FREQUENTLY ASKED QUESTIONS (FAQ) IN PAIN MANAGEMENT, ANSWERED BY JOE ORDIA, MD.

The FAQ will be updated periodically and additional questions answered.

Disclaimer: The opinions expressed here are for general information and based on my own professional experience. They are not intended to replace the advice of your health care provider on your particular condition.

1. Question: I did 6 weeks of physical therapy and they really helped my back pain, but every now and then I have a dull ache in my lower back. The physical therapist gave me a paper and said I should do the exercises at home to strengthen my core. What does that have to do with my back?

Answer: Mechanical pressure on the lower back is one of the consequences of our evolution to walking on 2 legs. The structures that keep us upright include the vertebrae, discs, ligaments, back and abdominal muscles. Of course our legs and ankles also play an important role. Weak core muscles or bad posture, result in more stress, wear and tear on the structures and joints of the lower back, arthritis, and pain. Strengthening the core muscles can alleviate or prevent back pain.

2. Question: I am 55 years old and I have worked in construction for 35 years and never missed a day of work. I pulled my back at work 6 months ago. I did PT but it did not help. I had cortisone injections at a pain clinic in New Hampshire, and they burned the nerves, but it only eased my pain for 2 months. I am taking Ibuprofen 3 times a day, and I use CBD oil but my back still hurts. I asked my doctor to fill out my disability papers but she said that I should get another test. Why do I need another test if I say that I cannot go back to work?

Answer: With a few exceptions such as complex regional pain syndrome (commonly known as RSD) which is often associated with characteristic changes in the skin, and affected limb, determination of functional impairment and disability cannot be based on subjective symptoms of pain alone. Most people in your age group have degenerative arthritis changes in the spine that do not necessarily reflect the degree of chronic pain. Testing such as functional capacity evaluation can provide objective evidence to assist your doctor determine your level of impairment, readiness to return to work, and possibility for gainful employment.

3. Question: I have had back pain off and on for 5 years. The pain started to go into my right leg just before Christmas last year, and I was limping and really in bad shape. My surgeon performed a laminectomy in my back in March of this year. He said that he removed a bone spur from my nerve. My leg pain is gone, and I am walking fine, but why does my back still hurt?

Answer: A variety of arthritic changes occur in the structures of spine from wear and tear, and can result in back pain. The usual treatment includes exercise, good posture and ergonomics, physical therapy, proper diet, and weight control. When arthritic bone spurs develop or the intervertebral disc herniates, the back pain may travel to the leg. If conservative measures and steroid injections do not control the leg pain, some patients may require surgical decompression to take the pressure off the nerve root and relieve the leg symptoms. The primary goal of such surgery is to treat the leg pain and related nerve symptoms, and not to alleviate the back pain. We have described the ongoing back pain as part of the “Post-surgical spine syndrome.” [MORE INFORMATION]

4. Question: My 82 year old grandmother has fractures in her spine and she is taking 2 Oxycodone 5mg tablets a day. Her helper puts the pills in a daily pill organizer for her. When I came with her to the pain clinic last month she was told to take a urine drug test. Do they think that she is a drug abuser?

Answer: No. There are several reasons to do periodic urine drug screen (UDS) and the most important is patient safety. It is reassuring to find prescribed medications in the test. Failure to find the Oxycodone may indicate that she is taking it but her body is not absorbing it, or that she is not taking it. It is possible that her helper loaded the organizer with a different medication. UDS also helps to alert the prescriber if your grandmother is taking another prescribed or over the counter medication which may have an adverse interaction with Oxycodone.

5. Question: I had an epidural injection in my back in Florida during the winter and I no longer have pain in right leg. A few months later I was having pain in my right hip. I sent the reports from Florida and I wanted to get another epidural, but the Nurse Practitioner said I had to come in to be examined. She said that I had bursitis, and I am glad to say that I had the bursa injection, and after 3 days I was pain free. Why didn’t they do the bursa injection in Florida?

Answer: You said that the epidural injection took care of your leg pain. The likelihood is that you had a “pinched nerve” and that the inflammation of the nerve subsided with the epidural steroid injection. A bursa is a fluid filled cushion that is close to the muscles and ligaments of joints. Bursitis is the term used to describe inflammation of the bursa, and it often manifests with pain in the proximity of the joint.

6. Question: I have diabetes and take insulin. I started to have severe burning pain in my feet and legs 6 months ago. The pain wakes me up every two hours. I take Ibuprofen and it’s starting to hurt my stomach, but it does nothing to the pain. My primary got an MRI of my spine and sent me for cortisone injection. I came to your clinic and the doctor looked at the MRI, showed me the pictures of the disc degeneration and said that he did not see the reason for my pain, and ordered a nerve test. Am I missing something? I thought an MRI is to show what is causing my pain.

Answer: MRI does not show pain. The purpose of an MRI of the spine is to show the structures, identify any abnormalities such as arthritis, bone spurs, disc degeneration or herniation, fracture, tumor, or infection of the spine. The information provided may help your provider to determine which of the findings may be causing your pain or other findings on examining you. MRI does not identify neuropathy which is a possibility with the burning pain that you describe. The nerve test may confirm the diagnosis, though the test may be normal in some types of neuropathy. Cortisone injection is not the usual treatment for neuropathy. Diabetes is one of the common causes of neuropathy, but there are other causes such as chemotherapy, toxins, vitamin deficiency. Initial treatment may include medications such as Gabapentin, Pregabalin.

7. Question: My chiropractor treated my back for 12 weeks and my back pain is better but I am still having pain going into my legs. He ordered MRI and told me that I have a herniated disc, and that I should see you for an epidural. What is the next step and how do I know if my insurance will pay for it?

Answer: The first thing is that we see you in consultation, obtain a history of your pain and your general medical condition, examine you, and review the MRI scan. If we determine that epidural steroid is best for you, we explain the procedure, potential risks, and other treatment options, and give you the opportunity to ask questions. If you decide to proceed, our office will be able to check and let you know if it is covered by your insurance, and any co-pay that the insurance has determined. Some insurance companies may require prior authorizations and it may take a few days to make a decision. Worker’s Comp may take a week or more to complete their review.

8. Questions: I pulled a muscle in my back 2 weeks ago while lifting heavy machinery at work. I saw the company doctor and she said that I should go for PT. I asked for an MRI but she wouldn’t order one. Isn’t it just a band-aid and waste of time going to PT?

Answer: Most “pulled back”, muscle or back strain, are soft tissue injuries and often resolve within a few weeks with PT or other conservative management. In the absence of significant neurological deficits, an MRI is not likely to change the initial treatment.

9. Question: I had spinal fusion 3 years ago and I have scar tissue in my back and I take Vicodin and Gabapentin. I recently started smoking marijuana to help me sleep. My doctor did a urine test and warned me not to smoke marijuana otherwise the office will stop prescribing Vicodin. But marijuana is no longer illegal in Massachusetts, so what’s the problem?

Answer: There is some evidence that marijuana may have some therapeutic benefit in some conditions such as pain, anxiety, nausea, sleep disorder, seizures, and multiple sclerosis. However, the adverse reactions include short-term memory disturbance, paranoia, psychosis, impairment of motor co-ordination and increased risk of driving a vehicle. Andrew H. Rogers, and colleagues studied the outcome of opioid use alone versus combined use of opioid and cannabis, for chronic pain. They concluded “Potential clinical implications of these findings include that it may be important for clinicians to assess cannabis use prior to initiating opioids for the treatment of chronic pain. The results from this study suggest that cannabis use in the context of opioid use for chronic pain is associated with significantly worse mental health and substance use out-comes.” [MORE INFORMATION]

10. Question: I got a series of 3 epidural steroid injections here 2 years ago and the pain in my right leg went away. Now I am having back pain and it goes into the left leg. My PCP said that I should come back for another injection. I thought that I could only get 3 steroid injections in my life time?

Answer: Steroids have potential side effects with frequent or prolonged use, and they include elevation of blood sugar making it difficult to control diabetes, suppression of immune system and increased risk of infection, osteoporosis and risk of fractures, reduction of adrenal gland hormone production, weight gain, muscle weakness, poor wound healing, erectile dysfunction and loss of libido . In order to avoid these unwanted effects, we monitor the amount of steroid that we administer in epidural injections. As a result we often limit the number of injections to not more than 3 every 6 months. Your thought that it is 3 injections in a lifetime is incorrect.