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DUKE MEDICINE

Making the Most of Your Doctor Visit #2

Here are the rest of the suggestions (had to break into to two parts due to the...

Posted by Joe T Minchew, MD

Here are the rest of the suggestions (had to break into to two parts due to the character limits)

5. Make sure that all records pertaining to your treatment to that point are present at the provider’s office to coincide with your visit. This includes all previous physician notes, hospital treatment records, particularly operative reports. You will usually need to contact the physician offices and hospitals separately to obtain these records as one will often not have the records of the other. Hopefully, the age of the electronic medical record and shared data will eliminate this requirement but we are not there yet. The best way to ensure that the records are present when you are is to take them with you. If you are specifically seeing the provider for a second opinion on surgery, make sure you have a clear statement from the surgeon as to the planned procedure and the rationale for that procedure. You can not get a second opinion if the provider can not review the “first opinion”. Unfortunately, many times physician offices fail to forward records to other offices despite your requests. It is best if you obtain the records yourself if you can. If time and/or distance precludes this option, definitely check with the new provider’s office well prior to your visit to insure that they have received the necessary information. There is a tendency among some patients to want the new provider or physician to “start fresh” without being biased or influenced by the prior records or diagnoses and opinions of others. Unfortunately, while there is some understandable logic in this perspective, the new provider will be severely limited in their ability to evaluate your problem and make recommendations if they can not review clear documentation of the evaluation and treatments you have had in the past. The majority of physicians are extremely conscientious and will make their own diagnoses and formulate their own opinions based on the data
6. As with prior records, make sure that all previous imaging studies and diagnostic test (nerve tests, etc) are available for the provider to review. This includes the actual images as well as the reports. You do not necessarily have to have printed films as most providers can now review images on a compact disc (CD) but it is critical that the provider can review the pictures. Most spine specialists review studies themselves in order to make diagnoses and treatment recommendations. While the radiologist’s interpretations are useful, they do not have the benefit of talking to you and examining you in order to correlate you symptoms and examination findings to the findings on your imaging studies. Unfortunately, most people over the age of twenty have findings on lumbar x-rays and MRIs even if they are asymptomatic. It is critical to correlate your symptoms to the studies. It is also very important to have all the imaging studies that you have had with you. X-rays, MRIs, CT scans, myelograms all have different indications for use and purposes. The do provide some overlapping information but they also provide information that the other studies can not or do not demonstrate as well. For example, MRI scans do not demonstrate problems with bone very well but CT scans evaluate the bone very well. So don’t just take your most recent MRI to the visit.
7. Go to the visit with a clear list of questions that you would like the provider to address and make these questions known to the provider at the appropriate time.
8. Go to the visit with an open mind. Try to listen to the provider’s assessment of the situation and their recommendations without being overly swayed by prior diagnoses or the findings or you x-ray or MRI reports.
Good luck and I hope these suggestions help!View Thread

Posted byJoe T Minchew, MD

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DUKE MEDICINE

Making the Most of Your Doctor Visit #1

Due to the complexity of the problem, the difficulty in determining a definitive...

Posted by Joe T Minchew, MD

Due to the complexity of the problem, the difficulty in determining a definitive diagnosis, and the invasive nature of many of the treatments, patients with back pain often seek evaluation by several physicians or providers. These evaluations and second opinions can be very helpful and worthwhile. However, if you are poorly prepared for these visits, they can end up being of very limited value. The following are some suggestions for maximizing the benefit from your next evaluation:
1. Pay close attention to your symptoms prior to your visit so that you can communicate them well to provider. In particular, pay attention to the pain that is the most problematic for you. Is the major problem your back or pain in one or both legs? Pretend (and it may not be completely pretending) that the pain in the back and leg(s) are separate problems. If you could get rid of one but not the other, which pain would you pick. If you have pain in both the back and leg(s), how would attribute a percentage to the pain? For example, is the pain 80% in your lower back and 20% in your leg or legs. Pain attention to where the pain radiates or travels and be prepared to describe that radiation to the provider. Sometimes the pain is so severe that it seems everything is involved but try to pay attention to whether the pain radiates primarily down the front, side or back of the leg. Does it regularly go below the knee? If so, where.
2. Pay attention to associated symptoms like numbness, tingling, prickling or weakness. Try to be able to describe or draw out with a finger where you experience these symptoms. Try to determine which joint or joints is/are affected by weakness in the legs. Is it primarily your hip, knee or ankle/foot. Try to separate limitations of the use of the leg due to pain from times when you had weakness with minimal pain. Definitely pay attention to any changes in your bladder or bowel function or habits but also pay attention to any prior history you have had with these problems related to medication usage, stress, coughing, etc.
3. Make sure that the visit with the provider is authorized by your insurer or other provider prior to the visit. In particular, if the problem is due to a work related injury make sure that the visit is authorized. Many times patients want to get an “independent” evaluation outside of the worker’s compensation system. This can be appropriate and can be authorized. However, you can not be seen under your health care insurance for a problem that is related to a work injury. This is an exclusion in every health care policy. The provider may have to refuse to see you that day if the visit is not authorized.
4. Go to the visit prepared to have a thorough evaluation. Arrive at least 15-30 minutes prior to the scheduled visit time to complete necessary registration paperwork. Also allot enough time for the provider to review your prior records and imaging studies (x-rays, MRIs, etc.). This also includes dressing so that you can be comfortable with an examination even if it includes being asked to disrobe and wear a hospital gown. A thorough examination of the lumbar spine often requires the patient be in a hospital gown and if you are self conscious about this during the examination if may limit the providers ability to assess you.

To Be Continued....View Thread

Posted byJoe T Minchew, MD

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Reply: My sciatica and other lower back pain is getting u...

Anon I am sorry that you are going through such a difficult period with your...

Posted by Joe T Minchew, MD

Anon

I am sorry that you are going through such a difficult period with your pain issues as well as with phsychological, emotional and family issues in your life. You have already gotten some very supportive and useful advice from other members of the exchange. As you know, this is an extremely difficult and complex problem and there are clearly no simple or easy solutions. Chronic pain is a terrible illness that devestates both the patient and their loved one. The worst part is that often there really is not a "fix" but only things that can make it better.

Unfortunately, your depression has a negative impact on your pain condition and your pain condition has a negaive impact on your depression. It is a very viscious cycle that is hard to break. This is not to imply that the "pain is in your head" but point out that the "pain gets into your head". Studies have shown that people that are under psychological or emotional distress percieve painful stimuli more intensely. In other words, if you perform something painful like a poke with a pin exactly the same way to a person under stress, they will rate the pain caused as greater than someone not under stress (a 5 of 10 intensity versus a 2 of 10 intensity. It is critical that any pain treatment that you pursue has a psychological component. This can include a person in the pain clinic or a separarte therapist like mentioned seeing or both. It is important that your pain physicians and you psychological therapist or psychiatrist work closely together to ensure you address pain and depression and that meds to not negatively interact.

Another important step moving forward is work hard on changing your daily focus from "fixing the pain" to minimizing the pain and maximizing your function. The pain is probably going to be there no matter what so you can either withdraw from everything you love and hurt or you can do the things you love and hurt. The latter would seem to be the better place. You do not have to be afraid of being active and hurting. The pain you experience is not like the pain from a burn. You are not "burning" your back if it hurts. There is no tissue damage associated with the pain from fibromyalgia and other similar conditions. There is no danger of damaging things if you try to do more.

Good luck! I hope that this was helpful in some way.

JTMView Thread

Posted byJoe T Minchew, MD

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Reply: Injections

Unfortunately, it is difficult to tell from your description of your symptoms and...

Posted by Joe T Minchew, MD

Unfortunately, it is difficult to tell from your description of your symptoms and situation as to whether your major problem is lower back or leg pain. As I have indicated before, this is a key distinction with respect to the appropriateness and potential efficacy of various treatments. All the injections that spinal specialists recommend or perform are "cortisone" injections. They are usually a combination of a local anesthetic (numbing agent) similar to Novocain and a steroid. The "success" rate of these injections varies a great deal depending on the injection type and the problem being treated.
Based on the information and your comment about the recommendation to "burn the nerves", I am assuming that your major pain is back pain. I am also assuming that the recommended injections are facet injections. Facet joints are the small joints in the back of the spine that work in conjunction with the disc (also a type of joint) to allow the spine to move. While the discs and facets work in cooperation and aging of one affects the other, "slipped discs" are a different issue than facet joint pain. The facet blocks or injections are either an injection of medicine directly into the joint (like a knee injection) or of the medicine in the area of the very small nerve branches that supply the joint. If the "facet block" provides significant relief, then a facet joint nerve ablation is considered a more "permanent" way to treat facet pain. This involves using a radiofrequency "probe" or needle that heats up at the tip to "burn" the nerves. I put permanent in quotations because these small nerve endings can grow back as the treatment does not destroy the nerve cell just some if it's branches. A procedure to "burn the small nerves supplying the discs would be very different and I assume this is not the procedure being recommended. As Joy and Dave indicated the scientific evidence as to the effectiveness of injections is limited, particularly with respect to facet injections. Furthermore, no procedure is without possible risks or side effects and any patient can have significant reactions to procedures and medications. However, the risks associated with this procedure are very small and if all other treatments have failed, it may be an option.
Epidural injections are also cortisone injections. They are usually used to treat leg pain. There is also limited scientific evidence supporting epidurals but there is more than that for facet injections. Approximately 75% of patients will respond positively to an epidural injection. Unfortunately, the positive effects are temporary for many patients and can last from minutes to months. It is impossible to predict if any given person will have long term or short term improvement. If the patient responds positively to an epidural with effects longer than just minutes to hours, they may be a candidate for 1-2 more injections over a period of weeks to a few months. Most physicians feel like patients should not have more than 3-4 epidural injections in a few month period. The injections can be repeated if they have been effective and a significant period of time has passed since the last injections. One study demonstrated that in patients with herniated discs and sciatica, less patients had surgery in the end if they had a special type of epidural called a transforaminal injection.
While clearly the physician performing the injection is reimbursed for his or her work and there are some "injection mills" out there, the majority of physicians are very conscientious about ordering injections. Furthermore, while there are possible sided effects of injected cortisone (increased blood sugar in diabetics) the risks are much less than oral steroids or even many other oral medications. As long as the physician is not recommending numerous injections, more than 3-4, it is not an unreasonable treatment option.

Good luck!

JTMView Thread

Posted byJoe T Minchew, MD

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Reply: bulging disc and pinched nerve

SDC Your symptoms do seem to be consistent with a disc herniation at C6-7. The...

Posted by Joe T Minchew, MD

SDC

Your symptoms do seem to be consistent with a disc herniation at C6-7. The natural history of this problem is the approximately 90% of people will improve with conservative care in a period of 3-6 months. Therefore, it is very likely that with some additional treatment that the symtpoms will improve dramatically. Conservative care usually includes medications and physical therapy. Spinal manipulation with the chiropractor includes some aspects that may be a part of physical therapy or PT but there are other parts that it does not cover. It is generally shown that active treatments such as PT are more effective in the long run than "passive" therapies like manipulation. In addition to PT, many patients will respond to an epidural injection or nerve root block. This is something that could be ordered through a spine specialist. Also, many patients respond to medications that are specific for the nerve pain. These include medications that are classically used to treat seizures or depression but taken low doses they seem to help "nerve" pain. The down side of these medications is that they can make you sleepy or drowsy though this tends to pass after you have taken them for a while.

With respect to the long term, you are at some risk for neck pain due to the degenerative disc that resulted in the disc herniation. Even if the nerve pain improves, which it should, the disc will not go back to being "normal" or young. The key to trying to avoid chronic neck pain is a regular neck range of motion and strengthening program that you would learn in PT. With respect to the "cause" of the degeneration, it is just the natural aging process of the spine. It affects everyone, albeit, with different degrees in different people. It does tend to be hereditary though not as directly as things like hair and eye color.

Hope this was helpful. Good luck and the odds are on your side for improvement if you get active in recovery.

JTMView Thread

Posted byJoe T Minchew, MD

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Reply: Excercises for post surgery

Daniel It is great that you have had exellent results from your surgical...

Posted by Joe T Minchew, MD

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Reply: Needing Some Relief

Anon I would agree with some of the suggestions that you have already received...

Posted by Joe T Minchew, MD

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Reply: Problems......Problems......Problems

Porter1971 Unfortunately, your post has limited information on your prior...

Posted by Joe T Minchew, MD

Porter1971

Unfortunately, your post has limited information on your prior history. However, I assume that you had an L5-S1 fusion at some time in the past for back pain or some type of instability. It is clear that you are either having a recurrence of your pain or have continued to have pain since the time of your surgery. That is actually a critical distinction as to whether you had a period of pain improvement or not. If you had a significant period of improvement (more than 6 months), then it is possible that changes at L4-5 could causing pain. This is a described phenomenon called "adjacent segment degeneration" and is accelerated deterioration at a level above or below a prior fusion. However, it would seem that there has not been significant degeneration at L4-5 if your x-ray and MRI "came back clean" with no abnormalities for you. Having said that, it may be the case that your L4-5 level already demonstrated some degenerative changes at the time of your surgery and no apparent changes were noted on the new studies. You can develop increased mobility at a level above a fusion but this really can not be "diagnosed" with any type of physical examination maneuver or test. The "test" performed by the therapist could have placed stress on any number of structures that can cause pain including your pelvis and lumbar facet joints (small joints of the spine). It is not specific for any type of abnormal motion of the vertebra. Furthermore, the therapists' definition of "instability" or "hypermobility" is not the same as used by physicians. I have discovered this fact by participating in journal clubs (meetings to discuss scientific studies of back pain) with our therapists at Duke who teach in the PT school. If there is any instability or abnormal motion of your L4-5, this would be demonstrated on x-rays with you bending forward or backward (flexion-extension) x-rays. This may be something to discuss with your surgeon. In reality, there are a multitude of things that could cause new pain and there is no test where a flashing red light goes off at the source of the pain. I know this is frustrating for you as a patient but trust me; it is also frustrating for your doctors that would truly like to help you.

If your pain never improved after surgery, it would not be logical to attribute the pain to a new problem. Possible causes of pain after surgery include a failure of the surgery to heal, additional problems that were not addressed at the time of surgery, and simply a poor outcome that is not explainable. I assume that your surgeon has assessed you for a possible non-healing of the fusion if there is any question on the x-rays. This is most often done with a CT scan as it demonstrates the bone much better than an MRI.

Good luck!

JTMView Thread

Posted byJoe T Minchew, MD

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Reply: Fibromyalgia, Sciatica, Spinal Stenosis, Oste Arth...

Anon In light of your various medical problems, your back and leg pain is most...

Posted by Joe T Minchew, MD

3 Replies | Reply | Watch This DiscussionReport This| Share this:Fibromyalgia, Sciatica, Spinal Stenosis, Oste Arthritis Anon In light of your various medical problems, your back and leg pain is most...

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Reply: back pain

01sis It certainly sounds at though your brother is in a lot of pain and has a...

Posted by Joe T Minchew, MD

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