March 18, 2009 by sevalgunes.

I had written before about addiction risk in patients who take opioids for chronic pain.

An excellent review conducted  by  David Fishbain et al. (Department of Psychiatry at the University of Miami) published in Pain Medicine (Volume 9, Number 4, 2008) calculated that among patients without a past or current history of drug abuse the chance of aberrant drug-related behaviors was about 0.2%. In other words: only 1 out of 500 patients without a past or current history of drug abuse will develop addictive behavior. The risk in patients with a past or current history of drug abuse was three times higher at 0.6%. In this group you would expect about 1 out of 170 patients on chronic opioids to develop an addiction.

Some may think that even a low risk is not acceptable. As a general rule physicians make treatment decisions based on the overall perceived risk and benefit of any therapy, be it medication, procedures or even doing nothing. All of these options have their complications and risks such as medication-related complications (allergic reactions, side effects, drug-drug-interactions, addiction risk), procedure -related complications and what is often forgotten: the risk and side effects of not doing anything.

Many patient will describe years of spending all day in bed, in miserable pain, unable to do anything. After some time patients get dysfunctional, deconditioned, alienated from family and friends, depressed and suicidal. Many are in tears about the years they wasted not being able to enjoy life.

When patients ask me about their risk of addiction to opioids I tell them that it is very low if they do not have an addictive personality and past addiction issues with drugs. Patients with current and a strong history of past addiction issues  are very difficult to treat and will benefit from the involvement of a psychiatrist-addiction specialist.

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February 25, 2009 by sevalgunes.

Naomi Allen at al. published an excellent study in the Journal of the National Cancer Institute (JNCI) in the March 4th, 2009 issue. They followed almost 1.3 million women in Great Britain for 7.2 years looking for the incidence (new diagnosis) of 21 different cancers.

The conclusion is that even one drink a day will increase the risk for breast cancer, oral cancer, larynx (voice box) cancer, esophageal cancer, rectal cancer, liver cancer and overall cancer.

There was no safe limit of alcohol use regarding the development of future cancers.

Some will wonder “Well, isn’t alcohol/red wine supposed to be good for your heart?”

The editorial in the same issue of JNCI written by Michael Lauer and Paul Sorlie sums up the research regarding the protective cardiovascular effects of red wine that is always mentioned in the mainstream media. They conclude that even if there is (questionable) minimal or modest cardioprotective effects of red wine, the increased risk for cancer clearly outweighs that modest benefit.

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February 22, 2009 by sevalgunes.

I just came a across a very interesting article in the New York Times Magazine titled: What’s wrong with Summer Stiers?

It describes in detail the new NIH (National Institutes of Health) Undiagnosed Diseases Program. The focus is Summer Stiers, a young (although much older looking) female patient from Oregon with a multitude of symptoms and medical conditions. It follows her evaluation at the NIH and explains that sometimes there is no clear diagnosis.

This reporting is different from the usual sensationalistic reporting of “miracle cures and wonder drugs” we see in the mainstream media. It shows the process of coming up with a right diagnosis or multiple diagnoses.

It is 8 pages long but definitely worth the time!

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May 18, 2008 by sevalgunes.

This is one of the most commonly asked questions: Should I have surgery for my back (or neck) pain?

There are many factors that have to be considered to give an informed answer.
In some situations undergoing an operation is the best way and sometimes the only way to treat the pain and loss of function.

I recommend my patients see a spine surgeon in the following scenarios:
1. significant and worsening neurological impairment like inability to control bowel or bladder function and significant weakness in legs (or in arms if the problems are in the neck).
2. severe unrelenting pain despite aggressive treatment by a pain specialist.

The decision to undergo an operation is relatively easy to make in case of significant neurological impairment. If you cannot stand up or walk or lift your arm, you have to be emergently evaluated. Often these situations are surgical or medical emergencies and I instruct patients to call 911 or get to the nearest emergency room as soon as possible to be evaluated if they need surgery right away. Sudden weakness, numbness or incontinence can not only be caused by a massive disc herniation pressing on the spinal cord but can also be caused by a stroke and other disease processes. In all of these circumstances immediate evaluation and treatment is in order.

The situation gets more complicated in the vast majority of cases when there is no or only minimal numbness and weakness and no incontinence. One of the rules of surgery is “If you operate for pain, you will get more pain”. This means that if you operate when there is no clear neurological damage due to operable structures (like herniated disc) you may end up with more pain. One of the most commonly made statements I hear in my practice are patients who underwent multiple operations with worsening outcomes: “If I had known that I would end up like this, I would have never had the first operation!” Of course my patient population is skewed as the ones who do great after neck or back surgery do not seek a pain specialist.

Another way to look at this question is to compare the incidence of back operations in the United States with the statistics in other countries and even in different regions within the US. In the UK you usually have to wait to undergo a back operation unless you have a severe neurological impairment. As luck would have it, some of the patients on the waiting list get slowly better and then end up canceling the surgery as they slowly recover on their own. As nobody waits in the US, those patients that would have recovered on their own, will end up undergoing an operation. Most patients do well for at least some time after a back or neck operation. The statistics for neck operations are more encouraging than for low back surgery. The problem is that often patients who initially do well after surgery start to develop scar tissue and a recurrence or even worsening of the symptoms they had before the first operation. This often leads to repeat operations and many patients end up with fusion of parts of the spine. It is also very interesting that the incidence of lumbar fusions (number of fusions per 1000 population) varies greatly depending on where you live within the United States. The incidence in Medicare patients ranged from a low of 0.2/1000 in Bangor, Maine to a 23-fold higher rate of 4.6/1000 in Idaho Falls, Idaho. Read: United States’ Trends and Regional Variations in Lumbar Spine Surgery: 1992-2003 (pdf).

Read also these articles: Variation in Surgical Decision Making for Degenerative Spinal Disorders. Part I: Lumbar Spine, Evidence-based Guidelines in Lumbar Spine Surgery - Free Preview (pdf), Evidence-Based Guidelines for the Performance of Lumbar Fusion (pdf). Here are some abstracts regarding reoperation rates and outcomes of low back operations: Outcome of lumbar fusion in Washington State workers’ compensation, Lumbar fusion outcomes in Washington State workers’ compensation, 5-year reoperation rates after different types of lumbar surgery, Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures, Outcomes of posterolateral lumbar fusion in Utah patients receiving workers’ compensation: a retrospective cohort study and Are lumbar spine reoperation rates falling with greater use of fusion surgery and new surgical technology?

In the past many patients were quick to undergo a back or neck operation. Nowadays, everybody has a friend/relative/neighbor who had back or neck surgery, underwent multiple re-operations and then finally was disabled and is now dependent on a scooter to get around. Therefore, the public has an appreciation that success with spine operations is not “guaranteed” as it is with appendix or gallbladder operations which have a much higher success rate.

The bottom line is that patients should discuss their concerns frankly with their physicians. The decision when to obtain a surgical consultation and when to proceed with the operation should be made after detailed discussions between the patient and the physicians (primary care physicians/family doctors, pain specialists and spine surgeons). Going into surgery with unrealistic expectations will just produce frustration, regret and anger after the procedure.

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April 5, 2008 by sevalgunes.

Intradiscal electrothermal therapy is a modality to treat low back pain caused by annular tears in lumbar intervertebral discs. A meta-analysis (pooling of data from multiple comparable studies to achieve greater statistical significance) published in Pain Medicine (2006;7:308-316, PMID: 16898940) combined the available data from 17 peer-reviewed studies published between January 1998 and March 2005 and came to the following conclusions:

• on average the patients had a 2.9 point mean reduction of pain (on a 0-10 pain scale)
• a 7.0 mean decrease in disability level as measured by the Oswestry Disability Index (Fairbank JC, Couper J, Davies JB, OBrien JP (1980) The Oswestry low back pain disability questionnaire. Physiotherapy 1980 Aug;66(8), 271-273)
• an 18 point mean improvement in bodily pain as measured with the SF-36
• a 7.0 point mean decrease in disability level as measured by the Oswestry Disability Index.

This meta-analysis clearly shows that some patients do benefit from the procedure which saves them from undergoing an open back operation. The problem is that while Medicare pays for this procedure (they do usually not pay for anything unless it is proven to be beneficial) most commercial insurance companies refuse to pay for the procedure!

On the surface this does not make any sense as the IDET procedure is much cheaper and requires much less recovery time than a surgical discectomy. The explanation is “churn”. What does that mean? On average commercially insured patients switch their insurance coverage about every 3 years. The commercial insurance companies just want to delay care of the patient until the patient switches to a different company and they can get rid of the “problem patient”.

Medicare is in the opposite situation as they know that once a patient is eligible for Medicare, the only way they will usually lose coverage is in the event of death. Therefore, they choose to cover the cheaper procedure, realizing that a successful IDET will keep many patients from advancing to a back operation.

Unbelievable but true: you get better coverage for IDET with Medicare than with UnitedHealthcare, Aetna, Cigna or BlueCross/Blue Shield.

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