Search for tag: "pain"

Interviewer: Severe, sudden, and sometimes debilitating face pain is a symptom of a disease called trigeminal neuralgia and some people suffer with the condition and don't even realize that's what they have. Or maybe it was misdiagnosed as something else so they can't get treatment.

Dr. Shervin Rahimpour is a neurosurgeon who specializes in the surgical treatment of trigeminal neuralgia, and he's going to help us understand how to come to that diagnosis. So first of all, you tell me it's a poorly diagnosed disease. What exactly do you mean by that?

Dr. Rahimpour: Often this pain is distributed around the cheek and jaw area. And so it's natural for patients to think that this is likely a result of their dental health. And so they often seek treatment through a dentist, usually, you know, undergo a tooth extraction or something like that, and that pain persists. So that's often why this is poorly diagnosed is because it overlaps with other common issues like having tooth pain.

Interviewer: Yeah. And I think a lot of us think well, the pain is here, this must be the source of the pain. It's in my mouth or my cheek, it must be the source. But that's not the case with this disease. Where does the pain originate from?

Dr. Rahimpour: The trigeminal nerve, which is one of the 12 cranial nerves that we have, supplies, amongst other things, the sensation that we feel over our face. So there are two nerves, one for each side. Each nerve supplies the sensation to that half of the face. And the nerve has three divisions associated with it. There's one that kind of overlays the forehead and around the eye. The other division is around the cheek area, and then a third division encompasses the jaw. And so most commonly, the pain is likely to affect those bottom two divisions, which is around the cheek and the jaw area, and that's where this overlap comes with potentially pain coming from your teeth.

Interviewer: And somebody goes to the dentist, they have an extraction done and that doesn't solve anything. Do they try to get a diagnosis beyond that, or do most people just give up or do you know?

Dr. Rahimpour: Yeah, I should add that sometimes it can be your teeth. So it is worth having that evaluation done by your dentist. But eventually, this pain syndrome is referred either to a pain specialist or even a neurologist. Those are the folks that typically end up diagnosing this as trigeminal neuralgia-type pain.

Interviewer: Explain some of the common symptoms that people might experience.

Dr. Rahimpour: Yeah, absolutely. So again, this pain used to be . . . this disease used to be known as suicide disease because it was such a horrible pain for patients to experience. And it's often a severe electric type jolt or stabbing pain involving one or more of the divisions of the trigeminal nerve of the face. It's often set off by very relatively innocuous stimuli. What I mean by that is anything as simple as just a gust of wind, or talking or brushing your teeth, or having water hit your face when you're taking a shower. These are kind of the very, very basic and innocuous things that can trigger that type of pain.

Interviewer: And what's going on with the nerves that is causing this pain?

Dr. Rahimpour: The vast majority of cases are thought to be caused by a vessel sitting on the nerve root as it enters into the brainstem. And so what this vessel causes is damage over a period of time that ends up injuring the insulation around the nerve known as myelin. And then this can result in sort of aberrant firing of the nerve.

Interviewer: So it's rubbing against there, damaging the insulation every time your heart beats.

Dr. Rahimpour: That's exactly right.

Interviewer: It's damaging the . . . Okay.

Dr. Rahimpour: So the thought is that if we can remove or transpose this vessel from the nerve root . . .

Interviewer: Yeah, get it away from there.

Dr. Rahimpour: Get it away from there, that could potentially allow the nerve to heal and prevent some of this aberrant firing.

Interviewer: And if a patient has this type of pain, they would go to their primary care physician first likely. What would that workup look like?

Dr. Rahimpour: Typically, the patient has these classic types of symptoms or the stabbing electric type pains of the facial region, again, involving either one or more divisions of the trigeminal nerve. And we often ask patients, you know, "How is this pain brought about?" If it's something, again, wind, chewing, talking, anything like that, that's pretty consistent with trigeminal neuralgia. The pain also again persists to seconds to potentially minutes, and so that's another signature or hallmark of the disease. And we often look for patients that, you know, typically we find that this disease occurs more often in the older population. So the incidence kind of climbs as age goes up. But this can also be a result of some other secondary processes. Certainly, it can range anything from facial trauma and include other secondary causes like multiple sclerosis.

Interviewer: At what point should a person consider consulting with a physician who specializes in trigeminal neuralgia?

Dr. Rahimpour: I think early on it's best to have the medical therapy be optimized. So a lot of the medications we use for this type of pain are actually anticonvulsants used in epilepsy. The reason why is because, similar to epilepsy, the nerve can act on its own and fire. And so the idea is can we stabilize this nerve so that it prevents it from firing, the same way that we try for epilepsy. Those types of medications are started, they're increased to a therapeutic level and then the patient is evaluated to see if this treats their pain. Again, the vast majority of patients respond to these medications, something upwards of 90%, but half of those patients end up having unwanted drug side effects. And then, of course, there's a 10% that did not respond to the medication at all.

Interviewer: Yeah. And this medication, is it kind of a dialing-in process, you've kind of got to figure out the sweet spot for everybody?

Dr. Rahimpour: Yeah, I would say that most anticonvulsants are started at a low dose and gradually titrated up.

Interviewer: And for the individual that is not responding to medication, or the side effects are just so terrible that it's really impacting the quality of life, and that's where the microvascular decompression procedure comes in. That's what you're doing there.

Dr. Rahimpour: That's exactly right. So for patients that aren't responding to the medication, if they've had an MRI scan that shows that potentially there might be a vessel there pushing on the nerve, that's where microvascular decompression can play a role.

Interviewer: What about for patients where they have the condition, and it's not pressing against that nerve? That's possible, right?

Dr. Rahimpour: Patients where we don't necessarily see a blood vessel pushing on the nerve, or they might not necessarily be a good operative candidate, we can offer other minimally invasive approaches. Those approaches include percutaneous rhizotomies. The premise there is that we with a needle go to the base of this nerve, known as the trigeminal ganglion, and we try to damage that nerve to sort of disrupt the pain signal. The other option is using radiation in the same way that folks use it for tumors to try to focus the radiation and try to damage the nerve again, to stop this pain signaling.

Interviewer: Are these other last two procedures, are they an alternative to somebody getting a microvascular decompression?

Dr. Rahimpour: They are alternatives, but I should add that they're not as efficacious. So when we do find patients are good candidates for microvascular decompression, we try to advocate for that as it gives us the best chance for pain freedom.

Interviewer: After somebody has the microvascular decompression, what is the success rate that that actually takes care of the pain?

Dr. Rahimpour: We expect that patients often have immediate pain relief after surgery, especially if we do find a blood vessel that's compressing the nerve. Historically, 70% to 80% of patients are still pain-free at five years.

Interviewer: And the other 20%?

Dr. Rahimpour: Pain can reoccur. And if that's the case, we can always revisit other possible interventions, including some of the percutaneous and radiosurgery techniques that I mentioned.

Interviewer: For the patients who get the microvascular decompression, what's the satisfaction rate among those patients? I hear this could be life-changing for some people.

Dr. Rahimpour: Absolutely. So again, this is a very debilitating disease. I mean, you can imagine if it's affecting the way you eat, and the way you conduct yourself throughout your day-to-day in anticipation of a sudden pain strike, being pain-free means everything. And so when patients are pain-free again, where we expect that to be the case in the vast, vast majority of times after microvascular decompression, this is absolutely life-changing.

Interviewer: Before considering surgery for back pain, there could be other options you might want to consider first. Dr. Andrew Joyce is a physical medicine and rehabilitation specialist, focuses on non-surgical treatment of various muscle and spine issues. So here's a scenario. A patient has been told by another provider that their back pain might benefit from surgery. They come to you for a second opinion or just wanting to know if there's something that they can do before surgery. First question is there?

Dr. Joyce: Definitely. In the vast majority of cases, there's something that we can offer to at least try to ameliorate the pain before jumping to surgery. There's a variety of treatments that we look at, whether it be medications, therapies, modalities, or procedures to go and help manage people's pain.

Interviewer: And does that happen often that you end up talking to a patient that has been told surgery is what is going to help with their back pain and have not been told about some of these other options?

Dr. Joyce: Yes. I would say, you know, we're fortunate here at the university because most of the way our referrals are sent in, they get sent to us first to evaluate for non-operative treatments before we decide whether or not the patient would really benefit from surgery. But in the community, that's not always the case. And so it's not uncommon for patients to have back pain or pain originating from their back and sciatica, who see another provider who offers them surgery, and then come to us for a second opinion to see what else we can do.

Interviewer: Let's talk about some of the options that somebody might take. Where do you start that conversation?

Dr. Joyce: The first thing we do is we try to get a comprehensive physical and history from the patient. And what we're looking for is to try to identify what the exact source of the pain is. And so we'll review with you, you know, the history of your pain, where exactly is it located, we'll take a look at imaging, and we'll look at different other medical conditions which may factor into our decision. And then once we've looked at all of that, we'll discuss the different options that we can use for different procedures. And so it varies depending a little bit on which diagnosis we think you have.

Interviewer: And I think a lot of times patients think these non-surgical options tend to be like some sort of like a cortisone injection or something like that, which is definitely an option, but there are other options as well. So walk me through some of those options and how they might apply to a patient.

Dr. Joyce: So the most common injection and the ones that people call, you know, cortisone injections are basically steroid injections. And what matters is not necessarily that you're injecting steroid, it matters where you're injecting the steroids. So we use these steroid injections in various parts of the body depending on where we think your pain is coming from. So if you're having pain that's caused by a herniated disc pressing on a nerve, well then we would do an epidural steroid injection, where we place steroid in and around the epidural space to bathe that nerve and calm down any inflammation and irritation that's happening to the nerve. On the other hand, if you're having pain that we think is coming from your sacroiliac joint, which is a large joint at the base of the spine, then we would inject the steroid into the sacroiliac joint and use that to calm down inflammation and irritation to the area.

Interviewer: And then other than the injections, what are some of the other options that you can offer a patient and what situation with those apply?

Dr. Joyce: Some of the more common things when people have arthritis related pain in their back, we do a series of procedures where we do test blocks to help determine if the arthritis is truly the source of the pain. And those are called medial branch blocks. And if patients do feel substantially better after those test blocks, then there's another procedure called radiofrequency ablation, where we actually burn those little tiny branches of nerves that go to the joints and help relieve the pain. And those can actually be very durable. They can often last anywhere from six months to a year and a half, at which point we can repeat it and get similar pain relief.

Interviewer: And then I've also heard of electrical stimulation. Is that another option?

Dr. Joyce: Yeah, and this is kind of an emerging technology. Spinal cord stimulation itself has actually existed for over 50 years. But in the past 10 to 15 years, there's been huge advances in the technology that we can use for it. Now this is almost never a first line treatment that we use. But for people who are having severe pain in their back and aren't getting better, we can use electricity to kind of help modulate the pain signals. And so that involves putting electrical leads either in the epidural space behind the spinal cord or even more superficially, around nerves in the low back to help block the pain signals.

Interviewer: And then does the type of treatment that we've talked about, we've talked about injections, we've talked about the burning the nerves, we've talked about the electrical stimulation, does that really, really depend on the type of pain somebody has? Or are those options suitable for all types of pain and you just kind of cycle through one after another? I mean, is there some sort of a procedure you like to go through?

Dr. Joyce: No. Yeah, it definitely depends on the type of pain and where the source of the pain is. So, you know, if your pain is coming from purely the arthritis in your back and I do an epidural steroid injection, I'm not expecting you to get substantial relief of that pain. So it really depends on where the pain is. And where this becomes more complicated is when patients have more than one thing going on, right? It's not uncommon for patients to have arthritis in their back, that then causes some pressure on a nerve. And so they have more than one thing going on. And so then, in those cases, we will use more than one of these types of procedures to help with their pain. But really, it depends on what the source of their pain is.

Interviewer: And I'm kind of getting the feeling that back pain can be kind of a complicated thing. I mean, it sounds like you have to know what's causing it and then what treatments are the most effective for that type of pain, depending on what kind of pain, what's causing it, the location. How often just kind of after a couple of visits do patients find relief, versus you've kind of got to look a little bit further in the cases where patients might have multiple things going on?

Dr. Joyce: It depends on the patient. I would say, you know, for many of our more acute patients, so patients who have had pain for between 6 and 12 weeks, those patients tend to, on average, do a lot better, because they haven't had the pain for quite so long and oftentimes it's less complex. But certainly, when it gets more complicated, sometimes it does take a little bit of trial and error and some searching. And sometimes these injections can actually be helpful, both therapeutically to help people with their pain, but also diagnostically to help us determine the exact source of pain and help us get a better treatment program put together.

Interviewer: Kind of a mystery that you have to unravel in that case.

Dr. Joyce: Exactly.

Interviewer: Yeah. And then at what point would you even recommend somebody for surgery?

Dr. Joyce: Most common reasons that I will have someone be seen by surgery is back pain or neck pain going down their arms or their legs, with associated numbness, tingling, and in particular weakness. When people are having symptoms that are causing, you know, objective findings on our examination when they're objectively weak, that's when surgery is most indicated. And that's oftentimes when I will send them to surgeons earlier rather than later because we don't want patients to be left with any sort of neurological problems long term. And surgery is the only way to decompress nerves and help prevent that from happening.

Interviewer: Is weakness generally always a sign you're going to be sending somebody to surgery or not always?

Dr. Joyce: So it depends a little bit on having objective weakness, but also on the pattern of weakness. So we know certain nerves in the body go to certain muscles. And so we'd expect that if a nerve is being compressed and causing weakness, it would affect those muscles that it innervates. And so what we look for is to try to see if the pattern of weakness matches the nerve being pinched. And if that's the case, then surgery might be necessary.

Interviewer: And again, it just really sounds like coming to a specialist like you is really just a great step just to make sure.

Dr. Joyce: Yeah. I think at that point, if there's any concern that you might have weakness, or you're having neurological findings and you're not sure what to do, definitely seeing a specialist, like us, I think makes a lot of sense.

Interviewer: What you described, you know, choosing the right place for an injection, the type of injection you want to use sounds really, really complicated. What do you recommend a patient look for in a provider that's doing that type of work?

Dr. Joyce: You want to make sure that the person who is doing your injection has done hundreds of these types of injections and is well versed with it before you go in with them.

Interviewer: Whether that be through a fellowship that they did, that extra year after medical school specializing in this, or they've done numerous procedures over the length of their career.

Dr. Joyce: Agreed. Yeah.

Interviewer: You hurt your back. What can you do on your own, and when should you go see a doctor? Dr. Andrew Joyce is a physical medicine and rehabilitation specialist. He's also an expert at helping patients manage neck and back pain.

Dr. Joyce, I was shocked to find out that low back pain is the number two reason Americans see their healthcare provider. Is it for this kind of acute back pain that we're talking about that they're usually seeing their doctor for?

Dr. Joyce: In most cases, yes. I think a lot of people have chronic low back pain as well, but I think most of us tend to see a lot of acute low back pain, and particularly my primary care colleagues see tons of it.

Interviewer: And we're talking in this particular Q&A that we're doing together about acute back pain, which is back pain that you were just doing something and you hurt yourself, right? Is that kind of what we're talking about there?

Dr. Joyce: Yeah. And it doesn't even have to be doing anything in particular, but you wake up, you have back pain, and you don't know where it came from. Or you were lifting something and tweaked something, threw out their back is a common phrase that people will use, all of those count as what we're talking about today.

Interviewer: And technically, when you say "acute back pain," that's back pain that lasts less than four weeks, right, four weeks or less?

Dr. Joyce: Depending on which guidelines you use, some people say four weeks, some people say less than six weeks, but somewhere in that range.

Interviewer: All right. So, but if I hurt my back like one day, I don't know how long it's going to last. So is there a better way to kind of determine what type of back pain I have? I suppose if I was doing something, it's pretty obvious that, oh, well, I tweaked my back doing that. But like this wake up scenario, how could I tell that maybe that isn't a symptom of something bigger? Because a lot of times back pain is a symptom of other things, isn't it, you've got to kind of rule out?

Dr. Joyce: Yeah. Yeah. And so that's when we start looking at kind of these what we call red flags. So it's very common that people will hurt their back, and oftentimes the pain can be very severe and debilitating. Severity doesn't always correspond with something being necessarily worse. There's actually set of red flags that we look for to kind of try to triage and look for people who might be at risk for having other sources of back pain that warrant further investigation.

Interviewer: All right. So before we kind of get to then acute back pain, I think it's really important to hit those kind of red flags to somebody can make an informed decision that they need to see their healthcare provider sooner than later, or trying to take care over themselves. What are those red flags?

Dr. Joyce: Big ones are trauma. Obviously, if you were like in a car accident, that would factor in. If you have new fevers, numbness, tingling, weakness in your legs. If you have a history of cancer, if you're having any bowel or bladder changes, you use any blood thinners, have cancer, have IV drug use, all these things could put potentially be risk factors. And those were reasons that we'd want you to be evaluated more soon.

Interviewer: And if a patient doesn't believe that that's the case, if they truly just believe, oh, I must have slept funny, or I did something, what can a patient do on their own for acute back pain before they need to see a doctor? What are some recommendations you would have?

Dr. Joyce: Yeah. So the first thing we actually recommend is that you avoid bed rest. Fifty years ago, everyone got recommended, "Oh, just stay in bed, let yourself heal." And what we found is that we were actually giving people a lot of bad advice.

What we recommend now is actually that you try to stay as active as you can tolerate. For most people when they're having an acute back pain flare, they're pretty uncomfortable. So even simple things like getting up, showering, cooking a meal, eating can be somewhat uncomfortable, but our recommendations are to actually try to stay active because recovery is faster when you do that.

Interviewer: And is that because you're getting more blood to the area? What's going on there? Do we know?

Dr. Joyce: I'm not sure if we have exact answers on that. Some of it is that we're probably reducing some of the stiffness. When people have a lot of back pain, they don't move their muscles, they get really stiff and that can cause more pain.

I think we're also testing it. Some people with back pain are really afraid that they're going to do damage and so they don't do anything. And so then their muscles start getting weaker. Within a week, you can lose a large percentage of your overall muscle mass just by not moving and staying in bed. And so by keeping your muscle strong and keeping you moving, you help stretch and strengthen those muscles and help your body on the way to recovery.

Interviewer: And this extra moving, you're not going to hurt yourself most of the time. Is that correct?

Dr. Joyce: As long as you don't have one of those red flags, in most cases, you are able to go out and do whatever you need to do, knowing that there may still be some pain due to this flare-up. But it's safe to go out and be active. In fact, it's kind of the treatment of choice at that early stage.

Interviewer: All right. So get active or just be active as much as you can tolerate. What are some other things that a person could do before they go see a doctor?

Dr. Joyce: They can try over-the-counter medications. So nowadays, we have the Salonpas patches or other lidocaine patches that people can use. There are a variety of topical creams. There's Tylenol. There's oral anti-inflammatories that people can take. All of those are over-the-counter and are medications that patients can try out.

Additionally, this somewhat depends on your insurance plan, but sometimes you can get direct access to physical therapy without even needing to see a doctor in certain cases. And so that's often a reasonable place to start.

Interviewer: And then what amount of time doing those types of things should a patient wait until they start to see some relief or start to be concerned that, "Oh, maybe this isn't acute"?

Dr. Joyce: Yeah. So I would give it at least two weeks and see how you're feeling at that point. If at that point you're not getting better, that might be a good time to at least start scheduling an appointment with your doctor. Most patients with back pain will recover within two weeks.

The next set will kind of get better over the course of six weeks. And definitely if it's been over six weeks, it's probably worth seeing a physician to evaluate you.

Interviewer: And then when you come into your physician, you could go to a primary care physician, or could you come to an expert such as yourself at that point? What would you recommend there?

Dr. Joyce: If you have a good, established care with a primary care physician, I think that's a great place to start, and they will often be able to help you. If you have any concerns, or if for some reason you're not able to get in, or you don't have a primary care physician, we're always happy to see people and get people in from the ground up and make sure that they're getting treated appropriately.

Interviewer: All right. And then what types of things would you do at that point for a patient that has gone two to four weeks not necessarily seeing the kind of recovery that they'd like? What are you looking for at that point?

Dr. Joyce: Yeah. So, at that point, we likely would get some imaging, probably starting with an X-ray, just to check to see that the bony structures are intact and there's no new issues. And sometimes there are things on the X-rays that can clue us into other potential sources of pain that we might not otherwise be able to see just from our physical examination.

We'd prefer a full history and a physical examination to really get a better picture of the back pain and understand how it fits in with your other medical conditions and if there's any other rarer conditions that we really need to be looking at.

At that point, then we make a decision, based on everything, on what the next treatment plan should be, whether it be a formal referral to physical therapy, whether it be more advanced imaging in preparation for certain procedures, and considering different injections.

Interviewer: What about surgery at that point, or when does that come into play?

Dr. Joyce: Most patients don't need surgery. And that's one of the great things. The natural history of these, which means how people do if we do nothing and just let people live their lives, is that most people recover with it over time. It just can be very debilitating during that time.

And so, in most cases, surgery isn't recommended. If you do have one of those red flags, I think it's worthwhile to get evaluated, and then we can see whether surgery makes sense. But in most cases, there's nonsurgical options that we will try first and see if we can help get this under control or get your pain better before having you meet with the surgeons.

Interviewer: And then how about you using opioid medications for back pain? Is that ever a good idea?

Dr. Joyce: In most cases, I would say probably not. There are always exceptions to the rule, so I don't want to say never. But in general, opioids aren't really a first-line treatment for back pain. And if you look at the CDC or you look at other organizations, such as the American Academy of Family Medicine, they don't recommend opioids. And part of the reason is that they've been shown to have higher risks, which we all know through the opioid epidemic, but also no significant benefit when compared to other over-the-counter medications. So Tylenol and Advil versus opioids, the studies show that they're roughly equal in terms of controlling the pain and the opioids carry a much greater risk. So, in most cases, we try our best to avoid opioids because we don't want to risk our patient's health.

Interviewer: And when you're talking about over-the-counter painkillers for back pain, do you just follow the directions on the boxes to what your dosage should be, or generally do you recommend to your patients a higher dosage?

Dr. Joyce: It depends on the medication, but, in general, I probably will recommend for Tylenol, you can take up to two Extra Strength Tylenols, and you can do that three times a day as kind of a high-level dose of Tylenol.

And then for the anti-inflammatories, the low doses of the medication tend to be more pain relievers. And at the higher doses, they tend to have a little bit more anti-inflammatory effect. And so sometimes, for a medication like Advil, we can recommend up to three tablets of regular Advil three times a day.

Any more than that, you should probably be seeing a doctor or checking in with them to make sure you're not using too much medication because that can have other side effects.

Interviewer: If your loved one is experiencing some sort of serious spine issue, perhaps stenosis or herniated disc, you may be looking into spinal surgery. Now, typically you might be imagining your back being opened up for major surgery, but there's another option that is available.

We're here with Dr. Mark Mahan. He is an associate professor of neurosurgery at University of Utah Health. Now, Dr. Mahan, we're talking today about endoscopic surgery for the spine. Why don't you kind of talk me through exactly what happens with an endoscopic procedure like this and how it differs from say what I as a layperson think when I think about back surgery?

Dr. Mahan: Endoscopic spine surgery is very similar to what people would refer to as traditional spine surgery, meaning that we're the same goals. We're there to decompress the nerves and in doing so with either removing disc fragments or treating narrowing that presses on the nerve roots, but doing it in a much smaller, much less traumatic fashion than previously accessed.

For most of us, the spine is really kind of in the center of the body, so getting there is always an art, to put it mildly. The older techniques, they work great for treating their intended targets, but the problem is, is there's a fair amount of tissue trauma involved with getting there.

And I've been intrigued for quite some time of finding a way of doing that same surgery, but in a way that does not cause the same tissue disruption, tissue trauma, and as a consequence, the same sort of pain or disability and recovery.

Like for so many things in medicine, we stand on the shoulders of others. Other pioneers had really developed using endoscopes previously, starting in about the 1980s, to create the same surgical corridor but through a much smaller opening. So now with the modern surgical endoscopes, we get beautiful illumination. We get beautiful magnification. We get beautiful video representation of the soft tissues in a way that we're able to perform those same delicate procedures, but through oftentimes really small, like 7 millimeters size skin incisions. That's, you know, 7 millimeters means it's less than your nail width depending on your fingers, but somewhere between your index finger. That's how big the skin incision is.

So that also means that that translates it's not just the skin incision size, it's because now you're going to go down with a very narrow caliber set of tools. So the things that you're going to be doing is that you're not going to be opening up as widely. You're not going to be disrupting joints. You're not going to be getting as much bleeding because we're constantly irrigating.

In fact, the operative field never actually gets to see air. There's none of the circulating air even in an ultra sterile OR environment that actually makes contact with the tissue. We're using constant irrigation with sealing. And so, again, it provides beauty and clarity to the surgeon but also minimizes any risk of infection or other bleeding type complication with regard to the surgery itself.

Interviewer: And again, as someone who's a layperson who might be kind of curious about this, how long have surgeons in the medical field been doing this kind of procedure? It seems kind of new I guess to me.

Dr. Mahan: I'd say it hasn't been done at a large volume for quite some time. There were some initial pioneers who were in the 1980s when they were coming out with the initial endoscopes who were starting it and trying it.

And you can imagine what using 1980s technology meant kind of dark kind of grainy, not necessarily with the same precision. Things really got a boost I would say in the, you know, the 2010s with the introduction of more modern, you know, high-definition televisions, easier access to those techniques, and then just greater popularity.

So we started seeing that the endoscopic technique was really taking off in Germany, and there there's a couple of key innovations that allowed it to be safe for the spine. So whereas you can think of joints having arthroscopes, those are endoscopes specific for joints, those were a little earlier take on, but they were using really high-pressure pumps and those high-pressure pumps would be dangerous if not lethal in the spine. So we had to really develop lower pressure technologies. You had to develop specific tools sets that were able to do the same sort of meticulous and very detailed work we do with the spine.

We saw that those tools and techniques and instrumentation sets really start about 2010-ish, and so there's a very small fraction of spine surgeons in the United States who are trained to do this, unfortunately, because I think it's the technique that should really predominate. And I do, you know, have the good fortune of being able to go train other spine surgeons on how to do this and adopt this technique, which I really enjoy teaching the other spine surgeons how to do it because hopefully it will become the dominant technique and it's not just a single or specialty practice.

Interviewer: It sounds like this procedure has been getting more and more popular over the last two decades, and you sound confident that it could be the next standard practice for a procedure like this. What is it that you see in this particular type of procedures and what are some of the pros and cons of it that make you think that this is going to be the way that surgery is going to be going?

Dr. Mahan: I really like the fact that it has minimal tissue trauma, which means that it has quicker recoveries. So when you ask about the pros and cons, the certain positive that I particularly love and I particularly enjoy about the surgery is that it provides rapid recovery for my patients. That the next day when I talk to my patients or find out how they're doing, they're describing that they're already back to more activities oftentimes than they were before surgery, which is relatively rare.

When we think about surgery, where most people are like, "Yeah, I've got a down period," and I don't have patients coming back to me with like down periods. They're like, "I'm out walking." I hear reports over and over again. They're like, "I am walking now more like the day after surgery than I was in like the several months leading up to surgery." It is that dramatic as far as differences in outcomes. So that's the most certain person and positive note.

Now, some of the other positives I particularly like, again, its lower blood loss. It has a substantially lower risk of infection. There's a substantially lower risk of a specific complication that occurs in spine surgery and that's spinal fluid in leaks or thecal sac injuries. And that's unique to the endoscopic technique is again, we're using sealing to put a little bit of pressure and create space and so the thecal sac is moved away and so you have less risk of that specific complication.

There are downsides, right? I tell all my patients almost repeatedly, you know, if it's powerful enough to help, it's powerful enough to harm. There are cases where people have injured, you know, individuals with using minimally invasive techniques. Endoscopic spine surgery is no stranger to that.

I would certainly say that I think, in my hands, the complication rate is lower, but it's not it's a freebie. It's not like there are no risks. Secondarily and I think the most of the negatives really accrue to the surgeon. You imagine like if you had to do the same work, let's say it's painting a wall, and you were given the choice of a big paintbrush or a tiny paintbrush, which do you think would lead to be faster endpoint?

Interviewer: It's the big brush, right?

Dr. Mahan: The big brush. It's the big brush. The big brush is going to do something quicker. And so, if you force the surgeon to do the same procedure with tinier tools, it's going to take longer. And the way that the insurance in the United States reimburses surgeons, it's on sort of work product. And so again, they pay you to paint the wall. If you can paint the wall faster, then it can be a choice.

Interviewer: What are the success rates like on a procedure like this?

Dr. Mahan: The success rate on anything in life really kind of depends on what your probabilities of success are. So if I take somebody who has relatively straightforward problem and has a very focal problem that's apparent on MRI and is clear on their physical exam and their description of their symptoms, we're going to have a good success rate whether it's an open technique or an endoscopic procedure.

If it's something that's a little bit more challenging, somebody has multiple problems, multiple medical issues, other interdependencies, you know, things that are going on in their lives that are either participating or motivating the pain, then we're going to be less successful. But so for that, let's take the good situation which is for most people where they are.

This is, you know, somebody who has singular problems, relatively identifiable things that could fix their problem, and they're going to have an 80% to 90% success rate with a surgical treatment and it's going to be durable. We want to do a simple procedure that doesn't necessarily create problems that need treatment later.

There are some spine procedures out there that cause further problems down the road. This is one of the ones that leaves a person essentially with more or less their native anatomy, their normal anatomy. And so the goal there is that the only thing that contributes to future problems is really, you know, the nature of time and body's ability to resist time but not the surgery itself.

Interviewer: Say that a patient has now received their diagnosis, they know they have one of these spine issues like we've talked about earlier. What is their first step? Say they're listening to this right now and they're intrigued about this procedure, what is their very first step to get more information and maybe even meeting up with someone like you or another trained professional?

Dr. Mahan: One of the things that we want oftentimes in medical practice, and this applies to a lot of things, is that we want somebody to ideally for somebody to come to me or to come to one of another trained practitioners. If they've had a degree of workup, meaning that they've been evaluated, they've been seen by somebody, and that the process has already been started.

For example, a classic thing is that sometimes you have back pain that can be treated with physical therapy, some exercises, some stretching, maybe some modest medications, right? We're talking about like anti-inflammatories and other things that can get you back to recovery that you don't need surgery for. And so both insurance and the surgeons really want to have that evaluated ahead of time so that when you're coming to somebody, it's meaningful. It's a meaningful use of the patient's time. That you're not coming to see somebody who's going to talk about surgery when you don't need it.

And so it's not a waste of the patient's time. It's not a waste of, you know, of resources or other things. So an initial evaluation, maybe some time with the physical therapist, trial of medications. And then if those aren't working and the MRI, which is a critical component of all of our evaluations, because that's where we can come back to saying is an anatomical surgery going to fix your problem.

And so we need a view of that anatomy, and fortunately, MRIs just do such a beautiful job of doing that is that. If an MRI shows that there's a problem, then clearly there's something that we may be able to intervene on and achieve a good outcome.

Interviewer: Wow. So it sounds like it's a kind of newer procedure and you've got to find the right doctor to do it, the right surgeon and you got to make sure that you have done your homework, gotten your imaging and your workups and everything but maybe they're curious about this type of procedure and treatment, where is somewhere where they can get more information?

Dr. Mahan: Well, one place to start would be the University of Utah website. We have a lot of wonderful information there that can give you the breadth because no patient has the same and what no problem is the same either. So there's oftentimes very distinct treatments that endoscopic spine surgery may not be for you. I would love to think that it is, but at the same time, realistically, there are plenty of things that may need to be done and it may not be endoscopic spine surgery and so that's a great resource to go to.

Interviewer: So a little bit of elbow pain if you're a pitcher in baseball is okay, but if it starts to get pretty severe, you're going to want to do something about that.

Dr. Chalmers, how much elbow pain for a pitcher is acceptable? And what's kind of the threshold that you maybe want to have somebody look at what's causing that pain?

Dr. Chalmers: Yeah, we've done some studies that have helped to inform of us of that. And I think one thing to understand that it's not a normal human motion to pitch a baseball. There's nothing we're evolved to that makes us good at pitching a baseball. And there's a lot of adaptations pitchers undergo, as they pitch through adolescence, that help them to become better at it for sure.

But we've done two studies that I think help and inform our thinking about this. We did a large study of youth baseball players, kind of youth and adolescent baseball players, where we asked them whether or not they have pain. And about 30% of kind of normal, uninjured players will say they have regular pain with play. Now this study we did, though, I think is even more informative is we took pitchers and we had them throw through a simulative game. So they threw 90 pitches kind of in simulated 15 pitch innings. And what happened is that . . . and we collected pain scores and fatigues scores, and what we found is that as pitchers get towards that sixth inning, pain scores start to creep up to somewhere around 1 or 2 out of 10, which just kind of still qualifies as minimal to mild amount of pain but not zero pain.

So I usually tell pitchers, if you're throwing and you're getting above a 2 or a 3 out of 10, that that's not normal, it's not expected, it's not something that can be just swept under the rug with the classic saying of, "There's no crying in baseball," and that it's something that probably you should look into. But if you're having a little bit of soreness, 1 or 2 out of 10 with heavy use six innings of pitching, that's probably very normal and something that you could expect with this particular sport.

Interviewer: How do you, when you do the 1 to 10 ranking, help somebody understanding like what a 1 what might be? Because somebody's 1 might be somebody else's 6.

Dr. Chalmers: Well, no, I think you're right. I mean, I think this is always the issue with pain is there's no objective measure of pain. We have no way to measure that in a way that can be comparable between patients. We have the subjective scale. Usually, the ways that we qualify that are, you know, the number, which can be hard, the words which to say mild, moderate, severe, mild being kind of a 0 to 3, moderate being 4 to 6, and severe being 7 to 10. And then the other way we use this is the scale called the Wong-Baker Scale. It has this . . . you know, starts with a smiley face at zero and like a very unhappy face at 10. I usually think of 2 out of 10 as being a place where there's still maybe a little bit of a smile if you have a really good game, but definitely there's some grimacing if things get bad. And if you start to get to the place where there's no longer a smile on your face, then probably it's too much.

Interviewer: And that's during. What about pain afterward? How long until that pain would go away for kind of the average player?

Dr. Chalmers: Well, usually what I tell people is that you should be able to do what you're doing in a reproducible way every other day. So if you feel like I could pitch like this every other day, then that's a right amount. If you feel like, "Ah, I need four days to recover from this pitching outing because it was so painful or took that much recovery," then what you're doing is too much.

Interviewer: And you said, you know, the saying is, "There's no crying in baseball," and sometimes pitchers tend to be a little tougher than the rest. If somebody is having elbow pain above the threshold you described, what are some of the downsides to not having that looked at?

Dr. Chalmers: Yeah, there are definitely downsides to just pitching through significant pain. The significant pain can be a sign of a substantial injury to the elbow. So, for instance, if you do have ligament tear and you're trying to just work through it, I've definitely seen players that years later have developed arthritis in their elbow or they have bones spurs that have worked to kind of help the elbow to stabilize even though the ligament is not functioning properly. So there's definitely a downside to thinking, "I'm just going to push through this."

Interviewer: And then, what about the repair? Some of these elbow surgeries can take a long time for patients to recover. Do you think that plays into why perhaps sometimes pitchers choose to play through it, because they don't want to be out of the game for any period of time?

Dr. Chalmers: Yeah, I think that's definitely part of it, is that pitchers think, "Oh, I can't afford to take 12 to 18 months off." So, if you know that there's a solution that can get you back in six months, that's the length of the offseason, and I don't think you need to worry so much about, "Oh, I'm going to lose next season." So it's definitely worth if you're having pain thinking, the very least get it looked at the end of the season, to see maybe if there is something that can be done that could still you get back in time for next year.

Interviewer: Yeah, and new procedures are coming along all the time that have shorter recovery periods. So even if you are of the opinion or if you've heard, "Well, if I get this done, I'm going to be out for 24 months," that might not be the case anymore.

Dr. Chalmers: Oh absolutely. And not only that but if you're listening to this and it's two years from now, let me tell you, it's going to be even better, because we've got all sorts of things coming down the line that will help to bring down recovery periods for pitchers in the future.

Interviewer: Yeah. So, if you have some elbow pain while you're pitching, there is something you can do about it and actually something you should do about it. And there's a new procedure that might be the thing that you need.

Dr. Peter Chalmers is an orthopedic surgeon. He's an elbow specialist. He's also the current team physician for University of Utah baseball and Salt Lake City Bees Triple-A baseball. So if somebody does have elbow pain while they're pitching, where do you start with that diagnosis, Dr. Chalmers?

Dr. Chalmers: Yeah. Absolutely. So elbow pain during pitching, it's not normal to have really, really a sore elbow with pitching. And there can be a couple of different causes, and some of them can be problematic for the future for a pitcher. So, definitely, I think it's worth, after a period of rest, if the pain doesn't go away, seeing someone to be fully evaluated with, you know, having someone take a look at the elbow, and then potentially getting an MRI to take a look at the cartilage and the ligaments within the elbow.

Interviewer: All right. And if the condition happens to be something called an ulnar collateral ligament injury, then there's a procedure that's been used for a long time called Tommy John surgery. Tell me a little bit about that, and then we're going to talk about the alternative, which could be better for some patients.

Dr. Chalmers: Yeah. Absolutely. So, for a long period of time, if you tore your ulnar collateral ligament, the ligament on the inside of the elbow that basically holds the upper arm and the lower bones together when you pitch a baseball, if you don't have that ligament, those bones try and fall apart, and it's basically not possible to pitch a baseball. If you tore that ligament, historically, then your career was just over.

And there was a pitcher named Tommy John, who had that injury, and he went to a surgeon who said, "Well, there's got to be something we can do," and they invented this procedure to reconstruct or rebuild the ligament using a tendon graft. And that actually works pretty well, but it has a very long recovery. It takes about a year to get back to play because the new tendon has to become a ligament over the top of the old ligament. And that process is very slow.

So that was the historic way that we would treat ulnar collateral ligament injuries, and the pitcher that first underwent it, his name was Tommy John. So they're commonly referred to as the Tommy John ligament or Tommy John surgery.

Interviewer: And now there's a new procedure. So I've heard that considered called reconstruction, and now there's a new procedure that actually just repairs the ligament and has some better outcomes. So tell me a little bit about that.

Dr. Chalmers: The good thing about many of these ligament tears is often the ligament is torn right off of either the upper arm bone or lower arm bone side. And the ligament itself is still good quality tissue. So, historically, we would replace that whole ligament with a new tendon graft.

The new procedure is to repair the patient's own ligament and allow their own ligament to serve as their ligament going forward. That has a much quicker recovery and can get pitchers back to play in six months. So that's been a huge advance in our treatment for this injury and has certainly, for a lot of our players, granted them ability to get back to another season or even sometimes to get two seasons in depending on the timing.

Interviewer: So, when you're working with a pitcher, how do you determine which one of these two that you're going to use?

Dr. Chalmers: So there's a number of factors that go into that. Certainly, the appearance of the ligament on the MRI and the location of the tear play a role, but often during surgery, we'll also assess the quality of the tissue. And if the tissue is robust enough, then we can use the patient's own tissue to do the repair.

Interviewer: If it is an option, then is it just as good as the Tommy John surgery? You said, definitely, you could get back to playing faster. Is it as a robust of a repair?

Dr. Chalmers: It may be better.

Interviewer: Oh.

Dr. Chalmers: Some of our early data suggests that the rates of return to play may be higher after repair than they are after reconstruction.

Interviewer: And I understand another advantage of the ligament repair is if you have a younger athlete, that this would be an option where Tommy John surgery would not be an option. Tell me about that.

Dr. Chalmers: Yeah. Definitely, younger athletes have the highest capacity for healing. And so, in a younger athlete, this surgery can work very, very well, and that's who it's been performed in mostly to date. But in someone who's really young, if they have open growth plates, you may be concerned about performing a surgery with a ligament graft, where we may have to drill tunnels in the bone that may disrupt the growth in the future. So this is a nice option for that patient population.

Interviewer: And what does the recovery look like then? You said that the recovery is faster. You know, Tommy John surgery could take up to a year. How fast is this recovery, and what's the rehabilitation process like?

Dr. Chalmers: So as early as two weeks out from surgery, the patient begins moving their elbow. About a month from surgery, they begin strengthening. And the whole goal here is that you have to start strengthening early because as early as three months out from surgery, the pitchers will start throwing again.

Interviewer: Wow.

Dr. Chalmers: And the goal then is to get back to full play with full velocity, pitching full games by six months.

Interviewer: That sounds pretty amazing. Is that pretty amazing from your perspective as an orthopedic surgeon?

Dr. Chalmers: It's a huge advance. It's a huge change over the year, sometimes 18-month recovery we saw historically with reconstruction surgery.

Interviewer: Are there downsides to this type of repair?

Dr. Chalmers: Well, it's a relatively new option, and so we don't have 5 or 10-year outcomes with it so far. But so far, it appears to have few downsides as compared to the reconstruction. There had been some concern that if you do this surgery, it may make another surgery in the future more difficult. And so far, those have not appeared to be true, but there have been very few of those performed because it works so well.

Interviewer: And it sounds like this is a very specialized procedure still at this point. What advice would you have for somebody choosing an orthopedic surgeon to do this type of procedure?

Dr. Chalmers: Well, I think that one of the most important things patients need to understand is that surgery itself is a technical skill, and it's important to find a surgeon that you feel like performs enough of those procedures to feel competent at it. So, as a result, I think when you look for a procedure that's less common like this, you need to find a surgeon that feels comfortable and performs enough of them, that they'll have already worked through the kinks and make sure that they're not going to have any problems performing this procedure for you.

That's one of the benefits of coming to a place like the University of Utah, where you have specialists in a large variety of areas. It allows each of us doctors to find a smaller niche and then, as a result, to be better at what we do.

Interviewer: I want to talk a little bit about this procedure. So what is, in your mind, the youngest patient that you would do this type of a procedure on?

Dr. Chalmers: One of the things that is unique about this area of the elbow is that right above the ligament is a growth plate. So for people who are skeletally immature, it's very rare to have the ligament be injured. And the vast majority of those that are skeletally immature, the growth plate itself sees most of the injury, if there is an injury. As a result, we very rarely perform this procedure for anyone under the age of 14 really.

Interviewer: Is there anything else about this procedure that you feel that a patient or a patient's parents would be interested in hearing that I missed?

Dr. Chalmers: One of the things that I think is really interesting about this procedure and really important for people to understand is that we've talked historically about the reconstruction and the tissue within the reconstruction as though we can make you a new ligament. But I will tell you that the tissue that we bring in from somewhere else is not the same as what you were born with. It doesn't have the same nerve fibers. It doesn't have the same pressure fibers.

And we demonstrated that actually pretty elegantly recently in a study we did with the Angels, where we looked at the changes in reconstructed ligaments as compared to non-reconstructed ligaments over the course of a single season or off-season on ultrasound, and found actually that the ligaments that had undergone a prior reconstruction respond differently to stress than native ligaments. And I think that's probably because they don't have all of their normal sensors within them.

So one of the big benefits of this procedure is that it preserves all that. It preserves all the normal pressure sensors and nerve fibers within your own ligament and allows it to respond normally to stress in the future. So that's a real benefit of this procedure over the reconstruction, and one reason why I think we're probably going to head more and more in this direction in probably a lot of areas of our field in the future.

Announcer: Health hacks with Dr. Troy Madsen on The Scope.

Interviewer: What is today's health hack?

Dr. Madsen: Today's health hack is yoga for chronic low back pain. So here we're talking about people who have had lots of issues, who may have been prescribed even opioids for pain, who have looked into surgery. This was a study in "Annals of Internal Medicine," a few months ago, that looked at patients with this type of pain, chronic low back pain. They placed these patients in yoga classes. Other patients, they placed in physical therapy. Other patients, they just gave some education to, some information. Those who were in yoga did just as well as those in physical therapy. They used fewer pain medications, and even a year later, they saw these same results. They were still doing well.

So I think the big take-home for me from this was if yoga works for you, do yoga. If you're having issues accessing physical therapy, because of insurance issues potentially, consider yoga. Or if you're doing physical therapy, talk to your physical therapist potentially about even supplementing that with some yoga classes. It can make a big difference in the long run for a chronic issue that can cause all sorts of problems.

Announcer: For more health hacks, check out thescoperadio.com, produced by University of Utah Health.

Interviewer: When should you have your knee pain checked out? Dr. Matheau Eysser is an orthopedic surgeon. What advice do you have for patients?

Dr. Eysser: Well, I tell my patients to look for two things: number one, pain. Acute pain or pain that interrupts your sleep could indicate a torn tendon, meniscal tear, or arthritis. Second, symptoms. If your knee locks up on you or you are unable to fully straighten your knee, it could indicate a torn meniscus. Feelings of instability, a painful clicking or popping, or sharp stabbing pain are also some of the complaints or symptoms of a meniscal tear.

However, if your symptoms are a dull ache, pain when standing from a sitting position, or pain that improves after walking a couple of steps, this could indicate arthritis. If you are experiencing these types of symptoms, it is a good idea to have your knee checked out by your doctor.

updated: July 6, 2021
originally published: May 29, 2019

Interviewer: When should you have your hip pain checked out by a doctor? Dr. Matheau Eysser is an orthopedic surgeon. What's your advice?

Dr. Eysser: Well, hip arthritis is a common condition that causes hip pain. Hip arthritis is characterized by wearing away of the cartilage of your hip joint. Symptoms of hip arthritis include pain in the hip joint that may include pain in the groin, outer thigh or buttocks, pain that is typically worse in the morning and lessened with activity, and some patients even have difficulty walking or walking with a limp. Sometimes the pain worsens with vigorous or extended activity and stiffness in the hip or limited range of motion. Hip arthritis symptoms tend to progress as the condition worsens. What is interesting about hip arthritis is that symptoms do not always progress steadily with time. If you are experiencing these type of hip symptoms, please see your doctor.

updated: March 17, 2021
originally published: March 13, 2019

Interviewer: If you have carpal tunnel syndrome, it might seem like surgery is the only means of relief from your symptoms. But what about simple splinting? Could that be an effective, non-invasive alternative? Dr. Douglas Hutchinson is a hand surgeon. Does splinting work for carpal tunnel syndrome?

Dr. Hutchinson: You know, it's very effective actually, and splints alone are the mainstay of our treatment. And if a person can sleep at night and not wake up with numb fingers, they're going to feel a lot better, they're going to do better during the day, their hands are not going to hurt them, and/or go to sleep on them as much during the day as well, and they're going to get several years out of that type of treatment before they may get to the point where despite splinting they're still getting numbness, and that's when they probably should talk about surgery.

updated: November 23, 2020
originally published: March 28, 2018