In this series, we have been looking at spine-related musculoskeletal conditions that many dentists and surgeons suffer from. In this post, we will be looking at spinal and foraminal stenosis.
Cervical Spinal Stenosis:
Definition: The narrowing of the spinal canal in the cervical vertebrae, often due to inflammation of the surrounding cartilage and tissue.
Overview: The spinal canal is formed by the hollow spaces in the middle of the vertebrae, which form a protective tunnel for the spinal cord to pass through the spinal column. Cervical spinal stenosis is a progressive and potentially dangerous condition that occurs when inflammation narrows the cervical spinal canal. The narrowing of this already tight space can result in direct pressure on the spinal cord, leading to a number of neurological complications. Cervical spinal stenosis can be crippling if the spinal cord becomes damaged.
Symptoms: Symptoms usually develop gradually over time and can include numbness, weakness, tingling in neck, shoulders, arms, hands, or legs, as well as intermittent, sharp pain in the arms and legs, especially when bending forward. Deterioration of fine motor skills and issues with gait and balance can also occur. In more severe cases, bladder and bowel issues may develop.
Causes: Though in rare cases cervical spinal stenosis is a congenital condition, it often results from inflammation due to other spinal conditions, such as spinal osteoarthritis, degenerative disc disease, and disc bulging.
Diagnosis: A combination of X-ray, MRI, and computed tomography (CT) scans may be used to diagnose spinal stenosis. Blood tests may be used to eliminate other diseases such as multiple sclerosis and vitamin B12 deficiency.
Treatment: Conservative, non-invasive treatments may include exercise, physical therapy, and activity modification. Medications may include anti-inflammatory drugs, narcotic pain medication, muscle relaxers, and epidural steroid injections. In more severe cases, several surgical options exist, dependent upon the particular characteristics of the patient’s condition:
Anterior cervical discectomy/corpectomy with fusion (ADCF): The spine is accessed through the front of the patient’s neck, the disc is removed from between the two vertebrae, and the vertebrae are then fused together to stabilize the spine.
Laminectomy: This is a “decompression” surgical procedure performed to relieve pressure on the spinal cord. In this surgery, the lamina (the rear portion of the vertebra covering the spinal canal) is removed from the affected vertebra to enlarge the spinal canal and decrease pressure on the spinal cord.
Interspinous Process Spacers: In this procedure, small metal spacers are surgically placed between the vertebrae to restore the spacing typically created by a healthy disc. This procedure is typically reserved for individuals with foraminal stenosis, however, and has only had limited effectiveness with patients suffering from spinal stenosis.
Definition: Compression of the nerve roots connected to the spinal cord, caused by the narrowing of the passageway through which the nerves exit the spinal column.
Overview: The nerve roots branching off the spinal cord to other parts of the body exit the spinal column through small openings on the sides of the vertebrae called a foramen. This space can become clogged or narrowed due to a number of spine-related conditions. The narrowing or partial obstruction of the foraminal canal caused by one of these conditions can put pressure on the nerve roots emerging from the spinal column, and may lead to an array of neurological symptoms that get progressively worse over time.
Symptoms: Tingling, numbness, or weakness in the feet or hands. Local pain in the extremities. “Pins and needles” or burning sensation. Intermittent neck or back pain.
Causes: Bulging or herniated discs may obstruct the foraminal canal, putting pressure on the nerve roots. It can also be caused by spinal osteoarthritis, osteophytes, and spondylolisthesis. Dentists are susceptible to foraminal stenosis, as they often hold their necks in extended positions.
Diagnosis: A CT scan and a Myelogram are used to diagnose foraminal stenosis. A Myelogram is an X-ray in which an opaque dye (which shows up on the X-ray) is injected into the sac around the nerve roots. The dye moves through the foramina, allowing the doctor to see the degree to which the foramen is narrowed or obstructed.
Treatments: Conservative treatments may include physical therapy, stretching and strength training, and oral pain-relieving medication. Corticosteroid injections are an option for more severe cases to reduce inflammation and pain. In extreme cases, a surgical procedure known as a foraminotomy may be used to remove the bone spur or disc material that is putting pressure on the nerve root as it exits the spinal column through the foramen.
Our next post in this series will discuss spondylolisthesis.
These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.
Many disability claimants suffering from chronic, intense pain are surprised and disheartened when their reported pain levels are received with skepticism by their insurance company. Since pain is a subjective feeling, treating doctors typically ask patients to self-report their pain on a scale of 0-10, so that they can diagnose and treat the pain. Unfortunately, most insurance companies are unwilling to accept self-reported pain levels and will often try to downplay the severity of the claimant’s pain, citing a lack of objective evidence.
Recently, researchers have developed a technology called functional MRI scans, or fMRIs, for short, which may provide a new way to objectively verify the existence of pain. In this post, we will examine this technology and discuss how it might be used in the context of disability claims.
What is an fMRI?
fMRI scanning is a noninvasive technique used by doctors to map and measure brain activity. More specifically, fMRIs are used to measure and observe increases in MR signal caused by neural activity in the brain. The fMRI data is then analyzed to determine which parts of the brain were active during the scan. The data is then compared to known neurological signatures, or “biomarkers,” to determine if there are any correlations between the neural activity in the brain and the symptoms reported by the patient (such as chronic pain).
The Use of fMRI Scans to Prove Pain
Recently, a number of companies and researchers are focusing on using fMRI scans to produce objective evidence of pain. For instance, Dr. Joy Hirsch, a professor at the Yale School of Medicine, claims to have developed a test that is capable of distinguishing real, chronic pain from imagined pain.
fMRI scans are also now being used to support the cases of claimants in disability cases. For example, a woman in New York recently used an fMRI scan to convince her insurer, after two years of litigation, that her disability claim never should have been denied. An fMRI scan was also recently used in the case of Carl Koch, a truck driver from Arizona who suffered severe burns when the hose of his tanker broke loose and sprayed him with molten tar. Mr. Koch visited Dr. Hirsch, who used functional brain mapping to conclude that Mr. Koch’s pain was real. When the judge ruled that Dr. Hirsch’s testimony would be admissible at trial, the case settled for $800,000 – an amount ten times higher than the company’s original offer.
What the Skeptics Say
The use of fMRI scans to prove pain remains controversial. Some critics argue that the techniques being used in litigation have little support in existing publications. Others, such as Tor Wager, a professor of psychology and neuroscience at UC Boulder, contend that the sample size in available studies is too small. Proponents of fMRI refute both of these claims, arguing that a number of credible studies support the validity of their methods.
The Future of fMRI Scans in Disability Cases
It’s easy to see how fMRI scans could prove useful in a disability claim. For example, many dentists suffer from musculoskeletal disorders, particularly in their spines, that cause chronic, debilitating pain. However, as noted above, these types of claims can be particularly difficult, because many insurance companies refuse to accept a claimant’s self-reported pain levels and limitations. Co-workers, family, and friends can provide statements describing how the dentist’s pain is affecting his performance at work and his quality of life, but once again, insurance companies will typically similarly claim that such statements are “objectively verifiable” evidence of the pain. Sometimes a cervical or lumbar MRI can identify potential causes for the pain, and/or a functional capacity exam (FCE) can help document the limitations the pain is causing—but these types of reports are also commonly challenged by insurance companies intent on denying benefits.
In such a case, an fMRI scan illustrating the doctor’s pain might serve as an additional, objectively verifiable method of establishing the existence of chronic pain. Whether or not insurance companies are willing to accept fMRIs as reliable evidence of pain remains to be seen, and will likely depend, in large part, on how willing courts are to accept fMRIs as admissible evidence of pain. If, in the future, this technology continues to develop and become more precise, and courts and juries demonstrate a willingness to accept fMRIs as proof of pain, fMRIs may eventually be enough to convince insurance companies to accept legitimate disability claims without ever setting foot in a courtroom.
- UC San Diego Sch. of Med., What is fMRI?, available at http://fmri.ucsd.edu/Research/whatisfmri.html.
- Sushrut Jangi, Measuring Pain Using Functional MRI, The New England Journal of Medicine, available at http://blogs.nejm.org/now/index.php/9863/2013/04/10/.
- Steven Levy, Brain Imaging of Pain Brings Success to Disability Claim, EIN Presswire (June 29, 2016), available at http://www.einpresswire.com/article/333249721/brain-imaging-of-pain-brings-success-to-disability-claim.
- Kevin Davis, Personal Injury Lawyers Turn to Neuroscience to Back Claims of Chronic Pain, ABA Journal (Mar. 1, 2016), available at http://www.abajournal.com/magazine/article/personal_injury_lawyers_turn_to_neuroscience_to_back_claims_of_chronic_pain.
In Part 1 of this post, we listed some of the symptoms and potential causes of myelopathy. In Part 2, we will discuss some of the methods used to treat myelopathy.
Methods of Treating Myelopathy
- Avoidance of activities that cause pain;
- Using a brace to immobilize the neck;
- Physical therapy (primarily exercises to improve neck strength and flexibility);
- Various medication (including nonsteroidal anti-inflammatory drugs (NSAID), oral corticosteroids, muscle relaxants, anti-seizure medications, antidepressants, and prescription pain relievers);
- Epidural steroid injections (ESI);
- Narcotics, if pain is very severe;
- Surgical removal of bone spurs/herniated discs putting pressure on spinal cord;
- Surgical removal of portions of vertebrae in spine (to give the spinal cord more room); and
- Spinal fusion surgery.
Myelopathy can be severely debilitating, particularly for doctors and dentists. Obviously, any physician or dentist who is experiencing a loss of motor skills, numbness in hands and arms and/or high levels of chronic pain will not be able to effectively treat patients.
If you are experiencing any of these symptoms, you may want to ask your doctor to conduct tests to see if your spinal cord is being compressed. If you have myelopathy and the pain and numbness has progressed to the point where you can no longer treat patients effectively or safely, you should stop treating patients and consider filing a disability claim.
In previous posts, we have discussed a number of disabling conditions, such as Parkinson’s disease, essential tremors, carpal tunnel syndrome, and fibromyalgia. In this post, we are going to talk about another serious condition that can severely limit a physician or dentist’s ability to practice—myelopathy. In Part 1, we will discuss some of the causes and symptoms of myelopathy. In Part 2, we will discuss some of the methods used to treat myelopathy.
What is Myelopathy?
Myelopathy is an overarching term used to describe any neurologic deficit caused by compression of the spinal cord.
The onset of myelopathy can be rapid or it can develop slowly over a period of months. In most cases, myelopathy is progressive; however, the timing and progression of symptoms varies significantly from person to person.
What Causes Myelopathy?
There are several potential causes of myelopathy, including:
- Bone fractures or dislocations due to trauma/injury;
- Inflammatory diseases/autoimmune disorders (e.g. rheumatoid arthritis);
- Structural abnormalities (e.g. bone spurs, disc bulges, herniated discs, thickened ligaments);
- Vascular problems;
- Infections; and
- Degenerative changes due to aging.
Symptoms of Myelopathy
The symptoms of myelopathy will vary from case to case, because the nature and severity of the symptoms will depend on which level of the spine is being compressed—i.e. cervical (neck), thoracic (middle), or lumbar (lower)—and the extent of the compression.
Some of the symptoms of myelopathy include:
- Neck stiffness;
- Deep aching pain in one or both sides of neck, and possibly arms and shoulders;
- Grating or crackling sensation when moving neck;
- Stabbing pain in arm, elbow, wrist or arms;
- Dull ache/tingling/numbness/weakness in arms, hands, legs or feet;
- Position sense loss (i.e. the inability to know where your arms are without looking at them);
- Deterioration of fine motor skills (such as handwriting and the ability to button shirts);
- Lack of coordination, imbalance, heavy feeling in the legs, and difficulty walking;
- Clumsiness of hands and trouble grasping;
- Intermittent shooting pains in arms and legs (especially when bending head forward);
- Incontinence; and
- Paralysis (in extreme cases).
Chronic back pain is one of the issues that countless doctors and dentists face every day. Many of our clients have suffered from pain that doesn’t allow for effective practice, and thus have had to deal with the disability insurance claims process. According to the American Society of Anesthesiologists, there is a new treatment that could help alleviate some forms of back pain in certain patients. We’re going to be taking a look at the study they published regarding spinal cord stimulation (SCS), as well as answer some questions about SCS for those who don’t know about it.
This study compared the effectiveness of high frequency to traditional SCS therapy for back and leg pain. Researchers treated 90 patients with high frequency therapy while 81 received the traditional SCS. After three months, 85% of back pain patients, and 83% of leg pain patients reported a 50% or greater reduction in pain, while only 44% of back pain patients and 56% of leg pain patients in the traditional SCS group experienced a 50% reduction in pain.
Also, more patients (55% to 32%) in the high frequency group stated that they were “very satisfied” with their pain relief. Patients of the high frequency treatment didn’t experience any paresthesia, which is commonly associated with SCS.
- What is SCS?
SCS is therapy that delivers low-level electrical signals to the spinal cord or to specific nerves in order to block pain signals from reaching the brain.
- How does SCS work?
A device is implanted in the back near the spinal cord through a needle and generator is placed through a small incision in the upper buttock. The patient is able to adjust the intensity of the signals or turn the current on or off.
- How does the SCS stay charged?
It depends on the device: some SCS systems have a pulse generator, which is like a battery, some have a rechargeable pulse generator system that can be charged through the skin, and others do not require recharging but last a shorter time before they need to be replaced.
- How much higher is the high frequency SCS?
The high frequency SCS pulses at 10,000 Hz, while traditional SCS has a frequency between 40 and 60 Hz.
- What is paresthesia?
Paresthesia is a sensation such as tingling or buzzing that is commonly associated with SCS. It is thought to potentially mask a patient’s perception of pain, and is often distracting or uncomfortable, thus limiting the effectiveness or desirability of SCS treatment.
- What are the risks of SCS?
SCS doesn’t address the source of the pain; it merely interrupts the pain signals sent to the brain from your body. If you have pain that stems from a correctable anatomical problem, it is probably best to look for treatment that will address this problem first. SCS also involves an implant and surgery, which naturally comes with risks and potential complications.
- Allergic reactions to the implanted material
- Weakness, numbing, clumsiness, paralysis
- Fluid lead from the spinal cord
- Migration of the electrode
- What is this treatment called?
The treatment is being called HF10™.
This study is just the first step in a new treatment that could bring relief to people suffering from chronic pain. We encourage you to speak with your doctor before starting any sort of treatment.