Ask the Expert: Dr. Semih Gungor, Pain Medicine Specialist, Answers Questions on Interventional Therapy for Neck & Back Pain

Q1. When you have both hip and lower back pain, how do you know which is the primary source of pain? How should you treat the secondary pain issue?

In some patients, there may be coexisting pain generators in both the lower spine and hip. The pain from the lower back may radiate to the hips, or vice versa. If in the patient’s medical history, physical examination and diagnostic studies are not conclusive to determine the primary source of pain, precise image-guided spine and joint interventions may be used to block the possible pain generators by using a small dose of local anesthetics. This may help to determine the degree in which the pain generator contributes to current clinical presentation. This may help to clarify the correct diagnosis, which in turn helps to formulate a better therapy plan for a better outcome.

Oftentimes, before or during treatment of the primary source of pain, other interventions to treat the secondary source of pain are recommended for effective rehabilitation and to speed the recovery.

Q2. Is healing the disc a viable option?

In adult discs, blood vessels are normally restricted to the outmost layers. Metabolite transport is by diffusion. As a result, once the disc is degenerated, there is only a limited ability to recover from any metabolic or mechanical injury. There are therapies aiming to regenerate the discs. Most of these therapies are still in the experimental stage and their clinical efficacy is yet to be confirmed by clinical trials. Although these therapies are not used routinely, they may be available for routine clinical use in the future.

Q3. I have neck pain caused by a whiplash. The pain has lasted about two months. What can I do to treat the pain?

Whiplash injuries may lead to chronic neck pain. Early evaluation by a medical professional is recommended to determine the possible sources of pain and the severity of the problem. Only after thorough evaluation, more effective and safer therapy plan can be recommended. However, there are a variety of interventional therapies used successfully for these patients if the conservative therapies fail or as an adjunct to conservative therapies.

Q4. How can you treat neck pain that is caused by rheumatoid arthritis?

Rheumatoid arthritis is a systemic problem and primarily treated by systemic therapies. However, if a local pain generator is determined to be the cause of pain, interventional pain management therapies may also be considered to diminish the local source of pain.

Q5. How does spinal cord stimulation treat chronic back pain? How often do you have to receive treatments?

Pain is an electrical signal that travels along nerve fibers through the spinal cord to the brain. Tiny catheters with special electrode contacts are placed through a needle next to the spinal cord under image guidance. These electrodes deliver electrical impulses to a specific location on the spinal cord to mask the pain signals. The system changes the pain signal into something your brain interprets as a pleasant sensation called paresthesia. Patients describe paresthesia as feeling like a gentle tingling or massage.

Spinal cord stimulation is a two-stage procedure and both stages are completely reversible. The first step is the trial procedure where the temporary leads are placed through a needle and kept in place for a few days, to determine whether the patient will benefit from this therapy.

If the trial period is successful in diminishing the pain and increasing the functionality, the second stage procedure to implant the entire system may be considered as an option. The second stage is a simple surgery and patients go home a few hours after the procedure.

Current technology allows us to use the rechargeable batteries, therefore, once the second step is completed successfully, there is usually no more intervention needed and the spinal cord stimulator may work to alleviate pain for an indefinite period of time.

Q6. How does a neuropathy induce swelling? Do nerve blocks stop it?

A nerve is an enclosed, cable-like bundle of fibers, each of which may have a different function, such as sensation or movement, as well as fibers that are responsible for autonomic system, such as dilation and constriction of blood vessels. In patients with neuropathy, all or some of these fibers may be affected and may lose their normal function. The autonomic nervous system modulates numerous body functions. If the nerve fibers responsible for autonomic system are affected and lose their normal function, blood vessels cannot constrict the way they are supposed to and the fluid may leak outside the blood vessels, leading to edema. This is one of the mechanisms of edema formation in patients with neuropathy.
