the Valley already, he specializes in minimally
invasive surgery; arthroplasty, including artificial disc replacement; and cervical and lumbar
spine surgery. He now also serves as The CORE Institute’s Spine Division Director. Joining Dr.
Araghi, we are excited to inform patients that Dr. Joshua Abrams has also come on board at
The CORE Institute. Dr. Abrams is a fellowship-trained orthopedic spine surgeon, specializing
in minimally invasive surgery; arthroplasty, including artificial disc replacement; and cervical
and lumbar spine surgery. We invite you to read their articles in this issue of CORE Ink.
Our interventional spine division has rapidly expanded this year as well. Leading the division as
Interventional Spine Division Director, Dr. Eric Feldman has helped establish The CORE Institute
as the premier destination for non-surgical spine procedures. He is joined by Drs. Clifford
Baker, Rene Lucas, Andrew Morchower and, most recently, David Tom. Located at each of our
facilities for your convenience, all of our interventional spine specialists are fellowship-trained
in their areas of interest, including pain management, neurostimulation, electromyography
and much more. You will see several articles contributed by our interventional spine team in
this issue of CORE Ink.
This year has also brought our patients new treatment options, including acupuncture. With
our subspecialty-trained physician, Dr. David Ben-Aviv, The CORE Institute has introduced
acupuncture for patients at our Sun City West location. Acupuncture is now used around
the world as an alternative treatment for chronic and acute diseases, acute sports injuries
and almost any type of pain. Acupuncture can be integrated with other therapies to treat
symptoms associated with pain and many orthopedic conditions, including osteoarthritis,
bursitis, tendinitis, myofascial pain, fibromyalgia, acute or chronic neck and back pain, sprains
and contusions.
In our last issue of CORE Ink, we brought you news of a joint venture between The CORE
Institute and Banner Del E. Webb Medical Center. We are pleased to announce that the public
Grand Opening will take place on Saturday, March 10, 2012. Please join us in the festivities at
Banner Del E. Webb Medical Center in Sun City West, Arizona, at 8 a.m. Officially named the
Banner CORE Center for Orthopedics, the partnership between Banner Del E. Webb Medical
Center and The CORE Institute is dedicated to delivering innovative, revolutionary orthopedic
care to patients from around the world. The Banner CORE Center provides a fully integrated
continuum of care to patients, from pre-admission through hospital admission and from
surgery to inpatient rehab and outpatient therapy. The Banner CORE Center for Orthopedics
adheres to strict quality guidelines focused on increasing efficiency and, more importantly,
providing exceptional quality of care.
On behalf of all of our physicians, providers and staff members, The CORE Institute appreciates
your continued support. We wish you and your families a healthy 2012!
Keep Life in Motion!
David J. Jacofsky, MD
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TABLE OF C
8
NTENTS
What About My Degenerating
Discs and Joints?
12 Neuropathic Pain
14 Medical Sonography
15 Radiculopathy
16 New Joints for Aging Hands –
Part Two
18 Spinal Cord Stimulation
19 Minimally Invasive
Spine Surgery
20 Total Disc Arthroplasty
21 The Role of Neuromuscular
Electrical Stimulation in
Physical Therapy
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What About
My Degenerating
Discs and Joints?
If you are over 50 years old,
then you most likely have had
an X-ray taken of your cervical
(neck) or lumbar (low back) spine
at some point in the past. And
you have probably been told by
your physician that you have
“degenerative joint disease”
or “degenerative disc disease.”
Sounds scary, doesn’t it? The word
“degenerative” certainly conjures
up images of having severe pain and
becoming progressively disabled.
Rest assured that this does not
mean you are “degenerating” at
all. In fact, you may have no pain at
all as a result of degenerative joint
and disc disease.
by Clifford Baker, MD
What Is Degenerative Joint
and Disc Disease?
The terms “degenerative joint disease”
and “degenerative disc disease” (DJD/
DDD) are perhaps some of the more poorly
coined phrases in medical terminology.
First of all, DJD/DDD is not necessarily
a disease. It is part of the normal
wear and tear process that occurs with
aging. Second, the word “degenerating”
does not necessarily mean pain, and
it certainly does not mean that your
joints or discs will become even more
degenerated with time. In fact, the
condition often stabilizes and symptoms
improve over time.
DJD/DDD refers to the typical
X-ray findings that are seen with
osteoarthritis, the most common form
of arthritis in the United States,
affecting more than 20 million people.
Unlike other forms of arthritis, such
as rheumatoid arthritis and systemic
lupus, osteoarthritis affects only
the joints and does not affect other
organs of the body. Osteoarthritis of
the spine is also called spondylosis.
In osteoarthritis or spondylosis, the
cartilage, which acts as a cushion
between the joints, begins to wear
away and may eventually disappear.
At this point, bone may begin to rub
on bone. In order to compensate for
the increased load on the joints, bony
growths, called spurs or osteophytes,
usually form around the joint, thereby
causing hypertrophy, or enlargement,
of the joints. This bony growth is not
necessarily a good thing, as it may
contribute to the pinching of a nerve
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or become a source of arthritic pain. In
particular, the facet joints of the spine,
which serve as a site of attachment for
many muscles and ligaments to limit
rotation, are prone to developing spurs
and becoming hypertrophied. This is a
common finding on X-rays. The facet
What Causes DJD/DDD?
Unfortunately, the most common cause
of DJD/DDD is aging. As people age, the
composition of the cartilage of the body
also changes, resulting in thinner and
more fragile cartilage. The discs also
become less hydrated and begin to lose
their height. In fact, this is part of the
reason we become shorter as we age.
Other conditions can also contribute to
the earlier onset of DJD/DDD. These
include obesity, repetitive trauma or
injury to the joint structures, abnormal
joints at birth, gout, diabetes and other
hormone disorders.
Does DJD/DDD Cause
Low Back Pain?
Figure 1
joints are very similar to your knee
joint in that they have a surrounding
capsule and are filled with synovial
fluid, which acts as a lubricant. As can
be seen in knee arthritis, these joints
can become swollen and inflamed,
thereby causing low back or neck pain
that typically does not radiate below
the knee or elbow, respectively. In
addition, the surrounding ligaments of
the spine may also hypertrophy due
to the additional stresses and forces
placed upon them. Each of these
processes may contribute to narrowing
of the spinal canal, called spinal
stenosis, or a narrowing of the holes
through which the nerves exit, called
neuroforaminal stenosis (see figure 1).
Finally, the discs, which act as shock
absorbers between the vertebrae, are
another area of the spine prone to
degeneration. While the discs are not
joints per se, degenerative disc disease is
considered to be part of the normal wearand-tear process seen in osteoarthritis.
As we age, the nucleus of the disc begins
to lose some of its water content, and the
outer ring begins to weaken. This results
in an inability of the disc to handle
mechanical stress. Subsequently, when
an excessive load is placed on the disc,
such as that which occurs with bending
forward, the disc may bulge, herniate
(push outward) or even rupture, resulting
in pain. The process of a disc becoming
dehydrated, narrowed or herniated is
referred to as degenerative disc disease.
Perhaps the most important and
reassuring thing your doctor can tell
you is that degenerative joint and disc
disease is extremely common and may
not cause any pain at all. There are many
people walking around with “severely”
degenerated discs and joints who have no
pain whatsoever.
Many studies, using MRIs and X-rays,
have shown that as many as 80 percent
of healthy adults without any pain had
DJD/DDD by age 60, up to 20 percent had
spinal stenosis, and bulging discs were
common in all age groups and did not
management specialist that can aid in
the diagnosis of your pain, in addition to
giving long-lasting pain relief.
The important point is that DJD/DDD
does not always cause pain. Rather than
ruminating on why you have such “bad”
discs and joints, it is more important to
understand that many things can be done
to treat your pain.
What Can I Do to Prevent DJD/DDD?
DJD/DDD is a normal wear-and-tear
process that occurs with aging. Therefore,
it cannot be completely prevented.
However, there are many things you can
do to reduce your chances of developing
DJD/DDD earlier on in life, in addition to
minimizing the pain associated with it.
Weight loss is an important first step
in reducing the pain associated with
DJD/DDD. In fact, obesity is the second
most powerful risk factor for developing
osteoarthritis, due in large part to the
increased mechanical stress that is
placed on the cartilage.
Weight-bearing exercise can also be
effective for preventing or delaying
the onset of DJD/DDD. Weight-bearing
exercises, including walking, serve to
strengthen the ligaments and muscles
Perhaps the most important and reassuring thing
your doctor can tell you is that degenerative joint
and disc disease is extremely common and may not
cause any pain at all. There are many people walking around with “severely” degenerated discs and
joints who have no pain whatsoever.
correlate to pain. Furthermore, these
patients were followed long-term and
were no more likely to have pain than
those who had no evidence of DJD/DDD
on radiographic studies.
On the contrary, if you do have pain,
it is certainly possible that your pain
can be a result of DJD/DDD. Only after
performing a thorough history and
physical examination can a physician
determine if your pain symptoms are
a result of osteoarthritis of the spine.
Additionally, certain injections and
blocks can be performed by a pain-
surrounding the joints, thereby reducing
the strain and stress placed on them.
In addition, abdominal and low-back
strengthening exercises serve to form a
natural “brace” for your back, minimizing
the strain on the lumbar spine joints.
Smoking has been shown to have an
association with chronic low back pain.
It is believed that smoking results in
reduced oxygen supply to the structures
of the spine, particularly the discs and
ligaments. In fact, smokers are 2.5 times
more likely to experience chronic low
back pain than those who do not smoke.
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that encourage you to become more
active. Bed rest is strongly discouraged
for any period greater than two days,
as this contributes to deconditioning,
weakening of the muscles, shortening
and spasm of the muscles and an overall
reduction in cardiovascular health.
Lumbar spine X-ray of an 83-year-old patient
showing severe degenerative joint/disc
disease and scoliosis. Surprisingly, this patient
had minimal low back pain and enjoyed
gardening regularly.
What Types of Treatment Are
Available for DJD/DDD?
The most effective treatments for pain
associated with DJD/DDD are those
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Physical therapy is an integral
component in the treatment of pain
related to DJD/DDD. Physical therapists
have a strong knowledge base of the
different types of exercises that may
be more effective for various painful
arthritic conditions of the spine, such
as disc-related pain, facet joint pain
and pain due to spinal stenosis. It is
important to continue performing these
exercises even after you are finished
with therapy. Physical therapists can
also perform many passive treatments
to help relieve your pain, including
massage, manual therapy, traction,
ultrasound, heat and ice.
Many prescription and over-the-counter
(OTC) medications and supplements are
available that can reduce pain and possibly
delay the progression of DJD/DDD. Some
OTC medications may cause significant
side effects, such as kidney damage or
peptic ulcer disease. You should always
discuss what medications are appropriate
to use with your physician.
Interventional spine and pain management
physicians are specialists in the treatment
of pain associated with DJD/DDD and
other painful disorders of the spine and
joints. Injections of the spine, such as
facet joint and lumbar epidural steroid
injections, may be very effective in
relieving the pain associated with DJD/
DDD and herniated discs. In addition,
pain management physicians can perform
many other less-invasive procedures
that can provide long-lasting pain relief,
such as radiofrequency ablation and the
use of spinal-cord stimulators for the
treatment of pain related to DJD/DDD,
sciatica, nerve injury, failed-back surgery
syndrome and peripheral neuropathy.
The CORE physicians are fellowshiptrained in interventional spine and pain
management and offer a multi-disciplinary
approach to the treatment of spine-related
pain. Each patient’s treatment plan is
customized to his or her specific goals to
ensure the most optimal patient care.
For more information on pain management,
please e-mail us at contactus@thecoreinstitute.
com or call 1.866.974.2673.
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Neuropathic Pain
Diagnosis and Management
An estimated four million Americans suffer from neuropathic pain. Neuropathic
pain is defined by the International Association for the Study of Pain as “pain
initiated or caused by a primary lesion or dysfunction in the nervous system.” If
you have neuropathic pain, you may experience symptoms ranging from numbness
to weakness or even pain. The pain is most often described as burning, shooting,
stabbing, lancinating or shock-like. Allodynia and hyperalgesia are medical terms
by Rene Lucas, MD
typically used to describe neuropathic pain.
Neuropathic pain can clearly impact your mood, quality of life,
activities of daily living and work performance. A variety of
conditions are associated with neuropathic pain and include
low back pain, diabetes, fibromyalgia, postherpetic neuralgia,
trigeminal neuralgia, phantom limb pain and complex regional
pain syndrome.
The Abnormal Sensations
of Neuropathic Pain
•Spontaneous pain: burning, shooting, lancinating
•Paresthesias: abnormal non-painful sensations
•Dysesthesias: abnormal pain that is unpleasant
•Allodynia: a painful response to a normally
non-noxious stimulus
•Hyperalgesia: an exaggerated painful response
to a normally noxious stimulus
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Sometimes, your physicians may not recognize the neuropathic
nature of your pain. This lack of awareness is primarily due
to the complicated nature of the onset of neuropathic pain,
difficulty in confirming the diagnosis and the lack of effective
treatments. At The CORE Institute, we help you accurately
diagnose your neuropathic pain and together, find the most
effective management strategies to reduce the pain and
improve function.
Diagnosis
If you present at our clinic with signs and symptoms suggestive
of neuropathic pain — especially with allodynia, a painful
response to a normally non-painful stimulus — a history and
physical examination would be the most important tools that
assist us in accurately diagnosing you.
The location, quality, timing and pattern of involvement of the
pain are also important parts of historical information.
The physical examination will focus on sensory testing, manual
strength testing, reflex testing and coordination assessment.
Additionally, electrodiagnostic tests such as electromyography
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(EMG) and nerve conduction studies (NCS) may assist with an
accurate diagnosis and provide prognostic information. Also,
quantitative sensory testing (QST) may help when the EMG is
normal to assess for a “small-fiber” neuropathy.
Management
After assembling the historical information, conducting a
physical examination and examining results of electrodiagnostic
studies, an accurate diagnosis of your pain can typically be
made. A wide variety of treatment options are available for
managing neuropathic pain, reflecting the lack of any one highly
effective regimen. The best treatment options are then explored
based on your specific diagnosis, needs and circumstances.
Neuromodulation
If your neuropathic pain fails to respond to medical therapies,
then spinal-cord stimulation (SCS) may be recommended for
significant pain reduction. Numerous studies now support the
use of spinal-cord stimulation for reduction of neuropathic pain.
For this procedure, electrodes are placed in the epidural space.
Passing gentle electrical currents through the spinal column
blocks the transmission of pain signals and activates the body’s
Neuropathic Pain Syndromes
Peripheral
As with many challenging medical issues, a multidisciplinary
approach to treatment is often the most successful. Almost
everybody with neuropathic pain should be offered a physiciansupervised exercise program, usually carried out by a physical
therapist. A prescription of flexion/stretching exercises for
neuropathic low back pain, along with strengthening exercises
to tolerance, assures that you will maintain and improve
function. The use of physical modalities such as transcutaneous
electrical nerve stimulation — commonly called TENS — may help
provide pain relief and encourage your body to release its own
endorphins, known as the body’s natural painkillers.
•Painful peripheral neuropathies –
e.g., diabetic peripheral neuropathy
•Focal entrapment neuropathies –
e.g., carpal tunnel syndrome
•Post-surgical syndromes –
e.g., phantom pain after amputation
Neuropathic pain tends to respond poorly to traditional
analgesics. A number of medications have been found and
developed to reduce neuropathic pain. These medications
include over-the-counter analgesics, anticonvulsants, tricyclic
antidepressants (TCAs), selective serotonin-norepinephrine
reuptake inhibitors (SNRIs), topical anesthetic agents,
nonsteroidal anti-inflammatory drugs (NSAIDs), antiarrhythmics
and opioids. The variety of medications available reflects
the different pathophysiologic mechanisms responsible for
neuropathic pain as well as patient heterogeneity — hence the
need for individualized treatment.
Mixed
Nevertheless, numerous treatment algorithms based on some
well-done studies and expert opinions list trials of common
analgesics such as ibuprofen or acetaminophen, topical
treatment such as capsaicin cream or lidocaine patches or
ointment, TCAs or other antidepressants and anticonvulsants
— such as gabapentin (Neurontin) or pregabalin (Lyrica) — as
first-line therapy for neuropathic pain. These medications can
be used alone or in combination. The choice of medications is
based on your pain diagnosis and medical circumstances.
Central
•Traumatic brachial plexus lesions
•Traumatic spinal cord injury
•Fibromyalgia
•Lumbar radiculopathies – e.g., sciatica
•Acute and postherpetic neuralgia
•Complex regional pain syndrome
own pain inhibitory mechanisms. After a trial period to ensure
that SCS works, an adjustable, battery-powered pulse generator
is implanted and connected to the electrodes.
Conclusion
Accurate recognition and aggressive management of neuropathic
pain are the key to a successful outcome. Numerous treatment
modalities are available and are individualized based on your
specific diagnosis and medical condition.
For more information about neuropathic pain, please e-mail us at
[email protected]
or call 1.866.974.2673.
Controversy currently surrounds the use of medical marijuana
for neuropathic pain or a variety of chronic pain
conditions. While research holds potential promise
for modulation of the body’s own cannabinoid
receptor system for reduction of pain,
current evidence does not support
the use of smoked marijuana for
chronic pain.
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Medical
Sonography
by Eric Feldman, MD
Medical sonography (ultrasound) has been around for more than 50 years and has become one of the
most widely used diagnostic tools in modern medicine. When people think of ultrasound, they usually
envision it for prenatal care. However, only in the past 10 years have advances been made in medical
sonography that allow for superior resolution of superficial structures, such as ligaments, tendons and
nerves. These advances have made sonography integral in pain medicine.
Ultrasound imaging utilizes sound waves
that are transmitted from an ultrasound
probe. The sound waves safely travel
into the body and reflect off the various
tissues. The reflected sound waves
are then received by the probe and
interpreted by a computer, and a realtime picture is generated.
Ultrasound is generally described as a
“safe test” because it does not use ionizing
radiation that can pose hazards to humans.
Properly performed, ultrasound poses no
risks to humans.
Many pain procedures involve placing a
needle into the body in order to deposit
a medicine adjacent to or in a target
structure. Historically, these procedures
were done using surface anatomy and bony
landmarks. Although this technique can be
effective and safe, it is considered a “blind”
procedure. By “blind,” we mean that once
the needle passes through the skin, the tip
of the needle can no longer be seen, and the
passage of the needle through tissue is not
visualized by the provider. This technique
is certainly the least expensive and most
convenient way to perform a procedure.
However, landmark-guided procedures
carry much more inherent risk compared
to doing a procedure using some form of
needle guidance. In addition, landmarkguided procedures can be inaccurate and
less effective than a procedure done using
needle guidance. X-ray and CT provide
excellent visualization of a needle inside
the body but carry the risk of ionizing
radiation to the patient and are less than
optimal for superficial procedures involving
the first few centimeters underneath the
skin. Many nerves are situated less than 1
14
centimeter beneath the skin and are most
safely targeted with ultrasound guidance.
MRI is another safe alternative but is
extremely expensive and unavailable to
most providers.
Ultrasound-guided procedures have several
advantages. The primary advantage is the
real-time assessment of human anatomy
beneath the skin. Ultrasound allows
continuous visualization of a needle
throughout a procedure. Procedure time
is usually reduced compared to CT or
X-ray guidance. Ultrasound is relatively
inexpensive and portable; it allows for rapid
scan time; and it features improved patient
tolerability and safety.
Ultrasound guidance reduces procedurerelated complications such as nerve injury
or inadvertent injection of medicine into
a blood vessel. With the advent of high-
path is first performed to make sure that no
nerves or blood vessels lie in the intended
path of the needle. Remember that not
all humans are anatomically identical, and
anatomic variations could result in potential
dangers if a needle is inadvertently placed
into a vital structure. Using ultrasound,
the needle is visualized passing through
the skin and subcutaneous tissue, then
through muscle and finally into the desired
joint space or bursa. Finally, the medicine
is observed carefully as it flows into the
desired location.
Portable, high-resolution ultrasound
systems are now used in the office to
perform procedures that, five to 10
years ago, would have required an
anesthesiologist in a hospital or a surgery
center. For example, a patient with
a stiff hand after a wrist fracture can
undergo an ultrasound-guided nerve
The primary advantage is the real-time assessment
of human anatomy beneath the skin.
frequency ultrasound probes, ultrasound is
often as good as or even better than MRI
for visualizing superficial structures in the
body, such as ligaments, tendons, nerves
and blood vessels.
block in the office, followed by physical
therapy minutes after the procedure to
mobilize the joints of the hand. This is
a huge advance for improving a patient’s
functionality and quality of life.
Take, for example, a cortisone injection into
the shoulder. This procedure can be done by
using surface anatomy and bony landmarks.
However, even in the best-trained hands, the
medicine might not end up in the intended
location. When done under ultrasound
guidance, a survey of the intended needle
The CORE Institute physicians and
physician assistants have expertise in using
ultrasound in the field of pain medicine.
For more information on medical
sonography, please e-mail us at contactus@
thecoreinstitute.com or call 1.866.974.2673.
CORE Ink
Radiculopathy
A Common Reason for Leg Pain
by Andrew
Morchower, MD
Anatomy
Determining why someone is experiencing
pain is oftentimes difficult and not easy
to pinpoint. This is especially true for
pain that develops in the buttocks or legs.
One could assume that if pain is located
in a particular area of the body, then that
is where it is originating from; however,
this is not always the case. In the field of
pain management, it is often determined
that buttock or leg pain is actually caused
by changes within the low back.
The low back is comprised of
spine bones called vertebrae that
are jointed together by small
joints referred to as facet joints.
Two of the spine sections that
make up the low back are called
the lumbar and sacral spines.
The lumbar and sacral spines
house the spinal cord and the
“nerve roots,” which come
directly off of the spinal cord
and exit from the spine. Within
the lumbar spine, there are five
Normal anatomy of a lumbar
individual vertebrae separated by
vertebra with spinal cord
discs composed of annular fibers
surrounding a jelly-like center.
The sacrum is made up of five vertebrae that are usually fused
from birth. Between each segment of the lumbar and sacral
vertebae, there is a nerve that comes out from the spine.
Given that the spinal discs and joints are so close to the
exiting nerves, it is not uncommon to have an exiting nerve
root impacted by degeneration of the spine. When a nerve is
compressed by an adjacent
structure, it can cause what
is called a radiculopathy. This
is the process where nerves
coming out of the spine
are affected in a way that
causes pain down the leg.
Oftentimes, this is referred
to as “sciatica.” In fact,
the most common reason to
experience a radiculopathy
is due to nerve compression
caused by a disc herniation
or spinal narrowing from
degeneration of the spine.
Lumbar disc herniation; the colWhen this occurs, the exiting
ored arrow indicates the direction
nerve can cause “referred”
of the extruding disc material
pain or numbness down the
length of the nerve. Lumbar and
sacral nerves travel to different
parts of the buttocks and lower
limbs. Depending on where the
affected nerve runs within the
leg, a person could experience
symptoms down the front, back
or side of the leg or foot. In
more severe radiculopathies,
weakness can develop in the
muscles that are controlled by
the nerve or nerves affected.
Diagnosing
A detailed history and a thorough
physical exam oftentimes
give enough information to
make an accurate diagnosis of
Diagram shows the radiation
radiculopathy. There are also
of pain down the leg resulting
imaging modalities such as MRI,
from a herniated disc
CT or nerve studies, sometimes
referred to as EMGs. Each of
these tests gives valuable information as to which nerves may
be affected and what may be the best approach to treatment
of the underlying problem.
Treatment
There are a variety of ways to approach treating pain from an
acute or long-standing radiculopathy. Studies show that the
majority of painful radiculopathies improve over a period of a
few months with conservative care. This may include physical
therapy, activity modification, ice, heat and various pain
medications. Often, it’s beneficial to take an anti-inflammatory
medication because disc herniations and degenerative arthritis
typically cause inflammation near the nerve, which can result
in a great deal of leg pain. In the event that this does
not adequately improve the pain symptoms, an X-ray-guided
epidural steroid injection may offer significant pain relief by
reducing the inflammation that has developed. If the leg pain
continues, or if weakness should develop, a consultation with a
surgeon is recommended to determine what surgical options may
be appropriate.
All of the fellowship-trained interventional spine physicians at
The CORE Institute are able to diagnose and treat the above
maladies using a combination of medication management,
X-ray-guided injections and surgery to target the areas causing
your pain.
For more information on leg pain or radiculopathy, please e-mail us at
[email protected] or call 1.866.974.2673.
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New Joints for Aging
Joint Replacement for the Fingers and Thumb
by Robert D.
Beckenbaugh, MD
The CORE Institute introduced a two-part
series on joint replacement of the hand by our
own Dr. Robert Beckenbaugh, world-renowned
hand arthroplasty pioneer. To review “New
Joints for Aging Hands – Part One,” please
see the CORE Ink summer 2011 edition.
PyroCarbon is used as an implant to
replace the lower diseased portion
of the thumb joint. Although removal
of the diseased bone works well,
reconstruction of the joint with an
implant is shown to have a better
outcome, including a more normal
motion and strength sensation to
the patient. With the improvements
in patient outcomes, PyroCarbon
implants for the thumb joint have
been used since 2003 and have been
found to be quite useful in providing
for maintenance of thumb length,
hand strength and patient satisfaction
16
in the vast majority of instances in
appropriately chosen patients. Due to
the success with the partial fingerjoint replacement during the last three
years, we have redesigned this concept
of finger-joint arthroplasty with a new
implant designed especially for the
thumb. The goal of this new procedure
is to provide for improved stability and
restoration of hand motion.
Figure 1: Ascension NuGrip CMC Implant
The base of the thumb is actually
comprised of two joints. The thumb
joint that is closer to the tip of the
thumb, called the carpometacarpal,
or “CMC,” joint, at the base of the
thumb, is comprised of two bones.
Each bone has cartilage on its end that
comprise the internal surface of the
joint. In about 60 percent of thumbs,
the only joint involved by the arthritic
disease is the CMC joint, and in these
situations, it is not necessary to remove
the entire wrist bone (the trapezium)
when there is no major disease at the
second joint on the wrist side of the
trapezium. In this setting, performing
a partial thumb-joint replacement is
very appealing and allows preservation
CORE Ink
Hands – Part Two
of normal thumb length, improved pinch
strength and a sense of greater normality
of function. This artificial PyroCarbon
partial joint replacement of the CMC joint
is revolutionary but should be considered
a higher-risk and higher-reward operation.
Up to one in five patients with this
arthroplasty procedure will require some
additional surgery for slippage or change
in positioning of the implant but will have
a greater potential for return to normal
function. However, if there is disease
at both sides of the basal thumb bone
(trapezium), then, generally, we will need
Figure 2: MCP Joint
to perform a traditional tendon operation
with removal of the entire trapezium
bone, and the patient is not a candidate
for a joint replacement procedure due to
the larger extent of arthritic change about
the base of the thumb.
The MCP joint or the base joint (the junction
of the fingers to the hand) is typically
involved in rheumatoid arthritis; these
patients have soft-tissue damage in addition
to joint surface damage and, therefore, are
better salvaged with silicone arthroplasty
than PyroCarbon total joint arthroplasty.
A smaller number of patients develop
degenerative arthritis from osteoarthritis
or injury to the joint. Like in rheumatoid
arthritis, these patients do develop damage
to the articular surfaces (cartilage) of the
joint; however, these patients maintain
relatively normal soft tissues around the
joint, and, therefore, PyroCarbon total joint
replacement is extremely successful. These
joints can be replaced by the near-anatomic
ball-and-socket implant design and results in
excellent motion and pain relief in almost all
cases. Occasionally, finger joints degenerate
following metabolic disease or autoimmune
disease, such as hemochromatosis (a blood
disorder) or lupus. In any event, no matter
what the inciting cause, if there is not
soft-tissue destruction of the ligaments
and the tendons, the functional results of
arthroplasty at the MCP joint are uniformly
very good.
PIP Joint
The majority of surgical procedures
performed on finger joints is due to
osteoarthritis or post-injury arthritis of
the proximal interphalangeal joint (the
finger joint closest to the hand). This joint
is a stable hinge joint similar to the knee.
The use of silicone implants may result in
fracture and/or bending of the implants,
due to the large bending forces at these
joints. Therefore, stronger materials such
as PyroCarbon are preferred in these joints.
Joint replacement here is performed with
two components and allows realignment
of the angle of the joints and restores
variable degrees of motion with pain
relief. If all PIP joints in all the fingers
are stiff and swollen pre-operatively,
pain relief is still seen, but limited
improvement in actual motion is achieved
post-operatively. The better the finger
motion prior to surgery, the better the
expected motion after surgery.
The surgical procedure and post-operative
therapy are dependent upon the nature of
the arthritis and the surgeon’s experience
and preference. Most commonly, the joint
is implanted through an incision on the
top of the finger but may be done through
the side or from underneath the finger for
special reasons, according to the surgeon’s
discretion. After insertion of the joint
replacement, if the soft tissues are in
good condition following repair, protected
motion in a specialized splint can usually
begin within a few days from surgery.
In general, the anatomy of the PIP
joint and its surrounding tendons and
ligaments is quite complex; therefore,
the post-operative care and exercise
programs are individualized for every
Figure 3: X-ray of the MCP joint. Note the
narrowing of the space between the bone
(osteoarthritis) in the upper radiograph. Then
note the PyroCarbon MCP replacement, which
is a ball-and-socket joint, and mimics closely
the natural MCP joint seen above.
patient. This operation is a sophisticated
balancing process, and approximately
one in five patients may require some
form of a reoperation or soft-tissue
balancing during the first five years after
the surgery, while 80 percent of patients
require no further surgery.
Summary
Joint replacement in the hand, fingers
and thumb is now possible, and more
than 30,000 of these joints were inserted
worldwide from 2000 to 2011. Pain relief,
restoration of deformity and improved
motion may all be achieved with surgery.
In general, most have been returned
to more normal activities, such as
golf, heavy working and standard daily
activities, without restrictions within
three months following surgery.
For more information on joint replacement
for the hand, please e-mail us at contactus@
thecoreinstitute.com or call 1.866.974.2673.
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Spinal Cord Stimulation
Cutting-Edge Technology in the Treatment of Chronic Pain
by David Tom, MD
Pain can arise from a variety
of sources, including joints,
muscles, peripheral nerves,
vertebral discs, vertebral
bodies or nerve roots. While
orthopedic surgeons, spine
surgeons and interventional
spine physicians have a
wide array of diagnostic and
treatment options, sometimes
a patient’s pain is refractory.
Refractory pain refers to pain that has
been resistant to treatment regimens.
Some patients may have previously
tried physical therapy or medications
and undergone back surgery, epidural
steroid injections or radiofrequency
nerve ablations without substantial or
long-lasting pain relief. Often, these
patients struggle with their continued
pain symptoms and seek an improved
quality of life. For some individuals,
the answer may lie in spinal cord
stimulation (SCS).
What Is Spinal Cord Stimulation?
A diagram on how SCS works provided by
Boston Scientific
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Spinal cord stimulation was introduced in
1967 for the treatment of refractory pain.
During the past 40 years, SCS technology
has advanced and improved remarkably.
Today, spinal cord stimulation is a wellestablished, FDA-approved, reversible
therapy for chronic pain that can result
in substantial pain relief, increased
physical activities and a reduction in
pain-medication use. SCS has significantly
improved the quality of life for hundreds
of thousands of patients living with
chronic pain.
The Spinal Cord
Stimulation Trial Period
As opposed to destructive or surgical
techniques used to reduce pain, spinal cord
stimulation technology does not destroy
tissue or change anatomy. Through a
quick procedure, SCS leads can be placed
through the skin without an incision into
the epidural space. Then, the SCS system
applies a pleasant and controllable electrical
stimulation to the spinal cord, also known as
neuromodulation. While SCS works through
a variety of mechanisms, spinal cord
stimulation primarily works by masking the
patient’s pain symptoms, resulting in less
pain. Instead, the patient feels a smooth,
tingling sensation over the typical areas of
pain, also known as paresthesia.
The Boston Scientific Spinal Cord Stimulation
System. From left to right: remote control,
battery charger and implantable pulse generator attached to percutaneous SCS leads.
Spinal cord stimulation is first performed
on a trial or temporary basis during the
span of a few days to a week. SCS leads are
placed without an incision into the epidural
space using intravenous sedation. The SCS
leads are secured to the skin and connected
to an external battery SCS device. With a
series of customized programs and an easyto-use remote control, the patient is now
ready to evaluate the sensation and the
effectiveness of spinal cord stimulation.
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During the testing period, patients work
closely with SCS representatives and
providers to enable patients to make a solid
decision of whether or not they would like to
pursue permanent spinal cord stimulation.
Specifically, the patient is evaluating
improvement in a few key areas — pain
reduction, increased activity, decrease in
pain medication use and an overall better
quality of life. After the short trial period,
the entire SCS system is removed.
Often, patients respond wonderfully to
the SCS trial and would like to pursue
permanent implantation of the device.
In an outpatient surgery, physicians
will place SCS leads in the same area
as the trial; a small incision will be
made to secure the device; and a small
implantable stimulator device will be
placed under the skin, likely near the
upper buttock or hips.
Who Are the Best Candidates for
Spinal Cord Stimulation?
Common indications for spinal cord
stimulation and peripheral nerve stimulation
for chronic pain include:
• Failed back surgery syndrome
• Complex regional pain syndrome, or RSD
• Cervical and thoracic radiculopathy
• Lumbar radiculopathy or sciatica
• Peripheral neuropathy, like
ilioinguinal neuralgia
• Arachnoiditis
• Postherpetic neuralgia
• Occipital neuralgia
• Refractory headaches
• Multiple sclerosis
• Visceral pain (including abdominal,
pelvic and bladder pain)
• Phantom limb pain/stump pain
• Limb ischemia
• Angina pectoris
Effectiveness
The effectiveness of SCS has been studied
for more than 40 years. In a 20-year
literature review, success rates for spinal
cord stimulation has ranged from 57
percent to 83 percent for back and leg
pain, complex regional pain syndrome,
failed back surgery syndrome, stump
pain, peripheral neuropathy, ischemic
limb pain and postherpetic neuralgia.
Patients who undergo spinal cord
stimulation trials are often the patients
whose pain has been non-responsive to
all treatments to date; the results of SCS
are quite significant and enable patients
to keep their lives in motion.
For more information about spinal
cord stimulation, please e-mail us at
[email protected] or call
1.866.974.2673.
Minimally Invasive
Spine Surgery
by Ali Araghi, DO
If your back hurts, don’t be surprised. More than 85
percent of people over the age of 50 have experienced
back pain at some point in their lives. There are many
reasons for having back pain, such as muscle spasms,
which are the most common. Degenerative disc disease
(DDD) and slippage of vertebra (spondylolisthesis)
can also cause back pain. Degenerative disc disease
usually comes from injury or a lifetime of wear and
tear. In addition, genetics can also play a role. If
you come from a family of back-pain sufferers, then
you will be more likely to experience back problems.
But you don’t have to keep on suffering. There are a
variety of new techniques that may help your back.
Your spine is made up of bones called vertebrae, which are separated and
held together by a structure called discs. Discs act as a cushion in between
the vertebrae and are made of an elastic outer layer called the annulus
and a gel-like center called the nucleus. When discs are damaged by injury,
disease or age, they degenerate and lose their height. The outer elastic
layer tears, and the gel-like center leaks out. This can pinch the nearby
spinal nerves, resulting in serious pain. The damaged and degenerated discs
can cause pain without pressing on a nerve as well. Slipped vertebrae can
be a source of pain as well. There are many structures that make your back
hurt, but degenerative disc disease is the most common.
Surgery is not the first thing you want to do if your back hurts. The
conservative approach is the best. This may involve one or more of the
following: physical therapy, osteopathic manipulation, pain management,
medications and possible steroidal injections. However, if conservative
measures fail and do not diminish the pain, and your problem is significantly
interfering with your life, surgery may be a reasonable option. Spinal disc
replacement may be one such option, which allows for the painful disc to be
replaced by an artificial disc that will help maintain motion. Spinal fusion
is another potential option that essentially “welds” two or more vertebra
together. If you do decide to have surgery, and you are determined as a
potential surgical candidate for a spinal fusion, there is now good news. In
years past, back surgery required large incisions that cut muscles, creating
additional recovery challenges for the patient. However, today, there are
minimally invasive options that work through a 1.5-inch incision instead of
the traditional 6-inch incision.
Specially trained and experienced spine surgeons use fluoroscopic (realtime X-ray) techniques and special retractors called ports to slip in
between small sections of the muscle fibers and complete the surgery. This
technique separates the muscle fibers, rather than cutting them, which
decreases blood loss, immediate post-operative pain, muscle scarring and
complications such as infections. The surgeon can then remove a portion or
most of the defective discs that are causing a problem and install medical
hardware that fuses the two or three vertebrae together, depending on the
extent of the damage to the discs. Fusion of the vertebra immobilizes the
vertebrae and prevents pinching and/or irritation of the spinal nerves, thus
reducing pain in most cases once the healing of the bones is complete. The
less-risky and minimally invasive procedure also has less associated blood
loss and a shorter hospital stay. They are generally less-painful operations.
For more information on our spine division and our comprehensive spine
treatment options, please e-mail us at [email protected] or call
1.866.974.2673.
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Total Disc Arthroplasty
Is All Back Surgery the Same?
potential for accelerated
degeneration of the discs
next to the fusion. Artificial
disc replacement was
designed to avoid these
shortcomings. Artificial discs
originally gained approval
for use in the United States
in 2004. Since that time,
the design has improved,
and patient satisfaction
has too.
Low back pain is a significant cause of
disability in the United States, as well as
worldwide. National estimates show that
70 percent to 80 percent of people will
experience low back pain at some point in
their lives. Most episodes of back pain are
self-resolving, often aided by conservative
measures such as physical therapy and
anti-inflammatory medications.
Degeneration of the intervertebral disc
or degenerative disc disease (DDD) is a
common cause of back pain and can be
a very painful condition that can greatly affect the quality of
one’s life. The intervertebral disc is a specialized structure
that lies between two adjacent vertebrae and acts as a shock
absorber, absorbing the impact of the body’s daily activities.
While disc degeneration is a normal part of aging, some
individuals have an accelerated process or other conditions
that make it very painful. Some individuals may even develop
chronic low back pain.
by Joshua
Abrams, DO
Symptomatic degenerative disc disease can radiate to the
hips, thighs or buttocks while walking. Similar pains may
increase while sitting, bending, lifting and/or twisting. This
condition may also occur after an injury, when some discs
may become painful due to inflammation. When pain from a
degenerative disc becomes severe, traditional non-operative
treatment is often ineffective.
Surgery?
On first glance, this word can
provoke many different feelings.
Spine surgery has had incredible
advancements within the last five
years. Lumbar spine surgery that
was performed 10 to 15 years ago is
dramatically different than what is
often performed today by the spine
surgeons at The CORE Institute.
Who Is a Candidate for Artificial Disc Surgery?
To determine who is a good candidate for disc replacement,
the surgeon may require a few tests. These may include
magnetic resonance imaging (MRI), discography, computed
tomography (CT or CAT scan) and X-rays. These tests will also
help the surgeon determine the source of the pain.
Good candidates for disc replacement have the following:
•Back pain localized to one or two discs
•No significant facet joint disease or bony compression on nerves
•Not excessively overweight
•No prior major surgery in the lumbar spine
•No deformity (scoliosis)
Rehabilitation
Most patients are encouraged to stand and walk by the first
day after surgery. Early motion may translate into quicker
recovery. The typical hospital stay is two to four days.
Routine walking and stretching are recommended during the
first several weeks.
Artificial disc replacement is a
newer surgical procedure for relieving
low back pain for patients with
degenerative disc disease. Similar
to hip or knee joint replacements,
a disc replacement substitutes a
mechanical device for an intervertebral disc in the spine. The
device is meant to restore motion to the spine by replacing
the worn, degenerated disc. This is an alternative to lumbar
spine fusion with the goal of reducing and/or eliminating pain
and simultaneously maintaining motion.
Spinal fusion, more commonly performed, locks two or more
spinal vertebrae together so they cannot move. This may
alleviate the pain but does not allow motion or flexibility,
permanently alters the biomechanics of the spine and has the
20
For more information about lumbar spine surgery and artificial
disc replacement, please e-mail us at contactus@thecoreinstitute.
com or call 1.866.974.2673.
CORE Ink
The Role of Neuromuscular Electrical
Stimulation in Physical Therapy
by Jamie Hartzell,
PT, DPT
A Clinical Perspective
What Is Electrical
Neuromuscular Stimulation?
Electronic muscle stimulation (EMS, NMES) generates electric
impulses through a device or piece of equipment that delivers an
ordinary electrical current and converts it to produce physiologic
effects on human tissue. The signal/impulse mimics the action
potential coming from the central nervous system, causing the
muscle to contract. The signal is delivered via electrodes placed
directly onto the skin proximal to the muscles to be stimulated,
“telling the muscle how to work” again. The settings on the device
can be changed to allow for a gentle or forceful contraction.
Treatment times are generally 10 to 30 minutes when combined
with voluntary exercise in the clinic using both isometric and
dynamic muscle movement.
Uses for Electrical Stimulation
Within Physical Therapy
EMS is often used following musculoskeletal injuries, surgeries
and prolonged immobilization, as well as in neurological settings
for those who have suffered from muscle paralysis or stroke.
Electrical stimulation is used to improve the performance of
the skeletal muscular tissue when the patient cannot voluntarily
contract a muscle. In orthopedic settings, EMS is implemented
to prevent muscle atrophy or strength loss, to improve muscle
function, to increase local blood circulation, to re-educate
muscles and/or to help increase range of motion by causing
muscle adaptation/training of the skeletal muscle fibers. The
goals in using EMS are to improve a patient’s quality of life,
including activities of daily living, return to sports and work and
functional mobility, and to increase overall strength.
This concept is important for a patient after having undergone
a surgery, as muscle weakness is almost always identified upon
initial evaluation.
The Benefits of EMS Following Anterior Cruciate
Ligament (ACL) Reconstruction
Electrical stimulation is another tool in the physical therapy
arsenal to help assist muscle strength and recruitment when a
weakness has been identified upon evaluation. EMS is effective
in the recovery of a patient when used in conjunction with
voluntary exercise. Research and studies of the Journal of Science
and Medicine (2006, Vol. 5, p. 276-281), the Journal of Sports
Physical Therapy (Vol. 4., No. 3, p. 162-168) and the Journal of
Orthopaedic & Sports Physical Therapy (2010, Vol. 40. No. 7, p.
383-391) have proven the efficacy of using electrical stimulation
to negate muscle atrophy and weakness. Studies indicate patients
who did not have EMS with rehabilitation may experience postoperative weakness ranging from 6 percent to 18 percent when
compared to the uninvolved side. This weakness is identified up to
as late as one to six years following ACL reconstruction.
Studies have also shown significant improvement in isometric
muscle strength and function when having patients use
electrical stimulation (NMES, EMS) with voluntary exercise
versus exercise or NMES alone. These gains are identified
within the first six weeks following ACL reconstruction; thus,
the rationale in using electrical stimulation following an ACL
reconstruction is to prevent postoperative weakness and
muscle atrophy and to influence the recovery of the patient’s
quadriceps and knee function.
What a Patient Can Expect in the Clinic
Electrodes are placed over the vastus medialis musculature
with intensity set to tolerance, with treatment time lasting
10 to 30 minutes when used in conjunction with voluntary
exercise. These exercises may include, though are not limited
to: quadriceps isometric contractions, short- and long-arc
quadriceps sets, terminal knee extension and straight leg raises.
Following several treatment sessions (four to 18 visits), the
patient will be re-evaluated to determine the effectiveness
of EMS on muscle strength and function. These outcomes are
measured with isometric quadriceps strength, a step-up test and
a unilateral squat.
Conclusion
Evidence-based practice, clinical experience and research
indicate NMES combined with exercise may be more effective in
improving quadriceps strength than exercise alone following ACL
reconstruction. Thus, electrical stimulation may be beneficial in
influencing a person’s short- and long-term recovery.
For more information on neuromuscular electrical stimulation,
please e-mail us at [email protected] or call
1.866.974.2673.
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The CORE Institute
3010 W. Agua Fria Freeway, Suite 100
Phoenix, AZ 85027
®
24
PRSRT STD
US POSTAGE
PAID
CHAMPAIGN, IL
PERMIT NO. 100
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